Multi-institutional Cohort Of Patients Research Articles

Peri-operative factors predisposing to pharyngocutaneous fistula after total laryngectomy: analysis of a large multi-institutional patient cohort

BackgroundPharyngocutaneous fistula (PCF) is a problematic complication following total laryngectomy. Disagreement remains regarding predisposing factors. This study examines perioperative factors predicting PCF following total laryngectomy using a large multicenter data registry.MethodsRetrospective cohort analysis was performed using patients undergoing total laryngectomy in the ACS-NSQIP database for 2006–2014. Sub-analysis was performed based on reconstruction type. Outcome of interest was PCF development within 30 days.ResultsMultivariate analysis of 971 patients was performed. Three variables showed statistical significance in predicting PCF: wound classification of 3 and 4 vs. 1–2 (OR 6.42 P < 0.0004 and OR 8.87, P < 0.0042), pre-operative transfusion of > 4 units of packed red blood cells (OR 6.28, P = 0.043), and free flap versus no flap reconstruction (OR 2.81, P = 0.008).ConclusionsThis study identifies important risk factors for development of PCF following total laryngectomy in a large, multi-institutional cohort of patients, thereby identifying a subset of patients at increased risk.

Targeting Moderate and Severe Male Stress Urinary Incontinence With Adjustable Male Slings and the Perineal Artificial Urinary Sphincter: Focus on Perioperative Complications and Device Explantations.

PurposeTo analyze perioperative complications and postoperative explantation rates for selected readjustable male sling systems and the perineal single-cuff artificial urinary sphincter (AUS) in a large, contemporary, multi-institutional patient cohort. MethodsTwo hundred eighty-two male patients who underwent implantation between 2010 and 2012 in 13 participating institutions were included in the study (n=127 adjustable male sling [n=95 Argus classic, n=32 Argus T], n=155 AUS). Perioperative characteristics and postoperative complications were analyzed. The explantation rates of the respective devices were assessed using the Fisher exact test and the Mann-Whitney U-test. A Kaplan-Meier curve was generated. Potential features associated with device explantation were analyzed using a multiple logistic regression model (P<0.05). ResultsWe found significantly increased intraoperative complication rates after adjustable male sling implantation (15.9% [adjustable male sling] vs. 4.2% [AUS], P=0.003). The most frequent intraoperative complication was bladder perforation (n=17). Postoperative infection rates did not vary significantly between the respective devices (P=0.378). Device explantation rates were significantly higher after AUS implantation (9.7% [adjustable male sling] vs. 21.5% [AUS], P=0.030). In multivariate analysis, postoperative infection was a strong independent predictor of decreased device survival (odds ratio, 6.556; P=0.001). ConclusionsComplication profiles vary between adjustable male slings and AUS. Explantation rates are lower after adjustable male sling implantation. Any kind of postoperative infections are independent predictors of decreased device survival. There is no significant effect of the experience of the implanting institution on device survival.

Challenging surgical dogma in the management of proximal esophageal atresia with distal tracheoesophageal fistula: Outcomes from the Midwest Pediatric Surgery Consortium

