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ABSTRACT: CONTEXT: Despite the effectiveness of bacillus Calmette-Guérin (BCG) therapy in non-muscle-invasive bladder cancer (NIMBC) to delay recurrence and disease progression, the evidence supporting maintenance treatment and its optimal duration is unkown. OBJECTIVE: The purposes of this paper are to critically review the evidence supporting the use of maintenance BCG after an initial series of induction instillations and to illustrate the factors contributing to current dilemmas in establishing the optimal duration of BCG treatment. EVIDENCE ACQUISITION: The following terms were used in Medline database searches for original articles published before February 1, 2013: bladder cancer, urothelial cancer, bacillus Calmette-Guérin, maintenance, and induction. All randomized controlled trials and meta-analyses, including those based on indirect comparisons, were evaluated. EVIDENCE SYNTHESIS: Seven randomized studies compared induction BCG plus maintenance to induction alone, with or without retreatment with BCG on recurrence. All but one of these studies were underpowered and the largest study used a broad, composite end point: worsening-free survival. Seven meta-analyses have been conducted, three of which included data from observational cohort studies. They demonstrated the benefit of maintenance BCG to reduce disease recurrence and delay progression compared to various control groups; however, the analyses were based on suboptimal data. Although there is new evidence that 1 yr of maintenance BCG is sufficient treatment in intermediate-risk patients, the optimal duration of BCG maintenance remains unknown. A new randomized trial is proposed, which includes induction BCG with retreatment on recurrence as a control arm, to study this question. CONCLUSIONS: The optimal duration of BCG treatment in patients with NMIBC remains unknown and should be the subject of further studies. We recommend that in addition to 3 yr of maintenance BCG, guideline panels also include 1 yr of therapy and induction BCG with retreatment on recurrence as a possible treatment options for patients with NMIBC, albeit with a lower level of evidence and grade of recommendation.
European urology 05/2013; · 7.67 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: 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; · 2.84 Impact Factor
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ABSTRACT: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Intravesical bacille Calmette-Guérin (BCG) is generally considered to be contraindicated in immunologically compromised patients with bladder cancer because it may be ineffective and potentially toxic. Therefore, there is little experience with BCG in individuals with impaired immune systems. The present study provides evidence that intravesical BCG is safe and effective in the short term against non-muscle-invasive bladder cancer affecting patients who were receiving immunosuppressive medications. This included anti-rejection drugs to support a solid organ transplant, high-dose steroids for autoimmune inflammatory diseases, and the first description of BCG use in patients who were receiving concomitant systemic chemotherapy for unrelated malignant neoplasms. OBJECTIVE: To investigate the outcomes of bacille Calmette-Guérin (BCG) therapy in patients with bladder cancer who were immunologically compromised. PATIENTS AND METHODS: In all, 45 immunosuppressed patients with high-grade non-muscle-invasive bladder cancer received BCG therapy. Twelve had functioning organ transplants, 23 were undergoing systemic chemotherapy for unrelated cancers, and 10 were taking steroids for autoimmune or related diseases. Patients received a 6-week induction course of BCG therapy. Relapsing patients were eligible for retreatment. All patients were followed for median (range) of 40 (12-72) months. End points were response to BCG and 5-year recurrence-free, progression-free and overall survival rates. RESULTS: In all, nine of the 12 transplant patients responded completely to one or two cycles of BCG compared with 99% (32/33) of other immunosuppressed patients. Half the patients with unrelated cancers and autoimmune diseases recurred vs all but one of the transplant patients (P = 0.008). Of the 12 transplant patients, six of 12 progressed vs five of 33 (15%) of the other patient groups (P = 0.02). Five patients died (11%), two of bladder cancer (both in transplant patients), and three of unrelated causes. BCG was well tolerated. None of the patients developed bacterial or BCG sepsis. Although this is largest series evaluating BCG in transplant and other immune-suppressed patients, it represents few patients and results must be interpreted with caution. CONCLUSIONS: We conclude that intravesical BCG is safe and effective in immunologically compromised patients with bladder cancer. Transplant patients fare worse and should be considered for early cystectomy if they fail BCG therapy.
