Eric Estey

Contemporary outcomes of 2287 patients with bladder cancer who were treated with radical cystectomy: a Canadian multicentre experience.

Study Type – Therapy (case series)

Associations Among Age, Comorbidity and Clinical Outcomes After Radical Cystectomy: Results From the Alberta Urology Institute Radical Cystectomy Database

PURPOSE We determined the associations among age, comorbidity and clinical outcomes after radical cystectomy. MATERIALS AND METHODS The study was a retrospective cohort analysis of 314 consecutive patients with primary bladder cancer treated with radical cystectomy between January 2000 and December 2006 in Edmonton, Canada. Comorbidity was obtained through a medical record review using the Adult Comorbidity Evaluation-27 instrument. The main clinical outcomes were 90-day mortality, early postoperative complications, and major and minor early postoperative complications. Logistic regression analyses were used to determine predictors of clinical outcomes. RESULTS The 90-day mortality, any early postoperative complications, and major and minor early postoperative complications occurred in 18 (5.7%), 148 (47.1%), 78 (24.8%) and 92 (29.3%) patients, respectively. In univariate and multivariate logistic regression analysis age was not associated with 90-day mortality or early postoperative complications. In contrast, compared to patients with no or mild comorbidity, multivariate logistic regression analysis adjusted for age and surgeon procedure volume showed that severe comorbidity was associated with an increased risk of 90-day mortality (OR 6.4, p = 0.03). In addition, compared to patients with no or mild comorbidity, multivariate logistic regression analysis adjusted for age, sex, surgeon procedure volume, type of urinary tract reconstruction and American Joint Committee on Cancer stage showed that moderate and severe comorbidity were associated with any early postoperative complications (moderate OR 5.2, p <0.001; severe OR 7.0, p <0.001), major early postoperative complications (moderate OR 11.4, p <0.001; severe OR 15.2, p <0.001) and minor early postoperative complications (moderate OR 2.1, p = 0.019; severe OR 2.2, p = 0.038). CONCLUSIONS Increasing comorbidity was independently associated with an increased risk of 90-day mortality and early postoperative complications after radical cystectomy.

Associations Between Comorbidity, and Overall Survival and Bladder Cancer Specific Survival After Radical Cystectomy: Results From the Alberta Urology Institute Radical Cystectomy Database

PURPOSE We determined the associations between comorbidity, and overall survival and bladder cancer specific survival after radical cystectomy. MATERIALS AND METHODS The Alberta Urology Institute Radical Cystectomy database is an ongoing multi-institutional computerized database containing data on all adult patients with a diagnosis of primary bladder cancer treated with radical cystectomy in Edmonton, Canada from April 1994 forward. The current study is an analysis of consecutive database patients treated between April 1994 and September 2007. Comorbidity information was obtained through a medical record review using the Adult Comorbidity Evaluation 27 instrument. The outcome measures were overall survival and bladder cancer specific survival. Cox proportional regression analysis was used to determine the associations between comorbidity, and overall survival and bladder cancer specific survival. RESULTS Of the database patients 160 (34%), 225 (48%) and 83 (18%) had no/mild comorbidity, moderate comorbidity and severe comorbidity, respectively. Compared to patients with no or mild comorbidity, multivariate Cox proportional regression analyses that included age, adjuvant chemotherapy, surgeon procedure volume, pathological T stage, pathological lymph node status, total number of lymph nodes removed, surgical margin status and lymphovascular invasion showed that increased comorbidity was independently associated with overall survival (moderate HR 1.59, 95% CI 1.16-2.18, p = 0.004; severe HR 1.83, 95% CI 1.22-2.72, p = 0.003) and bladder cancer specific survival (moderate HR 1.50, 95% CI 1.04-2.15, p = 0.028; severe HR 1.65, 95% CI 1.04-2.62, p = 0.034). CONCLUSIONS Increased comorbidity was independently associated with an increased risk of overall mortality and bladder cancer specific mortality after radical cystectomy.

Surveillance guidelines based on recurrence patterns after radical cystectomy for bladder cancer: the Canadian Bladder Cancer Network experience

Study Type – Prognosis (cohort)

Referral and treatment rates of neoadjuvant chemotherapy in muscle-invasive bladder cancer before and after publication of a clinical practice guideline.

