Evidence that high volume hospitals have better outcomes is increasing for urological cancer surgeries. Whether volume affects quality or better clinicians and services attract more patients can be debated. Centralizing health care will have major health policy implications, ie high volume hospitals may be overwhelmed and low volume hospitals may be at a disadvantage. An alternative would be to attempt to improve outcomes at low volume hospitals by identifying drivers of high quality care at high volume hospitals and transferring some of these characteristics.
Aging appears to be associated with a decreased response to intravesical immunotherapy and is particularly apparent in patients older than 80 years. A potential explanation could be their depressed baseline immune status and consequent inability to mount an immune reaction to BCG or IFN-alpha.
Study Type – Prognosis (individual cohort)
Level of Evidence 2b
What's known on the subject? and What does the study add?
RENAL nephrometry is a quantitative, reproducible scoring system that characterizes RENAL masses and standardizes reporting. Previous work has suggested that the system may be useful in predicting outcomes after partial nephrectomy. This study is the first to correlate RENAL nephrometry score with operative approach or risk of complication in patients undergoing either partial or radical nephrectomy.
OBJECTIVE
To evaluate the utility of the RENAL scoring system in predicting operative approach and risk of complications. The RENAL nephrometry scoring system is designed to allow comparison of renal masses based on the radiological features of (R)adius, (E)xophytic/endophytic, (N)earness to collecting system, (A)nterior/posterior and (L)ocation relative to polar lines.
METHODS
A retrospective review of all patients at a single institution undergoing radical nephrectomy (RN) or partial nephrectomy (PN) for a renal mass between July 2007 and May 2010 was carried out.
Preoperative RENAL score was calculated for each patient. Surgical approach and operative outcomes were then compared with the RENAL score.
RESULTS
In all, 249 patients underwent either RN (158) or PN (91) with average RENAL scores of 8.9 and 6.3, respectively (P < 0.001).
Patients who underwent RN were more likely to have hilar tumours (64% vs 10%, P < 0.001) than patients who underwent PN, but were no more likely to have posteriorly located tumours (50% each).
There were more complications among patients with RN (58%) vs patients with PN (42%, P= 0.02).
RENAL scores were higher in patients with PN who developed complications than in patients with PN who did not develop complications (6.9 vs 6.0, P= 0.02), with no difference noted among patients with RN developing complications (8.9 vs 8.9, P= 0.99).
CONCLUSION
The RENAL system accurately predicted surgeon operative preference and risk of complications for patients undergoing PN.
In a population based cohort partial nephrectomy and total nephrectomy are associated with low morbidity and mortality profiles, and all complications affect mortality, length of hospital stay and charges.
TURBT and/or RC specimens to a group of controls who did not have LVI on TURBT (34) or RC (32).
RESULTSPatients with LVI present in their TURBT specimen had a shorter disease-specific survival than those without LVI, with a 5-year survival of 33.6% vs 62.9% (log-rank test P = 0.027; hazard ratio 2.21). LVI at TURBT varied with clinical stage ( P = 0.049). Patients with LVI and who were clinical stage I or II had lower survival than those without LVI ( P = 0.049; hazard ratio 2.68). LVI did not affect survival among those with clinical stage III or IV ( P = 0.29). There was a trend for patients with LVI at TURBT to be clinically understaged compared to those without LVI (75% vs 46%) but the difference was not significant ( P = 0.086). Patients with LVI detected in their RC specimen were significantly more likely to have cancer recurrence than were those with no evidence of LVI (48% vs 19%, P = 0.006). For the RC group there was also a significant difference in survival distribution between patients with evidence of LVI vs those without (5-year survival 45.5% vs 78.4%, P = 0.017). Those with LVI were significantly more likely to die from the disease than those without LVI ( P = 0.017; hazard ratio 2.92).
CONCLUSIONSOur findings suggest that LVI is a histological feature that might be associated with a poorer prognosis in patients with urothelial carcinoma of the bladder. The presence of LVI in TURBT specimens predicts shorter survival for patients with stage I or II disease. The presence of LVI in RC specimens predicts recurrence of disease and shorter survival. Further studies are needed to determine whether this group of patients would benefit from early RC and/or perioperative chemotherapy to improve clinical outcomes.
KEYWORDSbladder cancer, lymphatic metastasis, neoplasm staging, cystectomy Study Type -Prognosis (case series) Level of Evidence 4
OBJECTIVETo test the hypothesis that patients with bladder cancer who had evidence of lymphovascular invasion (LVI) in their transurethral resection of bladder tumour (TURBT) and radical cystectomy (RC) specimens would have a worse prognosis and higher likelihood of clinical understaging, and to assess the effect of LVI discovered at RC on subsequent diseaserelated mortality, as the prognostic significance of LVI in TURBT or RC specimens of patients treated for urothelial carcinoma of the bladder is not completely established.
PATIENTS AND METHODSWe retrospectively reviewed the records of 163 patients with urothelial carcinoma of the bladder seen at our institution, and who had TURBT (69) or RC (94) between 1995 and 2005. We compared patients with LVI on
Intraoperative time as defined in our study is a significant risk factor for development of postoperative neuropathy. We also found that split-leg positioning appears to put the femoral nerve at risk for injury, instead of the common peroneal nerve as has been previously reported from prolonged lithotomy positioning.
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