Radical nephroureterectomy for pathologic T4 upper tract urothelial cancer: can oncologic outcomes be improved with multimodality therapy?

Purpose To report the outcomes of patients with pathologic T4 UTUC and investigate the potential impact of peri-operative chemotherapy combined with radical nephroureterectomy (RNU) and regional lymph node dissection (LND) on oncologic outcomes. Materials and Methods Patients with pathologic T4 UTUC were identified from the cohort of 1464 patients treated with RNU at 13 academic centers between 1987 and 2007. Oncologic outcomes were stratified according to utilization of perioperative systemic chemotherapy and regional LND as an adjunct to RNU. Results The study included 69 patients, 42 males (61%) with median age 73 (range 43-98). Median follow-up was 17 months (range: 6-88). Lymphovascular invasion was found in 47 (68%) and regional lymph node metastases were found in 31 (45%). Peri-operative chemotherapy was utilized in 29 (42%) patients. Patients treated with peri-operative chemotherapy and RNU with LND demonstrated superior oncologic outcomes compared to those not treated by chemotherapy and/or LND during RNU (3Y-DFS: 35% vs. 10%; P = 0.02 and 3Y-CSS: 28% vs. 14%; P = 0.08). In multivariate Cox regression analysis, administration of peri-operative chemotherapy and utilization of LND during RNU was associated with lower probability of recurrence (HR: 0.4, P = 0.01), and cancer specific mortality (HR: 0.5, P = 0.06). Conclusions Pathological T4 UTUC is associated with poor prognosis. Peri-operative chemotherapy combined with aggressive surgery, including lymph node dissection, may improve oncological outcomes. Our findings support the use of aggressive multimodal treatment in patients with advanced UTUC. .

Robot-assisted vs. Laparoscopic Partial Nephrectomy: utilization rates and perioperative outcomes

Objectives To examine the effect of surgical approach on perioperative morbidity and mortality after partial nephrectomy. Materials and Methods Within the Nationwide Inpatient Sample, patients who underwent RAPN or LPN between October 2008 and December 2009 were identified. Propensity-based matching was performed to adjust for potential baseline differences between the two groups. The rates of intraoperative and postoperative complications, blood transfusions, prolonged length of stay, and in-hospital mortality, stratified according to RAPN vs. LPN, were compared. Results Overall, 851 (72.5%) patients underwent RAPN and 323 (27.5%) underwent LPN. For RAPN and LPN respectively, the following rates were recorded in the propensity-score matched cohort: blood transfusions, 4.5 vs. 6.8% (p = 0.223); intraoperative complications, 5.2 vs. 2.6% (p = 0.096); postoperative complications, 10.6 vs. 13.5% (p = 0.268); prolonged length of stay, 6.8 vs. 9.4% (p = 0.238); in-hospital mortality, 0.0 vs. 0.0%. Conclusions RAPN has supplanted LPN as the predominant minimally invasive surgical approach for renal masses. Perioperative outcomes after RAPN and LPN are comparable. Interpretation of these findings needs to take into account the lack of adjustment for case complexity and surgical expertise. .

Intravesical therapy for urothelial carcinoma of the urinary bladder: a critical review

The management of non-muscle-invasive urothelial carcinoma of the bladder (UCB) is a challenge for physicians and patients alike. This is largely due to the heterogeneous natural history of this disease, in which tumors range from indolent to rapidly progressive and eventually fatal. Moreover, the high rate of recurrence and progression cause significant morbidity, expense, and detriment to quality of life. The advent of effective and safe intravesical therapies has improved the management of non-muscle-invasive UCB. Nevertheless, despite over 30 years of research and clinical experience, the mechanism, risks, benefits, and optimal regimens and treatment algorithms remain unclear. Although immunotherapy with bacillus Calmette-Guerin (BCG) has been the mainstay of intravesical treatment and represents a significant advance in the interaction of immunology and oncology, its clinical effectiveness is accompanied by a wide range of adverse events. Here, we review the literature on intravesical immunotherapy and chemotherapy with the aim of evaluating the clinical utility of the different treatments and providing recommendations. Many studies over the years have compared efficacy and toxicities of different agents and regimens, and certain conclusions are now well supported by high-level evidence. Future perspectives and promising advances in drug development are discussed and areas of improvement are identified in order to promote better cancer control and decrease the rate and severity of side-effects.