Bogomir Milojevic

Prognostic significance of non-muscle-invasive bladder tumor history in patients with upper urinary tract urothelial carcinoma

OBJECTIVE To evaluate the prognostic factors for survival and disease recurrence in patients treated surgically for upper tract urothelial carcinoma (UTUC), focusing especially on the impact of history of non-muscle-invasive bladder cancer. PATIENTS AND METHODS A single-center series of 221 consecutive patients who were treated surgically for UTUC between January 1999 and December 2010 was evaluated. Patients who had a history of bladder tumor at a higher stage than the upper tract disease, preoperative chemotherapy, or previous contralateral UTUC were excluded. None of the patients included in this study had distant metastasis at diagnosis of UTUC. In total, 183 patients (mean age 66 years, range 36-88) were then available for evaluation. Tumor multifocality was defined as the synchronous presence of 2 or more pathologically confirmed tumors in any upper urinary tract location (renal pelvis or ureter). All patients were treated with either open radical nephroureterectomy (RNU) or open conservative surgery. Recurrence-free probabilities and cancer-specific survival were estimated using the Kaplan-Meier method and Cox regression analyses. RESULTS Fifty-one patients (28%) had previous carcinoma not invading bladder muscle. Previous history of non-muscle-invasive bladder cancer was significantly associated with tumor multifocality (P < 0.001), concomitant bladder cancer (P < 0.001), higher tumor stage (P = 0.020), and lymphovascular invasion (P = 0.026). Using univariate analyses, history of non-muscle-invasive bladder cancer was significantly associated with an increased risk of both any recurrence (HR = 2.17; P = 0.003) and bladder-only recurrence (HR = 3.17; P = 0.001). Previous carcinoma not invading bladder muscle (HR = 2.58; P = 0.042) was an independent predictor of bladder-only recurrence. Overall 5-year disease recurrence-free (any recurrence and bladder-only recurrence) survival rates were 66.7% and 77%, respectively. Previous history of non-muscle-invasive bladder cancer was not associated with cancer-specific survival. Our results are subject to the inherent biases associated with high-volume tertiary care centers. CONCLUSIONS Patients with previous history of non-muscle-invasive bladder cancer had a higher risk of having multifocal and UTUC with higher tumor stages (pT3 or greater). History of bladder tumor was an independent predictor of bladder cancer recurrence but had no effect on non-bladder recurrence, and cancer-specific survival in patients who underwent surgical treatment of UTUC.

Upper urinary tract transitional cell carcinoma: location is not correlated with prognosis.

Study Type – Therapy (case series)

Testis sparing surgery in the treatment of bilateral testicular germ cell tumors and solitary testicle tumors: A single institution experience.

To assess the oncologic and functional outcomes of testicular sparing surgery (TSS) based on a single institution experience.

Prognostic Impact of Preoperative Anemia on Urothelial and Extraurothelial Recurrence in Patients With Upper Tract Urothelial Carcinoma

BACKGROUND To investigate the prognostic impact of preoperative anemia on urothelial and extraurothelial recurrence after radical nephroureterectomy. METHODS A single-center series of 238 consecutive patients who were treated with radical nephroureterectomy for upper tract urothelial carcinoma was evaluated. We categorized patients on the basis of hemoglobin level into 2 groups, including normal or anemia. Survival was estimated using the Kaplan-Meier method. Cox proportional hazard regression models were used to evaluate the association of preoperative anemia with outcome, controlling for clinicopathologic variables. RESULTS Ninety-seven patients (40.8%) had anemia (median hemoglobin level, 143 vs. 107 g/L). Preoperative anemia was associated with history of bladder cancer (P = .01), tumor multifocality (P = .03), lymphovascular invasion (P = .05), and adjuvant chemotherapy (P = .01). Higher tumor stage and grade, and lymph node metastasis were significantly associated with preoperative anemia. Preoperative anemia was independently associated with extraurothelial recurrence (hazard ratio, 1.95; 95% confidence interval, 1.14-3.34; P = .01) in multivariate Cox regression analyses. Only a history of bladder tumor (hazard ratio, 2.07; P = .009) and tumor multifocality (hazard ratio, 3.97; 95% confidence interval, 2.37-6.67; P < .001) were independently associated with urothelial recurrence. The 5-year cancer-specific survival for patients with normal hemoglobin level was 82.1% and for patients with preoperative anemia was 54.2%. CONCLUSION Patients with preoperative anemia had a greater probability of having upper tract urothelial carcinoma with higher tumor stages, higher tumor grades, and lymph node metastasis (pN+). Preoperative anemia was statistically significantly associated with worse cancer-specific survival and extraurothelial recurrence in patients who underwent radical nephroureterectomy.

