Scandinavian Journal of Urology

Minimising warm ischaemia time during robot-assisted partial nephrectomy. A video-based assessment of tumour excision, kidney reconstruction and intermediate time

Ovidiu S. Barnoiu — 2024-06-19

Introduction: Surgical video review is an emerging tool for assessing patient outcomes, especially in complex surgeries such as robot-assisted partial nephrectomy (RAPN). Assessing and measuring warm ischaemia time (WIT) during RAPN by dividing it into the time used for tumour excision time (ExcT), time used for kidney reconstruction time (RecT) and intermediate time (IntT) has not been performed before. This study aimed to analyse the factors that can influence all surgical times and assess their impact on positive surgical margins (PSMs) and complication rates.

Methods: We evaluated 32 surgical video recordings from patients undergoing RAPN and measured WIT, ExcT, RecT and IntT with a stopwatch. Factors such as tumour characteristics and surgeon experience were also recorded. SPSS software was used to identify the predictors for all surgical times and to correlate ExcT with PSM and RecT with complication rate.

Results: We recorded a median WIT of 1,048 s (17 min and 28 s). The median of ExcT, RecT and IntT was 398 s (37.1% of WIT), 518 s (46.7% of WIT) and 180 s (16.2% of WIT), respectively. We found a significant correlation (P < 0.001) between R.E.N.A.L. score and all surgical times. No correlation was found between ExcT and PSM (P = 0.488) and between RecT and the probability of developing complications (P = 0.544).

Conclusion: Tumour morphology influences all surgical times, and surgeon experience influences only ExcT. We observed a short RecT during RAPN though at the cost of increased ExcT, and we believe that improving surgical experience, especially for the excision of more complex tumours, can reduce WIT during RAPN.

Violation of onco-surgical principles is associated with survival outcomes in upper tract urothelial carcinomas after radical nephroureterectomy

Ioannis Patras — 2024-06-19

Objective: Disease recurrence, particularly intravesical recurrence (IVR) after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC), is common. We investigated whether violations of onco-surgical principles before or during RNU, collectively referred to as surgical violation (SV), were associated with survival outcomes.

Material and methods: Data from a consecutive series of patients who underwent RNU for UTUC 2001–2012 at Skåne University Hospital Lund/Malmö were collected. Preoperative insertion of a nephrostomy tube, opening the urinary tract during surgery or refraining from excising the distal ureter were considered as SVs. Survival outcomes in patients with and without SV (IVR-free [IVRFS], disease-specific [DSS] and overall survival [OS]) were assessed using multivariate Cox regression analyses (adjusted for tumour stage group, prior or concomitant bladder cancer, comorbidity and preoperative urinary cytology).

Results: Of 150 patients, 47 (31%) were subjected to at least one SV. Overall, SV was not associated with IVRFS (HR 0.81, 95% CI 0.4–1.6) but with worse DSS (HR 1.9, 95% CI 1.03–3.7) and OS (HR 1.9, 95% CI 1.2–3) in multivariable analysis. Additional analyses with a broader definition of SV including also preoperative instrumentation of the upper urinary tract (ureteroscopy and/or double J stenting) showed similar outcomes for DSS (HR 2.1, 95% CI 1.1–4.3).

Conclusion: Worse survival outcomes, despite no difference in IVR, for patients that were subjected to the violation of sound onco-surgical principles before or during RNU for UTUC strengthen the notion that adhering to such principles is a cornerstone in upper tract urothelial cancer surgery.

Reduction of lower urinary tract symptoms in prostate cancer patients treated with robot assisted laparoscopic prostatectomy

Lars Fredrik Qvigstad — 2024-06-18

Problem: The aim of this study was to evaluate the change in LUTS in patients treated with RALP and to assess factors that may predict an improvement of LUTS.

Materials and method: In our institutional prospective research registry, 1935 patients operated in the period between 2009 and 2021 with complete baseline- and 12-month EPIC-26 questionnaire were eligible for the study. Also SF-12 data estimating general quality of life (QoL) were analyzed. A LUTS summary score was constructed from the two questions concerning voiding stream/residual and frequency, and transformed linearly to a 0-100 scale with higher scores representing less symptoms A change of 6 points or more were considered Meaningful Clinical Differences (MCD). Two summary scores were calculated from the SF-12 – a mental component score (MCS-12) and a physical component score (PCS-12). Multivariate regression was used to estimate covariates associated with postoperative MCD, MCS-12 and PCS-12.