BJU International 01/2013; · 2.84 Impact Factor
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ABSTRACT: OBJECTIVE: To review our experience managing bladder cancer (BCa) in patients who have had renal transplantation. Optimal oncologic treatment can be challenging due to the immunosuppressed state and higher comorbidity. METHODS: From January 2000 to August 2011, we identified 17 patients with a history of renal transplantation who were treated for BCa. Clinical, demographic, and oncologic data were collected. Patients treated with intravesical bacillus Calmette-Guérin (BCG) were assessed for complications. RESULTS: BCa diagnosis occurred at a median of 88.1 months after renal transplantation. Median age was 62.4 years and median follow-up was 9.2 months. The most common presentation was gross hematuria (58.8%), and the median Charlson comorbidity index was 5. Twelve patients were identified with non-muscle invasive (NMI) BCa. Four patients with NMI BCa received intravesical BCG, with no urinary tract infection, fever, or BCG-associated sepsis. Four patients were identified with muscle-invasive bladder cancer (MIBC), and 1 patient had biopsy proven metastatic disease. Five patients underwent radical cystectomy (RC) with diversion, 7 underwent transurethral resection and surveillance, 3 underwent chemotherapy, and 1 received palliative radiation for metastatic disease. Overall, 6 patients were deceased, 4 of whom died of disease at a median of 9.7 months from the time of BCa diagnosis. CONCLUSION: Treatment of patients with BCa after renal transplantation is challenging because of immunosuppression and overall high comorbidity. Optimal management with stage-appropriate therapy should be considered in appropriate patients. Intravesical BCG may be considered in select patients, although overall efficacy may be reduced.
Urology 01/2013; · 2.43 Impact Factor
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ABSTRACT: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Bladder cancer patients with lamina propria invasion (T1 disease) and residual T1 disease on restaging transurethral resection of bladder tumour (re-TURBT) are at a very high risk for recurrence and progression. Despite this risk, most patients are treated with a bladder preserving approach and not immediate radical cystectomy (RC). In this study we have shown that a quarter of patients with T1 bladder cancer and residual T1 on re-TURBT who are treated with immediate RC are found to have carcinoma invading bladder muscle at RC and 5% have lymph node metastases. We have also found that >30% of patients treated with deferred RC after initial bladder-preserving therapy harbour carcinoma invading bladder muscle and almost 20% of these patients have lymph node metastases. Thus, immediate RC should be considered in all patients with T1 bladder cancer and residual T1 on re-TURBT. OBJECTIVE: To report the overall survival (OS) and cancer-specific survival (CSS) of patients with residual T1 bladder cancer on restaging transurethral resection of the bladder tumour (re-TURBT). MATERIALS AND METHODS: We performed a retrospective review of 150 evaluable patients treated for T1 bladder cancer with residual T1 disease found on re-TURBT between 1990 and 2007. Patients were treated with immediate radical cystectomy (RC) or a bladder-preserving approach (deferred or no RC). A univariate Cox proportional hazards regression model was used to test the association between treatment approach and survival. RESULTS: Residual T1 bladder cancer was found in 150 evaluable patients, of whom 57 received immediate RC and 93 were treated with a bladder-preserving approach. Fourteen out of 57 patients receiving immediate RC and 8/26 patients receiving deferred RC had carcinoma invading bladder muscle in the RC specimen. Three out of 57 and 5/26 patients had lymph node metastases in the RC specimen. Median follow-up was 3.74 years. Thirty-nine patients died during follow-up, 16 from bladder cancer. There was no significant association between immediate RC and CSS (hazard ratio [HR] 1.15, 95% confidence interval [CI] 0.43-3.09, P = 0.8) or OS (HR 0.79, 95% CI 0.4-1.53, P = 0.5). CONCLUSIONS: Because of the low number of events we cannot conclude whether RC offers a survival advantage in patients with residual T1 bladder cancer on re-TURBT. Since a quarter of patients had carcinoma invading bladder muscle, RC should be considered in these patients. A larger, preferably randomized, study with longer follow-up is needed.
