S Machele Donat

Memorial Sloan-Kettering Cancer Center, New York City, New York, United States

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Publications (96)353.97 Total impact

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    ABSTRACT: Surveillance after radical cystectomy is recommended to detect tumor recurrence and treatment complications. We evaluated adherence to National Comprehensive Cancer Network (NCCN) guidelines using a large population-based database.
    Urologic oncology. 06/2014;
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    ABSTRACT: Men are diagnosed with bladder cancer at three times the rate of women. However, women present with advanced disease and have poorer survival, suggesting delays in bladder cancer diagnosis. Hematuria is the presenting symptom in a majority of cases. Our objective was to assess gender differences in hematuria evaluation in older adults with bladder cancer.
    The Journal of urology. 05/2014;
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    ABSTRACT: To report cancer-specific outcomes of micropapillary NMIBC. The records of 36 patients restaged within three months of initial micropapillary NMIBC diagnosis were retrospectively reviewed. Early radical cystectomy ([RC] within a three-month landmark after restaging transurethral resection of bladder tumor [TURBT]), or conservative management (intravesical Bacillus Calmette-Guérin, surveillance, or deferred RC) was offered according to surgeon and patient preference. Cumulative incidence of cancer-specific mortality (CSM) and metastasis was estimated using Kaplan-Meier methods. Differences in cumulative incidence of CSM and metastasis between groups were tested using the log rank test. Median patient age was 68 (interquartile range [IQR] 63, 77) years. Male-to-female ratio was 3:1. At restaging, all patients had ≤cT1 disease. Fifteen (42%) patients underwent early RC; 21 (58%) conservative management. Median follow-up time from landmark for cancer-specific survivors was 3.1 years (IQR 1.1, 5.9). Five-year cumulative incidence of CSM was 17% in the early RC group and 25% in the conservative management group, with an absolute difference of 7% (95% confidence interval [CI]: -26%, 41%; p = 0.8). The 5-year cumulative incidence of metastasis was 21% and 34%, respectively, with an absolute difference of 13% (95% CI: -23%, 49%; p = 0.9). The extent of the micropapillary component was not significantly associated with CSM (p = 0.4) or metastasis (p = 0.9). Using proper selection criteria, including patient and pathologic factors, certain patients with cT1 micropapillary UC managed conservatively were not found to have significantly worse outcomes compared to patients undergoing early radical cystectomy.
    The Journal of urology 03/2014; · 4.02 Impact Factor
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    ABSTRACT: Purpose To report cancer-specific outcomes of micropapillary NMIBC. Materials and Methods The records of 36 patients restaged within three months of initial micropapillary NMIBC diagnosis were retrospectively reviewed. Early radical cystectomy ([RC] within a three-month landmark after restaging transurethral resection of bladder tumor [TURBT]), or conservative management (intravesical Bacillus Calmette-Guérin, surveillance, or deferred RC) was offered according to surgeon and patient preference. Cumulative incidence of cancer-specific mortality (CSM) and metastasis was estimated using Kaplan-Meier methods. Differences in cumulative incidence of CSM and metastasis between groups were tested using the log rank test. Results Median patient age was 68 (interquartile range [IQR] 63, 77) years. Male-to-female ratio was 3:1. At restaging, all patients had ≤cT1 disease. Fifteen (42%) patients underwent early RC; 21 (58%) conservative management. Median follow-up time from landmark for cancer-specific survivors was 3.1 years (IQR 1.1, 5.9). Five-year cumulative incidence of CSM was 17% in the early RC group and 25% in the conservative management group, with an absolute difference of 7% (95% confidence interval [CI]: -26%, 41%; p = 0.8). The 5-year cumulative incidence of metastasis was 21% and 34%, respectively, with an absolute difference of 13% (95% CI: -23%, 49%; p = 0.9). The extent of the micropapillary component was not significantly associated with CSM (p = 0.4) or metastasis (p = 0.9). Conclusions Using proper selection criteria, including patient and pathologic factors, certain patients with cT1 micropapillary UC managed conservatively were not found to have significantly worse outcomes compared to patients undergoing early radical cystectomy.
