Michele Marchioni

High Neutrophil-to-lymphocyte Ratio as Prognostic Factor in Patients Affected by Upper Tract Urothelial Cancer: A Systematic Review and Meta-analysis

&NA; Given the increasing interest in the possible role of the neutrophil‐to‐lymphocyte ratio (NLR) as an easily available oncologic marker for upper tract urothelial cancer (UTUC), we sought to quantify the prognostic effect of this biomarker and assess its consistency in UTUC. A systematic review of the published data was performed up to May 2016 using multiple search engines (PubMed, Ovid, and Scopus) to identify eligible comparative studies. A formal meta‐analysis was performed for studies comparing patients with a high and those with a low NLR before surgical treatment of UTUC to determine whether the NLR is an independent predictor of survival. Pooled estimates were calculated using a fixed‐effects model if no significant heterogeneity was identified. Alternatively, a random‐effects model was used when significant heterogeneity was detected. For continuous outcomes, the weighted mean difference was used as a summary measure. For binary variables, the odds ratio or risk ratio was calculated with the 95% confidence intervals (CIs). Statistical analyses were performed using RevMan, version 5. Six studies with 1710 patients were included. A high NLR was associated with poorer oncologic outcomes in patients affected by UTUC, in particular in terms of overall survival (hazard ratio [HR], 1.97; 95% CI, 1.27‐3.04; P = .002) and recurrence‐free survival (HR, 1.53; 95% CI, 1.19‐1.96; P = .0009) but not cancer‐specific survival (HR, 1.25; 95% CI, 0.29‐5.41; P = .77). Current evidence suggests that the NLR might have an independent role as a prognostic factor in patients affected by UTUC undergoing surgical treatment. The NLR potentially represents an easily available measurement of prognosis; however, it requires validation in larger prospective studies. Graphical abstract: Figure. No caption available.

Impact of diagnostic ureteroscopy on intravesical recurrence in patients undergoing radical nephroureterectomy for upper tract urothelial cancer: a systematic review and meta‐analysis

Aim of this study was to analyse the association between the use of diagnostic ureteroscopy (URS) and the development of intravesical recurrence (IVR) in patients undergoing radical nephroureterectomy (RNU) for high‐risk upper tract urothelial carcinoma. A systematic review of the published data was performed up to December 2016, using multiple search engines to identify eligible studies. A formal meta‐analysis was conducted of studies comparing patients who underwent URS before RNU with those who did not. Hazard ratios (HRs), with their 95% confidence intervals (CIs), from each study were used to calculate pooled HRs. Pooled estimates were calculated using a fixed‐effects or random‐effects model according to heterogeneity. Statistical analyses were performed using RevMan, version 5. Seven studies were included in the systematic review, but only six of these were deemed fully eligible for meta‐analysis. Among the 2 382 patients included in the meta‐analysis, 765 underwent diagnostic URS prior to RNU. All examined studies were retrospective, and the majority examined Asian populations. The IVR rate ranged from 39.2% to 60.7% and from 16.7% to 46% in patients with and without prior URS, respectively. In the pooled analysis, a statistically significant association was found between performance of URS prior to RNU and IVR (HR 1.56, 95% CI 1.33–1.88; P < 0.001). There was no heterogeneity in the observed outcomes, according to the I2 statistic of 2% (P = 0.40). Within the intrinsic limitations of this type of analysis, these findings suggest a significant association between the use of diagnostic URS and higher risk of developing IVR after RNU. Further research in this area should be encouraged to further investigate the possible causality behind this association and it potential clinical implications.

