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Urology Jun 2024To describe the management and outcomes of patients with Ta predominantly low-grade urothelial carcinoma with focal high-grade features (FHG) (<5%), compared to those...
OBJECTIVES
To describe the management and outcomes of patients with Ta predominantly low-grade urothelial carcinoma with focal high-grade features (FHG) (<5%), compared to those with Ta low grade (LG) and Ta high grade (HG).
METHODS
Retrospective review of all patients who underwent transurethral resection of bladder tumor (TURBT) between 2005 and 2023. Patients with Ta disease were identified and categorized into LG, FHG, and HG. Kaplan Meier method was used to depict high-grade recurrence, T-stage progression, and radical cystectomy-free survival.
RESULTS
449 patients with Ta disease were identified (LG 48%, FHG 12%, and HG 40%). Patients with FHG (32%) had a second-look TURBT more frequently compared to LG (7%) and HG (29%) (p<0.01). They received intravesical therapy more frequently compared to LG (36% vs 20%) but lower than HG (55%) (p<0.01). They received radical cystectomy less frequently (7% compared to 20% for HG and 11% for LG, p=0.01). HG recurrence-free survival at 1, 3, and 5 years was HG (68%, 52%, and 43%), FHG (74%, 53%, and 49%), and LG (87%, 79%, and 73%) (log-rank p<0.01). T progression-free survival at 1, 3, and 5 years was HG (84%, 77%, and 70%), FHG (92%, 82%, and 82%), and LG (94%, 89%, and 85%) (log-rank p=0.02). Cystectomy-free survival at 1, 3, and 5 years was HG (92%, 84%, and 80%), FHG (96%, 94%, and 94%), and LG (99%, 95%, and 92%) (log-rank p<0.01) CONCLUSION: Patients with Ta FHG seem to behave more like Ta HG disease in terms of high-grade recurrences, but they are less likely to experience T stage progression and convert to cystectomy.
PubMed: 38914229
DOI: 10.1016/j.urology.2024.06.035 -
Journal of Neurosurgery. Case Lessons Jun 2024Spinal extradural arachnoid cysts (SEACs) communicate with the subarachnoid space through small communicating dural holes. The precise preoperative detection of all...
Successful detection of multiple communicating holes in multiple spinal extradural arachnoid cysts by using time-spatial labeling inversion pulse magnetic resonance imaging: illustrative case.
BACKGROUND
Spinal extradural arachnoid cysts (SEACs) communicate with the subarachnoid space through small communicating dural holes. The precise preoperative detection of all communicating holes, followed by minimally invasive dural closure, is the ideal treatment to prevent postoperative spinal deformities, especially in cases of multiple SEACs. However, standard imaging methods often fail to detect communicating hole locations. Although a few cases of successful single-hole detection via cinematic magnetic resonance imaging (MRI) have been reported, this modality's ability to detect multiple holes has not been demonstrated.
OBSERVATIONS
The authors describe the case of a 14-year-old male with myelopathy due to multiple SEACs at T5-8 and T8-12. Myelography revealed a complete block at the T8 level; no cephalic cyst or communicating holes were identified. Time-spatial labeling inversion pulse (T-SLIP) MRI revealed cerebrospinal fluid flow into the cyst at T10 and T7. A limited laminectomy or hemilaminectomy was performed at T7 and T10, and two dural holes were closed without a total cystectomy. The patient's gait disturbance and rectal disorder disappeared. The cysts were confirmed to have completely disappeared on conventional MRI at 1 year postoperatively.
LESSONS
T-SLIP MRI, a cinematic MRI, is useful for detecting multiple communicating holes in SEACs.
PubMed: 38914022
DOI: 10.3171/CASE24200 -
Urology Practice Jun 2024Our goal was to determine if board certification status was associated with improved postoperative outcomes for certain urologic oncology operations.
INTRODUCTION
Our goal was to determine if board certification status was associated with improved postoperative outcomes for certain urologic oncology operations.
METHODS
We performed a retrospective cohort study of patients aged 65 and over having radical prostatectomy (RP), radical cystectomy (RC), and radical or partial nephrectomy (RPN) by surgeons with New York State licenses from 2015 to 2021 using the Medicare limited dataset. Our primary exposure was surgeon American Board of Urology certification determined by the New York State Physician Profile. All surgeons were in practice for at least 5 years. Our primary outcomes were 90-day mortality, 30-day unplanned readmission, and hospital length of stay (LOS). We used multivariable linear and logistic regression adjusted for surgeon, hospital, and patient characteristics. We performed the analysis in R, and 2-sided values < .05 were considered statistically significant.