    The Journal of Urology. 01/2014;
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    ABSTRACT: Objectives Surveillance after radical cystectomy is recommended to detect tumor recurrence and treatment complications. We evaluated adherence to National Comprehensive Cancer Network (NCCN) guidelines using a large population-based database. Methods and materials The Surveillance, Epidemiology, and End Results–Medicare database was used to identify patients aged ≥66 years diagnosed with nonmetastatic bladder cancer who had undergone radical cystectomy between 2000 and 2007. Medicare claims information identified recommended surveillance tests for 2 years after cystectomy as outlined in the NCCN guidelines. Adherence was defined as receipt of urine cytology and imaging of the chest, abdomen, and pelvis in each year. We evaluated the effect of patient and provider characteristics on adherence, controlling for demographic and disease characteristics. Results Of 3,757 patients who had undergone radical cystectomy, 2,990 (80%) were alive after 2 years. Adherence to all recommended investigations was 17% for the first and the second years following surgery. Among patients surviving 2 years, only 9% had complete surveillance in both years. In either year, adherence was less likely in patients with advanced pathologic stage (III/IV) (adjusted odds ratio [AOR] = 0.74, 95% CI: 0.60–0.91) and unmarried patients (AOR = 0.82, 95% CI: 0.68–0.99). Adherence was more likely in patients treated by high-volume surgeons (AOR = 2.00, 95% CI: 1.70–2.36) and those who saw a medical oncologist (AOR = 1.52, 95% CI: 1.27–1.82). We also observed significant geographic variability in adherence. Conclusion Patterns of surveillance after radical cystectomy deviate considerably from NCCN recommendations. Despite increased utilization of radiographic imaging investigations, the omission of urine cytology significantly contributed to the low rate of overall adherence to surveillance guidelines. Uniform adherence to surveillance guidelines was observed in patients treated by high-volume surgeons. This suggests an important opportunity for quality improvement in bladder cancer care.
    Urologic Oncology: Seminars and Original Investigations. 01/2014;
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    ABSTRACT: We report the toxicity and biochemical tumor control outcome of a prospective Phase II study using high-dose-rate brachytherapy (HDR) alone as a salvage therapy for recurrent disease after external beam radiotherapy (EBRT). Forty-two patients with biopsy-proven recurrence were enrolled on a Phase II study of salvage HDR monotherapy using iridium-192. Median pretreatment EBRT dose was 8100 cGy (6840-8640 cGy) and the median time from completion of EBRT to salvage HDR was 73 months. The protocol prescription dose of 3200 cGy was delivered in four fractions over 30 hours in a single insertion. Median followup after salvage HDR was 36 months (6-67 months). The actuarial prostate-specific antigen biochemical relapse-free survival and distant metastases-free survival rates at 5 years were 68.5% and 81.5%, respectively. Cause-specific survival was 90.3%. Late genitourinary Grade 1and 2 toxicities were found in 38% and 48%, respectively, and one patient developed Grade 3 urinary incontinence. Late Grade 1 and 2 gastrointestinal toxicity was noted in 17% and 8% of patients, respectively. Three patients (7%) developed Grade 2 late urinary toxicity (urethral stricture), which were corrected with urethral dilatation, and one patient developed Grade 3 urinary incontinence. No Grade 4 toxicities were observed. Genitourinary toxicity was the most commonly encountered toxicity observed after salvage HDR but severe toxicities were uncommon. Salvage HDR is an effective and well-tolerated modality for locally recurrent prostate cancer and should be considered even for patients who have previously been treated with ultra-high dose levels of EBRT.
    Brachytherapy 12/2013; · 1.22 Impact Factor
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    ABSTRACT: To determine the association between preoperative serum albumin and mortality and postoperative complications after radical cystectomy and urinary diversion. We conducted a retrospective review of 1097 radical cystectomies performed for the treatment of bladder cancer between 1992 and 2005. All data were entered prospectively into a hospital-based complications database. We used multivariable logistic regression to assess the association between preoperative serum albumin and complications and mortality within 90 days of surgery, while controlling for preoperative patient and disease characteristics. Low preoperative serum albumin was identified in 14% of the cohort. Preoperative serum albumin was a predictor of postoperative complications (adjusted odds ratio [OR] per unit increase in albumin: 0.61, 95% confidence interval [CI] 0.42-0.90) and 90-day mortality (OR 0.33, 95% CI 0.14-0.75) when controlling for sex, race, age-adjusted Charlson score, body mass index, prior history of abdominal surgery, clinical stage, and neoadjuvant chemotherapy. As serum albumin decreased, the risk of complications and mortality increased. In addition to age-adjusted Charlson score, low preoperative serum albumin is a significant predictor of complications and mortality after radical cystectomy. Serum albumin testing can be used to identify individuals at high-risk for morbidity and mortality.