Urology Residency Training in Italy: Results of the First National Survey

BACKGROUND Numerous surveys have been performed to determine the competence and the confidence of residents. However, there is no data available on the condition of Italian residents in urology. OBJECTIVE To investigate the status of training among Italian residents in urology regarding scientific activity and surgical exposure. DESIGN, SETTING, AND PARTICIPANTS A web-based survey that included 445 residents from all of the 25 Italian Residency Programmes was conducted between September 2015 and November 2015. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The main outcomes were represented by scientific activity, involvement in surgical procedures, and overall satisfaction. RESULTS AND LIMITATIONS In total, 324 out of 445 (72.8%) residents completed the survey. Overall, 104 (32%) residents had not published any scientific manuscripts, 148 (46%) published ≤5, 38 (12%) ≤10, 26 (8%) ≤15, four (1%) ≤20, and four (1%) >20 manuscripts, respectively. We did not observe any differences when residents were stratified by sex (p=0.5). Stent positioning (45.7%), extracorporeal shock wave lithotripsy (30.9%), transurethral resection of bladder tumor (33.0%), hydrocelectomy (24.7%), varicocelectomy (17%), ureterolithotripsy (14.5%), and orchiectomy (12.3%) were the surgical procedures more frequently performed by residents. Overall, 272 residents (84%) expressed a good satisfaction for urology specialty, while 178 (54.9%) expressed a good satisfaction for their own residency programme. We observed a statistically decreased trend for good satisfaction for urology specialty according to the postgraduate year (p=0.02). CONCLUSIONS Italian Urology Residency Programmes feature some heavy limitations regarding scientific activity and surgical exposure. Nonetheless, satisfaction rate for urology specialty remains high. Further improvements in Residency Programmes should be made in order to align our schools to others that are actually more challenging. PATIENT SUMMARY In this web-based survey, Italian residents in urology showed limited scientific productivity and low involvement in surgical procedures. Satisfaction for urology specialty remains high, demonstrating continuous interest in this field of study from residents.

Extent of lymph node dissection improves survival in prostate cancer patients treated with radical prostatectomy without lymph node invasion

To assess the effect of pelvic lymph node dissection (PLND) extent on cancer‐specific mortality (CSM) in prostate cancer (PCa) patients without lymph node invasion (LNI) treated with radical prostatectomy (RP).

Contemporary Trends and Survival Outcomes After Aborted Radical Prostatectomy in Lymph Node Metastatic Prostate Cancer Patients

BACKGROUND Aborted radical prostatectomy (aRP) in lymph node (LN) metastatic (pN1) prostate cancer (PCa) patients showed worse survival in European patients. Contemporary rates of aRP are unknown in North America. OBJECTIVE To examine the rate of aRP and its effect on cancer-specific mortality (CSM) in contemporary North American patients. DESIGN, SETTING, AND PARTICIPANTS Within the Surveillance Epidemiology and End Results database (2004-2014), we identified 3719 pN1 PCa patients. INTERVENTION RP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Incidence proportion and median survival of LN metastatic PCa patients who underwent aRP versus completed RP (cRP). Cumulative incidence plots and competing-risks regression (CRR) models tested CSM and other-cause mortality rates according to aRP versus cRP. The effect of selected variables on CSM rate was graphically depicted using LOESS methodology. All analyses were repeated after propensity score matching. RESULTS AND LIMITATIONS Between 2004 and 2014, the rate of aRP decreased from 20.4% to 5.6% (p<0.001). Ten-year CSM rates were significantly higher after aRP (38.9% vs 21.6%) versus cRP (p<0.001). In multivariable CRR models, aRP yielded higher CSM (hazard ratio [HR]: 1.99) than cRP. A higher 5-yr CSM rate was recorded after aRP through the entire range of baseline prostate-specific antigen (PSA) values and in patients with up to nine LN metastases. After propensity score matching, aRP resulted in overall higher CSM (HR: 1.72). Higher CSM was recorded after aRP for PSA values up to 50ng/ml and in patients with up to seven LN metastases. Results were limited by a selection bias that applies to aRP patients. CONCLUSIONS Of contemporary North American patients, 5% are affected by aRP. It confers a significant survival disadvantage that applies to patients with baseline PSA values up to 50ng/ml and in those with up to seven LN metastases. PATIENT SUMMARY Radical prostatectomy should not be aborted in pN1 prostate cancer individuals.

