Andrew J. Lightfoot

Lessons Learned from a Case of Calf Compartment Syndrome After Robot-Assisted Laparoscopic Prostatectomy

Robot-assisted laparoscopic prostatectomy is rapidly gaining favor as a minimally invasive method to surgically address prostate cancer. The sophisticated equipment and unique positioning requirements of this technology require exceptional preparation and attention to detail to minimize the chance of surgical complications. We present the case of a 57-year-old man who developed left calf compartment syndrome after (robot-assisted laparoscopic prostatectomy) requiring fasciotomies. We use this example to highlight specific areas of risk unique to the da Vinci Surgical System® using intraoperative photos to show danger areas as well as review basic positioning requirements common to all prolonged pelvic surgeries performed in Trendelenburg position.

Bacillus Calmette-Guérin with or without interferon α-2b and megadose versus recommended daily allowance vitamins during induction and maintenance intravesical treatment of nonmuscle invasive bladder cancer.

PURPOSE In a multicenter, prospectively randomized study we evaluated bacillus Calmette-Guérin alone vs bacillus Calmette-Guérin plus interferon α-2b and megadose vitamins vs recommended daily allowance vitamins during induction and maintenance intravesical therapy in the treatment of nonmuscle invasive bladder cancer. MATERIALS AND METHODS Patients who were bacillus Calmette-Guérin naïve with carcinoma in situ, Ta or T1 urothelial cancer were randomized to receive intravesical bacillus Calmette-Guérin or bacillus Calmette-Guérin plus interferon α-2b. Patients were further randomized to receive a recommended daily allowance or megadose vitamin preparation. Induction bacillus Calmette-Guérin treatment was given weekly for 6 weeks, and patients who were recurrence-free received maintenance treatment at 4, 7, 13, 19, 25 and 37 months. Patients were followed with quarterly cystoscopy for 2 years, then semiannually through year 4 and then annually. The primary end point was biopsy confirmed tumor recurrence or positive cytology. RESULTS A total of 670 patients were accrued and randomized. At 24-month median followup recurrence-free survival was similar in all groups with 63% in the bacillus Calmette-Guérin with recommended daily allowance vitamins group, 59% in bacillus Calmette-Guérin with megadose vitamins, 55% in bacillus Calmette-Guérin/interferon α-2b with recommended daily allowance vitamins and 61% in bacillus Calmette-Guérin/interferon α-2b with megadose vitamins (p >0.05). The addition of interferon α-2b was associated with a more frequent incidence of fever (11% vs 5%) and constitutional symptoms (18% vs 11%) vs bacillus Calmette-Guérin alone (p <0.05). CONCLUSIONS Interferon α-2b added to bacillus Calmette-Guérin induction and maintenance intravesical therapy did not decrease tumor recurrence in bacillus Calmette-Guérin naïve cases, but was associated with increased fever and constitutional symptoms. No difference in time to recurrence was present in patients receiving recommended daily allowance vs high dose vitamins.

Utility of the RENAL nephrometry scoring system in the real world: predicting surgeon operative preference and complication risk

Study Type – Prognosis (individual cohort)

Multi-institutional analysis of sequential intravesical gemcitabine and mitomycin C chemotherapy for non–muscle invasive bladder cancer

OBJECTIVE Apart from cystectomy, few treatment options exist for the management of bacillus Calmette-Guerin refractory non-muscle invasive bladder cancer (NMIBC). We report a multi-institutional experience with sequential intravesical combination chemotherapy using gemcitabine and mitomycin C (MMC) for NMIBC in the treatment of high-risk patients. METHODS We performed a retrospective review of patients who received 6 weekly treatments with sequential intravesical gemcitabine (1g) and MMC (40 mg) chemotherapy for NMIBC. Gemcitabine was administered first and retained for 90 minutes and then drained. MMC was then administered directly after and retained for an additional 90 minutes. Forty-seven patients received treatment from 3 academic tertiary referral centers between 2000 and 2010. RESULTS Forty-seven patients (median age 70, range 32-85; 36 males, 11 females) who previously failed a median of 2 intravesical treatments were reviewed. Complete response, 1-year, and 2-year recurrence-free survival rates for all patients were 68%, 48%, and 38%, respectively. Median recurrence-free survival for all patients was 9 months (range 1-80). Fourteen of 47 patients (30%) remained free of recurrence with a median time to follow-up of 26 months (range 6-80 mo). Ten patients required cystectomy. CONCLUSION Sequential intravesical combination chemotherapy using gemcitabine and MMC appears to be a useful treatment for patients with high-grade NMIBC as well as those with prior bacillus Calmette-Guerin failure. Further prospective studies are warranted.

