Influence of Antibiotic Administration on the Urinary Bladder Cancer Early Recurrence Rate.

Bladder cancer tends to recur, making treatment one of the most expensive in oncology. The limited efficacy and high cost of adjuvant therapies in the treatment of bladder cancer prompt research on new drugs which could replace them. In vitro studies have established that antibiotics can have a cytostatic and cytotoxic effect on urinary bladder cancer cells. The objective of the study was to investigate the influence of antibiotics on the recurrence rate of bladder cancer. In a retrospective study, we analyzed a group of 199 patients with urinary bladder cancer from four urological centers. The study groups consisted of 40 patients who received ciprofloxacin and 83 patients who received beta-lactams as perioperative antimicrobial prophylaxis. The control group included 76 patients who did not get perioperative antimicrobial prophylaxis. The groups were analyzed for risk stratification, degree of malignancy, and size of the primary tumor. The average follow-up time was 24 months. The main focus of the study was to investigate the early recurrence rate of bladder cancer among studied groups, which could correlate with the effectiveness of currently used intravesical instillations. Additionally, cancer's early progression was examined. Regardless of the division used, the highest recurrence rate was found in the ciprofloxacin group. There were no statistical differences in the recurrence rate between patients who received beta-lactams and patients who did not receive any antibiotics. In addition, there were no differences due to the progression rate between the groups. Perioperative antibiotic administration does not influence the early recurrence rate in patients with nonmuscle invasive urothelial bladder cancer.

A Personalized Approach to Radical Cystectomy Can Decrease Its Complication Rates.

The aim of this study was to assess the influence of a patient's general status on perioperative morbidity and mortality after radical cystectomy, and to assess which of the used scales is best for the prediction of major complications. The data of 331 patients with muscle-invasive bladder cancer, who underwent radical cystectomy, were analyzed. The general status was assessed according to the American Society of Anesthesiologists (ASA), Charlson Comorbidity Index (CCI), Eastern Cooperative Oncology Group (ECOG), and Geriatric-8 (G-8) scales. Complications were classified according to the Clavien-Dindo classification system. In a group of patients with the highest complication rate according to the Clavien-Dindo scale, (i) statistically more patients rated high according to the ASA and ECOG scales, (ii) patients had significantly higher CCI scores (minor complications (I-II), and (iii) there were significantly more patients rated as frail with G8-predominantly those with 11 points or fewer in the scale. A patient's general status should be assessed before the start of therapy because patients with a high risk of death or serious complications (evaluated with any rating scale) should be offered conservative treatment. None of the scales can describe the risk of cystectomy, because the percentage of patients with major complications among those who achieved worse score results on any scale was not significantly different from the percentage of patients with major complications in the general group.

A Comprehensive Approach to Clinical Staging of Bladder Cancer.

BACKGROUND: A significant number of patients with advanced urothelial cell carcinoma are under- or over-staged. Implementation of clinical variables could be useful for improving the accuracy of clinical staging. AIM: To explore the differences between clinical and pathological diagnosis in patients with UCC, and to identify clinical variables that might play a role in under- or overstating. MATERIALS: A total of 553 patients after radical cystectomy were included in the analysis. Clinical stage of the disease was diagnosed according to CT or MRI in relation to clinical data. RESULTS: Higher clinical stage correlated with a higher pathological stage (p < 0.00005), but in 306 patients did not correspond (142 patients were under-staged and 164 over-staged). Over half (54.2%) of the patients staged as cT1-cT2 were misdiagnosed: 137 patients were under-staged and 133 over-staged. Hydronephrosis was associated with a higher pathological stage (p < 0.000005), mostly pT3-4 (45.13% had pT4 disease) and higher risk of nodal metastasis (p = 0.0028). The highest percentage of PSM was found in patients with pT4 (33.12%). CONCLUSIONS: Clinical staging of bladder cancer is poorly executed, with one third of patients under-staged and one third over-staged. To improve accuracy, we recommend a multimodal approach, combining histopathological evaluation with results of imaging studies.

Complication Rate after Radical Cystectomy Depends on the Surgical Technique and Patient's Clinical Status.

