Luke T. Lavallée

Peri-operative morbidity associated with radical cystectomy in a multicenter database of community and academic hospitals.

Objective To characterize the frequency and timing of complications following radical cystectomy in a cohort of patients treated at community and academic hospitals. Patients and Methods Radical cystectomy patients captured from NSQIP hospitals from January 1 2006 to December 31 2012 were included. Baseline information and complications were abstracted by study surgical clinical reviewers through a validated process of medical record review and direct patient contact. We determined the incidence and timing of each complication and calculated their associations with patient and operative characteristics. Results 2303 radical cystectomy patients met inclusion criteria. 1115 (48%) patients were over 70 years old and 1819 (79%) were male. Median hospital stay was 8 days (IQR 7–13 days). 1273 (55.3%) patients experienced at least 1 post-operative complication of which 191 (15.6%) occurred after hospital discharge. The most common complication was blood transfusion (n = 875; 38.0%), followed by infectious complications with 218 (9.5%) urinary tract infections, 193 (8.4%) surgical site infections, and 223 (9.7%) sepsis events. 73 (3.2%) patients had fascial dehiscence, 82 (4.0%) developed a deep vein thrombosis, and 67 (2.9%) died. Factors independently associated with the occurrence of any post-operative complication included: age, female gender, ASA class, pre-operative sepsis, COPD, low serum albumin concentration, pre-operative radiotherapy, pre-operative transfusion >4 units, and operative time >6 hours (all p<0.05). Conclusion Complications remain common following radical cystectomy and a considerable proportion occur after discharge from hospital. This study identifies risk factors for complications and quality improvement needs.

The association between renal tumour scoring system components and complications of partial nephrectomy.

INTRODUCTION We evaluate the associations between 3 renal tumour scoring systems and their components with perioperative complications of partial nephrectomy. METHODS A consecutive cohort of partial nephrectomy patients was analyzed. Patient characteristics were abstracted from medical records. PADUA scores (preoperative aspects and dimensions used for anatomic classification), RENAL (radius exophyic/endophytic nearness anterior/posterior location scoring) nephrometry scores, and Centrality index (C-index) were determined from preoperative axial images by 2 independent reviewers. Cases were evaluated for postoperative complications up to 30 days after surgery. Pre-specified complication definitions were used for 33 potential medical and surgical complications. Unadjusted and adjusted associations between overall scores, individual components, and complications were determined using log binomial regression. RESULTS In total, 118 patients were included in the study. Of these, 36 (30.5%) surgical complications occurred in 27 (22.9%) patients. Fourteen (11.9%) were Clavien grade ≥3. Overall PADUA score was significantly associated with surgical and overall complications after adjusting for potential confounders. Among all components of the 3 scoring systems, only tumour diameter and exophytic/endophytic nature of the tumour were significantly associated with complications after adjusting for the other components of the respective scoring system (p < 0.05). CONCLUSIONS Renal tumour scoring systems may help predict the risk of complications after partial nephrectomy. Further refinement of current systems is required. A first step would be to include only components that are significantly associated with complications.

Reducing the Harm of Prostate Cancer Screening: Repeated Prostate-Specific Antigen Testing

OBJECTIVE To determine if repeating a prostate-specific antigen (PSA) test in men with an elevated PSA level is associated with a decreased risk of prostate biopsy and cancer diagnosis. PATIENTS AND METHODS A cohort of patients referred to the Ottawa Regional Prostate Cancer Assessment Clinic from April 1, 2008, through May 31, 2013, who had referral PSA levels between 4 and 10 ng/mL were included in the study. Univariate and multivariate associations between a normal result on repeated PSA testing and the risk of prostate biopsy, cancer diagnosis, and Gleason score of 7 or higher were examined. RESULTS The study cohort included 1268 patients. Repeated PSA test results were normal in 315 patients (24.8%). Men with normal results on repeated PSA testing were younger (mean ± SD age, 61.5±8.2 years vs 65.2±8.2 years; P<.001) and had lower referral PSA levels (mean ± SD, 5.5±1.4 ng/mL vs 6.6±1.5 ng/mL; P<.001) than men with an abnormal repeated PSA result. In multivariate analysis, men with normal results on repeated PSA testing were less likely to undergo prostate biopsy (relative risk [RR], 0.42; 95% CI, 0.34-0.50) and were at lower risk for cancer diagnosis (RR, 0.22; 95% CI, 0.14-0.34) and Gleason score of 7 or higher (RR, 0.16; 95% CI, 0.08-0.34) compared with men who had an abnormal repeated PSA test result. CONCLUSION Routinely repeating a PSA test in patients with an elevated PSA level is independently associated with decreased risk of prostate biopsy and prostate cancer diagnosis. Men with an elevated PSA level should be given a repeated PSA test before proceeding to biopsy.