Factors Affecting Response to Bacillus Calmette-Guérin Plus Interferon for Urothelial Carcinoma in Situ

PURPOSE The unpredictable behavior of carcinoma in situ and its high potential for recurrence and progression make identifying patient characteristics predicting a poor prognosis a priority. We assessed which factors affect the response to bacillus Calmette-Guérin plus interferon-α therapy in patients with urothelial carcinoma in situ. MATERIALS AND METHODS We analyzed data on a subset of 231 patients with carcinoma in situ enrolled in a multicenter, phase II trial of bacillus Calmette-Guérin plus interferon-α therapy for nonmuscle invasive bladder cancer. Analysis included patients who were bacillus Calmette-Guérin naïve and those with previous exposure to failed bacillus Calmette-Guérin therapy. We evaluated factors potentially affecting the bacillus Calmette-Guérin plus interferon-α response, including patient age, gender, tumor stage, multifocality, prior tumor stage, the previous bacillus Calmette-Guérin failure pattern, courses and maintenance, and prior chemotherapy. RESULTS The complete response rate at 3 and 6 months in naïve vs previously failed bacillus Calmette-Guérin cases was 76% and 70% vs 76% and 66%, respectively. The 24-month disease-free rate was decreased in the 53 patients with a history of 2 or more failed bacillus Calmette-Guérin courses vs that in the 71 with a history of 1 failed course and bacillus Calmette-Guérin naïve patients (23% vs 57% and 60%, respectively). The 22 patients with refractory carcinoma in situ had the worst outcome of a 23% disease-free rate at 24 months while the 59 with relapse within 1 year had an intermediate outcome of 42% vs 59% in the 33 with relapse after 1 year. Patients with a history of papillary disease did better than those without such a history (p=0.019). CONCLUSIONS Factors associated with a poor response to bacillus Calmette-Guérin plus interferon-α therapy in patients with carcinoma in situ are prior tumor stage, 2 or more prior bacillus Calmette-Guérin failures and a bacillus Calmette-Guérin failure pattern.

Recognition and treatment of BCG failure in bladder cancer.

Patients with high-grade Ta, T1, or carcinoma in situ non–muscle-invasive bladder cancer (NMIBC) are at high risk for recurrence and, more importantly, progression. Thus, both the American Urological Association and European Association of Urology recommend initial intravesical treatment with bacillus Calmette-Guerin(BCG) followed by maintenance therapy for a minimum of 1 year. The complete response rate to BCG therapy in patients with high-risk NMIBC can be as high as ∼80%; however, most patients with high-risk disease suffer from recurrence. BCG failure can be further characterized into BCG refractory, BCG resistant, BCG relapsing, and BCG intolerant. Current recommendations include one further course of BCG or cystectomy. In patients who continue to fail conservative treatment and who refuse surgical therapy or are not surgical candidates, treatment options become even more complicated. In this setting, treatment options are limited and include repeat BCG treatment, an alternate immunotherapy regimen, chemotherapy, or device-assisted therapy. To date, however, further research is necessary for all secondary treatment options in order to determine which might be the most efficacious. All conservative treatments should be considered investigational. Currently, cystectomy remains the standard of care for high-risk patients who have failed BCG therapy.

Usefulness of the Spanish Urological Club for Oncological Treatment Scoring Model to Predict Nonmuscle Invasive Bladder Cancer Recurrence in Patients Treated With Intravesical Bacillus Calmette-Guérin Plus Interferon-α

PURPOSE The Spanish Urological Club for Oncological Treatment recently developed a scoring model to stratify the recurrence risk in patients treated with intravesical bacillus Calmette-Guérin using gender, age, grade, tumor status, T category, multiplicity and associated carcinoma in situ. We investigated the ability of this model to stratify the recurrence risk in patients with nonmuscle invasive bladder cancer undergoing combination bacillus Calmette-Guérin plus interferon α-2B therapy. MATERIALS AND METHODS We retrospectively reviewed data from a national multicenter phase II trial of bacillus Calmette-Guérin plus interferon α-2B in patients with nonmuscle invasive bladder cancer to identify 718 with the data required to use the model. Recurrence was defined as visible tumor on cystoscopy unless histologically confirmed as benign, definitive positive cytology or biopsy proven disease even with negative cystoscopy. Time to recurrence was indexed to the first intravesical treatment date. Patients were assigned points based on the model and then divided into 4 groups based on total score, including 0 to 4, 5 or 6, 7 to 9 and 10 or greater. RESULTS The model successfully stratified the recurrence risk into 4 statistically different groups based on score with a 3-year recurrence-free rate of 58%, 52%, 42% and 26% for scores of 0 to 4, 5 or 6, 7 to 9 and 10 or greater, respectively (p < 0.001). CONCLUSIONS The Spanish Urological Club for Oncological Treatment scoring model is a useful prognostic tool to stratify recurrence risk in patients with nonmuscle invasive bladder cancer who are treated with combined intravesical bacillus Calmette-Guérin plus interferon α-2B. Larger, prospective trials are required for full model validation.

