Single-course bleomycin, etoposide, and cisplatin (1xBEP) as adjuvant treatment in testicular nonseminoma clinical stage 1: outcome, safety, and risk factors for relapse in a population-based study.

Introduction: Clinical stage 1 (CS1) nonseminomatous (NS) germ cell tumors involve a 30% probability of relapse upon surveillance. Adjuvant chemotherapy with one course of bleomycin, etoposide, and cisplatin (1xBEP) can reduce this risk to <5%. However, 1xBEP results are based solely on five controlled trials from high-volume centers. We analyzed the outcome in a real-life population. Patients and Methods: In a multicentric international study, 423 NS CS1 patients receiving 1xBEP were retrospectively evaluated. Median follow-up was 37 (range, 6-89) months. Primary end points were relapse-free and overall survival evaluated after 5 years. We also looked at associations of relapse with clinico-pathological factors using stratified Kaplan-Meier methods and Cox regression models. Treatment modality and outcome of recurrences were analyzed descriptively. Results: The 5-year relapse-free survival rate was 96.2%. Thirteen patients (3.1%; 95% confidence interval, 1.65-5.04%) relapsed after a median time of 13 months, of which 10 were salvaged (77%). Relapses were mostly confined to retroperitoneal nodes. Three patients succumbed, two to disease progression and one to toxicity of chemotherapy. Pathological stage >pT2 was significantly associated with relapse rate. Conclusion: The relapse rate of 3.1% found in this population of NS CS1 patients treated with 1xBEP at the routine care level was not inferior to the median rate of 2.3% reported from a meta-analysis of controlled trials. Also, the cure rate of relapses of 77% is consistent with the previously reported rate of 80%. This study clearly shows that the 1xBEP regimen represents a safe treatment for NS CS1 patients.

Can a Simple Geriatric Assessment Predict the Outcome of TURP?

PURPOSE: To determine the impact of a simple preoperative geriatric assessment on the outcome in older patients with recurrent urinary retention who underwent desobstructive surgery. PATIENTS AND METHODS: Patients aged 75 years or older with recurrent urinary retention referred for TURP entered this prospective, multicentre study. Several demographic, intra- and postoperative parameters were assessed. Preoperative geriatric assessment was performed by the 7-item Canadian Study of Health and Ageing (CSHA) frailty scale (1: very fit, 7: severely frail; completion takes less than a minute). The main outcome parameters were successful voiding rates at discharge and 3 months postoperatively. RESULTS: A total of 54 patients were recruited; 42 (77.8%) patients had a CSHA index of 1-3 and were considered as "fit", the remaining 12 (22.2%) formed the "frail" group (CSHA index 4-7). Age was identical in both cohorts (79.5 ± 3.7 vs. 79.7 ± 3.3 years); differences were demonstrable for the American Society of Anesthesiologists (ASA) score (p = 0.001), the number of daily medications (>4: 32 vs. 75%, p = 0.02), falls within the past 6 months (12 vs. 33%), and the necessity of home/nursing care (5 vs. 42%, p = 0.004). Intra- and perioperative complications, duration of postoperative catheterization, and length of hospitalization were identical in both cohorts. The success rate at discharge was 80.6% in fit and 75.0% in frail patients; the respective values at 3 months were 95.2 and 83.3%. CONCLUSIONS: A simple 1-min geriatric assessment tool can predict - to a certain extent - the outcome of desobstructive surgery in older patients with recurrent urinary retention. Fit patients achieve an excellent outcome while frail patients might benefit from a more in-depth urodynamic/geriatric evaluation.

Bladder cancer in nonagenarians: a multicentre study of 123 patients.

