John Hines

Robot-assisted intracorporeal pyramid neobladder

To describe a robot‐assisted intracorporeal pyramid neobladder reconstruction technique and report operative and perioperative metrics, postoperative upper tract imaging, neobladder functional outcomes, and oncological outcomes.

Molecular aspects of upper tract urothelial carcinoma

OBJECTIVES Primary upper tract urothelial carcinoma (UTUC) is a relatively rare tumor with up to 60% of cases being muscle invasive at presentation. In this article we review the molecular biology of UTUC, an understanding of which may help to address some of the dilemmas surrounding the diagnosis and treatment of this disease and ultimately lead to the introduction of personalized treatment plans. METHODS The literature search on the molecular aspects of UTUC was performed using the National Library of Medicine database. RESULTS UTUC and urothelial carcinomas of the bladder share many common biological pathways. UTUC are more commonly associated with conditions such as Balkan Endemic Nephropathy and Hereditary Non Polyposis Colon Cancer (HNPCC), the molecular basis of which is now being understood. A large number of potential biomarkers have been studied to help identify robust prognostic markers in UTUC. CONCLUSION Advances in our understanding of the biology of UTUC is may in the future help to identify novel druggable targets, clinically applicable biomarkers and guide treatment of the rare but lethal condition.

Analysis of open and intracorporeal robotic assisted radical cystectomy shows no significant difference in recurrence patterns and oncological outcomes.

OBJECTIVES To report and compare early oncological outcomes and cancer recurrence sites among patients undergoing open radical cystectomy (ORC) and robotic-assisted radical cystectomy with intracorporeal urinary diversion (iRARC). METHODS AND MATERIALS A total of 184 patients underwent radical cystectomy for bladder cancer. ORC cases (n = 94) were performed between June 2005 and July 2014 while iRARC cases (n = 90) were performed between June 2011 and July 2014. Primary outcome was recurrence free survival (RFS). Secondary outcomes were sites of local and metastatic recurrence, cancer specific survival (CSS) and overall survival (OS). RESULTS Median follow-up for patients without recurrence was 33.8 months (interquartile range [IQR]: 20.5-45.4) for ORC; and 16.1 months (IQR: 11.2-27.0) for iRARC. No significant difference in age, sex, precystectomy T stage, precystectomy grade, or lymph node yield between ORC and iRARC was observed. The ORC cohort included more patients with≥pT2 (64.8% ORC vs. 38.9% iRARC) but fewer pT0 status (8.5% ORC vs.vs. 22.2% iRARC) due to lower preoperative chemotherapy use (22.3% ORC vs. 34.4% iRARC). Positive surgical margin rate was significantly higher in the ORC cohort (19.3% vs. 8.2%; P = 0.042). Kaplan-Meir analysis showed no significant difference in RFS (69.5% ORC vs. 78.8% iRARC), cancer specific survival (80.9% ORC vs. 84.4% iRARC), or OS (73.5% ORC vs.vs. iRARC 83.8%) at 24 months. Cox regression analysis showed RFS, cancer specific survival and OS were not influenced by cystectomy technique. No significant difference between local and metastatic RFS between ORC and iRARC was observed. CONCLUSION This study has found no difference in recurrence patterns or oncological outcomes between ORC and iRARC. Recurrent metastatic sites vary, but are not related to surgical technique.

Benefits of robotic cystectomy with intracorporeal diversion for patients with low cardiorespiratory fitness: A prospective cohort study

