Introduction:We studied the learning curve for percutaneous nephrolithotomy of urology residents according to stone complexity.
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entire gland. Clearly these studies address a critically important question that is quite different than the diagnostic accuracy of biomarkers. I would caution that these studies do not add to our understanding of the diagnostic accuracy of these markers in predicting the likelihood of cancer. Men undergoing radical prostatectomy in these studies were diagnosed by systematic biopsy. Presumably men who did not have cancer on systematic biopsy did not undergo radical prostatectomy. As such, the population is selected and does not inform us regarding the predictive ability of the markers in diagnosis.I remain of the opinion that current diagnostic biomarker studies are extremely informative but they are limited by the use of systematic biopsy as reference standard. Further validation of biomarkers within the context of image guided, targeted biopsy may add to our understanding of the true diagnostic accuracy of all existing biomarkers. Such studies are under way. We applaud the authors for selecting a controversial topic. They attempt to define the impact of bleomycin on retroperitoneal histology at retroperitoneal lymph node dissection (RPLND) following chemotherapy for good risk germ cell tumors by retrospectively analyzing patients undergoing 3 cycles of bleomycin, etoposide and cisplatin or 4 cycles of etoposide and cisplatin (EC). However, some points need further explanation.The authors do not comment on the percentage of patients in the 2 groups demonstrating teratoma on RPLND histology. Teratoma is considered to be chemoresistant and may represent a confounding factor. In addition, no mention is made of relapse-free survival, disease specific survival or toxicity in the 2 groups. A significant number of patients receiving 4 cycles of EC underwent chemotherapy elsewhere, and the results may have been affected by differing policies regarding dosage and scheduling. Finally, no mention is made regarding the decrease in retroperitoneal mass size following chemotherapy or RPLND, which may be important for comparing the results of the 2 chemotherapy regimens. We request that the authors explain these confounding factors and their effects. Respectfully,Reply by Authors: The preoperative retroperitoneal mass size for each category (less than 2, 2 to 5, 5.1 to 10 and greater than 10 cm) was similar between the 2 treatment groups (p ¼ 0.99). We did not report on teratoma in the retroperitoneum because we believed that active cancer was the more important retroperitoneal histology impacting survival and additional treatment. Furthermore, acute toxicities of these 2 chemotherapy regimens are detailed in several prospective randomized trials, and thus were not a priority for this retrospective study. Finally, we agree with the limitation regarding the EC group. The majority of these patients received chemotherapy at various outside institutions, and the dosing and scheduling policies may differ from those of Indiana University. It is unclear how these potential dosage and scheduling differences affected the results of the...
can provide future direction toward bladder preservation in patients with bladder cancer. As they seem to have achieved good results, some points need to be explained.No mention was made about the morbidity related to the procedure itself. Number of cycles of the regimen (single or multiple) and timing of radiotherapy (simultaneous or metachronous, before or after chemotherapy) also were not specified. Timing of balloon deflation after the procedure and removal of the catheter should also be clear, as premature balloon deflation could release a massive dose of cisplatin to the systemic circulation. Use of any pre-medications, precautions or anticoagulation was not specified. As this is a novel technique, these points deserve mention.It is also unclear whether gemcitabine was used. The graphic in the article states that gemcitabine was given but this was not mentioned anywhere in the text. If gemcitabine was administered, then we also seek clarification about the dosing and side effect profile.One of the important aspects of systemic treatment with chemotherapeutic agents is treatment of micrometastases. This regimen aims to reduce systemic dosage. Does this decreased systemic dose have any adverse impact on the effective treatment of micrometastases? In other words, are the systemic levels achieved in this regimen sufficient to treat micrometastases?The modality used for initial staging was not mentioned (imaging with or without transurethral resection). Transurethral resection in patients with T2 disease, consisting of complete resection of the primary tumor, can potentially affect the outcome (complete response, progression-free survival, overall survival). Furthermore, the effect of histological grade (high or low) of urothelial tumor on outcomes was not mentioned, which is an important prognostic factor.The presence of hydronephrosis was a significant risk factor. It is unclear whether the degree of hydronephrosis or its association with obstructive uropathy has any impact and whether urinary diversion reverses the risk.In patients with Nþ disease was the response assessment done only for primary tumor or for primary tumor and lymph nodes (LNs)? What was the nodal response? Patients with progression in this study were treated with either bacillus Calmette-Gu erin (BCG) therapy or cystectomy. Were outcomes of this group different from the general population undergoing BCG treatment or cystectomy? We request that the authors explain these issues.Respectfully,
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