PURPOSE: This study aimed to explore the complication rates of radical cystectomy in patients with muscle-invasive bladder cancer and identify potential risk factors. METHODS: A total of 553 patients were included: 131 were operated on via an open approach (ORC), 242 patients via a laparoscopic method (LRC), and 180 by a robot-assisted procedure (RARC). Patient age, gender, American Society of Anesthesiologists (ASA) score, urinary diversion type, preoperative albumin level, body mass index (BMI), pathological (TNM) stage, and surgical times were collected. The severity of complications was classified according to the Clavien-Dindo scale (Grades 1-5). RESULTS: The surgical technique was significantly related to the number of complications (p < 0.00005). Grade 1 complications were observed most frequently following LRC (52.5%) and RARC (51.1%), whereas mostly Grade 2 complications were detected after ORC (78.6%). Those with less severe complications had significantly higher albumin levels than those with more severe complications (p < 0.05). Patients with an elevated BMI had fewer complications if a minimally invasive approach was used rather than ORC. The patient's general condition (ASA score) did not impact the number of complications, and urinary diversion type did not affect the severity of the complications. Mean surgical time differed according to the urinary diversion type in patients with a similar TNM stage (p < 0.005); however, no difference was found in those with more locally advanced disease. Longer operation time and lower protein concentration were associated with higher probability of complication rate, that is, Clavien-Dindo score 3-5. CONCLUSIONS: The risk of complications after RC is not related to the type of urinary diversion, and can be reduced by using a minimally invasive surgical technique, especially in patients with high BMI.

Radiofrequency ablation of small renal masses in comorbid patients.

INTRODUCTION: Over the recent years, the progress in imaging techniques has led to increased detection of small renal masses (SRMs), including in elderly and high-risk patients. Partial nephrectomy (nephron-sparing surgery - NSS), the current standard of care in T1a kidney tumours, has some limitations in patients who are poor candidates for surgery, as it is associated with potential perioperative complications and possible renal function loss. Radiofrequency ablation (RFA), a minimally invasive method that can be performed percutaneously, is an option in such cases. AIM: To present our experience in treatment of SRMs using RFA in comorbid patients. MATERIAL AND METHODS: In the years 2006-2012, 103 percutaneous, ultrasound-guided RFA procedures were performed in the Oncology Centre in Bydgoszcz in patients with an ASA score ≥ 3. Abdominal computed tomography and tumour biopsy were performed before the procedure. The average follow-up time was 46 months. RESULTS: The 1, 3 and 5-year overall survival rates were respectively 97%, 90% and 75%, while cancer-specific survival was 100%. No Clavien-Dindo grade ≥ 3 complications were observed. CONCLUSIONS: Radiofrequency ablation performed percutaneously is a minimally invasive treatment and may be applied in patients who are, due to comorbidities, poor candidates for surgery. In comorbid patients, where other causes of death play an important role, the application of a minimally invasive treatment method with satisfactory oncological effectiveness is justified.

Robot-assisted radical cystectomy - first Polish clinical outcomes.

INTRODUCTION: Urothelial cell carcinoma is the most common neoplasm of the genito-urinary tract, which, in advanced stages, is treated with radical cystectomy with pelvic lymphadenectomy. It can be performed by an open or minimally invasive approach (laparoscopic and robot-assisted radical cystectomy).Large meta-analyses showed a significantly lower complication rate in the RARC (robot-assisted radical cystectomy) group compared to ORC (open radical cystectomy) in thirty and ninety days after surgery, with similar oncological and functional outcomes. The clinical outcomes of the first forty Polish RARC are explored in this article. MATERIAL AND METHODS: The Polish Radical Robotic Cystectomy Program (PRRC) was started in 2016 at the Nicolaus Copernicus Hospital in Torun. Forty consecutive patients, with indications for cystectomy were included into the study. During radical robot-assisted cystectomy, obturator, external, internal, common iliac and presacral lymph nodes were dissected. Oncological outcomes, early complication rate, and the clinical variables were analyzed. RESULTS: The mean age in the study group was sixty-seven years, with the majority of patients being overweight and assessed as American Society of Anesthesiology Scale (ASA) - ASA III and ASA IV (2/3 of patients).RARC was performed, with the median time of surgery being 324 minutes (170 minutes being the shortest). Mean blood loss was 365 ml (lowest - 50 ml), and only 2 patients required intraoperative blood transfusion.Twenty patients had ileal conduit, and nineteen had other methods of urinary diversion. Only twenty-nine out of forty patients had minor complications (Clavien I and II), 11 had Clavien III and IV. Clavien V was not present. Only 3 patients required reoperation. CONCLUSIONS: RARC is a reproducible oncological procedure, which can be safely performed in centers with robotic expertise, with acceptable operative time, complications, and functional and oncologic outcomes.

