Ilias Cagiannos

Urology, Oncology

38.45

Publications

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    ABSTRACT: The proportion of patients with stage 1 renal tumours receiving partial nephrectomy is considered a quality of care indicator. The objective of this study was to characterize surgical practice patterns at Canadian academic institutions for the treatment of these tumours. The Canadian Kidney Cancer Information System (CKCis) is a multicentre collaboration of 13 academic institutions in Canada. All patients with pathologic stage T1 renal tumours in CKCis were identified. Descriptive statistics were performed to characterize practice patterns over time. Associations between patient, tumour, and treatment factors with the use of partial nephrectomy were determined. From 1988 to April 2014, 1453 patients with pathologic stage 1 renal tumours were entered in the CKCis database. Of these, 977 (67%) patients had pT1a tumours; of these, 765 (78%) received partial nephrectomy. Of the total number of patients (1453), 476 (33%) had pT1b tumours; of these, 204 (43%) received partial nephrectomy. The use of partial nephrectomy increased over time from 60% to 90% for pT1a tumours and 20% to 60% for pT1b tumours. Stage pT1b (relative risk [RR] 0.56, 95% confidence interval [CI] 0.50-0.63) and minimally invasive surgical approach (RR 0.78, 95% CI 0.73-0.84 for pT1a and RR 0.23, 95% CI 0.17-0.30 for pT1b) were associated with decreased use of partial nephrectomy. Most patient factors including age, gender, body mass index, hypertension, and renal function were not significantly associated with use of partial nephrectomy (p > 0.05). Almost all pT1a and most pT1b renal tumours managed surgically at academic centres in Canada receive partial nephrectomy. The use of partial versus radical nephrectomy appears to occur independently of patient age and comorbid status, which may indicate that urologists are performing partial nephrectomy whenever technically feasible based on tumour factors. Although the ideal proportion patients receiving partial nephrectomy cannot be determined, treatment distribution observed in this cohort may indicate an achievable case distribution among experienced surgeons.
    04/2015; 9(3-4). DOI:10.5489/cuaj.2598
  • The Journal of Urology 04/2015; 193(4):e865-e866. DOI:10.1016/j.juro.2015.02.2481 · 3.75 Impact Factor
  • The Journal of Urology 04/2015; 193(4):e965. DOI:10.1016/j.juro.2015.02.2756 · 3.75 Impact Factor
  • The Journal of Urology 04/2015; 193(4):e900. DOI:10.1016/j.juro.2015.02.2555 · 3.75 Impact Factor
  • The Journal of Urology 04/2015; 193(4):e697. DOI:10.1016/j.juro.2015.02.2008 · 3.75 Impact Factor
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    ABSTRACT: We evaluate the associations between 3 renal tumour scoring systems and their components with perioperative complications of partial nephrectomy. A consecutive cohort of partial nephrectomy patients was analyzed. Patient characteristics were abstracted from medical records. PADUA scores (preoperative aspects and dimensions used for anatomic classification), RENAL (radius exophyic/endophytic nearness anterior/posterior location scoring) nephrometry scores, and Centrality index (C-index) were determined from preoperative axial images by 2 independent reviewers. Cases were evaluated for postoperative complications up to 30 days after surgery. Pre-specified complication definitions were used for 33 potential medical and surgical complications. Unadjusted and adjusted associations between overall scores, individual components, and complications were determined using log binomial regression. In total, 118 patients were included in the study. Of these, 36 (30.5%) surgical complications occurred in 27 (22.9%) patients. Fourteen (11.9%) were Clavien grade ≥3. Overall PADUA score was significantly associated with surgical and overall complications after adjusting for potential confounders. Among all components of the 3 scoring systems, only tumour diameter and exophytic/endophytic nature of the tumour were significantly associated with complications after adjusting for the other components of the respective scoring system (p < 0.05). Renal tumour scoring systems may help predict the risk of complications after partial nephrectomy. Further refinement of current systems is required. A first step would be to include only components that are significantly associated with complications.