Results: Mean change of LUTS-score showed an increase of 10 points 12-months post-RALP. 52% of patients achieved MCD. In multivariate logistic regression, preoperative LUTS was statistically significant associated with MCD. Reduction of LUTS was associated improved mean score of MCS-12 and PCS-12.

Discussion and conclusion: Along with information about risk for urinary incontinence after RALP, patients with LUTS at baseline must be informed that these symptoms may be reduced after RALP. In our study, this LUTS reduction was associated with better general QoL.

End-stage renal disease after renal cancer surgery: risk factors and overall survival

John Åkerlund — 2024-05-15

Objective: Several risk factors for end-stage renal disease (ESRD), in patients undergoing surgical treatment for renal cell carcinoma (RCC), have been suggested by others. This study aimed to investigate such risk factors and disclose the effect of developing ESRD, postoperatively, on overall survival. The risk of developing ESRD after RCC diagnosis was also evaluated.

Material and methods: The data of 16,220 patients with RCC and 162,199 controls were extracted from the Renal Cell Cancer Database Sweden, with linkages across multiple national registers between 2005 and 2020. Cox proportional hazards regression, Kaplan–Meier curves and cumulative incidence were used for statistical analysis.

Results: The 5-year cumulative incidence of ESRD following RCC diagnosis was 2.4% (95% confidence interval [CI] 2.1–2.6) and 0.4% (95% CI 0.3–0.4) for the patients with RCC and controls, respectively. Age, chronic kidney disease, higher T-stage and radical nephrectomy (RN) were significant risk factors for ESRD within 1-year of surgery. A total of 104 and 12,152 patients with and without ESRD, respectively, survived 1-year postoperatively. The 5-year overall survival rates of patients with ESRD and those with RCC only were 50% (95% CI 0.40–0.60) and 80% (95% CI 0.80–0.81), respectively.

Conclusions: Patients who developed ESRD following renal cancer surgery had significantly poorer survival outcomes. Advanced age, comorbidities, higher-stage tumours and RN were identified as risk factors for developing ESRD. Surgical decisions are crucial. Efforts to spare renal function, including nephron-sparing surgery and active surveillance in appropriate cases, are highly relevant to reduce the development of severe kidney dysfunction.

Anorectal function and symptoms 6 months after robot-assisted laparoscopic radical prostatectomy: a single-center study

Theodoros Psarias — 2024-05-13

Introduction: Robot-assisted laparoscopic radical prostatectomy (RALP) is a common procedure for the treatment of localised prostate cancer. Anorectal symptoms such as fecal incontinence (FI), rectal urgency or disturbed defecation have been reported after the operation. Anorectal function is dependent on the integrity of anal and pelvic nerves and muscles, rectal sensory function as well as rectal reservoir function.

The aim of this study was to investigate the potential influence of RALP on anorectal physiological function and bowel symptoms.

Materials and Methods: In this pilot study, 29 patients with localised prostate cancer scheduled for RALP were included. Anorectal physiology was used to measure rectal sensitivity and reservoir function as well as anal sphincter pressures. Bowel symptoms were measured by a bowel function questionnaire and a 2-week bowel function diary. Measurements were done before the operation and repeated at 6 months after the operation.

Results: The study observed a significant postoperative increase in rectal sensory threshold for rectal balloon distention, from 20 to 40 mmHg, P < 0.001. This change is indicative of a decrease in rectal sensation after RALP. There were no other statistical significant differences in any of the physiological tests performed. Importantly, there was no change in any of the bowel symptoms after surgery.

Conclusion: This study showed that RALP may lead to impaired rectal sensory function. This finding did not, however, seem to have any influence on the patients´ postoperative clinical bowel function.

Risk of prostate cancer death in men diagnosed with prostate cancer at cystoprostatectomy. A nationwide population-based study

Pietro Scilipoti — 2024-05-13

Background and aims: One out of three men who undergo cystoprostatectomy for bladder cancer is diagnosed with incidental prostate cancer (PCa) at histopathological examination. Many of these men are PSA tested as part of their follow-up, but it is unclear if this is needed. The aim of this study was to assess the risk of PCa death in these men and the need of PSA-testing during follow-up.

