Daniel Parker

Is extended pharmacologic venous thromboembolism prophylaxis uniformly safe after radical cystectomy

OBJECTIVE To quantitate the risk of clinically significant renal function deterioration after radical cystectomy (RC), which could result in supratherapeutic levels of low-molecular-weight heparin (LMWH) and increased risk of bleeding events with the use of extended pharmacologic venous thromboembolism prophylaxis (EPVTEP) after hospital discharge. METHODS Patients undergoing RC between 2006 and 2011 were identified from the institutional registry. Estimated glomerular filtration rate (eGFR) was calculated and categorized as preoperative, discharge, and nadir. Perioperative eGFR trends in patients who would have been candidates for EPVTEP were evaluated. RESULTS Three hundred four patients with eGFR >30 mL/min/1.73 m(2) at the time of hospital discharge were included in the analysis as potentially eligible for EPVTEP. Large portion of patients (43%) exhibited decline in eGFR after discharge. Importantly, 13.0% of patients (n = 40), who would have qualified for EPVTEP at discharge, experienced nadir GFR below the 30-mL/min/1.73 m(2) threshold value at which LMWH would have become supratherapeutic. The odds ratio for developing a GFR <30 mL/min/1.73 m(2) was 9.1 (95% confidence interval, 4.3-19.3; P <.001), comparing those with a discharge GFR ≥60 mL/min/1.73 m(2) with those with a discharge GFR <60 mL/min/1.73 m(2). CONCLUSION More than 10% experienced an eGFR, which would have rendered LMWH supratherapeutic and potentially would have placed the patient at risk for clinically significant bleeding. Although postoperative venous thromboembolic event after RC is a recognized concern, a better understanding of the risks of EPVTEP is needed before this strategy is universally adopted in patients undergoing RC.

Understanding Chronic Kidney Disease of Surgical Versus Medical Origin: The Missing Link to the Partial Versus Radical Nephrectomy Debate?

In the USA and Europe, nephron-sparing surgery (NSS) has become accepted as the gold standard for renal masses of 4 cm in size [1,2]. There is general consensus in the urologic community that the acceptable increase in perioperative surgical risk inherent to partial nephrectomy (PN) is justified by the theoretical benefit of avoiding the long-term deleterious renal functional consequences associated with radical nephrectomy (RN). Concerns regarding adverse events associated with a decline in glomerular filtration rate (GFR) [3], such as cardiovascular compromise, chronic anemia, bone demineralization, and metabolic disturbances, have resulted in the intuitive and widely embraced hypothesis that NSS may result in a survival advantage when comparing PN and RN. Enthusiasm for NSS was fueled by observational studies demonstrating large differences in overall survival favoring PN [4,5], and PN rates have accordingly increased over the past decade [6]. Because of robust evidence of the oncologic efficacy of nephron-sparing excision of tumors of <5 cm [7], the indications for PN have expanded to include cT1b and cT2 lesions when technically feasible. However, momentum for the decision to perform PN in all amenable cases has been tempered by the results of European Organisation for Research and Treatment of Cancer (EORTC) trial 30904, which demonstrated an unanticipated survival advantage for RN [7]. The limitations of this study—early cessation because of failure to accrue and p values bordering statistical insignificance—have been cited as reasonswhy these data have largely been dismissed bymany kidney surgeons.With accumulating evidence that PN for renal masses of greater anatomic complexity is associated with higher perioperative risk [8] and that oncologic safety data for NSS for cT1b–2 tumors are lacking, preservation of a favorable risk/benefit ratio for complex PN versus RN for patients with a normal contralateral kidney remains contentious. It is indisputable that PN results in preserved renal function compared to RN [9]. However, the relationship between a surgically induced decline in GFR and overall health remains controversial, and clarification of this relationship will help us to understandwhy a demonstrable survival benefit was not observed for PN in EORTC 30904. In 2013, Lane et al [10] proposed that chronic kidney disease (CKD) resulting from surgical removal of nephrons (CKD-S) may be associated with a lower risk of CKD progression and improved overall survival when compared to CKD of medical etiology (CKD-M). While thought-provoking, this initial work was limited by a lack of data on cause of death and follow-up duration. In this issue of European Urology, Lane and colleagues [11] expand on their initial study by reporting extended follow-up of the impact of CKD-S on renal function, overall survival, and cause-specific survival in comparison to patients with CKD-M and those with no CKD. By retrospectively examining their institutional registry, the investigators were able to identify 2350 patients who developed CKD (GFR <60 ml/min/1.73 m) postoperatively from 1998 to 2008. Patients with postoperative CKD were further stratified into those with an estimated GFR <60 ml/min/1.73 m noted only after surgery (CKD-S) and EU RO P E AN URO LOG Y 6 8 ( 2 0 1 5 ) 1 0 0 4 – 1 0 0 6