    02/2015; 9(1-2). DOI:10.5489/cuaj.2303
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    ABSTRACT: Objective: To characterize the frequency and timing of complications following radical cystectomy in a cohort of patients treated at community and academic hospitals. Patients and Methods: Radical cystectomy patients captured from NSQIP hospitals from January 1 2006 to December 31 2012 were included. Baseline information and complications were abstracted by study surgical clinical reviewers through a validated process of medical record review and direct patient contact. We determined the incidence and timing of each complication and calculated their associations with patient and operative characteristics. Results: 2303 radical cystectomy patients met inclusion criteria. 1115 (48%) patients were over 70 years old and 1819 (79%) were male. Median hospital stay was 8 days (IQR 7-13 days). 1273 (55.3%) patients experienced at least 1 post-operative complication of which 191 (15.6%) occurred after hospital discharge. The most common complication was blood transfusion (n = 875; 38.0%), followed by infectious complications with 218 (9.5%) urinary tract infections, 193 (8.4%) surgical site infections, and 223 (9.7%) sepsis events. 73 (3.2%) patients had fascial dehiscence, 82 (4.0%) developed a deep vein thrombosis, and 67 (2.9%) died. Factors independently associated with the occurrence of any post-operative complication included: age, female gender, ASA class, pre-operative sepsis, COPD, low serum albumin concentration, pre-operative radiotherapy, pre-operative transfusion >4 units, and operative time >6 hours (all p<0.05). Conclusion: Complications remain common following radical cystectomy and a considerable proportion occur after discharge from hospital. This study identifies risk factors for complications and quality improvement needs.
    PLoS ONE 10/2014; 9(10):e111281. DOI:10.1371/journal.pone.0111281 · 3.53 Impact Factor
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    ABSTRACT: Purpose A positive surgical margin (SM) during radical prostatectomy (RP) increases risk of biochemical recurrence. We evaluated the effect of nerve-sparing procedures on risk of positive SM for pT2- and pT3-category tumors. We hypothesized that nerve sparing would increase rates of pT2 positive margins. Methods We evaluated a historical cohort of 9,915 consecutive RP patients treated at The Ottawa Hospital or Memorial Sloan-Kettering Cancer Center from 2000 to 2010. Patients underwent open, laparoscopic, or robotic RP. The primary outcome was presence of a positive SM stratified by pathologic pT2 and pT3 categories. The association between nerve sparing and positive margin was adjusted for prostate-specific antigen, RP Gleason sum, surgical modality, surgical date, and location in the multivariable model. Results Of 6,120 eligible patients, 3,958 (64.7%) had open RP, 1,566 (25.6%) had laparoscopic RP, and 596 (9.7%) had robotic RP. Approximately 8.6% (363/4,199) of patients with pT2-category disease and 25.2% (485/1,921) of patients with pT3-category disease had a positive margin. Patients with pT2-category disease who underwent a bilateral nerve-sparing procedure were more likely to have a positive margin when compared with those who underwent nerve resection on multivariable analysis (relative risk [RR] = 1.52, 95% CI: 0.97–2.39) after adjusting for confounders. Patients with pT3-category disease who underwent a bilateral nerve-sparing procedure had no associated increase in risk of positive margin after adjustment for other variables (RR = 0.96, 95% CI: 0.80–1.16). Prostate incision into tumor (pT2R1) was significantly more likely in patients treated with robotic surgery (RR = 1.76, 95% CI: 1.25–2.48) than in those with open surgery. There was no difference between laparoscopic and open RP (RR = 0.86, 95% CI: 0.65–1.12). Conclusions Bilateral nerve sparing is associated with increased risk of positive SMs in patients with pathologic T2-category disease during RP.