Methods: Between 2002 and 2020, 1,554 men were diagnosed with PCa after cystoprostatectomy performed for non-metastatic bladder cancer and registered in the National Prostate Cancer Register (NPCR) of Sweden. We assessed their risk of death from PCa, bladder cancer and other causes up to 15 years after diagnosis by use of data in The Cause of Death Register. The use of androgen deprivation therapy (ADT) as a proxy for PCa progression was assessed by fillings in The Prescribed Drug Register.

Results: Fifteen years after diagnosis, cumulative incidence of death from PCa was 2.6% (95% CI 2.3%–2.9%), from bladder cancer 32% (95% CI: 30%–34%) and from other causes 40% (95% CI: 36%–44%). Only 35% of men with PCa recorded as primary cause of death in The Cause of Death Register had started ADT before date of death, indicating sticky-diagnosis bias with inflated risk of PCa death.

Conclusions: For a large majority of men diagnosed with incidental PCa at cystoprostatectomy performed for bladder cancer, the risk of PCa death is very small so there is no rationale for PSA testing during follow-up.

A novel model of artificial intelligence based automated image analysis of CT urography to identify bladder cancer in patients investigated for macroscopic hematuria

Suleiman Abuhasanein — 2024-05-02

Objective: To evaluate whether artificial intelligence (AI) based automatic image analysis utilising convolutional neural networks (CNNs) can be used to evaluate computed tomography urography (CTU) for the presence of urinary bladder cancer (UBC) in patients with macroscopic hematuria.

Methods: Our study included patients who had undergone evaluation for macroscopic hematuria. A CNN-based AI model was trained and validated on the CTUs included in the study on a dedicated research platform (Recomia.org). Sensitivity and specificity were calculated to assess the performance of the AI model. Cystoscopy findings were used as the reference method.

Results: The training cohort comprised a total of 530 patients. Following the optimisation process, we developed the last version of our AI model. Subsequently, we utilised the model in the validation cohort which included an additional 400 patients (including 239 patients with UBC). The AI model had a sensitivity of 0.83 (95% confidence intervals [CI], 0.76–0.89), specificity of 0.76 (95% CI 0.67–0.84), and a negative predictive value (NPV) of 0.97 (95% CI 0.95–0.98). The majority of tumours in the false negative group (n = 24) were solitary (67%) and smaller than 1 cm (50%), with the majority of patients having cTaG1–2 (71%).

Conclusions: We developed and tested an AI model for automatic image analysis of CTUs to detect UBC in patients with macroscopic hematuria. This model showed promising results with a high detection rate and excessive NPV. Further developments could lead to a decreased need for invasive investigations and prioritising patients with serious tumours.

Cystectomy for bladder cancer in Sweden – short-term outcomes after centralization

Fredrik Liedberg — 2024-04-29

Objective: Radical cystectomy (RC) for bladder cancer is associated with an inherent risk of complications and even postoperative mortality. The number of hospitals performing RC has decreased in Sweden over time, and since a formal regional centralization in 2017 cystectomy care is currently provided by nine hospitals.

Material and methods: In the Swedish National Urinary Bladder Cancer Register (SNRUBC) 90-day complications after RC have been registered with high coverage since 2012. Descriptive data and short-term outcomes were compared in relation to centralization of the cystectomy care by stratifying data before (2012–2016) and after (2017–2023).

Results: Out of all 4,638 cystectomies, 2,738 (59%) were performed after the centralization in 2017 and onwards. The median age at RC increased from 71 (Inter Quartile Range [IQR] 65–76) to 73 (IQR 67–77) years, and the proportion of patients with comorbidity (American Society of Anesthesiologists [ASA] 3 or 4) increased from 32% to 37% after the centralization (p < 0.001). The number of patients suffering from high-grade complications within 90 days of surgery corresponding to Clavien grade three were 345 (18%) and 407 (15%), and corresponding to Clavien grade four 61 (3%) and 64 (2%) before and after centralization, respectively. Reoperations within 90 days of RC decreased from 234/1,900 (12%) to 208/2,738 (8%) (p < 0.001), and 90-day mortality decreased from 84/1,900 (4%) to 85/2,738 (3%) (p = 0.023) before and after centralization, respectively.

Conclusion: After the centralization of the cystectomy-care in Sweden, older patients and individuals with more extensive comorbidity were offered RC whereas 90-day mortality and the proportion of patients subjected to reoperations within 90 days of surgery decreased without increasing waiting times.