Bladder Cancer Recovery Pathways: A Systematic Review

Background: Enhanced recovery pathways, also known as fast-track protocols, have been adopted since the early 2000s by various surgical specialties with the goal of improving patient outcomes and reducing the cost burden of major surgery on the health care system. Objective: To review the scientific literature on the origin of enhanced recovery pathways, track the contemporary utilization of such practices for patients undergoing radical cystectomy, and analyze the available data regarding their effect on morbidity, mortality, and treatment cost. Methods: A literature search of multiple electronic databases was undertaken. Manuscripts including patients undergoing radical cystectomy were chosen based on predefined criteria with an emphasis on randomized controlled trials and cohort studies. Strength of evidence for each study that met inclusion criteria was assessed based on the risk of bias, consistency, directness, and precision. Results: Database searches resulted in 1,236 potentially relevant articles. A total of 485 articles were selected for full-text dual review and 106 studies in 52 publications met the inclusion criteria. Conclusion: The utilization of enhanced recovery pathways with the goal of improving overall patient morbidity and mortality is well supported in the literature, however standardization of implementation and adherence across institutions is lacking, and their direct efficacy on reducing preventable treatment related expenditures is unconfirmed.

Some Renal Masses Did Not “Read the Book”: A Case of a High Grade Hybrid Renal Tumor Masquerading as a Renal Cyst on Non-contrast Imaging

Hybrid renal tumors (HRT) are rare neoplasms that contain both benign and malignant components. Sporadic solitary HRT that contain high-grade malignant pathology appear to be extremely rare [1]. We describe a case at our institution of a tumor that was characterized as a type-2 papillary RCC and atypical oncocytoma hybrid that mimicked a simple cyst on non-contrast computed tomography.

Salvage Surgery After Renal Mass Ablation

Thermal ablative techniques represent treatment options for patients with small renal masses who are not candidates for surgery. The oncologic efficacy of ablation has not been compared in a randomized fashion with nephron-sparing surgery, and the urologist must be knowledgeable regarding the workup and treatment of patients with suspected residual or recurrent tumor following these therapies. Surveillance of patients with tumor recurrence after ablation may be indicated in select circumstances. When patients are deemed appropriate for salvage therapy, most undergo a repeat course of the same ablative modality. Salvage surgery is possible but often complicated by the prior ablative techniques.

Laparoscopic renal mass cryoablation: an operation in search of an indication

In this issue of BJUI, Nielsen et al. [1] report the oncological and surgical outcomes from a multi-institutional cohort of patients receiving laparoscopic cryoablation (LCA) as primary therapy for solitary renal masses <4 cm in size (cT1a). This work represents the latest addition to a growing body of literature in an important oncological space that lacks prospective/randomized evidence to guide practitioners counselling patients with kidney cancer. Although the article does not advance the discussion toward higher levels of evidence, the results are nonetheless provocative and several strengths and weaknesses deserve comment.

7-flap perineal urethrostomy.

Perineal urethrostomy (PU) has been performed with success for the treatment of refractory and advanced urethral stricture disease for at least the past six decades. Here, we review the indications and outcomes of PU for indications such as complex hypospadias repair and urethral stricture disease resulting from trauma, infection, and failure of prior urethroplasty. We also describe the role of 7-flap PU, a novel alternative to the conventional approach that offers the surgeon added flexibility in tailoring urethrostomy creation based on intraoperative findings. The authors’ updated experience with 7-flap PU demonstrates a comparable 95% success rate in patients with a wide variety of stricture etiology. PU through either a conventional approach or a 7-flap technique is a valuable option for improving the quality of life in patients with debilitating urethral stricture disease.

