Urologic Oncology-seminars and Original Investigations最新文献

Background: The Bosniak classification for cystic renal masses has undergone refinements since its inception. The 2019 version provides more objective criteria to enhance interrater agreement but needs validation. This study compares the interrater agreement of the 2005 and 2019 Bosniak classifications for cystic renal masses.

Methods: Forty cystic renal masses identified on computed tomography scans were selected, distributed equally among the five classes of the 2005 Bosniak classification. Eight radiology residents participated in 2 consecutive rating sessions using the 2005 and 2019 versions, respectively, with a 1-month wash-out period in between. Interrater reliability was assessed using Fleiss' κ, and changes in cyst classes between the versions were assessed using the Wilcoxon signed-rank test.

Results: Fleiss' κ values for interrater reliability were 0.354 (0.286-0.431) for 2005 and 0.373 (0.292-0.487) for 2019, indicating fair to moderate agreement. A significant decrease in cyst grades was noted using the 2019 version (Z = 3.49, r = 0.55, P < 0.001) among all cysts assessed by residents and only in complex cysts assessed by consultants (Z = 1.907, r = 0.275, P = 0.048).

Conclusion: Interrater agreement was similar for both classifications, ranging from fair to moderate. The 2019 version increased the proportion of masses downgraded to lower classes. Comprehensive training may enhance reliability and accuracy.

Background: Numerous studies indicate that the gut microbiome is closely associated with prostate cancer (PCa), however, owing to various confounding factors, the causal relationship between gut microbiota and PCa remains unclear.

Methods: A 2-sample Mendelian randomization (MR) analysis utilized genome-wide association study (GWAS) data on the gut microbiota of 18,340 participants and GWAS summary statistics on PCa involving 46,3010 participants. Inverse variance weighted (IVW) served as the primary method, complemented by the MR-Egger method, weighted median method (WME), simple mode method (SM), and weighted mode method (WM). Finally, to confirm the robustness of the results, heterogeneity test, pleiotropy test, and leave-one-out sensitivity test were conducted.

Results: IVW analysis revealed that 12 specific gut microbial taxa were potentially causally associated with PCa; the genera Victivallis, Akkermansia, Odoribacter, Butyrivibrio, and the families Enterobacteriaceae, Verrucomicrobiaceae, as well as the orders Verrucomicrobiales, Enterobacteriales and the class Verrucomicrobiae, were found to be positively associated with PCa risk. Conversely, the genera Eubacterium ruminantium group, Candidatus Soleaferrea, and RuminococcaceaeUCG003 were negatively associated with PCa risk.

Conclusions: Our MR study's results support a genetically predicted causal relationship between the gut microbiota and PCa, and we identified 12 specific gut microbial taxa. These findings could offer new targets for PCa screening and treatment.

Objectives: Radical cystectomy with urinary diversion is the gold standard treatment for bladder cancer (high-risk/muscle invasive). The transperitoneal approach is associated with significant gastrointestinal complications like ileus. In the elderly and frail with a single functional kidney, we describe an extraperitoneal technique of radical cystectomy, with a ureterostomy, to be performed without general anesthesia.

Materials and methods: The elderly, frail, and high-risk candidates for general anesthesia, with a prior history of nephroureterectomy with a second primary muscle-invasive bladder cancer, were chosen. All patients underwent the described procedure under combined spinal and epidural anesthesia. The posterior dissection was retrograde, caudal to cranial, with the peritoneum being opened only for resection of the dome. A cutaneous ureterostomy was fashioned on the side of the functional kidney. Peri-operative parameters were assessed for early recovery in this high-risk group.

Results: The mean age was 82 years (range: 73-91), with Charleson Comorbidity Index 5, and were all deemed unfit for neoadjuvant chemotherapy. With a median duration of 127.5 minutes, an average blood loss of 225ml, and no patient requiring general anesthesia; early ambulation, early return of bowel function, and a lesser hospital stay (7 days) with minimal morbidity were achieved. Negative surgical margins were achieved in all cases, with a mean harvest of 29 lymph nodes. Only 1 patient developed stomal stenosis. The cause-specific survival (CSS) is 100% at 2 years.

Conclusions: The highlighting features are the early return of bowel function (flatus passage on day 1) and the avoidance of the cardio-pulmonary complications of general anesthesia. The extraperitoneal cystectomy offers a promising alternative in this select group and warrants further studies to extrapolate this technique for bilateral urinary drainage.

Introduction: To report the long-term outcomes of robot-assisted radical cystectomy (RARC) for the treatment of muscle invasive and high-risk non-muscle invasive bladder cancer.

