Pietro Acquati

Robotic prostatectomy: an update on functional and oncologic outcomes

Since the first procedure performed in 2000, robotic-assisted radical prostatectomy (RARP) has been rapidly gaining increasing acceptance from both urologists and patients. Today, RARP is the dominant treatment option for localised prostate cancer (PCa) in the United States, despite the absence of any prospective randomised trial comparing RARP with other procedures. Robotic systems have been introduced in an attempt to reduce the difficulty involved in performing complex laparoscopic procedures and the related steep learning curve. The recognised advantages of this kind of minimally invasive surgery are three-dimensional (3D) vision, ten-fold magnification, Endowrist technology with seven degrees of freedom, and tremor filtration. In this article, we examine this technique and report its functional (in terms of urinary continence and potency) and oncologic results. We also evaluate the potential advantages of RARP in comparison with open and laparoscopic procedures.

A contemporary analysis of radiotherapy effect in surgically treated retroperitoneal sarcoma

BACKGROUND AND PURPOSE Contemporary data regarding the benefit of radiotherapy in surgically treated retroperitoneal sarcoma are scarce. The aim of the study was to evaluate the effect of radiotherapy on cancer specific mortality in surgically treated patients according to tumor size, histological subtype and grade. MATERIAL AND METHODS Within Surveillance, Epidemiology, and End Results database (2004-2014), we identified 1226 patients with non-metastatic retroperitoneal sarcoma. Univariable and multivariable logistic regression models tested for predictors of radiotherapy delivery. Univariable and multivariable Cox regression models tested the effect of radiotherapy on cancer specific mortality in the overall population. Subgroup analyses explored the result of tumor grade and tumor size on radiotherapy effect. All analyses were repeated after adjustment according to inverse probability of treatment. Additionally, all analyses were subjected to 1000 bootstrap resamples for internal validation. RESULTS Radiotherapy was delivered in 372 patients (30.3%). In univariable and multivariable logistic regression models high grade (OR: 1.46, CI:1.12-1.90; p = 0.006), and leiomyosarcoma histologic subtype (OR: 2.14, CI: 1.55-2.95; p < 0.001) predicted radiotherapy delivery. In the overall population multivariable Cox regression models showed lower cancer specific mortality (HR: 0.73, CI: 0.55-0.96; p = 0.025) with radiotherapy. In subgroup analyses multivariable Cox regression models showed radiotherapy benefit predominantly in high grade, large tumor size retroperitoneal sarcomas (HR 0.51: C.I.: 0.30-0.86; p = 0.02). CONCLUSIONS In this retrospective report, delivery of radiotherapy was associated with lower cancer specific mortality in high grade, large tumor size retroperitoneal sarcoma patients. Our findings are predominantly representative of liposarcomas and leiomyosarcomas that accounted for 90% of study population. Further study is needed to evaluate the role of radiotherapy in retroperitoneal sarcoma patients.

Nephroureterectomy with or without Bladder Cuff Excision for Localized Urothelial Carcinoma of the Renal Pelvis

BACKGROUND Few studies examined the rates of guideline implementation and the survival effect of bladder cuff excision (BCE) at nephroureterectomy (NU). OBJECTIVE To assess the rates of guideline implementation regarding NU with BCE relative to NU without BCE in patients with upper tract urothelial carcinoma (UTUC) and to test the effect of BCE on cancer-specific (CSM) and other-cause mortality (OCM). DESIGN, SETTING, AND PARTICIPANTS We relied on Surveillance, Epidemiology, and End Results database (2004-2014) for UTUC of the renal pelvis patients (T1-T3, N0, M0) treated with NU with or without BCE. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Cumulative incidence plots relying on competing-risks methodology illustrated 5-yr CSM and OCM rates. Multivariable competing-risks regression (MCRR) models tested the effect of BCE versus no BCE at NU. RESULTS AND LIMITATIONS Of 4266 assessable patients, 2913 (68.3%) underwent NU with BCE. Between 2004 and 2014, rates of BCE at NU increased from 63.0% to 74.5% (European Association for Palliative Care: 2%; p<0.001). At 60 mo, CSM rates were 19.7% versus 23.5% (p=0.005) in NU with BCE versus NU without BCE patients, respectively. In MCRR models, no difference in CSM was recorded according to BCE at NU (hazard ratio [HR]: 0.88, confidence interval [CI]: 0.75-1.03, p=0.1). Finally, OCM was unaffected by BCE at NU (HR: 0.94, CI: 0.77-1.15, p=0.5). This study is retrospective. CONCLUSIONS According to guideline recommendation, the rates of NU with BCE increased over time. However, BCE status does not appear to affect CSM or OCM. Thus, our study was unable to examine the rates of urothelial cancer recurrence or metastatic progression according to BCE status. PATIENT SUMMARY Rates of bladder cuff excision (BCE) at nephroureterectomy (NU) are increasing. This observation confirms improved adherence to guidelines over time. However, BCE status does not appear to affect survival after NU for upper tract urothelial carcinoma.

Survival Effect of Chemotherapy in Metastatic Upper Urinary Tract Urothelial Carcinoma

Background Few data examined the potential survival benefit of chemotherapy (CHT) in the setting of metastatic upper urinary tract urothelial carcinoma (mUTUC). We hypothesized that a survival benefit might be associated with the use of CHT in nonsurgically treated primary mUTUC and tested this hypothesis within a large population‐based cohort. Patients and Methods Within the Surveillance, Epidemiology, and End Results database (2004‐2014), we identified 539 patients with nonsurgically treated primary mUTUC. Inverse probability of treatment weighting (IPTW)‐adjusted Kaplan‐Meier plots, as well as multivariable Cox regression models relying on IPTW and landmark analyses, were used to test the effect of CHT versus no CHT on overall mortality and cancer‐specific mortality. Results Of 539 patients with metastatic UTUC, 277 (51.4%) underwent CHT. In nonadjusted and IPTW‐adjusted Kaplan‐Meier plots, CHT was associated with better overall survival (9 vs. 2 months; P < .001 in both analyses). In multivariable Cox regression models, CHT administration independently predicted lower overall mortality before IPTW (hazard ratio [HR], 0.31; 95% confidence interval [CI], 0.25‐0.39; P < .001), as well as after IPTW adjustment (HR, 0.31; 95% CI, 0.25‐0.38; P < .001). Similar results were recorded in landmark analyses (HR, 0.52; 95% CI, 0.38‐0.70; P < .001). Finally, virtually the same results were obtained for cancer‐specific mortality. Conclusions Our analyses suggest a survival benefit after CHT in the setting of nonsurgically treated primary mUTUC. Micro‐Abstract Chemotherapy (CHT) might offer a survival benefit in patients with nonsurgically treated metastatic primary upper tract urothelial carcinoma (mUTUC). We tested this hypothesis within 539 patients with mUTUC: 277 (51.4%) underwent CHT. In nonadjusted and fully adjusted Kaplan‐Meier analyses, CHT was associated with better overall survival (9 vs. 2 months; P < .001 in both analyses). In multivariable Cox regression models, CHT administration independently predicted lower overall mortality (hazard ratio, 0.31; 95% confidence interval, 0.25‐0.39; P < .001). Our analyses suggest a survival benefit of CHT in primary mUTUC.