BACKGROUND Patients undergoing radical cystectomy have associated comorbidities resulting in reduced cardiorespiratory fitness. Preoperative cardiopulmonary exercise testing (CPET) measures including anaerobic threshold (AT) can predict major adverse events (MAE) and hospital length of stay (LOS) for patients undergoing open and robotic cystectomy with extracorporeal diversion. Our objective was to determine the relationship between CPET measures and outcome in patients undergoing robotic radical cystectomy and intracorporeal diversion (intracorporeal robotic assisted radical cystectomy [iRARC]). METHODS A single institution prospective cohort study in patients undergoing iRARC for muscle invasive and high-grade bladder cancer. INCLUSION patients undergoing standardised CPET before iRARC. EXCLUSIONS patients not consenting to data collection. Data on CPET measures (AT, ventilatory equivalent for carbon dioxide [VE/VCO2] at AT, peak oxygen uptake [VO2]), and patient demographics prospectively collected. Outcome measurements included hospital LOS; 30-day MAE and 90-day mortality data, which were prospectively recorded. Descriptive and regression analyses were used to assess whether CPET measures were associated with or predicted outcomes. RESULTS From June 2011 to March 2015, 128 patients underwent radical cystectomy (open cystectomy, n = 17; iRARC, n = 111). A total of 82 patients who underwent iRARC and CPET and consented to participation were included. Median (interquartile range): age = 65 (58-73); body mass index = 27 (23-30); AT = 10.0 (9-11), Peak VO2 = 15.0 (13-18.5), VE/VCO2 (AT) = 33.0 (30-38). 30-day MAE = 14/111 (12.6%): death = 2, multiorgan failure = 2, abscess = 2, gastrointestinal = 2, renal = 6; 90-day mortality = 3/111 (2.7%). AT, peak VO2, and VE/VCO2 (at AT) were not significant predictors of 30-day MAE or LOS. The results are limited by the absence of control group undergoing open surgery. CONCLUSIONS Poor cardiorespiratory fitness does not predict increased hospital LOS or MAEs in patients undergoing iRARC. Overall, MAE and LOS comparable with other series.

Is Prebiopsy MRI Good Enough to Avoid Prostate Biopsy? A Cohort Study Over a 1-Year Period

INTRODUCTION Prebiopsy multiparametric magnetic resonance imaging (MRI) is increasingly used in clinical practice to detect clinically significant prostate cancer, although its role is controversial. We audited the accuracy of prebiopsy MRI for men clinically suspected to have prostate cancer who underwent initial transrectal ultrasound (TRUS) biopsy at our institution. PATIENTS AND METHODS All patients who had a prebiopsy prostate MRI and initial TRUS prostate biopsy from January 1, 2013 to December 31, 2013 were included in the study. Prostate MRI was performed using a 1.5-T machine with T2 and diffusion weighted imaging axial phase. TRUS prostate biopsy was performed using a monoplane ultrasound machine. Systematic 12-core prostate biopsies were taken with a Tru-Cut biopsy needle from the apex, middle, and base of the left and right lobe. RESULTS One hundred seventy-three patients met the inclusion criteria; 128 (74.4%) patients had a lesion detected on MRI and 114 (66.3%) patients had a positive biopsy. The sensitivity of MRI for significant prostate cancer on TRUS biopsy of the prostate was 83.5%, specificity was 35.2%, positive predictive value was 55%, and negative predictive value was 68.9%. A positive MRI scan was significantly associated with significant prostate cancer diagnosis, and higher National Comprehensive Cancer Network (NCCN) risk classification (P ≤ .001). MRI detected 62 of 63 NCCN high-risk and 18 of 18 Gleason score 8 to 10 cases. CONCLUSION The sensitivity and specificity of MRI appears insufficient to avoid TRUS biopsy in all men clinically suspected to have prostate cancer. Standardized MRI reporting and robust prospective studies are needed to define the role of prebiopsy MRI in this setting. For patients at risk of complications from biopsy, a negative MRI scan might be used to exclude high-risk disease.

