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Purpose Careful selection is critical to identify those with metastatic renal cell carcinoma who are most likely to benefit from cytoreductive nephrectomy. Surgery in patients who have metastatic renal cell carcinoma with tumor thrombus is complex and may not benefit some patients with poor overall survival. We evaluated whether preoperative variables or risk stratification systems could predict overall survival following cytoreductive nephrectomy. Materials and Methods Prognostic factors for overall survival after surgery were evaluated in patients who had metastatic renal cell carcinoma with venous tumor thrombus at 5 institutions from 2000 to 2014. Prognostic variables, including metastatic renal cell carcinoma risk models, were evaluated for associations with overall survival. Multivariable analysis was used to determine independent associations of preoperative variables with overall survival. Results A total of 427 patients with metastatic renal cell carcinoma were identified with tumor thrombus. Patients with inferior vena cava thrombus above the diaphragm had shorter median overall survival vs those with renal vein only thrombus (9.2 months, IQR 4.2–30.8, vs 21.7, IQR 7.7–42.8, p = 0.0165). Individual risk factors from prognostic models were evaluated among other preoperative characteristics for associations with overall survival in 122 patients (32%) who died within 270 days of surgery. Independent predictors of overall survival included lactate dehydrogenase greater than the upper limit of normal (p = 0.003), systemic symptoms (p = 0.003), inferior vena cava thrombus above the diaphragm (p = 0.02) and sarcomatoid features (p = 0.005). Conclusions Poor overall survival following cytoreductive nephrectomy in patients with metastatic renal cell carcinoma with tumor thrombus is associated with inferior vena cava thrombus above the diaphragm, poor risk group, systemic symptoms or sarcomatoid dedifferentiation. Patients with expected poor overall survival should be considered for preoperative systemic therapy clinical trials. [ABSTRACT FROM AUTHOR]

Purpose We assessed survival dependent on pathological response after neoadjuvant chemotherapy in a large multicenter patient cohort, with a particular focus on the difference between the absence of residual cancer (pT0) and the presence of only nonmuscle invasive residual cancer (pTa, pTis, pT1). Materials and Methods We retrospectively reviewed records of patients with urothelial cancer who received neoadjuvant chemotherapy and underwent radical cystectomy at 19 contributing institutions from 2000 to 2013. Patients with cT2-4aN0M0 and eventual pN0 disease were selected for this analysis. Estimated overall survival was compared between patients with pT0 and pTa/Tis/T1 disease. A multivariable Cox proportional hazards regression model for overall survival was generated to evaluate hazard ratios for variables of interest. Results Of 1,543 patients treated with neoadjuvant chemotherapy and radical cystectomy during the study period 257 had pT0N0 and 207 had pTa/Tis/T1N0 disease. The Kaplan-Meier mean estimates of overall survival for pT0 and pTa/Tis/T1 cases were 186.7 months (95% CI 145.9–227.6, median 241.1) and 138 months (95% CI 118.2–157.8, median 187.4), respectively (p=0.58). In the Cox proportional hazards regression model for overall survival pTa/Tis/T1N0 status (HR 0.36, 95% CI 0.23–0.67) and pT0N0 status (HR 0.28, 95% CI 0.17–0.47) compared to pT2N0 pathology, positive surgical margin (HR 1.75, 95% CI 1.07–2.86), and receiving a methotrexate, vinblastine, doxorubicin and cisplatin regimen compared to an “other” regimen (HR 0.45, 95% CI 0.27–0.76) were predictors of overall survival. Conclusions pTa/Tis/T1N0 and pT0N0 stage on the final cystectomy specimen are strong predictors of survival in patients treated with neoadjuvant chemotherapy and radical cystectomy. We did not discern a statistically significant difference in overall survival when comparing these 2 end points. [ABSTRACT FROM AUTHOR]