BJU International 11/2012; · 2.84 Impact Factor
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ABSTRACT: PURPOSE: Urachal carcinomas are rare urologic neoplasms that arise along the urachal remnant from the umbilicus to the dome of the bladder. No published study has examined the diagnostic accuracy of modern preoperative testing to differentiate urachal carcinoma from a benign urachal cyst and spare resection of potentially benign urachal tissue. Our objective was to determine if a urachal mass can be safely diagnosed preoperatively. MATERIALS AND METHODS: 104 patients with a urachal mass treated between 1979 and 2011. Exclusion criteria were unresectable metastatic disease at presentation, patients that did not undergo surgery, and management by transurethral resection alone. Of the patients that remained, only 65 had both preoperative diagnostic testing and definitive pathologic results available for analysis. Mean age was 51 years, 86% were Caucasian and 65% were male. Accuracy of diagnosis based on preoperative tests was compared to final pathology (cancer or benign). RESULTS: Fifty-seven tumors (87%) were malignant and the majority of masses (83%) were adenocarcinoma. Compared to computed tomography, cytology, and exploration under anesthesia, transurethral resection of the bladder tumor has the highest sensitivity (0.93), specificity (1), and positive predictive value (1), but a low negative predictive value (0.5). Limitations included small cohort size and few benign urachal masses for comparison. CONCLUSIONS: No test has a high enough negative predictive value to prevent excision of a urachal mass. With few treatment options for localized, advanced, and metastatic urachal cancer, these data suggest that early excision remains the best treatment for a suspicious urachal mass.
The Journal of urology 10/2012; · 4.02 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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Harry W Herr
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ABSTRACT: The outcome of intravesical bacillus Calmette-Guérin therapy was studied in patients with asymptomatic bacteriuria.
A total of 243 patients with high risk, nonmuscle invasive bladder cancer received induction intravesical bacillus Calmette-Guérin therapy. Before starting bacillus Calmette-Guérin they submitted voided urine samples for culture and were treated with bacillus Calmette-Guérin regardless of culture results without antibiotics. Patients were followed every 3 months for tumor recurrence or progression up to 2 years.
Of the 243 patients 61 (25%) had significant bacteriuria (greater than 10(4) or greater than 10(5) cfu/ml single organism). Febrile urinary tract infection developed in 1 patient (1.6%) and 2 overall (0.8%) after completing induction bacillus Calmette-Guérin therapy. No patients were admitted to the hospital for bacillus Calmette-Guérin or bacterial sepsis. The 2-year recurrence-free survival rate was 71% vs 73% in uninfected patients (p = 0.73).
These data suggest that intravesical bacillus Calmette-Guérin is safe in patients who have asymptomatic bacteriuria and the 2-year disease-free intervals are similar to those of uninfected patients. Such strategy facilitates the timely administration of bacillus Calmette-Guérin therapy and avoids the overuse of antibiotics.
The Journal of urology 12/2011; 187(2):435-7. · 4.02 Impact Factor
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ABSTRACT: We compared renal function and oncologic outcomes of parenchymal sparing ureteral resection with radical nephroureterectomy for the treatment of upper tract urothelial carcinoma confined to the ureter.
Review of a large institutional database identified 367 patients treated for primary upper tract urothelial carcinoma with radical nephroureterectomy or parenchymal sparing ureteral resection from 1994 to 2009. Patients with known renal pelvis tumors, muscle invasive urothelial carcinoma, prior cystectomy, contralateral upper tract urothelial carcinoma, metastatic disease or chemotherapy were excluded, leaving 120 patients for analysis. Estimated glomerular filtration rate was calculated using the Modification of Diet in Renal Disease equation. Recurrence-free, cancer specific and overall survival were estimated using Kaplan-Meier analysis.
Radical nephroureterectomy was performed in 87 patients and parenchymal sparing ureteral resection in 33. Median age at surgery was 73 years in the radical nephroureterectomy group (IQR 64-76) vs 70 years (IQR 59-77) in the parenchymal sparing ureteral resection group (p = 0.5). The radical nephroureterectomy and parenchymal sparing ureteral resection cohorts had several disparate clinicopathological variables including preoperative hydronephrosis (80% vs 45%, p = 0.0006), stage (pT3 or greater 26% vs 9%, p = 0.01) and baseline estimated glomerular filtration rate (51 vs 63 ml/minute/1.73 m(2), p = 0.009). Patients who underwent radical nephroureterectomy experienced a significantly greater decrease in estimated glomerular filtration rate after surgery (median -7 vs 0 ml/minute/1.73 m(2), p <0.001). Median followup was 4.2 years. Of the patients 79 experienced cancer recurrence and 44 died (28 of upper tract urothelial carcinoma). There were no obvious differences in the rates of recurrence, cancer specific death or overall death by procedure type. However, due to the limited number of events we cannot exclude the possibility that there are large differences in oncologic outcomes by procedure type.