INTRODUCTION The objective of this study was to compare referral and treatment rates of neoadjuvant chemotherapy for patients with muscle-invasive bladder cancer before and after publication of a clinical practice guideline. METHODS This was a retrospective comparative cohort study of 236 patients diagnosed with clinical stage >/= T2 bladder cancer in Alberta, Canada. Patients were divided into 2 groups based on the time of diagnosis relative to the publication of the Alberta Genitourinary Oncology Group Clinical Practice Guideline on Bladder Cancer (CPG), which recommends cisplatin-based neoadjuvant chemotherapy for muscle-invasive disease. The pre-CPG group included patients (n = 129) diagnosed prior to publication of the CPG (November 1, 2002 to October 31, 2004, inclusively). The post-CPG group included patients (n = 107) diagnosed after publication of the CPG (November 1, 2005 to October 31, 2007). There was an accrual blackout period of 6 months before and after the CPG release date. The primary analysis compared the two groups with respect to neoadjuvant chemotherapy referral rates, treatment-offered rates and treatment-administered rates. RESULTS Referral to medical oncology regarding neoadjuvant chemotherapy occurred in 2.3% and 23.4% of patients in the pre- and post-CPG groups, respectively (p < 0.01). Neoadjuvant chemotherapy was offered to 0.8% and 18.7% of patients in the pre- and post-CPG groups, respectively (p < 0.01). Neoadjuvant chemotherapy was administered to 0.8% and 14.0% of patients in the pre- and post-CPG groups, respectively (p < 0.01). INTERPRETATION Neoadjuvant referral and treatment rates increased after publication of the CPG. However, overall referral and treatment rates remained low, which warrants additional exploration.

Urinary incontinence after radical prostatectomy: can men at risk be identified preoperatively?

BACKGROUND Incontinence after radical prostatectomy for early stage prostate cancer can significantly affect quality of life. Identification of risk factors preoperatively would enable clinicians to counsel men and their partners about the risk of incontinence following surgery. We conducted a population-based study to identify subjective and objective preoperative factors, other than PSA and Gleason score, that may predict urinary incontinence following radical prostatectomy. METHODS Men booked for radical prostatectomy at 2 sites in Alberta were enrolled prospectively. Assessment was completed 2 weeks prior to surgery and included the International Prostate Symptom Score (IPSS) with a single quality-of-life (QOL) question, 24-hour pad test, and bladder diary. These parameters were repeated at 3 and 12 months postoperatively. A model predicting incontinence was developed using stepwise multivariable logistic regression analysis. Incontinence was defined as more than 8 g of urine loss on 24-hour pad test. RESULTS A total of 245 patients from 2 centers were enrolled; 228 (93%) completed data collection up to 12 months postsurgery. At the baseline preoperative assessment, 4% (10/228) of subjects had ≥ 8 g of urine loss on 24-hour pad test, although these and all other subjects described complete continence. At 3 months postop, 43% had ≥ 8 g on 24-hour pad testing (our definition of incontinence) (median 31 g, range 8.3–1654 g, SD 219.12); at 12 months, 15% had more than 8 g of urine loss on pad test (median 21.0 g, range 8.1–3380 g, SD 578.0). For all subjects, mean IPSS and the single QOL scores at baseline (7.4 and 1.5) did not change significantly at 3 months (7.2 and 2.5), but both were lower than or equal to baseline at 12 months (5.4 and 1.5). The IPSS was predictive of incontinence at 3 months, but not at 12 months. Bladder diary did not correlate with IPSS. Risk factors affecting continence at 12 months were preoperative urine loss ≥ 8 g, previous transurethral resection of prostate (TURP), and age greater than 65 years. CONCLUSION Our results support previous research on risk factors for incontinence after radical prostatectomy and add to the current data by having presurgery (baseline) measures. Interestingly, a small percentage of men (4%) who reported complete continence were incontinent preoperatively, based on our definition of ≥ 8 g weight gain on 24-hour pad test. Identified preoperative risk factors affecting continence were increasing age, baseline incontinence, and previous TURP. Mean IPSS was lower at 12 months than at baseline, suggesting that even mildly symptomatic men will improve after surgery. Men reported that regular contact with the continence research nurse provided a much-appreciated source of informed support as they recovered.

Comparison of oncological outcomes for open and laparoscopic radical nephroureterectomy: results from the Canadian Upper Tract Collaboration

Open radical nephroureterectomy (ORNU) with excision of the ipsilateral bladder cuff is a standard treatment for upper tract urothelial carcinoma (UTUC). However, over the past decade laparoscopic RNU (LRNU) has emerged as a minimally invasive surgical alternative. Data comparing the oncological efficacy of ORNU and LRNU have reported mixed results and the equivalence of these surgical techniques have not yet been established. We found that surgical approach was not independently associated with overall or disease‐specific survival; however, there was a trend toward an independent association between LRNU and poorer recurrence‐free survival (RFS). To our knowledge, this is the first large, multi‐institutional analysis to show a trend toward inferior RFS in patients with UTUC treated with LRNU.