    BJU International 08/2013; · 3.05 Impact Factor
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    ABSTRACT: PURPOSE: To evaluate the utility in routine upper tract imaging in patients followed for non-muscle-invasive bladder cancer (NMIBC). MATERIALS AND METHODS: A retrospective review of patients treated for NMIBC between 2000 and 2006 was conducted. Kaplan-Meier curves were calculated to determine upper tract urothelial carcinoma (UTUC)-free probability for stage Ta and T1.Bladder cancer stage was included as a time-dependent covariate. Descriptive statistics were used to report rates of imaging studies used and the efficacy in diagnosing UTUC. RESULTS: Fifty-one of a total of 935 patients treated and followed for NMIBC were diagnosed with UTUC; median follow-up was 5.5 years. Five-year UTUC-free probability among Ta and T1 patients was 98% and 93%, respectively. Ten-year UTUC-free probability among Ta and T1 patients was 94% and 88%, respectively. Only 15 (29%) patients were diagnosed on routine imaging while the others were diagnosed after developing symptoms. Overall, 3074 routine imaging scans were conducted for an overall efficacy of 0.49%. CONCLUSIONS: Upper tract recurrence is a lifelong risk in patients with bladder cancer, but most will be missed on routine upper tract imaging. The majority of UTUCs can been diagnosed using a combination of thorough history taking, physical exam, urine cytology and sonography, indicating that routine surveillance imaging may not be the most efficient way of detecting upper tract recurrences.
    The Journal of urology 05/2013; · 4.02 Impact Factor
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    ABSTRACT: PURPOSE: The purpose of this guideline is to provide a clinical framework for follow-up of clinically localized renal neoplasms undergoing active surveillance, or following definitive therapy. MATERIALS AND METHODS: A systematic literature review identified published articles in the English literature between January 1999 and 2011 relevant to key questions specified by the Panel related to kidney neoplasms and their follow-up (imaging, renal function, markers, biopsy, prognosis). Study designs consisting of clinical trials (randomized or not), observational studies (cohort, case-control, case series) and systematic reviews were included. RESULTS: Guideline statements provided guidance for ongoing evaluation of renal function, usefulness of renal biopsy, timing/type of radiographic imaging and formulation of future research initiatives. A lack of studies precluded risk stratification beyond tumor staging; therefore, for the purposes of post-operative surveillance guidelines, patients with localized renal cancers were grouped into strata of low- and moderate- to high-risk for disease recurrence based on pathologic tumor stage. CONCLUSIONS: Evaluation for patients on active surveillance and following definitive therapy for renal neoplasms should include physical exam, renal function, serum studies and imaging and should be tailored according to recurrence risk, comorbidities and monitoring for treatment sequelae. Expert opinion determined a judicious course of monitoring/surveillance that may change in intensity as surgical/ablative therapies evolve, renal biopsy accuracy improves and more long term follow-up data is collected. The beneficial impact of careful follow-up will also need critical evaluation as further study is completed.
    The Journal of urology 05/2013; · 4.02 Impact Factor
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    ABSTRACT: PURPOSE: To report our experience with intravesical gemcitabine for bladder cancer after failure of treatment with bacillus Calmette-Guérin (BCG). MATERIALS AND METHODS: A retrospective review of patients treated with intravesical gemcitabine after BCG failure at our cancer center. Progression-free survival (PFS), recurrence-free survival (RFS) and cancer-specific survival (CSS) were estimated using the cumulative incidence function, considering death from other causes as a competing risk. Comparisons were made using Gray's test. Overall survival (OS) was estimated using Kaplan-Meier methods and differences were compared with the log-rank test. RESULTS: Of 69 patients treated with intravesical gemcitabine, 37 had BCG-refractory disease. Median follow-up in progression-free patients was 3.3 years. PFS and CSS were similar among patients with BCG-refractory disease and patients with other types of BCG failures. OS was lower for patients with BCG-refractory disease (58% vs. 71%), but not statistically significant (p = 0.096). Twenty-seven patients experienced a complete response (CR). PFS, CSS, and OS did not differ significantly between patients with CR and those without. Twenty patients had subsequent cystectomy. Patients with CR had delayed time to cystectomy and no MIBC at cystectomy. There were no serious adverse events, and only a minority of patients had to discontinue treatment due to adverse events. CONCLUSIONS: In our experience intravesical gemcitabine should be considered after BCG failure in patients with bladder cancer who refuse radical cystectomy or are unfit for major surgery.