Temporal trend in risk of prostate cancer death in men with favourable-risk prostate cancer

Frederik F. Thomsen — 2024-04-29

Background and objectives: Changes in work-up and histopathological assessment have caused stage and grade migration in men with prostate cancer (PCa). The aim of this study was to assess temporal trends in risk of PCa death for men with favourable-risk PCa managed with primary radical prostatectomy or observation.

Methods and material: Men aged 75 or younger with Charlson Comorbidity index 0–1 diagnosed with favourable-risk PCa (T1–T2, prostate specific antigen [PSA] <20 ng/mL and Gleason score 6 or 7[3+4]) in the period 2000–2016 who were treated with primary radical prostatectomy or managed with observation in PCBaSe 4.0. Treatment groups were compared following propensity score matching, and risk of PCa death was estimated by use of Cox regression analyses.

Results: A total of 9,666 men were selected for each treatment strategy. The 7-year cumulative incidence of PCa death decreased in all risk and treatment groups. For example, the incidence in men diagnosed with low-risk PCa and managed with observation was 1.2% in 2000–2005, which decreased to 0.4% in 2011–2016. Corresponding incidences for men with intermediate-risk PCa managed with observation were 2.0% and 0.7%. The relative risk of PCa death was lower in men with low-risk PCa managed with radical prostatectomy compared to observation: in 2000–2005 hazard ratio (HR) 0.20 (95% confidence interval [CI] 0.10–0.38) and in 2011–2016 HR 0.35 (95% CI 0.05–2.26). Corresponding risks for men with intermediate-risk PCa were HR 0.28 (95% CI 0.16–0.47) and HR 0.21 (95% CI 0.04–1.18). The absolute risk reduction of radical prostatectomy compared to observation for men with low-risk PCa was 1% in 2000–2005 and 0.4% in 2011–2016, and for men with intermediate-risk PCa 1.1% in 2000–2005 and 0.7% in 2011–2016.

Conclusion: Men diagnosed in 2011–2016 with low-risk and favourable intermediate-risk PCa have a similar relative benefit but smaller absolute benefit of curative treatment compared to men diagnosed in 2000–2005.

National trends of surgery for benign prostatic hyperplasia in Finland

Alisa Salmivalli — 2024-04-22

Purpose: To investigate national trends of surgical treatment for benign prostatic obstruction (BPO).

Methods: The Care Register for Healthcare in Finland was used to investigate the annual numbers and types of surgical procedures, operation incidence and duration of hospital stay between 2004 and 2018 in Finland. Procedures were classified using the Nordic Medico-Statistical Committee Classification of Surgical Procedures coding. Trends in incidence were analyzed with two-sided Cochran-Armitage test. Trends in duration of hospital stay and patient age were analyzed with linear regression.

Results: Transurethral resection of the prostate (TURP) was the most common operation type during the study period, covering over 70% of operations for BPO. Simultaneous with the implementation of photoselective vaporization of the prostate (PVP), the incidence of TURP, minimally invasive surgical therapies, transurethral vaporization of the prostate (TUVP) and open prostatectomies decreased (p < 0.05). The mean operation incidence rate in the population between 2004 and 2018 was 263 per 100,000. The duration of hospital stay shortened (p < 0.05), and the average age of operated patients increased by 2 years (p < 0.0001).

Conclusion: The implementation of PVP did not challenge the dominating position of TURP in Finland, but it has probably influenced the overall use of other surgical therapies, excluding transurethral incision of the prostate. The results might suggest that the conservative treatment is accentuated, patient selection is more thorough, and surgical intervention might be placed at a later stage of BPO.

Prediction of clinically significant recurrence after partial nephrectomy. Data from the Cancer Registry of Norway with more than five years of follow-up

Ovidiu S. Barnoiu — 2024-01-16

Objective: To determine recurrence incidence after partial nephrectomy (PN) for renal cell carcinoma and identify predictors for local recurrence (LR) and metastasis.

Material and methods: We retrospectively evaluated a cohort of 524 patients from the Cancer Registry of Norway, who underwent PN between January 2014 and December 2015 and were followed-up for >6 years. Patient demographics and pathological characteristics were correlated with recurrence and progression-free survival using Kaplan-Meier and Cox regression analyses.