Age ≥ 80 years is independently associated with survival outcomes after radical cystectomy: Results from the Canadian Bladder Cancer Network Database ☆

OBJECTIVES The role of advanced age as an independent prognostic factor for clinical outcomes after radical cystectomy is controversial. The objective of the current study was to assess the associations between age and clinical outcomes in a large, multi-institutional series of patients treated with radical cystectomy for bladder cancer. MATERIALS AND METHODS Institutional radical cystectomy databases containing detailed information on bladder cancer patients treated between 1993 and 2008 were obtained from 8 academic centers in Canada. Data were collected on 2,287 patients and combined into a relational database formatted with patient characteristics, pathologic characteristics, recurrence status, and survival status. Patient age was coded as <60 years, 60-69 years, 70-79 years, or ≥ 80 years. Clinical outcomes were 30-day mortality, 90-day mortality, overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS). Logistic regression and Cox proportional hazards regression analysis were used to analyze survival data. RESULTS Five hundred fifty-seven (24.6%), 679 (30.0%), 846 (37.4%), and 181 (8.0%) patients were <60 years, 60-69 years, 70-79 years, and ≥ 80 years, respectively. Increased age was associated with decreased utilization rates of neoadjuvant chemotherapy (P = 0.0143), adjuvant chemotherapy (P < 0.0001), and continent urinary diversion (P < 0.0001) as well as advanced pathologic tumor stage (P = 0.0003), increased positive surgical margins (P < 0.0001), and lymphovascular invasion (P = 0.0335). Compared with patients < 60 years, multivariate regression analysis showed that age ≥ 80 years was independently associated with 90-day mortality (OR 2.98, 95% CI 1.22-7.30), OS (HR 2.03, 95% CI 1.51-2.75), DSS (HR 1.56, 95% CI 1.09-2.24), and RFS (HR 2.06, 95% CI 1.57-2.70). CONCLUSIONS Age ≥ 80 years at the time of radical cystectomy was independently associated with adverse survival outcomes. These data suggest that increased chronologic age should be considered in clinical trial design and in nomograms predicting survival.

Effect of body mass index on the outcomes of patients with upper and lower urinary tract cancers treated by radical surgery: Results from a Canadian multicenter collaboration

OBJECTIVE To evaluate the effect of body mass index (BMI) on the outcomes of patients with urinary tract carcinoma treated with radical surgery. MATERIALS AND METHODS Data were collected from 10 Canadian centers on patients who underwent radical cystectomy (RC) (1998-2008) or radical nephroureterectomy (RNU) (1990-2010). Various parameters among subsets of patients (BMI < 25, 25 ≤ BMI < 30, and BMI ≥ 30 kg/m(2)) were analyzed. Kaplan-Meier and multivariate analyses were performed to assess the effect of BMI on overall survival, disease-specific survival, and recurrence-free survival (RFS). RESULTS Among the 847 RC and 664 RNU patients, there was no difference in histology, stage, grade, and margin status among the 3 patient subsets undergoing either surgery. However, RC patients with lower BMIs (< 25 kg/m(2)) were significantly older (P = 0.004), had more nodal metastasis (P = 0.03), and trended toward higher stage (P = 0.052). RNU patients with lower BMIs (< 25 kg/m(2)) were significantly older (P = 0.0004) and fewer received adjuvant chemotherapy (P = 0.04) compared with those with BMI ≥ 30 kg/m(2); however, there was no difference in tumor location (P = 0.20), stage (P = 0.48), and management of distal ureter among the groups (P = 0.30). On multivariate analysis, BMI was not prognostic for overall survival, disease-specific survival, and RFS in the RC group. However, BMI ≥ 30 kg/m(2) was associated with more bladder cancer recurrences and worse RFS in the RNU group (HR = 1.588; 95% CI: 1.148-2.196; P = 0.0052). CONCLUSIONS Increased BMI did not influence survival among RC patients. BMI ≥ 30 kg/m(2) is associated with worse bladder cancer recurrences among RNU patients; whether this is related to difficulty in obtaining adequate bladder cuff in patients with obesity requires further evaluation.

Best practices for the treatment and prevention of urinary tract infection in the spinal cord injured population

The purpose of this review of clinical guidelines and best practices literature is to suggest prevention options and a treatment approach for intermittent catheter users that will minimize urinary tract infections (UTI). Recommendations are based both on evidence in the literature and an understanding of what is currently attainable within the Alberta context. This is done through collaboration between both major tertiary care centres (Edmonton and Calgary) and between various professionals who regularly encounter these patients, including nurses, physiatrists and urologists.