Survival after Cytoreductive Nephrectomy in Metastatic Non-clear Cell Renal Cell Carcinoma Patients: A Population-based Study

BACKGROUND The benefit of cytoreductive nephrectomy (CNT) for cancer-specific mortality (CSM)-free survival is unclear in contemporary metastatic non-clear cell renal cell carcinoma (non-ccmRCC) patients. OBJECTIVE To assess the role of CNT in non-ccmRCC patients. DESIGN, SETTING, AND PARTICIPANTS Within Surveillance, Epidemiology, and End Results registry (2001-2014), we identified patients with non-ccmRCC. INTERVENTION CNT versus no CNT in non-ccmRCC patients. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Multivariable logistic regression, cumulative incidence, competing-risks regression models, incremental survival benefit (ISB), conditional survival, and landmark analyses were performed. Sensitivity analyses focused on histological subtypes and most contemporary patients (2010-2014). RESULTS AND LIMITATIONS Of 851 patients with non-ccmRCC, 67.6% underwent CNT. In multivariable logistic regression, year of diagnosis in contemporary (p<0.001) and intermediate (p=0.008) tertiles, as well as age ≥75 yr (p<0.001) yielded lower CNT rates. Cumulative incidence showed 2-yr CSM of 52.6% versus 77.7%, respectively, after CNT versus no CNT. CSM after CNT versus no CNT was invariably lower in all histologic subtypes and in contemporary patients. Multivariable competing-risks regression models predicting CSM favored CNT (hazard ratio [HR]: 0.38, confidence interval: 0.30-0.47, p<0.001) in all patients and in all subgroups defined by histologic subtypes (HR: 0.14-0.43, all p≤0.02), as well as in contemporary patients (HR: 0.32, p<0.001). The ISB analyses yielded statistically significant and clinically meaningful CSM-free survival benefit of +3 mo after CNT versus no CNT in individuals with observed CSM-free survival ≤24 mo. The 2-yr CSM-free survival increased from baseline of 46.1% versus 19.4% (Δ=26.7%, p<0.001) to 70.3% versus 54.4% (Δ=15.9%, p=0.005) after CNT versus no CNT, in patients that survived 12 mo, respectively. Landmark analyses rejected bias favoring CNT. Data were retrospective. CONCLUSIONS CSM is lower after CNT for non-ccmRCC in all histologic subtypes and in contemporary patients except for unproven ISB in collecting duct patients. This observation should encourage greater CNT consideration in non-ccmRCC. PATIENT SUMMARY Cytoreductive nephrectomy appears to improve survival in metastatic non-clear cell renal cell carcinoma, but it is used infrequently.

Survival benefit of local versus no local treatment for metastatic prostate cancer-Impact of baseline PSA and metastatic substages

To test whether local treatment (LT), namely radical prostatectomy (RP) or brachytherapy (BT) still confers a survival benefit versus no local treatment (NLT), when adjusted for baseline PSA (bPSA). To further examine whether the effect of LT might be modulated according to bPSA and M1 substages.

Tumor characteristics, treatments, and oncological outcomes of prostate cancer in men aged ≤50 years: a population-based study

BackgroundTo examine clinical characteristics, treatment modalities and oncological outcomes of prostate cancer (PCa) according to young (≤50) vs. old age.MethodsOf 407,599 men with primary adenocarcinoma of the prostate within the Surveillance, Epidemiology and End Results (SEER)-database (2004 to 2013), 18,387 were aged ≤50 years (4.5%). Time trends, cumulative incidence, and competing risks regression (CRR) analyses tested for differences between young and old patients. Multi-variable analyses were adjusted for year of diagnosis, race, marital status, Gleason Score, clinical tumor stage, and lymph node status.ResultsYounger men had more favorable tumor characteristics: lower Gleason Score, lower median PSA, and lower rates of metastases at diagnosis compared to their older counterparts. Over time, no local treatment (NLT) rates increased, radical prostatectomy (RP), and brachytherapy (BT) rates decreased and external beam radiation (EBRT) rates remained unchanged. Moreover, the rate of de novo metastatic prostate cancer increased in young patients from 2% (2004) to 3.2% (2013) (p = 0.004). CRR models showed no difference in prostate cancer-specific mortality (PCSM) between young and old, across all local treatment types.ConclusionsYoung PCa patients have more favorable disease characteristics at presentation, are less frequently treated with RP or BT and more frequently benefit of NLT. PCSM did not differ between young and old patients. However, it is worrisome that recently more young PCa patients are diagnosed at a metastatic stage.