Testis sparing surgery for treatment of small testicular lesions: Is it feasible even in germ cell tumors?: Testis Sparing Surgery

To evaluate the results of testis‐sparing surgery (TSS) in patients, with small testicular lesions and a normal contralateral testicle.

The Correlation of Biochemical and Morphologic Parameters in the Assessment of Sperm Maturity

OBJECTIVE To examine the relationship between biochemical markers and morphologic sperm characteristics, including head, neck, and tail changes. METHODS The study evaluated 154 patients who went to the Andrology Laboratory of the Clinic of Urology, Clinical Center of Serbia. Patients were divided into 4 groups: normozoospermic, oligozoospermic, severe oligozoospermic, and asthenozoospermic, according to the sperm concentration and motility. RESULTS The differences in creatine kinase (CK) and CK-M levels between normozoospermic and the 2 groups of oligozoospermic patients were significantly different (P <.01). The CK and CK-M levels correlated negatively with sperm concentration and sperm motility, but correlated positively with the pathologic sperm form. Patients with CK values >0.093 have a total number of pathologic forms higher than 0.40 (87.5% sensitivity, 77.3% specificity, the area under the curve was 0.832, P <.001). Patients with CK values <0.09 U/L have normal spermatogenesis and pathologic disorder of the head <15%, neck <12%, and tail <10%. CONCLUSION The relation between sperm morphology and biochemical markers included in the maturation process is established during the sperm genesis process. If the results of these markers are used together with the morphology of the spermatozoa in the interpretation of infertility, it would lead us to better insight of the fertility potential of the each patient.

Impact of hybrid molecular imaging in retroperitoneal fibrosis: a systematic review

The aim of this article was to critically assess the usefulness of hybrid molecular imaging (FDG PET/CT and FDG PET/MR) procedures in the evaluation of inflammatory activity in retroperitoneal fibrosis (RPF). A systematic review of the literature was performed using PubMed without timeline restriction and using the following keywords: retroperitoneal fibrosis, disease activity, diagnostic techniques, PET/CT, PET/MR. We evaluated full text articles written in the English language. Case reports, review articles or editorials and articles not in the field of interest of this review were excluded. Nine articles comprising a total of 186 patients met the inclusion criteria and were included and described in this systematic review. The new hybrid molecular imaging methods give promising results in the evaluation of the activity of the disease, quantification and prediction of therapeutic response and in tailoring medical therapy in RPF. FDG PET/CT can be a valuable tool in detecting disease activity, particularly in asymptomatic patients with RPF with acute phase reactant increase. Hybrid imaging can predict therapy response outcome and the best time for stent removal. Although PET/MR has potential advantage in small lesions and has reduced radiation exposure in comparison to PET/CT, PET quantification parameters have potentially higher diagnostic value over MR parameters in the evaluation of RPF. Acute phase reactants alone may not be reliable for the management and follow-up assessment of the disease. Hybrid imaging in RFP could be more comfortable, more accurate, with less radiation burden than different separate imaging studies acquired at different points in time.