Utility of 18F-FDG PET/CT in identifying penile squamous cell carcinoma metastatic lymph nodes

OBJECTIVES Due to the significant potential morbidity of inguinal and pelvic lymphadenectomy, the search for an imaging modality that can accurately identify penile squamous cell carcinoma (SCCA) lymphatic metastases continues. Initial (18)F-FDG PET/CT studies have reported 80% sensitivity and 100% specificity in the detection of inguinal and obturator lymph node metastasis. We review a single institutional experience of (18)F-FDG PET/CT imaging of SCCA of the penis to assess for accuracy and potential impact on clinical management. METHODS Three patients diagnosed with penile SCCA at a single institution underwent staging (18)F-FDG PET/CT and went on to subsequent inguinal lymph node dissection. The (18)F-FDG PET machine was a Philips Gemini Time-of-Flight PET with LYSO crystals with 4.7 mm spatial resolution. The CT was a 16-slice helical CT with 5 mm slice widths. (18)F-FDG PET/CT findings were compared with the histologic findings of these procedures. Decision to proceed with lymphadenectomy was based on clinical judgment of a single urologist and all fused (18)F-FDG PET/CT imaging was assessed by a single experienced radiologist. RESULTS No patient received chemotherapy or radiation before the (18)F-FDG PET/CT or surgery. The first patient was obese (BMI > 30), clinically node negative, and the (18)F-FDG PET/CT showed inflammation. Histologic examination showed a positive 2 cm right inguinal metastatic node. The second patients (18)F-FDG PET/CT showed a suspicious 1 cm left inguinal node. Histologically, the suspicious lymph node was positive for SCCA as was a second positive 2 cm lymph node not identified on preoperative (18)F-FDG PET/CT. Clinical exam of this patient was negative. The third patient was (18)F-FDG PET/CT and clinically negative but subsequently developed a palpable lymph node approximately 1 month later, which was suspicious on repeat (18)F-FDG PET/CT and positive for SCCA on histological examination. CONCLUSIONS (18)F-FDG PET/CT has shown initial promise in the staging of penile SCCA. However, our review shows that false negative studies occur at alarmingly high rates, and (18)F-FDG PET/CT is poor in detection of micro-metastasis. Thus, close follow-up in these patients is imperative.

Current and Future Need for Academic Urologists in the United States

PURPOSE We assessed the need for academic urologists in 2010 and for the following 5 years. MATERIALS AND METHODS An 8-question survey was emailed to the 115 accredited academic urology residency programs recognized by the American Urological Association. Questions were related to the anticipated number of hires during the next 5 years, ideal minimum level of training, areas of expertise needed, current top need and allotted research time. RESULTS Of 115 chairs or division heads 91 (79%) responded to the survey. Of all chairs 71% (65 of 91) expect to hire 2 to 4 physicians in the next 5 years. In total 91 chairs will be attempting to fill 292 openings. When carried out to 115 chairs, there will be 369 openings in the next 5 years (or 74 per year). The ideal minimum level of training was cited as clinical/research fellowship (37.1%), clinical fellowship (33.6%) and residency (10.5%). Areas of expertise needed most from each respective program include female urology/neurourology (51.7%), oncology (44.8%), and pediatrics and general urology (36.8%). The current top needs for respective programs include pediatrics 23.3%, female urology/neurourology 21.1% and oncology 18.9%. Of the chairs and division heads currently attempting to fill positions 53.5% have been searching for 2 or more years. CONCLUSIONS There will be a tremendous need for academic urologists in the next 5 years. This need is thought to be due to an increased number of physicians retiring and decreased level of compensation compared to private practice.

Safety and Efficacy of Intravesical Bacillus Calmette-Guérin Plus Interferon α-2b Therapy for Nonmuscle Invasive Bladder Cancer in Patients With Prosthetic Devices

PURPOSE Patients with bladder cancer who have prosthetic devices, such as a cardiac pacemaker, artificial heart valve or orthopedic hardware, and who undergo intravesical bacillus Calmette-Guérin therapy are theoretically at higher risk for complications, including bacterial seeding of pacemaker wires or orthopedic hardware, and at further risk for infective endocarditis. We assessed the safety and efficacy of bacillus Calmette-Guérin plus interferon α-2b therapy in patients with nonmuscle invasive bladder cancer and a pacemaker, artificial heart valve or orthopedic hardware. MATERIALS AND METHODS We evaluated 1,045 patients with nonmuscle invasive bladder cancer enrolled in a multicenter American phase II trial of bacillus Calmette-Guérin plus interferon α-2b therapy, including 143 with a prosthetic device (pacemaker in 87, artificial heart valve in 13 and orthopedic hardware in 43). Weekly physician toxicity assessments and standard adverse effect reporting were done. RESULTS No patient had infective endocarditis or hardware infection. One patient with a pacemaker, 2 with orthopedic hardware and none with an artificial heart valve required treatment cessation for fever greater than 102.5F. All defervesced within 24 hours and had no long-term sequelae. Due to intolerable, nonlife threatening side effects 12 patients with a pacemaker, 2 with orthopedic hardware and 1 with an artificial heart valve stopped treatment. Of the remaining patients with a prosthesis 99 and 24 stopped treatment due to intolerable, nonlife threatening and serious side effects, respectively. CONCLUSIONS Patients with a pacemaker, artificial heart valve or orthopedic hardware were no more likely than the general population to have infection or fever, or discontinue treatment due to side effects. These patients should not be excluded from intravesical bacillus Calmette-Guérin plus interferon α-2b therapy for nonmuscle invasive bladder cancer.