PurposePerioperative management of infants with esophageal atresia and tracheoesophageal fistula (EA/TEF) is frequently based on surgeon experience and dogma rather than evidence-based guidelines. This study examines whether commonly perceived important aspects of practice affect outcome in a contemporary multi-institutional cohort of patients undergoing primary repair for the most common type of esophageal atresia anomaly, proximal EA with distal TEF. MethodsThe Midwest Pediatric Surgery Consortium conducted a multicenter, retrospective study examining selected outcomes on infants diagnosed with proximal EA with distal TEF who underwent primary repair over a 5-year period (2009–2014), with a minimum 1-year follow up, across 11 centers. Results292 patients with proximal EA and distal TEF who underwent primary repair were reviewed. The overall mortality was 6% and was significantly associated with the presence of congenital heart disease (OR 4.82, p=0.005). Postoperative complications occurred in 181 (62%) infants, including: anastomotic stricture requiring intervention (n=127; 43%); anastomotic leak (n=54; 18%); recurrent fistula (n=15; 5%); vocal cord paralysis/paresis (n=14; 5%); and esophageal dehiscence (n=5; 2%). Placement of a transanastomotic tube was associated with an increase in esophageal stricture formation (OR 2.2, p=0.01). Acid suppression was not associated with altered rates of stricture, leak or pneumonia (all p>0.1). Placement of interposing prosthetic material between the esophageal and tracheal suture lines was associated with an increased leak rate (OR 4.7, p<0.001), but no difference in the incidence of recurrent fistula (p=0.3). Empiric postoperative antibiotics for >24h were used in 193 patients (66%) with no difference in rates of infection, shock or death when compared to antibiotic use ≤24h (all p>0.3). Hospital volume was not associated with postoperative complication rates (p>0.08). Routine postoperative esophagram obtained on day 5 resulted in no delayed/missed anastomotic leaks or a difference in anastomotic leak rate as compared to esophagrams obtained on day 7. ConclusionMorbidity after primary repair of proximal EA and distal TEF patients is substantial, and many common practices do not appear to reduce complications. Specifically, this large retrospective series does not support the use of prophylactic antibiotics beyond 24h and empiric acid suppression may not prevent complications. Use of a transanastomotic tube was associated with higher rates of stricture, and interposition of prosthetic material was associated with higher leak rates. Routine postoperative esophagram can be safely obtained on day 5 resulting in earlier initiation of oral feeds. Study typeTreatment study. Level of evidenceIII.

MP71-06 PROGNOSTIC SIGNIFICANCE OF EZH2 EXPRESSION IN UPPER TRACT UROTHELIAL CARCINOMA

You have accessJournal of UrologyBladder Cancer: Upper Tract Transitional Cell Carcinoma I1 Apr 2017MP71-06 PROGNOSTIC SIGNIFICANCE OF EZH2 EXPRESSION IN UPPER TRACT UROTHELIAL CARCINOMA Ahmet Aydin, Nirmish Singla, Vandana Panwar, Ryan Hutchinson, Solomon Woldu, Christopher Wood, Jose Karam, Alon Weizer, Jay Raman, Mesut Remzi, Nathalie Rioux-Leclercq, Andrea Haitel, Marco Roscigno, Christian Bolenz, Karim Bensalah, Arthur Sagalowsky, Shahrokh Shariat, Yair Lotan, Aditya Bagrodia, Payal Kapur, Vitaly Margulis, and Laura-Maria Krabbe Ahmet AydinAhmet Aydin More articles by this author , Nirmish SinglaNirmish Singla More articles by this author , Vandana PanwarVandana Panwar More articles by this author , Ryan HutchinsonRyan Hutchinson More articles by this author , Solomon WolduSolomon Woldu More articles by this author , Christopher WoodChristopher Wood More articles by this author , Jose KaramJose Karam More articles by this author , Alon WeizerAlon Weizer More articles by this author , Jay RamanJay Raman More articles by this author , Mesut RemziMesut Remzi More articles by this author , Nathalie Rioux-LeclercqNathalie Rioux-Leclercq More articles by this author , Andrea HaitelAndrea Haitel More articles by this author , Marco RoscignoMarco Roscigno More articles by this author , Christian BolenzChristian Bolenz More articles by this author , Karim BensalahKarim Bensalah More articles by this author , Arthur SagalowskyArthur Sagalowsky More articles by this author , Shahrokh ShariatShahrokh Shariat More articles by this author , Yair LotanYair Lotan More articles by this author , Aditya BagrodiaAditya Bagrodia More articles by this author , Payal KapurPayal Kapur More articles by this author , Vitaly MargulisVitaly Margulis More articles by this author , and Laura-Maria KrabbeLaura-Maria Krabbe More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2262AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Enhancer of zeste homolog 2 is a methyltransferase encoded by the EZH2 gene. The role of EZH2 upregulation has been studied in several malignancies, including bladder cancer, though its role in upper tract urothelial carcinoma (UTUC) is poorly understood. We sought to evaluate the prognostic value of EZH2 expression in UTUC. METHODS We reviewed a multi-institutional cohort of patients who underwent radical nephroureterectomy (RNU) for high-grade UTUC from 1990-2008. Immunohistochemistry for EZH2 was performed on tissue microarrays from RNU specimens. The percentage of staining was evaluated, with EZH2 positivity defined as >20% staining present. Clinicopathologic characteristics and oncologic outcomes including recurrence-free (RFS), cancer-specific (CSS), and overall survival (OS) were compared between patients stratified by EZH2 positivity. Prognostic role of EZH2 was assessed using Kaplan-Meier (KM) analysis. Predictors of oncologic outcomes were identified using univariate (UVA) and multivariate (MVA) Cox regression analysis. Significance was defined for p<0.05. RESULTS 402 patients were included for analysis, with median follow-up 35.5 months. 313 (77.9%) patients were EZH2-negative and 89 (22.1%) were EZH2-positive. While gender, pT stage, pN stage, and prior bladder cancer were similar between groups, EZH2 expression was more often associated with ureteral location, sessile architecture, necrosis, and CIS (Table). On UVA, EZH2 was a significant predictor for worse RFS (HR 1.63, p=0.019), CSS (HR 1.87, p=0.004), and OS (HR 1.97, p<0.001). On MVA adjusted for age, pT, pN, and LVI, EZH2 remained a significant predictor for worse OS (HR 1.65, p=0.005), while significance was lost for RFS and CSS. KM curves are shown (Figure). CONCLUSIONS EZH2 expression appears to be associated with adverse pathologic features and may predict worse oncologic outcomes in patients with high-grade UTUC. The role of EZH2 pathways in UTUC pathogenesis remains to be further elucidated. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e947 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Ahmet Aydin More articles by this author Nirmish Singla More articles by this author Vandana Panwar More articles by this author Ryan Hutchinson More articles by this author Solomon Woldu More articles by this author Christopher Wood More articles by this author Jose Karam More articles by this author Alon Weizer More articles by this author Jay Raman More articles by this author Mesut Remzi More articles by this author Nathalie Rioux-Leclercq More articles by this author Andrea Haitel More articles by this author Marco Roscigno More articles by this author Christian Bolenz More articles by this author Karim Bensalah More articles by this author Arthur Sagalowsky More articles by this author Shahrokh Shariat More articles by this author Yair Lotan More articles by this author Aditya Bagrodia More articles by this author Payal Kapur More articles by this author Vitaly Margulis More articles by this author Laura-Maria Krabbe More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Utilization and impact of adjuvant chemotherapy among patients with resected stage II colon cancer: a multi-institutional analysis