In-depth Critical Analysis of Complications Following Robot-assisted Radical Cystectomy with Intracorporeal Urinary Diversion

BACKGROUND Robot-assisted radical cystectomy with intracorporeal urinary diversion (iRARC) is an attractive option to open cystectomy, but the benefit in terms of improved outcomes is not established. OBJECTIVE To evaluate the early postoperative morbidity and mortality of patients undergoing iRARC and conduct a critical analysis of complications using standardised reporting criteria as stratified according to urinary diversion. DESIGN, SETTING, AND PARTICIPANTS A total of 134 patients underwent iRARC for bladder cancer at a single centre between June 2011 and July 2015. INTERVENTION Radical cystectomy with iRARC. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Patient demographics, pathologic data, and 90-d perioperative mortality and complications were recorded. Complications were reported according to the Clavien-Dindo (CD) classification and stratified according to urinary diversion type and either surgical or medical complications. The chi-square test and t test were used for categorical and continuous variables respectively. Multivariable logistic regression was performed on variables with significance in univariate analysis. RESULTS AND LIMITATIONS The 90-d all complication rate following ileal conduit and continent diversion was 68% and 82.4%, and major complications were 21.0% and 20.6% respectively. The 90-d mortality was 3% and 2.9% for ileal conduit and continent diversion patients, respectively. On multivariate analysis, the blood transfusion requirement was independently associated with major complications (p=0.002) and all 30-d (p=0.002) and 90-d (p=0.012) major complications. Male patients were associated with 90-d major complications (p=0.015). Critical analysis identified that surgical complications were responsible for 39.4% of all 90-d major complications. The incidence of surgical complications did not decline with increasing number of iRARC cases performed (p=0.742, r=0.31). Limitations of this study include its retrospective nature, limited sample size, and limited multivariate analysis due to the low number of major complications events. CONCLUSIONS Although complications following iRARC are common, most are low grade. A critical analysis identified surgical complications as a cause of major complications. Addressing this issue could have a significant impact on lowering the morbidity associated with iRARC. PATIENT SUMMARY We looked at the surgical outcomes in bladder cancer patients treated with minimally invasive robotic surgery. We found that surgical complications account for most major complications and previous surgical experience may be a confounding factor when interpreting results from a different centre even in a randomised trial setting.

Reorganising specialist cancer surgery for the twenty-first century: a mixed methods evaluation (RESPECT-21)

BackgroundThere are longstanding recommendations to centralise specialist healthcare services, citing the potential to reduce variations in care and improve patient outcomes. Current activity to centralise specialist cancer surgical services in two areas of England provides an opportunity to study the planning, implementation and outcomes of such changes. London Cancer and Manchester Cancer are centralising specialist surgical pathways for prostate, bladder, renal, and oesophago-gastric cancers, so that these services are provided in fewer hospitals. The centralisations in London were implemented between November 2015 and April 2016, while implementation in Manchester is anticipated in 2017.Methods/DesignThis mixed methods evaluation will analyse stakeholder preferences for centralisations; it will use qualitative methods to analyse planning, implementation and sustainability of the centralisations (‘how and why?’); and it will use a controlled before and after design to study the impact of centralisation on clinical processes, clinical outcomes, cost-effectiveness and patient experience (‘what works and at what cost?’). The study will use a framework developed in previous research on major system change in acute stroke services. A discrete choice experiment will examine patient, public and professional preferences for centralisations of this kind. Qualitative methods will include documentary analysis, stakeholder interviews and non-participant observations of meetings. Quantitative methods will include analysis of local and national data on clinical processes, outcomes, costs and National Cancer Patient Experience Survey data. Finally, we will hold a workshop for those involved in centralisations of specialist services in other settings to discuss how these lessons might apply more widely.DiscussionThis multi-site study will address gaps in the evidence on stakeholder preferences for centralisations of specialist cancer surgery and the processes, impact and cost-effectiveness of changes of this kind. With increasing drives to centralise specialist services, lessons from this study will be of value to those who commission, organise and manage cancer services, as well as services for other conditions and in other settings. The study will face challenges in terms of recruitment, the retrospective analysis of some of the changes, the distinction between primary and secondary outcome measures, and obtaining information on the resources spent on the reconfiguration.

Discrete-choice experiment to analyse preferences for centralizing specialist cancer surgery services: Preferences for centralizing specialist cancer surgery services

Centralizing specialist cancer surgery services aims to reduce variations in quality of care and improve patient outcomes, but increases travel demands on patients and families. This study aimed to evaluate preferences of patients, health professionals and members of the public for the characteristics associated with centralization.