    The Journal of urology 05/2013; · 4.02 Impact Factor
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    ABSTRACT: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Micropapillary bladder cancer is a high grade variant with poor prognosis. There is no consensus about patients with micropapillary bladder cancer receiving neoadjuvant chemotherapy, but many suggest that radical cystectomy should not be delayed. Data from this study suggest that patients with micropapillary bladder cancer have a similar rate of response to neoadjuvant chemotherapy to that of patients with urothelial carcinoma. If these patients have pT0 disease, their survival is significantly improved at 2 years. OBJECTIVE: To describe the pathological outcomes of patients with muscle-invasive micropapillary bladder cancer who have undergone neoadjuvant chemotherapy. PATIENTS AND METHODS: A total of 82 patients with muscle-invasive micropapillary bladder cancer were treated between 1997 and 2010. After excluding those with metastatic disease, micropapillary histology only at radical cystectomy (RC), and chemo-radiation as primary treatment, 44 patients remained. All patients had ≥cT2 disease before chemotherapy/surgery. The median follow-up after RC was 28 months. Neoadjuvant chemotherapy was initiated in 29 (66%) patients and all patients underwent RC (93%) or partial cystectomy (7%). RESULTS: Micropapillary histology was diagnosed at first transurethral resection in 37 (84%) patients. Final RC pathology revealed pT0 in 15 (34%) patients and positive lymph nodes in 13 (31%) patients. Down-staging to pT0 occurred in 13 (45%) of those who received neoadjuvant chemotherapy compared with two (13%) of those who did not (P = 0.049). Patients with pT0 disease with micropapillary histology had higher overall survival rates (25 vs. 92%) and lower rates of bladder cancer recurrence (21 vs. 79%) at the 24-month follow-up. CONCLUSIONS: Almost half of the patients responded completely to neoadjuvant chemotherapy with a pT0 rate of 45%; therefore, patients with the micropapillary variant of urothelial carcinoma should not be excluded from consideration for neoadjuvant chemotherapy.
    BJU International 02/2013; · 3.05 Impact Factor
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    ABSTRACT: Health care reform with the Affordable Care Act aims to control health care costs, in part, through the use of comparative effectiveness research and quality of care measures. Bladder cancer is one of the most expensive malignancies to manage as related to the need for continuous monitoring and the treatment of recurrence. The use of clinical practice guidelines relying on evidence based medicine in the management of patients with bladder cancer will help to ensure quality of care and cost containment. The goal of session I was to provide a thorough discussion of the quality of care and cost issues related to bladder cancer including an examination of levels of evidence, implementation and compliance with clinical practice guidelines, the use of standardized reporting methodologies, and comparative effectiveness research. Bladder cancer is a common malignancy with a variable biology and natural history. Although the majority of patients are diagnosed with non-invasive disease, approximately 20-40% of patients either present with or develop more advanced disease. The 5-year survival for patients with lymph node involvement at the time of surgery is 20-30% and patients with metastatic disease treated with chemotherapy have a median survival of only 15 months. Novel approaches for the management of patients with bladder cancer are desperately needed. The goal of session II was to review the current state of translational research in bladder cancer as related to both early and late stage disease including a discussion of novel molecular targets and targeted therapeutics, pharmacogenomics to predict response to therapy, and exploring the role for agents targeting angiogenesis.