BackgroundThe use of chemotherapy among patients with stage II colon cancer is controversial. We aimed to define the utilization and factors associated with the receipt of chemotherapy and the impact of chemotherapy on long-term prognosis among a large, multiinstitutional cohort of patients. Materials and methodsWe identified 876 patients who underwent resection for stage II colon cancer between 2004 and 2013 at one of seven participating institutions. Overall survival (OS) and recurrence-free survival (RFS) time was calculated from the date of the index procedure to the date of death. ResultsA total of 163 patients (18.6%) received adjuvant chemotherapy and this utilization decreased over time (P = 0.003). Younger age (P < 0.001), margin positivity (odds ratio [OR], 12.16; 95% confidence interval [CI]: 2.57-57.52; P = 0.002), and the presence of perineural invasion (OR, 1.24; 95% CI: 1.07-1.44; P = 0.005) increased the likelihood of receiving chemotherapy. Receipt of chemotherapy was associated with improved median OS and RFS. After controlling for all factors, the addition of oxaliplatin to 5-fluorouracil did not affect survival, and there was no difference in OS (hazard ratio [HR], 0.74; 95% CI: 0.27-2.06; P = 0.57) or RFS (HR, 0.71; 95% CI: 0.32-1.58; P = 0.88) with adjuvant treatment, including for patients with high-risk features (OS—HR, 0.63; 95% CI: 0.33-1.19; P = 0.15; RFS—HR, 0.77; 95% CI: 0.32-1.86; P = 0.56). ConclusionsThe utilization of chemotherapy has declined over time after resection for stage II colon cancer. Chemotherapy was not independently associated with improved OS or RFS in this study group, including in patients with high-risk features. Future prospective studies should strive to identify the subset of stage II colon cancer patients that will benefit the most from the addition of adjuvant chemotherapy.