Methods: We reviewed a single tertiary center database of RARC from 2004 to 2020. Concomitant extended pelvic lymph node dissection and extracorporeal urinary diversion were performed. Cox regression analysis and the Kaplan-Meier method were used to identify factors associated with and report time-to-event estimations of recurrence-free survival and overall survival. Clavien-Dindo complications were identified, categorized, and substratified by time from surgery within 90-days and between 90-days and >5-years postoperatively.

Results: A total of 510 patients with median follow-up of 57.1 months (IQR 21.8-103.6) were included. Continent diversion was performed in 259 (51%) patients. Of the 340 (67%) ≥cT2 patients, 153 (45%) received cisplatin-based neoadjuvant chemotherapy. Recurrence was identified in 157 (31%) patients, and 118 (23%) died from bladder cancer. The overall complication rate was 52% with 267 (41%) major grade ≥ III events. Infectious (25%) and genitourinary (22%) complications were the most common irrespective of the time interval beyond 90-days. The risk of recurrence or death were increased by extravesical disease (HR 1.91 and 1.97, respectively) and lymph node positivity (HR 4.58 and 2.42, respectively) in multivariable analysis (all, P < 0.001). The estimated 5-, and 10-year recurrence-free and overall survival rates were 69% and 64% and 61% and 44%, respectively.

Conclusions: RARC is a durable treatment that optimizes the probability of cure for patients requiring extirpation for bladder cancer. Targeting the modifiable complications of radical surgery may further improve the risk/benefit ratio of RARC.

Purpose: The use of immediate postoperative intravesical chemotherapy (IVC) following transurethral resection of bladder tumor (TURBT) has been shown to reduce the rate of recurrence of nonmuscle invasive bladder cancer. Historically, utilization of IVC following TURBT has been low. We sought to determine the rate of immediate postoperative IVC following TURBT, as well as assess factors that may influence its use.

Methods: We utilized the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to assess the rates of IVC between the years 2016 to 2021. All patients who underwent TURBT based on appropriate procedure codes were initially included. Patients with an additional procedure code for the administration of IVC were identified.

Results: From 2016 to 2021, 50,295 patients underwent TURBT for bladder cancer. There were 21,544 (43%) small, 18,135 (36%) medium, and 10,616 (21%) large tumors treated. In total, 2,833 (5.6%) patients received IVC. Use of IVC was associated with surgery performed in an elective setting, those who did not receive preoperative blood transfusion, and shorter operative time. Receipt of chemotherapy was more common in the later years examined.

Conclusions: The rate of use of IVC remains very low. Ongoing study and improvement initiatives are in place, though these predominantly are assessing academic centers. Further study and quality improvement should be performed and include community practice settings.

Importance: The Prostate Imaging Reporting & Data System (PI-RADS) scoring guidelines were developed to address the substantial variation in interpretation and reporting of prostate cancer (PCa) multiparametric MRI (mpMRI) results, and subsequent updates have sought to further improve inter-reader reliability. Nonetheless, the variability of PI-RADS scoring in real-world settings may represent a continuing challenge to the widespread standardization of prostate mpMRI and limit its overall clinical benefit.

Objective: To assess variability in mpMRI interpretation and reporting of PCa, we evaluated the discrepancies in PI-RADS scoring between community practices and a tertiary academic care center.

Design, setting, and participants: We identified 262 mpMRI studies from nonacademic facilities, reinterpreted by radiologists at our institution between January 2016 and July 2022. Results of targeted MRI fusion biopsy were identified for 193 of these patients, totaling 302 lesions. PI-RADS scoring from both community and academic interpreters were recorded in addition to presence of clinically significant PCa (csPCa) on pathological analysis of targeted cores.

Main outcome and measures: The primary outcome was inter-reader reliability via intraclass correlation (ICC) and the kappa statistic. We also assessed the diagnostic accuracy of PI-RADS scoring for detecting csPCa for both cohorts via receiver operator characteristics (ROC) analysis and compared these findings using paired-sample area difference under curve analysis.

Results: Inter-reader agreement and reliability of PI-RADS scoring per lesion was generally poor (absolute agreement ICC = 0.393, 95% CI: 0.288-0.488; consistency ICC = 0.407, 95% CI: 0.308-0.497; kappa = 0.336, 95% CI: 0.267-0.406). Reliability results from studies obtained after the publication of PI-RADSv2.1 were similar to those of the overall analysis. No agreement was observed in the subgroup of lesions scored as PIRADS 3 by community interpreters. No statistically significant difference in diagnostic accuracy was observed between cohorts (ROC area under curve [AUC]: 0.759 vs. 0.785, respectively; P = 0.337). PI-RADS 3 was determined to be the optimal cutoff for detecting clinically significant disease in both cohorts.