Purpose Selected patients with bladder cancer with pelvic lymphadenopathy (cN1-3) are treated with induction chemotherapy followed by radical cystectomy. However, the data on clinical outcomes in these patients are limited. In this study we assess pathological and survival outcomes in patients with cN1-3 disease treated with induction chemotherapy and radical cystectomy. Materials and Methods Data were collected on patients from 19 North American and European centers with cT1-4aN1-N3 urothelial carcinoma who received chemotherapy followed by radical cystectomy between 2000 and 2013. The primary end points were pathological complete (pT0N0) and partial (pT1N0 or less) response rates, with overall survival as a secondary end point. Logistic regression and Cox proportional hazard ratios were used for multivariate analysis of factors predicting these outcomes. Results The total of 304 patients had clinical evidence of lymph node involvement (cN1-N3). Methotrexate/vinblastine/doxorubicin/cisplatin was used in 128 (42%), gemcitabine/cisplatin in 132 (43%) and other regimens in 44 (15%) patients. The pN0 rate was 48% (cN1—56%, cN2—39%, cN3—39%, p=0.03). The complete and partial pathological response rates for the entire cohort were 14.5% and 27%, respectively. The estimated median overall survival time for the cohort was 22 months (IQR 8.0, 54). On Cox regression analysis overall survival was associated with pN0, negative surgical margins, removal of 15 or more pelvic nodes and cisplatin therapy. Conclusions Complete pathological nodal response can be achieved in a proportion of patients with cN1-3 disease receiving induction chemotherapy. The best survival outcomes are observed in male patients on cisplatin regimens with subsequent negative radical cystectomy margins and complete nodal response (pN0) with excision of 15 or more pelvic nodes. [ABSTRACT FROM AUTHOR]

Purpose Psychological distress has been associated with an impaired immune response and poor wound healing. We hypothesized that preoperative patient reported mental health would be associated with high grade 30-day complications after radical cystectomy. Materials and Methods We retrospectively identified patients who underwent radical cystectomy for bladder cancer who completed Short Form 12 (SF-12) surveys for self-assessment of health status less than 6 months before surgery. Median physical and mental composite scores were calculated. An expert model including known predictors of postoperative high grade complications was developed, and SF-12 physical composite score and mental composite score were added to determine their association with this end point. Results From January 2010 to August 2014, 472 patients underwent radical cystectomy for bladder cancer, of whom 274 (58.1%) completed preoperative SF-12 questionnaires. Responders were more likely to be white (p=0.024), have higher preoperative albumin (p=0.037), receive neoadjuvant chemotherapy (p=0.002), have pT3/T4 disease (p=0.044) and have positive soft tissue surgical margins (p=0.006). Median SF-12 physical composite score was 43.1 (IQR 33.0–51.5) and mental composite score was 48.5 (IQR 39.5–54.7) in responders. Overall 46 (16.8%) responders experienced a high grade 30-day complication. Patients with a high grade complication had a lower preoperative median SF-12 mental composite score (44.8 vs 49.8, p=0.004) but no difference in physical composite score (39.2 vs 43.8, p=0.06). SF-12 mental composite score was also a significant predictive variable when added to our expert model (p=0.01). Conclusions Preoperative patient reported mental health was independently associated with high grade complications after radical cystectomy. Therefore, patient self-assessment of health status before surgery through validated questionnaires may provide additional information useful in predicting short-term postoperative outcomes. [ABSTRACT FROM AUTHOR]

Purpose Penile carcinoma with bilateral pelvic lymph node metastasis is a relatively rare condition with poor outcomes. There are little data available on optimal strategies for staging and treating this group of patients. We assessed factors predicting bilateral pelvic lymph node metastasis in patients with penile cancer and confirmed inguinal lymph node metastasis. Materials and Methods Multi-institutional data from a total of 4 centers in Europe, the People's Republic of China and the United States were retrospectively analyzed. Patients with penile carcinoma and inguinal lymph node metastasis who underwent bilateral pelvic lymphadenectomy were included in analysis. The Kaplan-Meier and log rank tests were used to express overall survival. Logistic regression was used for multivariate analysis of factors predicting bilateral pelvic lymph node metastasis. Cox regression was done in the multivariable analysis of overall survival. Results We identified 140 patients with penile carcinoma who had confirmed pelvic lymph node metastasis. Of the patients 83 had bilateral inguinal lymph node metastasis and 64 underwent bilateral pelvic lymphadenectomy. Bilateral pelvic lymph node metastasis was observed in 16 patients (25%). The ROC of the total number of inguinal lymph node metastases and the detection of bilateral pelvic lymph node metastasis had an AUC of 0.76 (p = 0.002) with 95% sensitivity for the cutoff point of 4 inguinal nodes. On logistic regression analysis the detection of 4 or more positive inguinal nodes was the only independent predictor of bilateral pelvic lymph node metastasis (OR 14.0, CI 1.71–115). On Cox regression analysis 4 or more inguinal lymph node metastases, adjuvant chemotherapy, inguinal extraprostatic extension and bilateral procedures were associated with overall survival. Conclusions Patients with bilateral inguinal lymph node metastasis who are treated with unilateral pelvic lymphadenectomy should be considered for bilateral pelvic lymphadenectomy in the presence of 4 or more metastatic inguinal nodes. [ABSTRACT FROM AUTHOR]