Can we rely on PET in the follow-up of advanced seminoma patients?

The management of residuals after completion of chemotherapy in advanced seminoma is controversial. It has been proposed that fluorodeoxyglucose-positron emission tomography (FDG-PET) can be used as a follow-up. In this study we investigated FDG-PET as a follow-up tool in advanced seminoma patients treated previously with chemotherapy or radiotherapy. Thirty-seven patients assigned to an advanced seminoma group based on CT and/or FDG-PET/CT and then treated with chemotherapy were included in the study. All these patients underwent FDG-PET/CT examination as a part of the follow-up scheme. Patients underwent retroperitoneal lymph node dissection (RPLND), radiotherapy, or were followed clinically by CT and/or PET/CT every 6 months. In 8 cases FDG-PET was positive: 5 of them underwent RPLND and 3 radiotherapy. Two patients with negative FDG-PET but positive CT also underwent RPLND. The remaining patients with negative FDG-PET results were followed up. FDG-PET/CT was false positive in one case >3 cm and one <3 cm, in 6 cases >3 cm it was true negative. While FDG-PET can find a viable tumor, there also is an important question of false positive results. It was clinically proven that a negative FDG-PET was correlated with stable disease, but we were unable to examine specimens in these cases.

Lymph node dissection during laparoscopic (LRC) and open (ORC) radical cystectomy due to muscle invasive bladder urothelial cancer (pT2-3, TCC).

AIM: The aim of the study was to compare the number of nodes dissected during laparoscopic and open radical cystoprostatectomy in men or anterior exenteration in women due to muscle invasive bladder urothelial cancer (IBC). MATERIAL AND METHODS: Fifty-one patients treated with laparoscopic radical cystectomy (LRC) and 63 with open radical cystectomy (ORC) were compared. The LRC group consisted of 47 pT2 tumours and 4 pT3, while the ORC group was composed of 27 pT2 tumours and 36 pT3. During ORC external, internal, common iliac and obturator lymph nodes were removed separately, but were added and analysed together for each side. Nodes dissected from one side during ORC were compared to en bloc dissected nodes in the LRC group. RESULTS: There were no complications associated with extended pelvic lymph node dissection during LRC or ORC. There were significant differences in the mean number of resected lymph nodes between LRC and ORC for pT2 tumours. The laparoscopic approach allowed about 8-9 more lymph nodes to be removed than open surgery in the pT2 group. In 15% of patients with pT2 disease treated with open radical cystectomy node metastases were observed. Active disease was detected in 18% of nodes resected laparoscopically due to pT2 disease. Fourty-seven percentage of patients with pT3 disease treated with open surgery were diagnosed as harbouring metastatic lymph nodes. The laparoscopic group with pT3 disease was too small to analyse. CONCLUSIONS: We have found that laparoscopic radical cystectomy can be performed without any compromise in lymph node dissection. The technique of lymph node dissection (LND) during laparoscopic cystectomy (LRC) resulted in sufficient resected lymphatic tissue, especially in patients with bladder-confined tumours with a low volume of lymph nodes.

Radiofrequency ablation of small renal masses as an alternative to nephron-sparing surgery: preliminary results.

INTRODUCTION: Radical endoscopic minimal-invasive treatment methods, such as thermal ablation, are sought as an alternative to standard radical surgical treatment of kidney neoplasms. We analysed patients who could be qualified for radical treatment due to T1a renal tumour. MATERIAL AND METHODS: Twenty-three patients out of 129 who underwent radiofrequency thermal ablation of kidney tumours in the years 2003-2010 were analysed. The inclusion criteria were age below 70 years, lack of major comorbidities (ASA score 1, 2), and competent contralateral kidney. In all cases tumour size was below 4 cm. All patients were followed up with computed tomography (CT) and ultrasonography (USG) every 6 months for 3 years. RESULTS: In 20 patients kidney tumour was biopsied before radiofrequency ablation (RFA) and 10 of these biopsies were positive and revealed cancer. Six patients required additional treatment due to recurrence visible in CT - 3 with a positive biopsy result, 1 with negative and 2 without biopsy. Three of them were treated with a second session of RFA, 1 with radical nephrectomy and 2 with partial nephrectomy. No disease dissemination was observed and all patients who received additional treatment remain disease free. CONCLUSIONS: The RFA can be safely used in selected patients with T1a tumour as an alternative to partial nephrectomy. Careful follow-up is required after thermal ablation and allows early detection and successful treatment of recurrences.