    Urologic Oncology 10/2014; DOI:10.1016/j.urolonc.2014.09.006 · 3.36 Impact Factor
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    ABSTRACT: Introduction: We review a subset of men who had discordant prostate biopsy sums and were treated with radical prostatectomy. Methods: Consecutive patients treated with radical prostatectomy at The Ottawa Hospital between 2000 and 2012 were reviewed. Those with at least 1 prostate biopsy core of Gleason sum >= 8 and at least 1 prostate biopsy core of Gleason sum <= 7 cancer were included. Results: Of the 764 radical prostatectomies, 661 (87%) were eligible for the study and 35 (5%) met inclusion criteria. Of these, only 16 (46%) had prostatectomy Gleason sum of >= 8. When the highest biopsy core was Gleason sum 8 (n = 24), only 7 (29%) had a prostatectomy Gleason sum >= 8. When the highest biopsy core was Gleason 9 (n = 11), 9 (82%) had a prostatectomy Gleason sum >= 8 (relative risk [RR] 2.8; p = 0.004). Patients with clinical T3 tumours were at higher risk of Gleason sum = 8 compared to cT1 patients (RR 3.7; p = 0.008). Patient age (p = 0.89), preoperative prostate-specific antigen (p = 0.34), prostate volume (p = 0.86), number of biopsy cores (p = 0.18), and proportion of biopsy cores with cancer (p = 0.96) were not strongly associated with risk of prostatectomy Gleason sum >= 8. Conclusion: These data should be considered when assigning patients into prognostic risk categories based on prostate biopsy information. Further study to verify our findings using larger samples is warranted.
    07/2014; 8(7-8):E476-80. DOI:10.5489/cuaj.1737
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    ABSTRACT: Pelvic vasculature is complex and inconsistent while pelvic bones impede access to pelvic organs. These anatomic characteristics render pelvic surgery inherently difficult and some of these procedures are frequently associated with blood loss that necessitates blood transfusion. The aim of this study was to review the literature on the use of lysine analogs to prevent bleeding and blood transfusion during pelvic surgery. The objective of this study was to assess the safety and efficacy of lysine analogs during pelvic surgery. A systematic literature search was performed using Medline, Cochrane Register of Clinical Trials, Embase, and the reference lists of relevant articles. Randomized controlled trials or observational cohort studies comparing a lysine analog to placebo or standard care were included. Outcomes collected were blood transfusion, blood loss, thromboembolic adverse events (myocardial infarction, stroke, deep vein thrombosis, and pulmonary embolism), non-thromboembolic adverse events, and death. There were no language limitations. Fifty-six articles reported on 68 comparisons between a lysine analog and an inactive comparator, involving a total of 7,244 patients published between 1961 and 2013. Thirty-nine studies evaluated urologic procedures and 21 evaluated gynecologic procedures. Thirty-six (60%) studies were published before 1980. Of the 43 randomized comparisons, only 30 (44%) had a score of 3 or higher on Jadad’s five point-scale of methodological quality. Among randomized trials, lysine analogs reduced the risk of blood transfusion (pooled OR 0.47; 95%CI 0.35, 0.64) and blood loss (pooled OR 0.22; 95%CI 0.18, 0.27). There was a small, statistically insignificant, increased risk of thromboembolic events (pooled OR 1.07; 95% CI 0.72, 1.59) and non-thrombotic serious adverse events (pooled OR 1.11; 95%CI 0.67, 1.83). In the 17 randomized trials published since the year 2000, only 6 thrombotic events were reported, 4 of which occurred in the placebo arm. Lysine analogs did not increase risk of death (pooled OR 0.91; 95%CI 0.34, 2.48). These results are significant as they indicate that lysine analogs significantly reduce blood loss and blood transfusion during pelvic surgery. While there does not appear to be a large increase in the risk of thromboembolic and non-thrombotic adverse events, more data is required to definitively assess these outcomes. Based on this review, lysine analogs during pelvic surgery seem to reduce bleeding and blood transfusion requirements. While there does not seem to be a significant risk of adverse effects, larger studies would help clarify risks, if any, associated with lysine analog use.