Local treatment for metastatic prostate cancer: A systematic review

The potential oncological benefit for radical treatment in the setting of oligometastatic prostate cancer has been under investigation and is frequently discussed. We carried out a systematic review of English language articles using the Medline database (January 2000 to May 2017) to identify studies reporting local treatment in men with metastatic prostate cancer at diagnosis. Primary end‐points were oncological outcomes, such as cancer‐specific and overall mortality. Secondary end‐points were non‐oncological outcomes, such as complications, operating room time, blood loss or length of hospital stay. Two independent authors reviewed and extracted all search results. Overall, 18 studies reporting on local treatment in metastatic prostate cancer patients were identified (14 original articles, three brief correspondences and one letter to the editor). All of them were retrospective; one partly included prospective data. All studies addressed oncological outcomes, 16 compared local treatment with no‐local treatment and 14 adjusted for confounders using multivariable regression models. All but one study concluded a survival benefit for local treatment in the metastatic setting. Due to heterogeneity of available data, a representative meta‐analysis could not be carried out. Five studies reported non‐oncological outcomes. Although local treatment in metastatic prostate cancer appears to be feasible, its oncological effect remains unclear due to high susceptibility of available studies to significant selection bias.

Comparison of Partial Versus Radical Nephrectomy Effect on Other-cause Mortality, Cancer-specific Mortality, and 30-day Mortality in Patients Older Than 75 Years

BACKGROUND Historically, partial nephrectomy (PN) showed no benefit on other-cause mortality (OCM) in elderly patients with small renal masses. OBJECTIVE To test the effect of PN versus radical nephrectomy (RN) on OCM, cancer-specific mortality (CSM), as well as 30-d mortality in patients with nonmetastatic T1a renal cell carcinoma (RCC), aged ≥75 yr old. DESIGN, SETTING, AND PARTICIPANTS Within the Surveillance, Epidemiology and End Results registry (2004-2014), we identified surgically treated patients with nonmetastatic pT1a RCC aged ≥75 yr. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS We relied on propensity score (PS) matching to reduce the effect of inherent differences between PN and RN. After PS matching, cumulative incidence, multivariable competing-risks regression (CRR) and logistic regression models were used. LOESS plots graphically depicted the relation between nephrectomy type and OCM after adjustment for all the covariates. Landmark analyses at 6 mo tested for immortal time bias. RESULTS AND LIMITATIONS Of all 4541 patients, 41.6% underwent PN. After 1:1 PS matching, 2826 patients remained. In multivariable CRR models, lower OCM rates were recorded in PN patients (hazard ratio [HR]: 0.67, confidence interval [CI]: 0.54-0.84; p<0.001). LOESS plots showed lower OCM rates after PN across all examined ages. Lower CSM rates were also recorded in PN patients (HR: 0.64, CI=0.44-0.92; p=0.02). Landmark analyses rejected the hypothesis of immortal time bias. Finally, PN did not result in different 30-d mortality rates (odds ratio: 1.87; CI: 0.79-4.47; p=0.2) versus RN. Data are retrospective. CONCLUSIONS PN results in lower OCM in elderly patients with pT1a RCC. Moreover, PN does not contribute to higher CSM or 30-d mortality in patients aged ≥75 yr. In consequence, PN should be given strong consideration, even in elderly patients. PATIENT SUMMARY Partial nephrectomy (PN) may protect from renal insufficiency, hypertension, and other unfavorable health outcomes, even in elderly patients. This protective effect results in lower other-cause mortality. Moreover, PN benefits are not undermined by higher cancer-specific mortality or 30-d mortality.