Parenchymal sparing ureteral resection is associated with superior postoperative renal function. However, the impact on cancer control cannot be determined conclusively due to the small sample size and putative selection bias.
The Journal of urology 12/2011; 187(2):429-34. · 4.02 Impact Factor
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ABSTRACT: We compared clinical outcomes, and identified predictors of cancer specific and overall survival after radical cystectomy in patients with urothelial carcinoma with squamous differentiation and those with pure squamous cell carcinoma.
We reviewed data on 2,031 patients treated with radical cystectomy and pelvic lymph node dissection at a single high volume referral center. Of these patients 78 had squamous cell carcinoma and 67 had squamous differentiation. Survival estimates by histological subtype were described using Kaplan-Meier methods. Within histological subtypes pathological stage, nodal invasion, soft tissue margins, age and gender were evaluated as predictors of cancer specific survival and overall survival using univariate Cox regression.
Median followup was 44 months. Of 104 patient deaths 60 died of their disease. We did not find a statistically significant difference between survival curves of patients with squamous cell carcinoma and squamous differentiation (log rank overall survival p = 0.6, cancer specific survival p = 0.17). Positive soft tissue margins were associated with worse cancer specific survival (HR 6.92, 95% CI 2.98-16.10, p ≤0.0005) and overall survival (HR 3.68, 95% CI 1.84-7.35, p ≤0.0005) in patients with pure squamous cell carcinoma. Among patients with squamous differentiation, pelvic lymphadenopathy was associated with decreased overall survival (HR 2.52, 95% CI 1.33-4.77, p = 0.004) and cancer specific survival (HR 3.23, 95% CI 1.57-6.67, p = 0.002).
There appears to be no evidence of a difference in cancer specific survival or overall survival between patients with squamous cell carcinoma and those with squamous differentiation treated with radical cystectomy and pelvic lymph node dissection. Patients with squamous differentiation and tumor metastases to pelvic lymph nodes should be followed more closely, and adjuvant treatment should be considered to improve survival. Wide surgical resection is critical to achieve local tumor control and improve survival in patients with squamous cell carcinoma.
The Journal of urology 11/2011; 187(1):74-9. · 4.02 Impact Factor
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Harry W Herr
The Journal of urology 09/2011; 186(3):787-8. · 4.02 Impact Factor
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Harry W Herr
BJU International 08/2011; 108(4):479-81. · 2.84 Impact Factor
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ABSTRACT: To examine trends in bladder cancer survival among whites, blacks, Hispanics, and Asian/Pacific Islanders in the United States over a 30-year period. Racial disparities in bladder cancer outcomes have been documented with poorer survival observed among blacks. Bladder cancer outcomes in other ethnic minority groups are less well described.
From the Surveillance, Epidemiology and End Results cancer registry data, we identified patients diagnosed with transitional cell carcinoma of the bladder between 1975 and 2005. This cohort included 163,973 white, 7731 black, 7364 Hispanic, and 5934 Asian/Pacific Islander patients. We assessed the relationship between ethnicity and patient characteristics. Disease-specific 5-year survival was estimated for each ethnic group and for subgroups of stage and grade.
Blacks presented with higher-stage disease than whites, Hispanics, and Asian/Pacific Islanders, although a trend toward earlier-stage presentation was observed in all groups over time. Five-year disease-specific survival was consistently worse for blacks than for other ethnic groups, even when stratified by stage and grade. Five-year disease-specific survival was 82.8% in whites compared with 70.2% in blacks, 80.7% in Hispanics, and 81.9% in Asian/Pacific Islanders. There was a persistent disease-specific survival disadvantage in black patients over time that was not seen in the other ethnic groups.
Ethnic disparities in bladder cancer survival persist between whites and blacks, whereas survival in other ethnic minority groups appears similar to that of whites. Further study of access to care, quality of care, and treatment decision making among black patients is needed to better understand these disparities.
Urology 07/2011; 78(3):544-9. · 2.43 Impact Factor
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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. · 7.67 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. · 2.84 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
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Journal of Clinical Oncology 06/2011; 29(16):2135-7. · 18.37 Impact Factor
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Harry W Herr
JAMA The Journal of the American Medical Association 04/2011; 305(14):1413-4. · 30.03 Impact Factor