FGFR2 mutations are associated with poor outcomes in endometrioid endometrial cancer: An NRG Oncology/Gynecologic Oncology Group study

PurposeActivating FGFR2 mutations have been identified in ~10% of endometrioid endometrial cancers (ECs). We have previously reported that mutations in FGFR2 are associated with shorter disease free survival (DFS) in stage I/II EC patients. Here we sought to validate the prognostic importance of FGFR2 mutations in a large, multi-institutional patient cohort. MethodsTumors were collected as part of the GOG 210 clinical trial “Molecular Staging of Endometrial Cancer” where samples underwent rigorous pathological review and had more than three years of detailed clinical follow-up. DNA was extracted and four exons encompassing the FGFR2 mutation hotspots were amplified and sequenced. ResultsMutations were identified in 144 of the 973 endometrioid ECs, of which 125 were classified as known activating mutations and were included in the statistical analyses. Consistent with FGFR2 having an association with more aggressive disease, FGFR2 mutations were more common in patients initially diagnosed with stage III/IV EC (29/170;17%) versus stage I/II EC (96/803; 12%; p=0.07, Chi-square test). Additionally, incidence of progression (progressed, recurred or died from disease) was significantly more prevalent (32/125, 26%) among patients with FGFR2 mutation versus wild type (120/848, 14%; p<0.001, Chi-square test). Using Cox regression analysis adjusting for known prognostic factors, patients with FGFR2 mutation had significantly (p<0.025) shorter progression-free survival (PFS; HR 1.903; 95% CI 1.177–3.076) and endometrial cancer specific survival (ECS; HR 2.013; 95% CI 1.096–3.696). ConclusionIn summary, our findings suggest that clinical trials testing the efficacy of FGFR inhibitors in the adjuvant setting to prevent recurrence and death are warranted.

Curative Surgical Resection of Adrenocortical Carcinoma: Determining Long-term Outcome Based on Conditional Disease-free Probability.

To evaluate conditional disease-free survival (CDFS) for patients who underwent curative intent surgery for adrenocortical carcinoma (ACC). ACC is a rare but aggressive tumor. Survival estimates are usually reported as survival from the time of surgery. CDFS estimates may be more clinically relevant by accounting for the changing likelihood of disease-free survival (DFS) according to time elapsed after surgery. CDFS was assessed using a multi-institutional cohort of patients. Cox proportional hazards models were used to evaluate factors associated with DFS. Three-year CDFS (CDFS3) estimates at "x" year after surgery were calculated as follows: CDFS3 = DFS(x+3)/DFS(x). One hundred ninety-two patients were included in the study cohort; median patient age was 52 years. On presentation, 36% of patients had a functional tumor and median size was 11.5 cm. Most patients underwent R0 resection (75%) and 9% had N1 disease. Overall 1-, 3-, and 5-year DFS was 59%, 34%, and 22%, respectively. Using CDFS estimates, the probability of remaining disease free for an additional 3 years given that the patient had survived without disease at 1, 3, and 5 years, was 43%, 53%, and 70%, respectively. Patients with less favorable prognosis at baseline demonstrated the greatest increase in CDFS3 over time (eg, capsular invasion: 28%-88%, Δ60% vs no capsular invasion: 51%-87%, Δ36%). DFS estimates for patients with ACC improved dramatically over time, in particular among patients with initial worse prognoses. CDFS estimates may provide more clinically relevant information about the changing likelihood of DFS over time.

Impact of the ASA Physical Status Score on Adjuvant Chemotherapy Eligibility and Survival of Upper Tract Urothelial Carcinoma Patients: a Multicenter Study.

