Geoffrey Gotto

Impact of Prior Prostate Radiation on Complications After Radical Prostatectomy

PURPOSE Salvage radical prostatectomy is associated with a higher complication rate than radical prostatectomy without prior radiotherapy but the magnitude of the increase is not well delineated. MATERIALS AND METHODS A total of 3,458 consecutive patients underwent open radical prostatectomy and 98 underwent open salvage radical prostatectomy from January 1999 to June 2007. Data were collected from prospective surgical and institutional morbidity databases, and retrospectively from billing records and medical records. Medical and surgical complications were captured, graded by the modified Clavien classification and classified by time of onset. RESULTS Median followup after salvage radical prostatectomy and radical prostatectomy was 34.5 and 45.5 months, respectively. Patients with salvage had significantly higher median age, modified Charlson comorbidity score, clinical and pathological stage, and Gleason score. They were less likely to have organ confined disease and more likely to have seminal vesicle invasion and nodal metastasis. There was no significant difference in median operative time, blood loss or transfusion rate. The salvage group had a higher adjusted probability of medical and surgical complications, including urinary tract infection, bladder neck contracture, urinary retention, urinary fistula, abscess and rectal injury. Only 1 of 4 potent patients with salvage prostatectomy who underwent bilateral nerve sparing recovered erection adequate for intercourse. The 3-year actuarial recovery of continence was 30% (95% CI 19-41). CONCLUSIONS Medical and surgical complications of prostatectomy are significantly increased in the setting of prior radiotherapy. Understanding the magnitude of this increased risk is important for patient counseling.

Age, Obesity, Medical Comorbidities and Surgical Technique are Predictive of Symptomatic Anastomotic Strictures After Contemporary Radical Prostatectomy

PURPOSE Anastomotic strictures are relatively common after radical prostatectomy and are associated with significant morbidity, often requiring multiple surgical interventions. There is controversy in the literature regarding which factors predict the development of anastomotic strictures. In this study we determined predictors of symptomatic anastomotic strictures following contemporary radical prostatectomy. MATERIALS AND METHODS Between 1999 and 2007, 4,592 consecutive patients underwent radical prostatectomy without prior radiotherapy at our institution. Data were collected from prospective surgical and institutional morbidity databases, and retrospectively from inpatient and outpatient medical and billing records. Cases were assigned a Charlson score to account for comorbidities. Complications were graded according to the modified Clavien classification. RESULTS Open radical prostatectomy was performed in 3,458 men (75%) and laparoscopic radical prostatectomy was performed in 1,134 (25%). The laparoscopic radical prostatectomy group included 97 robotic-assisted cases. Median patient age was 59.5 years (IQR 54.7, 64.2). Symptomatic anastomotic strictures developed in 198 patients (4%) after a median postoperative followup of 3.5 months (IQR 2.1, 6.1). On multivariate analysis significant predictors included patient age, body mass index, Charlson score, renal insufficiency, individual surgeon, surgical approach and the presence of postoperative urine leak or hematoma. CONCLUSIONS Patient factors as well as technical factors influence the development of symptomatic anastomotic strictures following contemporary radical prostatectomy. The impact of these factors is influenced by the individual surgeon and the approach used.

Predictors of symptomatic lymphocele after radical prostatectomy and bilateral pelvic lymph node dissection

Objectives:  Lymphocele is the most common complication of pelvic lymphadenectomy (PLND). We sought to determine predictors of symptomatic lymphocele after radical prostatectomy (RP) and PLND, and in particular, to determine if the number of drains placed represents an independent predictor.

Prognostic Impact of Muscular Venous Branch Invasion in Localized Renal Cell Carcinoma Cases

PURPOSE Beginning with the 2002 American Joint Committee on Cancer staging system, renal sinus muscular venous branch invasion has prognostic equivalence with renal vein invasion in renal cell carcinoma cases. To validate this presumed equivalence we compared patients with isolated muscular venous branch invasion to those with renal vein invasion and those with no confirmed vascular invasion. MATERIALS AND METHODS From routine cataloging at our institution we identified 500 patients who underwent partial or radical nephrectomy from 2003 to 2008. After excluding patients with metastasis or noncortical renal cell carcinoma pathology we identified 85 with positive muscular venous branch invasion (+). The 259 patients with pT1-2 muscular venous branch (-) invasion and the 71 with renal vein (+) invasion served as comparison groups. We used a multivariate Cox model to control for tumor characteristics using the Kattan renal cell carcinoma nomogram. RESULTS On multivariate analysis the risk of recurrence in the pT1-2 muscular venous branch invasion (-) group was lower than in the muscular venous branch invasion (+) group (HR 0.06, 95% CI 0.02-0.18, p < 0.001). Patients with renal vein invasion (+) had a recurrence rate similar to that in those with muscular venous branch invasion (+) (HR 0.80, 95% CI 0.39-1.65, p = 0.6). The overall survival rate was higher in the muscular venous branch invasion (-) group than in the other groups. CONCLUSIONS Patients with muscular venous branch invasion have an outcome inferior to that in patients with pT1-2 disease. This confirms the adverse prognosis of muscular venous branch invasion and supports pathological up-staging. The prognosis of muscular venous branch invasion is similar to that of renal vein invasion, although we cannot exclude the possibility of a difference. Our findings underscore the importance of close patient followup and careful pathological assessment of the nephrectomy specimen.