    Urologic Oncology 11/2012; 30(6):944-947. · 3.65 Impact Factor
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    ABSTRACT: PURPOSE: To investigate trends in urinary diversion usage and surgeon characteristics in the utilization of incontinent and continent urinary diversions using data from American Board of Urology. METHODS: Annualized case log data for urinary diversions were obtained from the American Board of Urology for urologists certifying or recertifying, from 2002 to 2010. We evaluated the association between surgeon characteristics and the use of any urinary diversion or the type of urinary diversion. RESULTS: Of 5,096 certifying or recertifying urologist case logs examined, 37% (n=1,868) performed any urinary diversions. The median number was 4 per year (IQR 2-6),4% (n=222) performed =10 per year. On multivariable analysis, younger urologists, those self-identified as oncologists or female urologists, certifying in more recent years, in larger practice areas, or outside of the Northeast region of the United States were more likely to perform any urinary diversions. Only 9% (n=471) of the total cohort performed any continent urinary diversions. The likelihood of performing any continent urinary diversions increased with the number of urinary diversions (p <0.0001), and as the volume of urinary diversions increased, the proportion of these made up by continent urinary diversions also increased (p <0.0005). Surgeons in private practice settings or located in the Northeast were less likely to perform continent urinary diversions. CONCLUSION: A minority of urologists performs any urinary diversions, and continent urinary diversions are most frequently performed by high volume surgeons. The type of urinary diversion a patient receives may depend, in part, on the characteristics of their surgeon.
    The Journal of urology 09/2012; · 4.02 Impact Factor
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    ABSTRACT: To query the minimally invasive urological literature from 2006 to the middle of 2010, focusing on complications and functional outcome reporting in laparoscopic radical prostatectomy (LRP) and robot-assisted LRP (RALP), to see if there has been an improvement in the overall reporting of complications. We performed a Medline search using the Medical Subject Heading terms 'prostatectomy', 'laparoscopy', 'robotics', and 'minimally invasive'. We then applied the Martin criteria for complications reporting to the selected articles. We identified 51 studies for a total of 32,680 patients. When excluding functional outcomes the outpatient complications reporting was 20/51 (39.2%). In all, 35% and 43% of papers did not list any method for recording continence and potency, respectively. A complication grading system was only used in 30 studies (58.8%). Of the 16 papers using a grading scale in 2006-2007, only 31.3% used the Clavien system, compared with 69% from 2008 to the first half of 2010. In all, 27% of papers used some form of risk-factor analysis for complications. Multivariate analysis was used in 43% of papers, 29% looked at body mass index, while one looked at prostate weight, and another age. There has been an overall improvement in complications reporting in the minimally invasive RP literature since 2005. However, most studies still do not fulfil many of the criteria necessary for standardised complication reporting. Functional outcome reporting remains poor and unstandardised. Given our current reliance on observational studies, increased efforts should be made to standardise all complication outcomes reporting.
    BJU International 09/2011; 109(1):26-30; discussion 30. · 3.05 Impact Factor
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    ABSTRACT: To evaluate the performance of the Isbarn nomogram for predicting 90-day mortality following radical cystectomy in a contemporary series. We identified 1141 consecutive radical cystectomy patients treated at our institution between 1995 and 2005 with at least 90 days of follow-up. We applied the published nomogram to our cohort, determining its discrimination, with the area under the receiver operating characteristic curve (AUC), and calibration. We further compared it with a simple model using age and the Charlson comorbidity score. Our cohort was similar to that used to develop the Isbarn nomogram in terms of age, gender, grade and histology; however, we observed a higher organ-confined (≤pT2, N0) rate (52% vs 24%) and a lower overall 90-day mortality rate [2.8% (95% confidence interval 1.9%, 3.9%) vs 3.9%]. The Isbarn nomogram predicted individual 90-day mortality in our cohort with moderate discrimination [AUC 73.8% (95% confidence interval 64.4%, 83.2%)]. In comparison, a model using age and Charlson score alone had a bootstrap-corrected AUC of 70.2% (95% confidence interval 67.2%, 75.4%). The Isbarn nomogram showed moderate discrimination in our cohort; however, the exclusion of important preoperative comorbidity variables and the use of postoperative pathological stage limit its utility in the preoperative setting. The use of a simple model combining age and Charlson score yielded similar discriminatory ability and underscores the significance of individual patient variables in predicting outcomes. An accurate tool for predicting postoperative morbidity/mortality following radical cystectomy would be valuable for treatment planning and counselling. Future nomogram design should be based on preoperative variables including individual risk factors, such as comorbidities.