The aim of the present multi-institutional study was to assess the influence of the American Society of Anesthesiologists Physical Status (ASA-PS) classification on adjuvant chemotherapy eligibility and survival in a multi-institutional cohort of patients treated with radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). We retrospectively reviewed data from 416 patients who underwent RNU for UTUC at four Korean institutions between 2001 and 2013. The ASA-PS classification was obtained from the anesthesia chart. Locally advanced UTUC was defined as ≥ pT3 and/or pN1 disease. The influence of ASA-PS score on survival was evaluated by Kaplan-Meier analyses and a multivariate Cox regression model. Patients with a higher ASA-PS class were less likely to be eligible for adjuvant chemotherapy in locally advanced UTUC (P = 0.016). Kaplan-Meier estimates showed that the high-risk ASA-PS group has a poorer overallsurvival (OS) and cancer-specific survival (CSS) compared to low risk ASA-PS groups in both the total and locally advanced UTUC cohorts. Based on multivariate Cox regression analysis, the high-risk ASA-PS category was an independent predictor for overall mortality (OM) (hazard ratio [HR], 1.919; 95% confidence interval [CI], 1.017–3.619; P = 0.044) and cancer-specific mortality (CSM) (HR, 2.120; 95% CI, 1.023–4.394; P = 0.043). In conclusion, high-risk ASA-PS score was independently associated with a lower survival rate in patients with UTUC after RNU. However, the influence of ASA-PS classification on survival was limited to locally advanced UTUC. The lower eligibility of patients in the high-risk ASA category for adjuvant chemotherapy may contribute to the lower survival rate in this group.

Long-term follow-up of composite bladder augmentation incorporating stomach in a multi-institutional cohort of patients with cloacal exstrophy

Composite bladder augmentation, incorporating gastric and bowel segments, has the theoretical advantage of metabolic neutrality while potentially avoiding the morbidities of gastrocystoplasty, such as hematuria-dysuria syndrome. The most common indication for this operation is a paucity of bowel, such as in cloacal exstrophy. Despite several early descriptive studies of this technique, there are no reports, to date, of long-term follow-up in this population. To describe the outcomes of composite bladder augmentation utilizing stomach in a cohort of cloacal exstrophy patients. A retrospective review of cloacal exstrophy patients who underwent composite bladder augmentation from 1984 to 2006at two institutions was performed. The incidence of mortality and morbidities related to augmentation was evaluated. Eleven patients with cloacal exstrophy underwent composite bladder augmentation. Median age at initial augmentation was 6.4 years (interquartile range (IQR) 4.4-9.1). Median follow-up was 13.2 years (IQR 11.2-24.6). The Summary table describes the types of composite bladder augmentations. Of the three patients with pre-operative metabolic acidosis, two improved with composite bladder augmentation and one developed metabolic alkalosis. Three developed hematuria-dysuria syndrome: one improved with staged ileocystoplasty, and two had persistent symptoms successfully treated with H2 receptor blockers. Two of 11 developed symptomatic bladder stones. There were no reported bladder perforations, bladder malignancies, conversions to incontinent urinary diversions, or deaths. With long-term follow-up, very few patients developed metabolic acidosis/alkalosis after composite bladder augmentation. The composite bladder augmentation will continue to be used in patients with cloacal exstrophy, in order to minimize the impact on the pre-existing short gut in these patients.

Robot-assisted Surgery for Benign Ureteral Strictures: Experience and Outcomes from Four Tertiary Care Institutions

BackgroundMinimally invasive treatment of benign ureteral strictures is still challenging because of its technical complexity. In this context, robot-assisted surgery may overcome the limits of the laparoscopic approach. ObjectiveTo evaluate outcomes for robotic ureteral repair in a multi-institutional cohort of patients treated for ureteropelvic junction obstruction and ureteral stricture (US) at four tertiary referral centres. Design, setting, and participantsThis retrospective study reports data for 183 patients treated with standard robot-assisted pyeloplasty (PYP) and robotic uretero-ureterostomy (UUY) at four high-volume centres from January 2006 to September 2014. Surgical procedureRobotic PYP and robot-assisted UUY were performed according to previously reported surgical techniques. Outcome measurements and statistical analysisPreoperative, intraoperative, and postoperative variables and outcomes were assessed. A descriptive statistical analysis was performed. Results and limitationsNo robot-assisted UUY cases required surgical conversion, while 2.8% of PYP cases were not completed robotically. The median operative time was 120 and 150min for robot-assisted PYP and robot-assisted UUY, respectively. No intraoperative complications were reported. The overall complication rate for all procedures was 11% (n=20) and complications were mostly of low grade. The high-grade complication rate was 2.2% (n=4). At median follow-up of 24 mo, the overall success rate was >90% for both procedures. The study limitations include its retrospective nature and the heterogeneity of the study population. ConclusionsRobotic surgery for benign US is safe and effective, with limited risk of high-grade complications and good intermediate-term results. Patient summaryIn this study we review the use of robotic surgery at four different tertiary care centres in the treatment of patients affected by benign ureteral strictures. Our results demonstrate that robotic surgery is a safe alternative to the standard open approach in the treatment of ureteral strictures.