Vesicovaginal fistulas: transperitoneal surgical repair using omentum or peritoneal tissue interposition, a summary of 35 years of experience

SummaryObjectiveTo report the result of primary vesicovaginal fistula (VVF) repair using the transabdominal approach with omental or peritoneal flap interposition.MethodsThe study evaluated 38 patients who were treated with transabdominal approach with omental or peritoneal flap. The omental flap was used as the first choice if it was of sufficient length; otherwise, a peritoneal flap was created. Patients were followed postoperatively for 1 year and by telephone survey thereafter.ResultsThe age of patients ranged from 29 to 68 years, with a median of 52 years. The main causes of VVF in this study cohort were hysterectomy for benign conditions (60.5 %), hysterectomy for malignant conditions (34.2 %), and radiation therapy (5.3 %). Peritoneal flap interposition was used in 6 patients and omental flap was used in 32 patients. All patients were continent following catheter removal. Overall, 89.5 % (34 out of 38) of fistulae were successfully repaired at first attempt. The success with omental flap interposition was 100 %. Recurrence of the fistula was reported in four patients (all with primary peritoneal flap interposition). Two of them were successfully cured by peritoneal flap re-interposition. While in two patients, with a history of radiation therapy, sigma rectum pouch was performed.ConclusionTransperitoneal surgical repair using omentum or peritoneal tissue interposition should be considered in the first attempt of repair of supratrigonal VVFs. However, successful repair depends on the experience of the surgeon.

Editorial Comment on “Effect of tumor size on recurrence-free survival of upper tract urothelial carcinoma following surgical resection”

To the Editor: In this article, the authors tried to assess the effect of tumor size on oncological outcomes in upper tract urothelial carcinoma (UTUC) treated with radical nephroureterectomy [1]. According to the TNM classification, size is not mentioned specifically as a prognostic factor in UTUC [2]. However, we already know that pT3b UTUCs are more likely to have aggressive pathological features and have a higher risk of recurrence [3,4]. But it is about invasion of the tumor rather than size itself. Thus, one could say that the current study is interesting because it focuses on the influence of size. Only a few studies to date have focused on the prognostic effect of tumor size in patients with UTUC. Simone et al. [5] investigated the relationship between tumor diameter and metastasis-free survival in patients with UTUC. In their study, no metastases were noted in patients presenting with a tumor diameter o3 cm, whereas patients with a tumor diameter 43 cm had a 5-year estimated metastasis-free survival of 67%. Also, tumor diameter was an independent predictor of metastasis-free survival and disease-free survival and was the strongest prognostic indicator of the variables analyzed [5]. Matsui et al. [6] reported that smaller tumors increase the risk of intravesical recurrence. Recently, Milenkovic et al. [7] showed that tumor size is unable to predict bladder-only recurrence-free survival in a single-center series of consecutive patients treated surgically for UTUC. They failed to demonstrate a significant difference in disease recurrence-free survival between patients with tumor size o3 cm and those patients with tumor size 43 cm [7]. Subjectively, I do think that size is an important point to take into account. For instance, bulky and large tumors are not good candidates for conservative management of UTUC [8]. But, in the current study, it is not known whether all patients underwent a preoperative endoscopic evaluation of the size of the tumor or was it done only using computed tomography. Were all preoperative workup achieved by the same radiologists? Once again, the authors either undergo a very stringent protocol or fail to answer the question raised. In the case of multifocality, which tumor is taken into consideration? It remains unclear which grade and stage was present when Obviously there are some biases in the current study. Given the fairly short median follow-up time in the cohort (26.9 mo), a small minority of patients were followed for 5 years. Despite this, the authors wrote that a primary tumor diameter of 3 cm or greater, along with male gender and non–organ-confined disease, constitutes an independent prognostic indicator of recurrence-free survival for UTUC. They also stated that these patients warrant a more rigorous postoperative surveillance strategy and may potentially benefit from either adjuvant intravesical therapy or systemic chemotherapy. To date, there have been no reports confirming the efficacy of postoperative chemotherapy or radiotherapy in patients with UTUC. However, well-designed multi-institutional studies are still needed to provide stronger evidence and to promote the use of tumor size in clinical practice.