Conclusions and relevance: Our results suggest that mpMRI diagnostic accuracy for detecting csPCa is not significantly different between academic and community practices. However, significantly poor reliability of mpMRI was observed between cohorts, suggesting the risk of introducing practice variation for community prostate cancer management. Variability, particularly for PI-RADS 3 lesions, can lead to inconsistent biopsy recommendations, which may result in missed csPCa or unnecessary biopsies.

Robot-assisted partial nephrectomy (RAPN) has readily become the benchmark treatment of small renal masses (SRMs). The management of SRMs is focused on preserving renal function and limiting the morbidity of a traditional open operation, thus greatly impacting overall prognosis and long-term survival. Indications and techniques have evolved over the last 2 decades. In this article, we discuss the application of this nephron-sparing technique regarding its indications, surgical considerations, and functional outcomes.

Introduction: Neoadjuvant chemotherapy (NAC) before radical cystectomy (RC) is guideline-recommended in patients with cT2-T4N0M0 urothelial carcinoma of urinary bladder (UCUB). However, no population-based study validated the survival benefit of NAC recorded in clinical trials in a stage-specific fashion. We addressed this knowledge gap.

Methods: Within the Surveillance, Epidemiology, and End Results database (2007-2020), we identified patients with cT2-T4N0M0 UCUB treated with NAC before RC versus RC alone. Cumulative incidence plots and multivariable competing risks regression (CRR) models were fitted. Survival analyses were performed according to organ confined (OC: cT2N0M0) versus nonorgan confined stages (NOC: cT3-T4N0M0).

Results: Of 3,743 assessable patients, 1,020 (27%) underwent NAC versus 2,723 (73%) RC alone. NAC rates increased over time in OC stage (EAPC = 11.9%, P < 0.001) and NOC stage (EAPC = 8.6%, P < 0.001). In OC stage, cumulative incidence plots derived 5-year CSM was 15.6% in NAC and 19.9% in RC alone patients (P = 0.008). In multivariable CRR models, NAC independently predicted lower CSM (hazard ratio (HR): 0.74, P = 0.01). Similarly, in NOC stage, cumulative incidence plots derived 5-year CSM was 36.1% in NAC and 46.0% in RC alone patients (P = 0.01). In multivariable CRR models, NAC independently predicted lower CSM (HR: 0.66, P < 0.001).

Conclusion: NAC is associated with improved CSM compared to RC alone, both in OC and NOC stages. Specifically, the magnitude of the protective NAC effect was greater in NOC than OC patients. Thus, NAC should always be administered in all eligible patients before RC.

Background: Cisplatin-based chemotherapy has traditionally been the standard treatment for unresectable or metastatic urothelial carcinoma (mUC). Recently, the longstanding paradigm has changed with the emergence of immune checkpoint inhibitors and antibody-drug conjugates, such as pembrolizumab and enfortumab vedotin (EV). This longitudinal descriptive study aimed to identify real-world treatment patterns and assess the outcomes of patients with mUC between 2010 and 2023.

Methods: Patients with mUC who received first-line systemic therapy were identified from a Japanese electronic medical records database. A Sankey diagram was used to present the proportion of patients who transitioned to second- and third-line therapies. Kaplan-Meier survival analysis was used to estimate the time to next treatment (TTNT) and overall survival (OS).

Results: A total of 794 patients were included in this study. The median age of the patients was 73.0 years, and 72.9% were male. The most common primary tumor site was the bladder (59.7%). First-line therapy comprised cisplatin-based regimens in 52.0% of the patients (11.8% at standard doses, 32.4% at reduced doses, and 7.8% at unknown doses), carboplatin-based regimens in 32.1%, and other regimens in 15.9%. Among the patients enrolled after 2017, following the approval of pembrolizumab for mUC progressing after chemotherapy in Japan, 58.2% received pembrolizumab as second-line therapy, and 19.1% received EV monotherapy as third-line therapy. The median OS for the total population was 24.1 months, with patients enrolled between 2010 and 2016 having a shorter OS (21.1 months) than those enrolled between 2017 and 2022 (24.9 months). For patients with eGFRs of ≥60 and <60 mL/min/1.73 m², the median OS was 24.1 and 23.8 months, respectively.

Conclusion: Platinum-based regimens, including reduced-dose cisplatin and carboplatin, remain the predominant first-line systemic therapies. Since 2017, pembrolizumab and EV have become widespread choices for second-line and subsequent treatments, gradually surpassing the previously prevalent platinum-based regimens. The introduction of these novel therapies might have prolonged the OS of patients with mUC. A plain language summary is available in this article.