Recommendations for the improvement of bladder cancer quality of care in Canada: A consensus document reviewed and endorsed by Bladder Cancer Canada (BCC), Canadian Urologic Oncology Group (CUOG), and Canadian Urological Association (CUA), December 2015

This initiative was undertaken in response to concerns regarding the variation in management and in outcomes of patients with bladder cancer throughout centres and geographical areas in Canada. Population-based data have also revealed that real-life survival is lower than expected based on data from clinical trials and/or academic centres. To address these perceived shortcomings and attempt to streamline and unify treatment approaches to bladder cancer in Canada, a multidisciplinary panel of expert clinicians was convened last fall for a two-day working group consensus meeting. The panelists included urologic oncologists, medical oncologists, radiation oncologists, patient representatives, a genitourinary pathologist, and an enterostomal therapy nurse. The following recommendations and summaries of supporting evidence represent the results of the presentations, debates, and discussions. Methodology

A survey of patient expectations regarding sexual function following radical prostatectomy.

To assess the understanding of patients, who had previously undergone radical prostatectomy (RP), about their postoperative sexual function, as clinical experience suggests that some RP patients have unrealistic expectations about their long‐term sexual function.

Global Gleason grade groups in prostate cancer: concordance of biopsy and radical prostatectomy grades and predictors of upgrade and downgrade

To evaluate concordance, upgrades and downgrades from biopsy to prostatectomy, and associated clincopathological parameters, using the recently proposed Gleason grade groups/International Society of Urologic Pathology (ISUP) grades.

The role of PTEN tumor suppressor pathway staining in carcinoma in situ of the bladder.

OBJECTIVES The PI3k/Akt pathway has been associated with the development and progression of bladder tumors, with most studies focused on papillary or muscle-invasive tumors. We sought to characterize the expression patterns of the PI3K/Akt pathway in a large cohort of high-risk preinvasive carcinoma in situ (CIS) tumors of the bladder. Our goal was to understand whether PI3K/Akt pathway alterations associated with CIS resemble early- or late-stage bladder cancers. MATERIAL AND METHODS We evaluated tissue specimens from 97 patients with CIS of the bladder, of which 14 had a concomitant papillary tumor. All patients were treated with intravesical bacillus Calmette-Guerin. All specimens were evaluated for PTEN, p-AKT, and p-S6 immunoreactivity. Markers were evaluated for percentage and intensity of staining and were scored using a 0 to 3+grading system. RESULTS PTEN staining was noted as least intense in 67% of tumor specimens and 22% of normal urothelium. P-Akt and p-S6 had intense staining in 77% and 90% of tumor specimens vs. 44% and 68% in normal tissue, respectively. Low-intensity staining for PTEN at 12 months correlated with higher recurrence risk (P = 0.026). CONCLUSION We describe a large cohort of CIS bladder tumors with decreased staining intensity of PTEN and increased staining intensity of p-AKT and p-S6, similar to high-grade and high-stage papillary tumors. Low-intensity staining of PTEN at 12 months was associated with an increased risk of recurrence.

Outcomes after resection of postchemotherapy residual neck mass in patients with germ cell tumors--an update.

OBJECTIVE To examine histologic findings and clinical outcomes of patients who underwent neck dissection for residual neck masses. METHODS From 1987 to 2008, 968 postchemotherapy retroperitoneal lymph node dissections (RPLND) were performed at our institution. We identified 41 of these patients who underwent a postchemotherapy residual neck mass resection. RESULTS Thirty-nine patients presented with primary testis, one with retroperitoneal, and one with mediastinal GCT. Teratoma was present in 54% of patients at diagnosis. During the neck dissection, 23 (56.1%) patients had teratoma, 14 (34.2%) had fibrosis, three (7.3%) had viable GCT, and one had benign lymph nodes. There was histologic discordance between the neck and the RPLND in 22.5% of patients and between the neck and other extraretroperitoneal resection sites in 26.5% of patients. At a median follow-up of 49.5 months from diagnosis, 16 patients had recurrence, and seven had died of testis cancer. No patient had recurrence in the neck. Five of seven patients with residual viable cancer at extraretroperitoneal resection sites died of disease compared with two of 23 with teratoma and none with fibrosis (P = .0005). CONCLUSIONS Resection of residual postchemotherapy neck masses is indicated because of the high incidence of viable tumor or teratoma in the residual mass and the inability to accurately predict the histology of the neck masses. Resection of residual neck masses leads to excellent local control and can contribute to long-term disease control and survival.

Quality indicators in the management of bladder cancer: A modified Delphi study

BACKGROUND Survival in patients with bladder cancer has only moderately improved over the past 2 decades. A potential reason for this is nonadherence to clinical guidelines and best practice, leading to wide variations in care. Common quality indicators (QIs) are needed to quantify adherence to best practice and provide data for benchmarking and quality improvement. OBJECTIVE To produce an evidence- and consensus-based list of QIs for the management of bladder cancer. METHODS A modified Delphi method was used to develop the indicator list. Candidate indicators were extracted from the literature and rated by a 27-member Canadian expert panel in several rounds until consensus was reached on the final list of indicators. In rounds with numeric ratings, a frequency analysis was performed. RESULTS A total of 86 indicators were rated, 52 extracted from the literature and 34 suggested by the panel. After iterative rounds of ratings and discussion, a final list of 60 QIs spanning several disciplines and phases of the cancer care continuum was developed. CONCLUSIONS This is the first study to comprehensively produce common QIs representing structure, process, and outcome measures in bladder cancer management. Though developed in Canada, these indicators can be used in other countries with slight modifications to track performance and improve care.