RESULTS
We identified 12,601 patients who had a procedure performed. At the time of the procedure, a minority of procedures (1.3%) were performed by nonboard-certified (NBC) urologists. Among the patient cohort, there were 262 and 1419 mortality and readmission events, respectively; median LOS was 2 days (interquartile range 1155). Patients operated on by NBC urologists tended to have lower-volume surgeons who were less likely to be fellowship trained and to have surgery at smaller hospitals. Patients treated by NBC urologists were more likely to have RP, and less likely to have RC and RPN. On multivariate analysis, board certification was protective against readmission for RP ( < .001) and RC ( = .02), longer LOS for RC ( = .001), and mortality for RPN ( = .008).
CONCLUSIONS
Urology board certification was associated with fewer readmissions after RP and RC, a shorter LOS after RC, and a lower risk of mortality after RPN. Given low event numbers, these findings require validation with a larger dataset.
PubMed: 38913586
DOI: 10.1097/UPJ.0000000000000629 -
SAGE Open Medical Case Reports 2024Retroperitoneal cysts, a rare surgical phenomenon, present diagnostic challenges due to their typically asymptomatic nature. A 62-year-old male presented with a 4-month...
Retroperitoneal cysts, a rare surgical phenomenon, present diagnostic challenges due to their typically asymptomatic nature. A 62-year-old male presented with a 4-month history of abdominal distension and increased burping. Upon clinical examination, a soft, distended, nontender abdomen with a palpable mass extending from the epigastric region to 3 cm below the umbilicus was revealed. Imaging revealed a 14.6 cm × 15.8 cm × 16.4 cm nonenhancing retroperitoneal lesion, compressing the right ureter and causing mild right hydronephrosis. Multiple gall bladder calculi, an umbilical hernia, and lipomatous lesions associated with adrenal glands were also discovered. Laparoscopic retroperitoneal cystectomy, cholecystectomy, and umbilical hernia repair were performed. Intraoperatively, 150 ml ascitic fluid and 1200 ml cystic fluid were found. This case highlights the intricate clinical presentation of a retroperitoneal cyst, emphasizing the need for surgical exploration. Successful laparoscopic management contributes to the evolving understanding of optimal treatment strategies.
PubMed: 38911179
DOI: 10.1177/2050313X241263773 -
Cureus May 2024Ovarian cystadenomas are benign epithelial neoplasms, many of which are of the serous subtype. Most patients present with symptoms such as abdominal pain, bloating, and...
Ovarian cystadenomas are benign epithelial neoplasms, many of which are of the serous subtype. Most patients present with symptoms such as abdominal pain, bloating, and bladder issues. This patient, who had a BMI of 45, presented with a giant ovarian serous cystadenoma identified during an elective bariatric surgery; interestingly, she was completely asymptomatic at the time of discovery. A large, predominantly cystic pelvic mass with internal septations and soft tissue components, suspicious for ovarian neoplasm, was discovered on a CT abdomen and pelvis with IV contrast. She underwent an exploratory laparotomy with complete resection, right oophorectomy, and ovarian cystectomy. Her postoperative pathology report revealed the mass to be a benign serous cystadenoma. This case serves as an example of how a massive tumor can potentially get overlooked for many years, only to be detected unintentionally in an asymptomatic patient. Healthcare quality is often negatively impacted by the inherent prejudice that many healthcare providers have toward their obese patients. Providers may mistakenly over-attribute a patient's symptoms to their obesity, failing to effectively evaluate the patient's concerns, which could lead to overlooking potentially harmful diagnoses. A comprehensive history and physical exam in all patients, especially those who are obese, is vital in ensuring timely diagnosis and management to improve patient outcomes.
PubMed: 38910640
DOI: 10.7759/cureus.60807 -
Asian Journal of Surgery Jun 2024
PubMed: 38908977
DOI: 10.1016/j.asjsur.2024.05.188 -
Urology Jun 2024
PubMed: 38908567
DOI: 10.1016/j.urology.2024.06.024 -
Urology Jun 2024Limited data exists on the frequency with which clinical progression during neoadjuvant chemotherapy (NAC) for muscle invasive bladder cancer (MIBC) impacts eligibility...
Clinical upstaging after neoadjuvant chemotherapy impacting eligibility for vaginal-sparing cystectomy: identifying bladder cancer patients who may benefit from interim imaging.