    BJU International 07/2011; 109(6):855-9. · 3.05 Impact Factor
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    Harry W Herr, Guido Dalbagni, Sherri M Donat
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    ABSTRACT: Bacillus Calmette-Guérin (BCG) is the standard intravesical treatment of high-risk noninvasive (Ta, T1, Tis) bladder cancer. Maintenance BCG is recommended for maximum efficacy. We compared our results in a large cohort of high-risk bladder cancer patients who received BCG without maintenance with published results from randomized maintenance BCG trials. A cohort of 1021 patients underwent restaging transurethral resection for high-risk (Ta, T1, Tis) bladder cancer. Patients received a 6-wk induction course of BCG therapy. Responding patients did not receive maintenance BCG. Relapsing patients were eligible for retreatment with BCG. All patients were followed for a minimum of 5 yr. End points were 5-yr tumor- and progression-free survival rates. Of 816 complete responders to induction BCG, 2- and 5-yr recurrence-free survival rates were 73% and 46%, respectively. The progression-free survival rate was 89%. Progression-free survival time was 56 mo (95% confidence interval, 55-58 mo). Thirty-two percent of the patients required another course of BCG therapy. We cannot exclude that maintenance BCG may benefit patients beyond 5 yr over induction BCG alone and selective BCG retreatments. Our results with BCG treatment without maintenance of patients with high-risk non-muscle-invasive bladder cancer compare favorably with trials in which comparable patients received maintenance BCG.
    European Urology 07/2011; 60(1):32-6. · 10.48 Impact Factor
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    ABSTRACT: The types of surveillance recommended after radical cystectomy and the degree of patient compliance are not well characterized. We identified the pattern of post-cystectomy surveillance recommended in the oncologic community and assessed compliance to a predetermined schedule among a small group of urologists. A survey was sent inquiring about the number of patients followed after cystectomy, physician specialty, type of practice, whether the followup schedule was stage dependent, the frequency of office visits and the type of tests. To assess noncompliance to a strict followup schedule we analyzed the records of 647 patients who underwent radical cystectomy. The overall response rate to the survey was 37% (123 of 330). Of the respondents 96% were urologists, with 72% from United States academic centers, 13% from non-United States academic centers and 14% in private practice. In addition, 21% reported following yearly more than 100 patients after cystectomy, 29% between 51 and 100 patients, and 43% between 1 and 50. Of the respondents 60% tailored the followup schedule based on pathological stage. Computerized tomography of the abdomen and pelvis, chest x-ray and urine cytology were the most frequent tests used. Computerized tomography of the chest, magnetic resonance imaging and abdominal ultrasound were used occasionally. There was significant deviation from a predetermined followup schedule. There was no uniformity among urological oncologists in post-cystectomy surveillance and there was lack of compliance to a predetermined followup schedule.
    The Journal of urology 06/2011; 185(6):2091-6. · 4.02 Impact Factor
  • S Machele Donat
    Urology 04/2011; 77(4):1016-7; author reply 1017. · 2.42 Impact Factor
  • Harry W Herr, Sherri M Donat
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    ABSTRACT: To evaluate frequency of recurrences among patients with papillary bladder tumours followed sequentially with conventional white-light (WLI) cystoscopy and narrow-band imaging (NBI) cystoscopy. A cohort of 126 patients with recurrent low-grade papillary bladder tumours were followed every 6 months for 3 years by conventional WLI cystoscopy, and then over the next 3 consecutive years by NBI cystoscopy. Recurrent tumours detected were treated by outpatient fulguration or transurethral resection. We compared the tumour recurrence rate during follow-up with WLI and NBI cystoscopy, using patients as their own controls. Of the 126 patients, 94% had tumour recurrences during WLI cystoscopy vs 62% during NBI cystoscopy. The mean number of recurrent tumours was 5.2 with WLI cystoscopy vs 2.8 with NBI cystoscopy, and the median recurrence-free survival time was 13 vs 29 months (P= 0.001). Compared with follow-up with WLI cystoscopy, NBI cystoscopy was associated with fewer patients having tumour recurrences, fewer numbers of recurrent tumours, and a longer recurrence-free survival time.
    BJU International 02/2011; 107(3):396-8. · 3.05 Impact Factor
  • S Machele Donat
    The Journal of urology 10/2010; 184(6):2233-4. · 4.02 Impact Factor

Publication Stats

2k Citations
353.97 Total Impact Points

Institutions

  • 1996–2014
    • Memorial Sloan-Kettering Cancer Center
      • Department of Surgery
      New York City, New York, United States
  • 2012
    • Vanderbilt University
      • Department of Neurology
      Nashville, MI, United States
  • 1998–2002
    • University of Texas MD Anderson Cancer Center
      • Department of Urology
      Houston, TX, United States