Results: Median patient age was 64 years, and the median tumour size was 2.6 cm. A positive surgical margin (PSM) was observed in 11% of the cases, while the LR and metastasis rates were 3.4% and 3.2%, respectively. PSM (hazard ratio [HR], 55.4; 95% confidence interval [CI], 12.55–244.6), tumour number (HR, 45.4; 95% CI, 6.5–316.1) and stage (HR, 33.5; 95% CI, 5.4–205.3) were independent predictors for LR. Undetermined margin status was also a risk factor for LR. Tumour stage (HR, 41.05; 95% CI, 8.52–197.76), tumour necrosis (HR, 1.3; 95% CI, 0.4–4.31) and age (HR, 1.07; 95% CI, 1.01–1.14) were predictors for metastasis.

Conclusions: Both local and distant recurrences after PN were rare, and the pT stage was a common predictor. PSM or indeterminate surgical margin and tumour number were LR predictors, while age at surgery and the presence of tumour necrosis predicted metastasis.

Computed tomography for visible haematuria – a single nephrographic phase is sufficient for detecting renal cell carcinoma

Kristina Flor Galtung — 2024-01-16

Objectives: No previous studies have compared two computed tomography (CT) protocols in patients presenting with visible haematuria, and most patients undergo a multiphase CT in order to detect upper tract malignancies. We aimed to prospectively compare the diagnostic performance of single- and four-phase CT for detecting renal cell carcinoma (RCC) in patients with visible haematuria.

Materials & methods: ‘A Prospective Trial for Examining Hematuria using Computed Tomography’ (PROTEHCT) was a single-centre prospective paired diagnostic study in patients referred for CT due to painless visible haematuria between September 2019 and June 2021. All patients underwent four-phase CT (control) from which a single nephrographic phase dual energy CT (experimental) was extracted. Both were independently assessed for RCC by randomised radiologists. Histologically verified RCC defined a positive reference standard. Follow-up ascertainment of RCC diagnosis was completed in May 2022. Descriptive statistics were used to calculate the accuracies. Inter-reader agreement was assessed by kappa statistics.

Results: A total of 308 patients (median age, 68 years [interquartile range 53–77, range 18–96], 250 males) were included for analysis. RCC was diagnosed in seven (2.3%) patients during a median follow-up time of 19 months (interquartile range: 15–25). For the control and experimental CT, sensitivity was 100% versus 100%, specificity was 97% versus 98% and accuracy 97% versus 97%. The positive predictive value was 44% versus 50%, and the negative predictive value was 100% versus 100%. The agreement between the control and experimental CT was 98% (k = 0.79).

Conclusion: A single nephrographic phase dual energy CT is sufficient for detecting RCC in patients with visible haematuria.

Diagnostic pathways and treatment strategies in upper tract urothelial carcinoma in Sweden between 2015 and 2021: a population-based survey

Fredrik Liedberg — 2024-01-16

Objective: To report national data on diagnostics and treatment of upper tract urothelial carcinoma (UTUC) from the Swedish National Registry of Urinary Bladder Cancer (SNRUBC).

Patients and methods: Data from 2015 to 2021 were retrieved, and descriptive analyses were performed regarding incidence, diagnostic modalities, preoperative tumor staging, quality indicators for treatment including the use of standardized care pathways (SCP) and multidisciplinary tumor boards (MDTB). Time trends were explored for the study period.

Results: Registrations included 1,213 patients with renal pelvic cancer and 911 patients with ureteric cancer with a median age of 74 (interquartile range [IQR] 70–77) and 75 (IQR 71–78) years, respectively. Incidence rates of UTUC were stable, as were proportions of curative treatment intent. Median number of days from referral to treatment was 76 (IQR 57–99) and 90 (IQR 72–118) days, respectively, for tumors of the renal pelvis and ureter, which remained unchanged after introduction of SCP in 2016. Noticeable trends included stable use of kidney-sparing surgery and increased use of MDTB. For radical nephroureterectomy (RNU), robot-assisted technique usage increased even for non-organ-confined tumors (cT3-4) and in one out of three patients undergoing RNU a bladder cuff excision was not registered.

Conclusions: The population-based SNRUBC with high coverage contributes to the knowledge about UTUC with granular and generalizable data. The present study reveals a high proportion of patients not subjected to curatively intended treatment and suggests unmet needs to shorten lead times to treatment and use of bladder cuff excision when performing radical surgery for UTUC in Sweden.