OBJECTIVE: To investigate the oncological outcome of nonagenarians with bladder cancer, as a substantial rise in bladder cancer in the old-old age group in the upcoming decades is expected, due to demographic changes and the peak incidence around the age of 85 years. The paucity of data of nonagenarians prompted us to investigate the outcomes of such patients. PATIENTS AND METHODS: A retrospective, multicentre study was designed to assess patient demographics, tumour patterns, treatment strategies and outcome in patients aged ≥90 years treated at participating centres. Patients entered either as de novo or as recurrent cancer. The study period ranged from 01.01.2006 to 31.12.2016. RESULTS: A total of 123 patients with a mean (range) age of 91 (90-99) years were recruited. The American Society of Anesthesiologists Physical Status Classification (ASA-score) distribution was as follows: II, 38%; III, 50%; IV, 12%; and the male to female ratio 2.4:1. The median (range) follow-up was 8 (1-132) months. In all, 60% of patients had a de novo cancer diagnosis. Histological findings revealed: pTa 39% (n = 48), pT1 28.5% (n = 35), and ≥pT2 33% (n = 40). Overall, 67.5% patients had no recurrence, 25.2% one and 7.5% two or more. pTa tumours (n = 48) recurred in 20 patients (42%), pT1 tumours (n = 35) in 12 (34%), and ≥pT2 tumours (n = 40) in six (15%). The median overall survival (OS) was 30.0 months for patients with pTa tumours, 14.0 months for pT1 tumours, and 6.0 months for ≥pT2 tumours. The overall mortality rate of patients with pTa tumours was 40%, with pT1 tumours at 60%, and ≥pT2 tumours 75%. The ASA-score also had a strong influence on median OS after stratification by ASA-score (II, 30 months; III, 12 months; IV, 4 months). CONCLUSIONS: In nonagenarians with bladder tumours, pTa/pT1/≥pT2 stages are almost evenly distributed and two-thirds of patients had no recurrence after transurethral resection of the bladder. The mean OS was 1.3 years, and 6 months for ≥pT2 tumours. Further case-series of patients in this specific age-group are required to identify the best management of this increasing proportion of patients with bladder tumours.

The Impact of Gender on Tumour Stage in In-House Complications and Choice of Urinary Diversion: Results of the Austrian Cystectomy Registry.

INTRODUCTION AND OBJECTIVES: Bladder cancer is characterized by gender-dependent disparities. To further address this issue, we analysed a prospective, multicentre cystectomy registry. METHODS: An online database was developed that included patient demographics, intra/perioperative data, surgical data and in-house complications. RESULTS: Four hundred fifty-eight patients (112 [24.5%] women and 346 [75.5%] men) were analysed. Men and women were comparable regarding age (mean 68 years), body mass index (mean 26.5) and the mean Charlson score (4.8). Women had more advanced tumour-stages (pT3/pT4; women: 57.1%; men: 48.1%). The rate of incontinent urinary diversion was higher in women (83.1%) than in men (60.2%) and in a multivariate analysis, the strongest predictors were M+ status (OR 11.2), female gender (OR 6.9) and age (OR 6.5). Women had a higher intraoperative blood transfusion rate. The overall rate of in-house complications was similar in both genders (men: 32.0%, women: 32.6%). Severe (Clavien-Dindo grade >2) medical (women: 6.3%; men: 5.2%) and surgical (women: 21.5%; men: 14.4%) in-house complications, however, were more frequent in women. CONCLUSIONS: This multicentre registry demonstrates several gender-related differences in patients undergoing radical cystectomy. The higher transfusion rate, the rare use of orthotopic bladder substitutes and the higher in-house complication rate underline the higher complexity of this procedure in women.

Orally administered colistin leads to colistin-resistant intestinal flora and fails to prevent faecal colonisation with extended-spectrum ß-lactamase-producing enterobacteria in hospitalised newborns.

Colonisation and infection with extended-spectrum ß-lactamase-producing Enterobacteriaceae (ESBL-E) is an emerging problem. The aim of this study was to investigate whether colistin, which is reported to be effective against multiresistant enterobacteria, prevents ESBL-E colonisation in neonates. For prophylaxis of necrotising enterocolitis, oral gentamicin (15 mg/kg/day) is routinely used in all neonates hospitalised at the Neonatal Intensive Care Unit of University Hospital Graz (Austria). During the study period from May 2005 to September 2007, three ESBL-E outbreaks (total duration 18 months) occurred. During these outbreaks, gentamicin was immediately replaced by oral colistin (8 mg/kg/day) in all hospitalised neonates. All neonates colonised with ESBL-E during the study period were retrospectively analysed with regard to the influence of colistin on ESBL-E colonisation. Genetic relatedness of isolates was assessed by repetitive sequence-based polymerase chain reaction (rep-PCR). During the study period, 30 (4.5%) of 667 neonates were colonised with ESBL-E. Twelve of twenty-one patients colonised with Klebsiella pneumoniae (ESBL-Kp) and one of nine patients colonised with Klebsiella oxytoca (ESBL-Ko) had received oral colistin at time of colonisation with ESBL-E. Amongst ESBL-Kp, the rate of colistin resistance was significantly higher in the colistin group (P=0.0075). Four different clones of ESBL-Kp and three different clones of ESBL-Ko were isolated, indicating the occurrence of patient-to-patient transmission. Colistin-resistant as well as colistin-susceptible isolates were detected within the same clones, indicating induction of resistance. At the dosage used, oral colistin did not prevent colonisation with ESBL-E and appeared to select colistin-resistant strains or to induce colistin resistance.