Radiotherapy after Radical Prostatectomy: Treatment Recommendations Differ between Urologists and Radiation Oncologists

Purpose There is no consensus on optimal use of radiotherapy following radical prostatectomy. The purpose of this study was to describe opinions of urologists and radiation oncologists regarding adjuvant and salvage radiotherapy following radical prostatectomy. Methods Urologists and genitourinary radiation oncologists were solicited to participate in an online survey. Respondent characteristics included demographics, training, practice setting, patient volume/experience, and access to radiotherapy. Participant practice patterns and attitudes towards use of adjuvant and salvage radiotherapy in standardized clinical scenarios were assessed. Results One hundred and forty-six staff physicians participated in the survey (104 urologists and 42 genitourinary radiation oncologists). Overall, high Gleason score (Gleason 7 vs. 6, RR 1.37 95% CI 1.19-1.56, p<0.0001 and Gleason 8-10 vs. 6, RR 1.56 95% CI 1.37-1.78, p<0.0001), positive surgical margin (RR 1.43 95% CI 1.26-1.62, p<0.0001), and extraprostatic tumour extension (RR 1.16 95% CI 1.05-1.28, p<0.002) conferred an increased probability of recommending adjuvant radiotherapy. Radiation oncologists were more likely to recommend adjuvant radiotherapy across all clinical scenarios (RR 1.48, 95% CI 1.39, 1.60, p <0.001). Major differences were found for patients with Gleason 6 and isolated positive surgical margin (radiotherapy selected by 21% of urologists vs. 70% of radiation oncologists), and patients with extraprostatic extension and negative surgical margins (radiotherapy selected by 18% of urologist vs. 57% of radiation oncologists). Conclusions Urologists and radiation oncologists frequently disagree about recommendation for post-prostatectomy adjuvant radiotherapy. Since clinical equipoise exists between adjuvant versus early salvage post-operative radiotherapy, support of clinical trials comparing these approaches is strongly encouraged.

Active surveillance in Canadian men with low-grade prostate cancer

Background: Recent guidelines recommend against routine screening for prostate cancer, partly because of the risks associated with overtreatment of clinically indolent tumours. We aimed to determine the proportion of patients whose low-grade prostate cancer was managed by active surveillance instead of immediate treatment. Methods: We reviewed data for patients who were referred to the Ottawa regional Prostate Cancer Assessment Clinic with abnormal results for prostate-specific antigen (PSA) or prostate examination between Apr. 1, 2008, and Jan. 31, 2013. Patients with subsequent biopsy-proven low-grade (Gleason score 6) cancer were included. Active surveillance was defined a priori as monitoring by means of PSA, digital rectal examination and repeat biopsies, with the potential for curative-intent treatment in the event of disease progression. Results: Of 477 patients with low-grade cancer, active surveillance was used for 210 (44.0%), and the annual proportion increased from 32% (11/34) in 2008 to 67% (20/30) in 2013. Factors associated with immediate treatment were palpable tumour, PSA density above 0.2 ng/mL2 and more than 2 positive biopsy cores. Factors associated with surveillance were age over 70 years and higher Charlson comorbidity index. Of 173 men who received immediate surgical treatment, 103 (59.5%) had higher-grade or advanced-stage disease on final pathologic examination. Of the 210 men with active surveillance, 62 (29.5%) received treatment within a median of 1.3 years, most commonly (52 [84%]) because of upgrading of disease on the basis of surveillance biopsy. Interpretation: Active surveillance has become the most common management strategy for men with low-grade prostate cancer at our regional diagnostic centre. Factors associated with immediate treatment reflected those that increase the risk of higher-grade tumours.