INTRODUCTION AND OBJECTIVES
Limited data exists on the frequency with which clinical progression during neoadjuvant chemotherapy (NAC) for muscle invasive bladder cancer (MIBC) impacts eligibility for a vaginal-sparing surgical approach or on the utility of interim imaging assessment. We sought to evaluate the incidence of clinical upstaging following NAC that would render a patient ineligible for a vaginal-sparing cystectomy.
METHODS
89 female patients with non-metastatic MIBC treated with NAC and radical cystectomy (RC) (2012-2023) were retrospectively reviewed. Tumor location(s) was determined from transurethral resection of bladder tumor operative reports. Pre- and post-NAC clinical staging was determined from imaging. Outcomes of interest included clinical upstaging and upstaging to vaginal invasion after NAC.
RESULTS
75/89 patients had pre- and post-NAC imaging. 55 had no change in clinical staging, six patients were upstaged (4 cT2→cT3, 2 cT3→cT4), and 14 patients were downstaged (13 cT3→cT2, 1 cT4→cT2). Of the 75 patients with pre- and post-NAC imaging, 39 had trigone tumors. Of these, 28 had no change in clinical staging, two were upstaged (1 cT2→cT3, 1 cT3→cT4) and nine were downstaged (8 cT3→cT2, 1 cT4→cT2). Overall, 6/75 (8%) of patients demonstrated clinical upstaging after NAC. 2/39 (5%) of patients with trigone tumors clinically progressed after NAC and both had vaginal invasion (pT4) on final pathology.
CONCLUSIONS
Although clinical upstaging after NAC was infrequent, 5% of patients with trigonal MIBC were rendered ineligible for vaginal-sparing cystectomy following NAC due to progression. Interim imaging assessment may identify non-responders and preserve eligibility for vaginal-sparing RC.
PubMed: 38908561
DOI: 10.1016/j.urology.2024.06.029 -
European Urology Oncology Jun 2024There is no standardized regimen for follow-up after radical cystectomy (RC) for bladder cancer (BC). To address this gap, we conducted a multicenter study involving...
Consistencies in Follow-up After Radical Cystectomy for Bladder Cancer: A Framework Based on Expert Practices Collaboratively Developed by the European Association of Urology Bladder Cancer Guideline Panels.
BACKGROUND AND OBJECTIVE
There is no standardized regimen for follow-up after radical cystectomy (RC) for bladder cancer (BC). To address this gap, we conducted a multicenter study involving urologist members from the European Association of Urology (EAU) bladder cancer guideline panels. Our objective was to identify consistent post-RC follow-up strategies and develop a practice-based framework based on expert opinion.
METHODS
We surveyed 27 urologist members of the EAU guideline panels for non-muscle-invasive bladder cancer and muscle-invasive and metastatic bladder cancer using a pre-tested questionnaire with dichotomous responses. The survey inquired about follow-up strategies after RC and the use of risk-adapted strategies. Consistency was defined as >75% affirmative responses for follow-up practices commencing 3 mo after RC. Descriptive statistics were used for analysis.
KEY FINDINGS AND LIMITATIONS
We received responses from 96% of the panel members, who provided data from 21 European hospitals. Risk-adapted follow-up is used in 53% of hospitals, with uniform criteria for high-risk (at least ≥pT3 or pN+) and low-risk ([y]pT0/a/1N0) cases. In the absence of agreement for risk-based follow up, a non-risk-adapted framework for follow-up was developed. Higher conformity was observed within the initial 3 yr, followed by a decline in subsequent follow-up. Follow-up was most frequent during the first year, including patient assessments, physical examinations, and laboratory tests. Computed tomography of the chest and abdomen/pelvis was the most common imaging modality, initially at least biannually, and then annually from years 2 to 5. There was a lack of consistency for continuing follow-up beyond 10 yr after RC.
CONCLUSIONS AND CLINICAL IMPLICATIONS
This practice-based post-RC follow-up framework developed by EAU bladder cancer experts may serve as a valuable guide for urologists in the absence of prospective randomized studies.
PATIENT SUMMARY
We asked urologists from the EAU bladder cancer guideline panels about their patient follow-up after surgical removal of the bladder for bladder cancer. We found that although urologists have varying approaches, there are also common follow-up practices across the panel. We created a practical follow-up framework that could be useful for urologists in their day-to-day practice.
PubMed: 38906795
DOI: 10.1016/j.euo.2024.05.010