Risk of Ovarian Malignancy in Patients Undergoing Radical Cystectomy for Bladder Cancer

OBJECTIVE To determine whether there is an increased risk of ovarian cancer in women undergoing radical cystectomy (RC) for bladder cancer using a large population-based data source. Current American Urologic Association guidelines suggest removal of ovaries during RC in women with bladder cancer, presumably to mitigate the risk ovarian cancer. However, recent data have demonstrated an increased risk of all-cause mortality, cardiovascular disease, osteoporosis, cognitive impairment, and diminished sexual function in some populations of women after oophorectomy. METHODS We queried the surveillance, epidemiology and end results (SEER) database for all women with a diagnosis of primary bladder cancer who underwent RC between 1998 and 2010. Patients with concurrent or subsequent primary ovarian cancer were then identified using the SEER multiple primaries dataset. Multiple primary standardized incidence ratio was calculated as an estimate of the relative risk of a concurrent or subsequent ovarian malignancy using SEER*Stat software. RESULTS A total of 1851 women met inclusion criteria for analysis. Of this population, 221 (11.9%) women developed a subsequent nonbladder malignancy, of which 2 (0.11%) women developed subsequent ovarian cancer during the observation period. Multiple primary standardized incidence ratio for development of an ovarian malignancy was 2/4 (0.50). CONCLUSION The risk of concurrent or subsequent ovarian malignancy in women undergoing RC for bladder cancer is very low. Therefore, oophorectomy at the time of RC may be obviated in order to mitigate the undue risk of cardiovascular disease, osteoporosis, cognitive impairment, and diminished sexual function.

Downstream effects of regionalization: reconciling our predictions with the volume-outcome paradigm

In the United States, there has been widespread recognition among health care quality improvement experts that a strong relationship exists between the volume of particular surgical cases performed and the outcomes experienced by patients electing to undergo such procedures (1,2).

PD10-05 UNDERESTIMATION OF PROSTATE CANCER RISK AT DIAGNOSIS AMONG AFRICAN AMERICAN MEN

INTRODUCTION AND OBJECTIVES: African American (AA) men suffer from a disproportionately high burden of clinically significant prostate cancer, with an increased risk of aggressive or advanced stage disease. Even among men thought to have low risk disease at diagnosis, data suggests that AA men are at an increased risk of adverse pathology after radical prostatectomy (RP) compared to men of other races. These data suggest an underestimation of disease risk at diagnosis among AA men. In the current study, we compared preand post-treatment estimates of prostate cancer risk, to determine whether inaccurate assessment of disease risk at diagnosis differs by race. METHODS: We identified Caucasian and AA men who underwent radical prostatectomy (RP) at our institution between 2012 to 2016. CAPRA and CAPRA-S scores were determined as estimates of preand post-operative disease risk, and differences between each patient’s CAPRA and CAPRA-S scores were calculated. Underestimation of disease risk at diagnosis was defined as a CAPRA score less than CAPRA-S score. Rates of risk under and over-estimation were compared among racial groups, and multivariable logistic regression was used to determine factors associated with risk underestimation. RESULTS: 391 men met inclusion criteria, including 284 Caucasian (72.6%) and 107 AA (27.4%) men. As shown in table 1, the distribution of CAPRA and CAPRA-S scores did not differ significantly by race (CAPRA p1⁄40.81, CAPRA-S p1⁄40.69). Differences between each individual patient’s CAPRA and CAPRA-S score are shown in table 2. Risk underestimation occurred in 37% of AA men, compared to 26% of Caucasian men (p 1⁄4 0.09). Multivariable logistic regression showed that AA race (p 1⁄4 0.05) and higher serum PSA at diagnosis (p 1⁄4 0.01) were associated with risk underestimation, whereas age at biopsy, Gleason score, and clinical stage were not. CONCLUSIONS: Underestimation of prostate cancer risk at diagnosis appears to be more common in AA compared to Caucasian men. These findings suggest a need for improved risk assessment at diagnosis, and argue for more aggressive treatment of prostate cancer in AA men.