Multiple factors influence decision making for the surgical treatment in patients with renal cell carcinoma

Britt-Inger Kröger Dahlin — 2024-02-15

Background: Surgical strategy in renal cell carcinoma (RCC) is considered based on the renal function. Partial nephrectomy (PN) preserves kidney function better than radical nephrectomy (RN), lowering risk of chronic kidney disease (CKD). The aim was to evaluate whether renal function and other clinical variables were important for surgical treatment selection.

Methods: Patients with RCC, surgically treated between 1994 and 2018 were included. There were 663 patients in all stages, 265 women and 398 men, mean age 66 years. Clinical data: estimated glomerular filtration rate (eGFR), WHO performance status (WHO-PS), Charlson comorbidity index (CCI), surgery, T-stage, M-stage, RCC type, tumor size, age, and gender were extracted from the medical records. Statistical analysis included Mann-Whitney U, X2-test, and logistic regression analysis.

Results: Of 663 patients, 455 were treated with RN and 208 with PN. In all patients, preoperative eGFR was significantly higher in PN (80.8) than in RN (77.1, p = 0.015). Using logistic regression tumor size (odds ratio [OR]: 0.96; 95% confidence interval [CI]: 0.95–0.98, T-stage (OR: 0.46; 95% CI: 0.33–0.65), WHO-PS (OR: 0.39; 95% CI: 0.04–0.57), and CCI (OR: 1.23; 95% CI: 1.05–1.44), associated to treatment selection, while eGFR, M-stage, age, and gender did not.

In cTa subgroup, eGFR was also higher in PN (84.6) than in RN (75.0, p = 0.007). Using logistic regression, tumor size (OR: 0.93; 95% CI: 0.83–0.98) and WHO-PS (OR: 0.36; 95% CI: 0.20–0.66) associated to treatment selection, while eGFR, CCI, age, and gender did not.

Conclusion: Tumor size, CCI scores, T-stage, and WHO-PS, all had an impact on the surgical strategy for all RCC patients. In patients with T1a RCC, tumor size and WHO-PS associated independently with treatment decision. After adjusted analysis, renal function lost its independent association with the treatment strategy in RCC patients.

The association between age and long-term quality of life after curative treatment for prostate cancer: a cross-sectional study

Reidun Sletten — 2024-02-20

Objective: We aimed to investigate the associations between age at radical prostate cancer treatment and long-term global quality of life (QoL), physical function (PF), and treatment-related side effects.

Material and Methods: This single-center, cross-sectional study included men treated for localized prostate cancer with robotic-assisted radical prostatectomy (RARP) or external beam radiotherapy (EBRT) in 2014–2018. Global QoL and PF were assessed by the European Organisation of Research and Treatment in Cancer Quality of life Questionnaire-C30 (QLQ-C30), side effects by the Expanded Prostate Cancer Index Composite (EPIC-26). Adjusted linear regression models were estimated to assess associations between age (continuous variable) at treatment and outcomes. QLQ-C30 scores were compared to normative data after dividing the cohort in two groups, <70 years and ≥70 years at treatment.

Results: Of 654 men included, 516 (79%) had undergone RARP, and 138 (21%) had undergone EBRT combined with androgen deprivation therapy for 93%. Mean time since treatment was 57 months. Median age at treatment was 68 (min–max 44–84) years. We found no statistically significant independent association between age at treatment and global QoL, PF or side effects, except for sexual function (regression coefficient [RC] −0.77; p < 0.001) and hormonal/vitality (RC 0.30; p = 0.006) function. Mean QLQ-C30 scores were slightly poorer than age-adjusted normative scores, for men <70 years (n = 411) as well as for men ≥70 years (n = 243) at treatment, but the differences were not beyond clinical significance.

Conclusions: In this cohort of prostate cancer survivors, age at treatment had little impact on long-term QoL and function. Due to the cross-sectional design, short term impact or variation over time cannot be ruled out.

DaBlaCa-17: nationwide observational study in Denmark on survival before and after implementation of neoadjuvant chemotherapy prior to cystectomy for muscle-invasive bladder cancer

Stefanie Korsgaard Körner — 2024-02-26

Objective: To investigate the impact of neoadjuvant chemotherapy implementation with gemcitabine-cisplatin on survival outcomes for patients with muscle-invasive bladder cancer in Denmark.