The association between tumour density and prostate cancer recurrence following radical prostatectomy

PURPOSE Tumour density (TD) may be an independent prognostic factor in men with prostate cancer. The purpose of this study was to evaluate the association between prostate cancer TD and recurrence following radical prostatectomy. MATERIALS AND METHODS Between 1995 and 2007, 645 patients from The Ottawa Hospital or Memorial Sloan-Kettering Cancer Center who had cancer and prostate volumes measured from radical prostatectomy specimens. Tumour density was defined as the relative tumour to prostate volume (tumour volume/prostate volume) and recurrence was defined as a prostate-specific antigen (PSA) >0.2 ng/mL and rising, or postoperative use of radiation or hormonal therapy. Associations between TD and recurrence are adjusted for preoperative PSA, prostatectomy Gleason sum, tumour stage and margin status. RESULTS Median follow-up was 40.8 months. Tumour density was associated with preoperative PSA, Gleason sum, tumour stage and surgical margin status (all p < 0.0001). As a continuous variable, TD predicted recurrence-free survival (adjusted HR 1.34 per 10% increase in TD; p = 0.04). As a categorical variable, the group of patients with a TD of >10% had a 2.7 times greater hazard of recurrence compared to patients with a TD <5% (95%CI 1.41, 5.19; p = 0.003). Despite the independent association between TD and recurrence, the clinical value of TD remains in question as the discriminative performance (area under the curve) of predictive models only improved from 0.865 to 0.876. CONCLUSIONS Prostate cancer TD is associated with known prognostic factors and is also independently predictive of recurrence following radical prostatectomy.

Renal angiomyolipoma without visible fat: Can we make the diagnosis using CT and MRI?

AbstractRenal angiomyolipomas without visible fat (AML.wovf) are benign masses that are incidentally discovered mainly in women. AML.wovf are typically homogeneously hyperdense on unenhanced CT without calcification or haemorrhage. Unenhanced CT pixel analysis is not useful for diagnosis. AML.wovf are characteristically homogeneously hypointense on T2-weighted (T2W)-MRI and apparent diffusion coefficient (ADC) maps. Despite early reports, only a minority of AML.wovf show signal intensity drop on chemical-shift MRI due to microscopic fat. AML.wovf most commonly show avid early enhancement with washout kinetics at contrast-enhanced CT and MRI. The combination of homogeneously low T2W and/or ADC signal intensity with avid early enhancement and washout is highly accurate for diagnosis of AML.wovf.Key Points• AML.wovf are small incidental benign renal masses occurring mainly in women. • AML.wovf are homogeneously hyperdense with low signal on T2W-MRI and ADC map. • AML.wovf typically show avid early enhancement with washout kinetics. • Combining features on CT/MRI is accurate for diagnosis of AML.wovf.

Blood transfusion and hemostatic agents used during radical cystectomy

BACKGROUND Radical cystectomy may result in significant blood loss necessitating transfusion. The purpose of this study was to determine what intra-operative techniques and hemostatic agents are currently used by uro-oncologists to prevent and control blood loss during radical cystectomy. METHODS In August 2011, members of the Society of Urologic Oncology (SUO) were solicited to complete an online survey. Residents, fellows and non-urologists were excluded. Canadian members received a personal email invitation. Respondents were asked to provide demographic information and opinions regarding blood loss and transfusion. Participants were also asked to report techniques used to reduce blood loss. RESULTS Of the 34 Canadian SUO members with registered email addresses, 27 (79%) completed the survey and met inclusion criteria as staff urologists who perform radical cystectomy. In addition, 52 non-Canadian SUO members were included in the analysis. Among all SUO respondents, a high proportion (73; 88%) reported using topical hemostatic agents during cystectomy. Thirty-six (46%) surgeons reported occasionally using procedural techniques and 9 (11%) using systemic hemostatic agents. Number of years since training was associated with decreased use of topical agents and increased use of procedural techniques (p < 0.01). Number of cystectomies per year was associated with decreased use of topical hemostatic agents (p < 0.01). INTERPRETATION Based on a survey of practice, there is significant risk of blood loss requiring transfusion during radical cystectomy. Surgeons frequently use topical hemostatic agents and rarely use systemic drugs to prevent or control blood loss. Trials evaluating agents and techniques to reduce blood loss during radical cystectomy are needed.

Diagnostic tests in urology: urine cytology

Whats known on the subject? and What does the study add?

Evidence‐based urology in practice: composite endpoints

A 64-year-old man presents to your office with LUTS and an IPSS of 20. He has a quality of life score of 4 (mostly dissatisfied). On physical exam his prostate is benign but enlarged. His maximum urinary flow rate is 10 mL/s and post-void residual is 5 mL. His urine analysis is negative and his PSA is 3.8 ng/mL. You diagnose the patient with BPH and establish that he is interested in pursuing medical therapy to improve his symptoms and prevent future complications. When asked to provide details about the likely benefit of medical therapy you recall at least one large study evaluating the effects of medical BPH treatment on future disease-related complications, but fail to remember pertinent details. You decide to review the literature.