    Transfusion medicine reviews 07/2014; DOI:10.1016/j.tmrv.2014.05.002 · 4.54 Impact Factor
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    ABSTRACT: Objective: To evaluate risk factors for bladder cancer recurrence in a cohort of patients treated with radical nephroureterectomy (RNU). Patients and methods: At 10 Canadian University Centers, we retrospectively evaluated data, between 1990 and 2010, from 743 patients who were free from bladder cancer and were previously treated with RNU for upper tract urothelial cancer. Results: Of 743 patients, 167 (22.5%) developed bladder tumors after a median time of 17.2 months after RNU. Multivariable analysis detected age (hazard ratio [HR] = 1.028; 95% CI: 1.010-1.046; P = 0.0018), tumor location in both the renal pelvis and the ureter (ER = 2.205; 95% CI: 1.355-3.589; P = 0.0015), the use of adjuvant systemic chemotherapy (HR = 2.309; 95% CI: 1.439-3.705; P = 0.0005), and laparoscopic surgery (HR = 1.876; 95% CI: 1.226-2.87; P = 0.0037) as risk factors for bladder cancer recurrence. Open excision of a bladder cuff (HR = 0.661; 95% CI: 0.453-0.965; P = 0.0319) and transurethral resection of the intramural ureter (HR = 0.548; 95% CI: 0.306 0.981; P = 0.0429) on comparison with extravesical resection decreased the risk of bladder cancer recurrence significantly. Major limitations were the retrospective design and partially missing data, although the significance of variables did not change in the imputation analysis. Conclusion: Older patients, those with tumor location in both the renal pelvis and the ureter, and those treated with adjuvant systemic chemotherapy were found at higher risk for intravesical recurrence, as were those having undergone extravesical ureterectomy or laparoscopic RNU.
    Urologic Oncology 05/2014; 32(6). DOI:10.1016/j.urolonc.2014.04.006 · 3.36 Impact Factor
  • The Journal of Urology 04/2014; 191(4):e713. DOI:10.1016/j.juro.2014.02.1950 · 3.75 Impact Factor
  • The Journal of Urology 04/2014; 191(4):e640. DOI:10.1016/j.juro.2014.02.1774 · 3.75 Impact Factor
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    ABSTRACT: To evaluate the effect of body mass index (BMI) on the outcomes of patients with urinary tract carcinoma treated with radical surgery. Data were collected from 10 Canadian centers on patients who underwent radical cystectomy (RC) (1998-2008) or radical nephroureterectomy (RNU) (1990-2010). Various parameters among subsets of patients (BMI<25, 25≤BMI<30, and BMI≥30kg/m(2)) were analyzed. Kaplan-Meier and multivariate analyses were performed to assess the effect of BMI on overall survival, disease-specific survival, and recurrence-free survival (RFS). Among the 847 RC and 664 RNU patients, there was no difference in histology, stage, grade, and margin status among the 3 patient subsets undergoing either surgery. However, RC patients with lower BMIs (<25kg/m(2)) were significantly older (P = 0.004), had more nodal metastasis (P = 0.03), and trended toward higher stage (P = 0.052). RNU patients with lower BMIs (<25kg/m(2)) were significantly older (P = 0.0004) and fewer received adjuvant chemotherapy (P = 0.04) compared with those with BMI≥30kg/m(2); however, there was no difference in tumor location (P = 0.20), stage (P = 0.48), and management of distal ureter among the groups (P = 0.30). On multivariate analysis, BMI was not prognostic for overall survival, disease-specific survival, and RFS in the RC group. However, BMI≥30kg/m(2) was associated with more bladder cancer recurrences and worse RFS in the RNU group (HR = 1.588; 95% CI: 1.148-2.196; P = 0.0052). Increased BMI did not influence survival among RC patients. BMI≥30kg/m(2) is associated with worse bladder cancer recurrences among RNU patients; whether this is related to difficulty in obtaining adequate bladder cuff in patients with obesity requires further evaluation.