Materials and Methods: Data were collected on all patients in Denmark undergoing radical cystectomy who were potential candidates for neoadjuvant chemotherapy from 2010 to 2015 (n = 851). A cohort before the implementation of neoadjuvant chemotherapy (Cohort 2010–12) was compared with a cohort after implementation (Cohort 2013–15). Patients in Cohort 2013–15 receiving neoadjuvant chemotherapy (+NAC, n = 213) were compared with patients in Cohort 2013–15 not receiving neoadjuvant chemotherapy (-NAC, n = 139). Pathological results after radical cystectomy and oncological outcomes were compared between the study cohorts. Overall survival, disease-free survival, and disease-specific survival were compared with Kaplan-Meier plots and with univariable and multivariable Cox regression. Kaplan-Meier estimates of overall survival were also performed separately for treating hospital and for pathological stage.

Results: Pathological T0 (pT0) was more frequent in patients who received neoadjuvant chemotherapy: 34% versus 18% when comparing Cohort 2013–15 with Cohort 2010–12 (p < 0.001), and 46% versus 16% in +NAC compared with -NAC (p < 0.001). Overall survival, disease-free survival, and disease-specific survival at 5 years after cystectomy were not improved in Cohort 2013–15 compared with Cohort 2010–12 with adjusted hazard ratios of 1.11 (95% confidence interval [CI]: 0.87–1.43), 1.02 (95% CI: 0.81–1.29), and 1.06 (95% CI: 0.80–1.41), respectively.

Conclusions: This observational study found no improved survival in a national cohort of patients with muscle-invasive bladder cancer undergoing radical cystectomy after implementation of NAC. However, reservations should be made regarding the study design and the true effect of NAC on survival outcomes.

Do men adapt to lower urinary tract symptoms? An 11-year longitudinal study of male urinary urgency and associated bother

Jonne Åkerla — 2024-02-26

Objective: The study objective is to evaluate prognosis and predictors of bother caused by urinary urgency among middle-aged and older men.

Material and methods: A population-based sample of men born in 1974, 1964, 1954, 1944, 1934 and 1924 was followed-up from 2004 to 2015. The course of urgency and associated bother was evaluated with the Danish Prostatic Symptom Score at baseline and follow-up. Logistic regression was utilized to explore risk factors of increased bother at follow-up.

Results: A total of 2,480 men (39%) who had responded at baseline and follow-up were included in the study. Of them, 1,056 men (43%) had persistent mild urgency and 132 men (5%) persistent moderate or severe urgency at follow-up. The proportions of men experiencing at least moderate bother due to persistent urgency at follow-up were 6% (95% confidence interval 4.5–7.3) of those with mild and 79% (71.7–85.9) of the men with moderate or severe urgency. In multivariable-adjusted logistic regression, moderate to severe urgency was strongly associated with bother (odds ratio, OR 55.2, 95% CI 32.1–95.2). Other predictors of bother included cardiac disease (OR 1.8, 95% CI 1.0–31.1), pulmonary disease (OR 1.9, 95% CI 1.1–3.5) and medical treatment (OR 2.7, 95% CI 1.6–4.6).

Conclusions: Most men with urinary urgency have mild symptoms and bother. Only one out of five men with persistent moderate or severe urgency adapt to the symptoms. Men with a history of medical treatment for lower urinary tract symptoms (LUTS) or impaired cardiopulmonary health are more likely to experience bother from urinary urgency.

Normalised repeat serum prostate-specific antigen: associations with age and magnetic resonance imaging results

Hang Dang — 2024-03-06

Objective: To assess the value of a repeat prostate-specific antigen measurement (PSA2) before magnetic resonance imaging (MRI) in men with a raised PSA (PSA1) <10 µg/L.

Method: Medical records of men aged < 75 years referred in 2021 for PSA1 3.0–9.9 µg/L (< 70 years) or 5.0–9.9 µg/L (70–74 years) were reviewed. PSA2 was sampled before MRI within 60 days from PSA1. Odds ratios (ORs) were calculated with logistic regression. Chi-square and trend-test were used for categorical variables.