Abstract: Background: Preoperative glucocorticoid (GC) administration attenuates the physiological response to surgery and improves clinical outcomes. However, GC use is not yet universally implemented. A propensity score analysis was performed to evaluate preoperative GC use in elective colectomy. Methods: A retrospective review of prospectively collected data was conducted for all patients who had undergone elective colectomy within an established Enhanced Recovery After Surgery (ERAS) programme at our institution from January 2006 to 2010. Demographic data, surgery type, glucocorticoid administration and clinical outcomes including complication rates and length of hospital stay (LOS) were investigated. Univariate and propensity score analyses were conducted with statistical significance identified as p ≤ 0.05. Results: There were 253 patients included in the analysis, of which 146 received preoperative GC. There were significant baseline differences between those who received GC and those who did not in male gender (GC: 56 (38%); non-GC: 58 (54%); p = 0.02) and American Society of Anesthesiologists (ASA) III (GC: 40 (27%); non-GC: 43 (40%); p = 0.04). On univariate analysis, there were no significant differences in the incidence of total complications, major complication, anastomotic leak and infectious complication. On propensity score analysis, preoperative GC administration was found to be independently associated with a reduction in LOS (GC: 5; Non-GC: 6; p = 0.04). Conclusion: Preoperative GC administration is associated with a reduction in LOS without an increase in postoperative complications. [Copyright &y& Elsevier]

Abstract: Background: Multimodal care or Enhanced Recovery after Surgery (ERAS) protocols are gaining popularity in order to modify surgical stress responses after colonic resection. However, these protocols are not straightforward to implement as peri-operative care is varied. We aimed to identify areas that may need attention in order to successfully change practice. Method: The literature was reviewed for current practice, methods and issues in implementing ERAS. Based on this and our own experience we discuss several important areas that need particular attention in developing and sustaining an ERAS program. Results: International surveys have shown that current peri-operative care in colorectal resection is not evidence based. Important aspects of the ERAS philosophy including patient counselling, teamwork and attitude change are identified and discussed. Conclusion: Implementing evidence-based peri-operative care into practice is challenging. Barriers to multimodal recovery pathways should be addressed. [Copyright &y& Elsevier]

Fast-track (enhanced recovery) care pathways for colonic surgery are becoming increasingly popular; however, there have been concerns regarding protocol compliance, high readmission rates, and also the true impact on morbidity rates with these protocols. This study was conducted to assess the impact of a fast-track program for colonic surgery on hospital stay, complications, and readmission rates. From December 2005 to March 2007, consecutive patients undergoing colonic surgery were prospectively studied. The comparison group consisted of a comorbidity-matched group of patients who had undergone similar surgery before establishment of the fast-track program. Fifty patients were included in each group. Groups were comparable at baseline. The fast-track group received significantly smaller amounts of intraoperative and postoperative intravenous fluids, were fed earlier, mobilized earlier, passed flatus earlier, and were discharged earlier than the comparison group (4 vs. 6.5 days, P < 0.001). The numbers of patients with urinary infections (2 vs. 12, P = 0.008), ileus (5 vs. 18, P = 0.005), and cardiopulmonary complications (11 vs. 21, P = 0.032) were significantly lower in the fast-track group. There was no difference in the rate of readmission. Fast-track is a safe and effective approach for reducing hospital stay and morbidity following major colonic surgery. [ABSTRACT FROM AUTHOR]

To the Editor: In the retrospective study by te Marvelde and colleagues,1 the proportions of men in public and private health services receiving radical prostatectomy and curative external beam radiation therapy were examined in a multivariable logistic regression analysis. Moreover, te Marvelde and colleagues did not address clinical outcomes and have not presented evidence that the variation in treatment modalities between public and private services has had a negative impact on the final clinical outcome. [Extracted from the article]