    Urologic Oncology 01/2014; 32(4). DOI:10.1016/j.urolonc.2013.10.016 · 3.36 Impact Factor
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    ABSTRACT: Objective To evaluate risk factors for bladder cancer recurrence in a cohort of patients treated with radical nephroureterectomy (RNU). Patients and methods At 10 Canadian University Centers, we retrospectively evaluated data, between 1990 and 2010, from 743 patients who were free from bladder cancer and were previously treated with RNU for upper tract urothelial cancer. Results Of 743 patients, 167 (22.5%) developed bladder tumors after a median time of 17.2 months after RNU. Multivariable analysis detected age (hazard ratio [HR] = 1.028; 95% CI: 1.010–1.046; P = 0.0018), tumor location in both the renal pelvis and the ureter (HR = 2.205; 95% CI: 1.355–3.589; P = 0.0015), the use of adjuvant systemic chemotherapy (HR = 2.309; 95% CI: 1.439–3.705; P = 0.0005), and laparoscopic surgery (HR = 1.876; 95% CI: 1.226–2.87; P = 0.0037) as risk factors for bladder cancer recurrence. Open excision of a bladder cuff (HR = 0.661; 95% CI: 0.453–0.965; P = 0.0319) and transurethral resection of the intramural ureter (HR = 0.548; 95% CI: 0.306–0.981; P = 0.0429) on comparison with extravesical resection decreased the risk of bladder cancer recurrence significantly. Major limitations were the retrospective design and partially missing data, although the significance of variables did not change in the imputation analysis. Conclusion Older patients, those with tumor location in both the renal pelvis and the ureter, and those treated with adjuvant systemic chemotherapy were found at higher risk for intravesical recurrence, as were those having undergone extravesical ureterectomy or laparoscopic RNU.
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    ABSTRACT: To evaluate the impact of concomitant carcinoma in situ (CIS) on upstaging and outcome of patients treated with radical cystectomy with pelvic lymph node dissection. We collected and pooled a database of 1,968 patients who have undergone radical cystectomy between 1998 and 2008 in eight academic centers across Canada. Collected variables included patient's age, gender, tumor grade, histology and the presence of concomitant CIS with either cTa-1 or cT2 disease, dates of recurrence and death. In the presence of concomitant CIS, upstaging following radical cystectomy occurred in 48 and 55 % of patients with cTa-1 and cT2 disease, respectively. On univariate analysis, the presence of concomitant CIS with cT2 disease was associated with upstaging (p < 0.0001), and the presence of concomitant CIS with cTa-1 disease was also associated with upstaging but did not reach statistical significance (p = 0.0526). On multivariate analyses, the presence of concomitant CIS with either cTa-1 or cT2 tumors was independently prognostic of disease upstaging (p = 0.0001 and 0.0186, respectively). However, on multivariate analysis that incorporates pathologic stage, concomitant CIS was not significantly associated with worse overall, recurrence-free or disease-specific survival. These results demonstrate that while the presence of concomitant CIS on cystectomy specimens does not independently affect outcomes, its presence is significantly predictive of a higher rate of upstaging at radical cystectomy.
    World Journal of Urology 11/2013; 32(5). DOI:10.1007/s00345-013-1207-z · 3.42 Impact Factor
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    ABSTRACT: Our objective is to assess differences in practice patterns and outcomes across 3 regions in bladder cancer patients treated with radical cystectomy under a universal healthcare system. In total, we included 2287 patients treated with radical cystectomy at 8 Canadian centres from 1998 to 2008. Variables included various clinico-pathologic parameters, recurrence, and death stratified into different regions. In total, 1105 patients were from the east region (group 1), 601 from the centre region (group 2), and 581 from the west region of Canada (group 3). The median follow-up of groups 1, 2, and 3 was 22.1, 17.1, and 28.6 months, respectively. Although the overall rate of neoadjuvant chemotherapy was low (3.1%), rates were higher in group 2 compared with groups 1 and 3 (p = 0.07). Continent diversions and extended lymphadenectomy were performed in 23.5%, 8.5%, 23.9% and 39.7%, 27.7%, 12.6% across groups 1, 2, and 3, respectively. There were statistically significant differences in gender distribution, performance of lymphadenectomy, presence of concomitant carcinoma in situ and lymphovascular invasion across the 3 groups. There were no differences among the 3 geographical locations in terms of stage, surgical margin status, and use of adjuvant chemotherapy. The mean number of days from the transurethral resection of the bladder tumour to cystectomy was 50, 79, 69 days for groups 1, 2, 3, respectively (p = 0.0006). The 5-year overall survival was 53.6%, 66.8%, and 52.4% for groups 1, 2 and 3, respectively (p < 0.0001). Significant variations in practice patterns were noted across different geographic regions in a universal healthcare system. Use of continent diversions, extended lymphadenectomy, and neoadjuvant chemotherapy remains low across all 3 regions. Treatment delays are significant.