Results: A total of 341 men were included. Median time between PSA1 and PSA2 was 28 days (interquartile range 20–35 days). PSA normalised in 16% (95% confidence interval [CI]: 13–21). Younger men were more likely to have a normal PSA2 (OR: 0.95 per year older, 95% CI: 0.92–0.99). Among men aged < 70 years, those with PSA1 < 5 µg/L were more likely to have normalised PSA2 than those with PSA1 ≥ 5 µg/L (21% vs. 10%, p = 0.01). A greater proportion of men with normalised PSA2 had a Prostate Imaging Data and Reporting System MRI score of 1–3 than men with non-normalised PSA2 (93% vs. 77%, p = 0.01).

Conclusions: A clinically significant proportion of men with a moderately raised PSA value have a normal PSA2. Younger men and men with lower PSA1 were more likely to have a normal PSA2. Few men with normalised PSA2 had suspicious MRI findings. Routine repeat PSA-testing may be motivated in men with a moderately raised PSA value to save MRI resources, particularly in younger men.

Patients experience with the use of a penile clamp in post-prostatectomy incontinence – a prospective pilot study

Alexandru Jula — 2024-03-11

Objectives: The aim of this study was to assess the efficacy of a penile clamp in managing urinary incontinence (UI) and its impact on perceived quality of life (QoL) amongst post-prostatectomy patients.

Material and methods: A prospective pilot study was conducted including patients with post-prostatectomy UI treated with a penile clamp. Inclusion criteria consisted of UI after radical prostatectomy, good hand function, full cognitive function and a minimum penile length of 3 cm and a circumference of 5 cm. An appropriately sized penile clamp was selected during the first visit, and patients were given instructions on how to use it. The first follow-up was a scheduled phone call 1 week after the initial visit. Formal evaluations were performed prior to use of the penile clamp and again after 3 months of usage. These consisted of weighing pads during the daytime with evaluation of leakage, International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), incontinence-QoL (I-QoL) and a questionnaire specific for the penile clamp.

Results: There were 22 patients included, and two were excluded due to reduced hand function and surgery before the study endpoint. The results showed a significant median reduction of urinary leakage of 57% at rest and 58% during physical activity. One complication was observed, as one patient developed a pinching ulcer, after extensive usage. ICIQ-SF showed an increase of 6% for the included patients (n = 20). Ten patients were satisfied with the clamp, and 15 would recommend the clamp to others.

Conclusion: The penile clamp shows promising results in reducing leakage with minimal risks of complications. It can be used as a treatment for patients awaiting surgery. However, patient selection is important regarding hand function, cognitive function and the penile anatomy.

Triggers for transition from active surveillance to radical treatment of prostate cancer 2008–2020 – a case-control study

Mats Ahlberg — 2024-03-14

Objective: To examine associations between objective signs of progression (triggers) and transition from active surveillance (AS) to radical treatment for prostate cancer (PC).

Patients and methods: This case-control study included men with low- or favourable intermediate-risk PC in the region of Halland, with data from The National Prostate Cancer Register (NPCR), Sweden, starting AS between 2008 and 2020. Cases were men who transitioned to radical treatment. For each case, 10 controls who remained in AS were selected without further matching. Triggers for transition to treatment were histopathological progression, magnetic resonance imaging (MRI) progression and increases in prostate-specific antigen (PSA) levels. We compared the probabilities for triggers between cases and controls, in 2008–2014 and 2015–2020, using logistic regression.

Results: Amongst 846 men, we identified 98 cases in 2008–2014 and 172 cases in 2015–2020. Histopathological progression was associated with transition, most strongly in the later period (2008–2014: odds ratios [OR] 6.88, 95% confidence interval [CI] 3.69–12.80; and 2015–2020: OR 75.29, 95% CI 39.60–143.17). MRI progression was associated with transition in 2015–2020 (OR 6.38, 95% CI 2.70–15.06), whereas an increase in PSA was weakly associated with transition in the early period. The absence of triggers was associated with no transition (2008–2014: OR 0.24, 95% CI 0.15–0.40, and 2015–2020: OR 0.09, 95% CI 0.06–0.14). The probability of no trigger was 27% in cases 2015–2020.

Conclusion: The increase in association between histopathological trigger and transition to treatment indicates increased quality of AS. Still, amongst men treated from 2015 to 2020, 27% transitioned without any trigger.

Cutaneous adverse reactions associated to apalumide: two case reports of DRESS syndrome and maculopapular exanthema

Sanna Hallamies — 2024-06-13

Don’t throw out the baby with the bath water!

Amir Sherif — 2024-05-20