Complications and Short-Term Explantation Rate Following Artificial Urinary Sphincter Implantation: Results from a Large Middle European Multi-Institutional Case Series

Background/Aims/Objectives: To analyze perioperative complication and short-term explantation rates after perineal or penoscrotal single-cuff and double-cuff artificial urinary sphincter (AUS) implantation in a large middle European multi-institutional patient cohort. Methods: 467 male patients with stress urinary incontinence underwent implantation of a perineal single-cuff (n = 152), penoscrotal single-cuff (n = 99), or perineal double-cuff (n = 216) AUS between 2010 and 2012. Postoperative complications and 6-month explantation rates were assessed. For statistical analysis, Fisher's exact test and Kruskal-Wallis rank sum test, and a multiple logistic regression model were used (p < 0.05). Results: Compared to perineal single-cuff AUS, penoscrotal single-cuff implantation led to significantly increased short-term explantation rates (8.6% (perineal) vs. 19.2% (penoscrotal), p = 0.019). The postoperative infection rate was significantly higher after double-cuff compared to single-cuff implantation (6.0% (single-cuff) vs. 13.9% (double-cuff), p = 0.019). The short-term explantation rate after primary double-cuff placement was 6.5% (p = 0.543 vs. perineal single-cuff). In multivariate analysis, the penoscrotal approach (p = 0.004), intraoperative complications (p = 0.005), postoperative bleeding (p = 0.011), and perioperative infection (p < 0.001) were independent risk factors for short-term explantation. Conclusions: Providing data from a large contemporary multi-institutional patient cohort from high-volume and low-volume institutions, our results reflect the current standard of care in middle Europe. We indicate that the penoscrotal approach is an independent risk factor for increased short-term explantation rates.

Nomograms to Predict Recurrence-Free and Overall Survival After Curative Resection of Adrenocortical Carcinoma.

Adrenocortical carcinoma (ACC) is a rare but aggressive endocrine tumor, and the prognostic factors associated with long-term outcomes after surgical resection remain poorly defined. To define clinicopathological variables associated with recurrence-free survival (RFS) and overall survival (OS) after curative surgical resection of ACC and to propose nomograms for individual risk prediction. Nomograms to predict RFS and OS after surgical resection of ACC were proposed using a multi-institutional cohort of patients who underwent curative-intent surgery for ACC at 13 major institutions in the United States between March 17, 1994, and December 22, 2014. The dates of our study analysis were April 15, 2015, to May 12, 2015. The discriminative ability and calibration of the nomograms to predict RFS and OS were tested using C statistics, calibration plots, and Kaplan-Meier curves. In total, 148 patients who underwent surgery for ACC were included in the study. The median patient age was 53 years, and 65.5% (97 of 148) of the patients were female. One-third of the patients (35.1% [52 of 148]) had a functional tumor, and the median tumor size was 11.2 cm. Most patients (77.7% [115 of 148]) underwent R0 resection, and 8.8% (13 of 148) of the patients had N1 disease. Using backward stepwise selection of clinically important variables with the Akaike information criterion, the following variables were incorporated in the prediction of RFS: tumor size of at least 12 cm (hazard ratio [HR], 3.00; 95% CI, 1.63-5.70; P < .001), positive nodal status (HR, 4.78; 95% CI, 1.47-15.50; P = .01), stage III/IV (HR, 1.80; 95% CI, 0.95-3.39; P = .07), cortisol-secreting tumor (HR, 2.38; 95% CI, 1.27-4.48; P = .01), and capsular invasion (HR, 1.96; 95% CI, 1.02-3.74; P = .04). Factors selected as predicting OS were tumor size of at least 12 cm (HR, 1.78; 95% CI, 1.00-3.17; P = .05), positive nodal status (HR, 5.89; 95% CI, 2.05-16.87; P = .001), and R1 margin (HR, 2.83; 95% CI, 1.51-5.30; P = .001). The discriminative ability and calibration of the nomograms revealed good predictive ability as indicated by the C statistics (0.74 for RFS and 0.70 for OS). Independent predictors of survival and recurrence risk after curative-intent surgery for ACC were selected to create nomograms predicting RFS and OS. The nomograms were able to stratify patients into prognostic groups and performed well on internal validation.