    Canadian Urological Association journal = Journal de l'Association des urologues du Canada 11/2013; 7(11-12):E667-E672. DOI:10.5489/cuaj.201 · 1.92 Impact Factor
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    ABSTRACT: There is no consensus on optimal use of radiotherapy following radical prostatectomy. The purpose of this study was to describe opinions of urologists and radiation oncologists regarding adjuvant and salvage radiotherapy following radical prostatectomy. Urologists and genitourinary radiation oncologists were solicited to participate in an online survey. Respondent characteristics included demographics, training, practice setting, patient volume/experience, and access to radiotherapy. Participant practice patterns and attitudes towards use of adjuvant and salvage radiotherapy in standardized clinical scenarios were assessed. One hundred and forty-six staff physicians participated in the survey (104 urologists and 42 genitourinary radiation oncologists). Overall, high Gleason score (Gleason 7 vs. 6, RR 1.37 95% CI 1.19-1.56, p<0.0001 and Gleason 8-10 vs. 6, RR 1.56 95% CI 1.37-1.78, p<0.0001), positive surgical margin (RR 1.43 95% CI 1.26-1.62, p<0.0001), and extraprostatic tumour extension (RR 1.16 95% CI 1.05-1.28, p<0.002) conferred an increased probability of recommending adjuvant radiotherapy. Radiation oncologists were more likely to recommend adjuvant radiotherapy across all clinical scenarios (RR 1.48, 95% CI 1.39, 1.60, p <0.001). Major differences were found for patients with Gleason 6 and isolated positive surgical margin (radiotherapy selected by 21% of urologists vs. 70% of radiation oncologists), and patients with extraprostatic extension and negative surgical margins (radiotherapy selected by 18% of urologist vs. 57% of radiation oncologists). Urologists and radiation oncologists frequently disagree about recommendation for post-prostatectomy adjuvant radiotherapy. Since clinical equipoise exists between adjuvant versus early salvage post-operative radiotherapy, support of clinical trials comparing these approaches is strongly encouraged.
    PLoS ONE 11/2013; 8(11):e79773. DOI:10.1371/journal.pone.0079773 · 3.53 Impact Factor
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    ABSTRACT: Stereotactic ablative body radiotherapy (SABR) is currently under study regarding its clinical application in management of patients with kidney tumors. CyberKnife can accurately deliver ablative tumor radiation doses while preserving kidney function. We report Canada's first use of CyberKnife SABR system in treating primary kidney tumors. Between January 2011 and February 2012, we treated three patients with renal tumors using CyberKnife SABR. Two patients had tumors in solitary kidney. The third patient had a recurrent tumor after two previous radiofrequency ablation treatments. Platinum seed fiducials were used for real time tumor tracking. Magnetic resonance imaging registration was used for tumor delineation in all cases. The patients were followed with regular renal scans and renal function tests. The mean age was 79 years. Mean tumor size was 21.3 cm3. A dose of 39 Gy in 3 fractions was delivered. The post treatment follow up times were 15 months, 13 months and 12 months. Local control was obtained in all three patients. No acute or chronic toxicity was reported. Kidney functions remained unaffected after treatment. CyberKnife is technically feasible for treatment of medically inoperable renal tumors or tumors in a solitary kidney.
    The Canadian Journal of Urology 10/2013; 20(5):6944-6949. · 0.91 Impact Factor
  • European Urology 06/2013; 64(3). DOI:10.1016/j.eururo.2013.06.014 · 12.48 Impact Factor

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