Impact of smoking status on survival after cytoreductive nephrectomy for metastatic renal cell carcinoma.

To assess the association of smoking status with standard clinicopathological features and overall survival (OS) in a large multi-institutional cohort of patients with metastatic renal cell carcinoma (mRCC) treated with cytoreductive nephrectomy (CNT). A total of 613 patients with mRCC treated with CNT in US and Europe institutions between 1990 and 2013 were included. Smoking history comprised smoking status, smoking duration in years, number of cigarettes per day and years since smoking cessation. Cumulative smoking exposure was categorized as light short term, heavy long term and moderate. Association between smoking history and OS was assessed by Cox regression logistic analysis. One hundred and seventy-one patients (27.9%) never smoked, 193 (31.5%) were former smokers and 249 (40.6%) were current smokers. Smoking status was associated with a higher number of metastases (p<0.001) and an abnormal preoperative corrected calcium level (p=0.01). Median follow-up was 16 (IQR 7-24) months. Current smokers had a shorter OS than never and former smokers (log rank, p=0.004). Smoking status was significantly associated with OS in univariable analysis (HR 1.45; 95% CI 1.16-1.82; p<0.001), and in multivariable analysis that adjusted for established prognostic factors (HR 1.46; 95% CI 1.16-1.84; p=0.002). Daily consumption of more than 20 cigarettes, more than 20years of smoking exposure and heavy long exposure were all independent prognosticators of worse OS. Current smoking and a higher cumulative smoking exposure are associated with a higher risk of death in patients with mRCC treated with CNT. Even at this stage, smoking negatively affects kidney cancer outcomes.

Glucose Transporter 1 (SLC2A1) and Vascular Endothelial Growth Factor A (VEGFA) Predict Survival After Resection of Colorectal Cancer Liver Metastasis.

To investigate the individual and combined prognostic value of HIF1α, SLC2A1, and vascular endothelial growth factor A (VEGFA) in a multi-institutional cohort of patients with resected colorectal cancer liver metastasis (CRCLM). In the majority of patients with CRCLM, resection seems not to be curative, despite its curative intent. Overexpression of hypoxia-inducible factor 1α (HIF1α), glucose transporter 1 (SLC2A1; also known as GLUT1), and VEGFA has been associated with tumor progression and poor prognosis of patients with colorectal cancer (CRC). Tissue microarrays were generated using CRCLM and patient-matched primary CRC from patients who underwent CRCLM resection between 1990 and 2010. Prognostic value of HIF1α, SLC2A1, and VEGFA was determined by immunohistochemistry. A 500-fold cross-validated hazard rate ratio (HRRav) for overall survival was calculated. HIF1α, SLC2A1, and VEGFA expression could be evaluated in 328, 350, and 335 patients, respectively. High SLC2A1 expression was associated with good prognosis (HRRav, 0.67; P (HRR >1) < 0.01) and high VEGFA expression to poor prognosis (HRRav, 1.84; P (HRR < 1) = 0.02), also after multivariate analysis including established clinicopathological prognostic variables (HRRav, 0.67; P (HRR > 1) < 0.01 and HRRav, 1.50; P (HRR < 1) = 0.02, respectively). SLC2A1 showed prognostic value particularly in patients treated with systemic therapy (P < 0.01), whereas the prognostic value of VEGFA expression was mainly observed in patients not treated with systemic therapy (P < 0.01). Prognosis was especially poor in patients with both low SLC2A1 and high VEGFA expression (P < 0.01). HIF1α expression was not associated with survival. SLC2A1 and VEGFA expression are prognostic molecular biomarkers for patients with CRCLM with added value to established clinicopathological variables.

Prognostic value of Caveolin-1 in patients treated with radical prostatectomy: a multicentric validation study.

To validate Caveolin-1 as an independent prognostic marker of biochemical recurrence (BCR) in a large multi-institutional cohort of patients with prostate cancer treated with radical prostatectomy (RP). Caveolin-1 expression was evaluated by immunochemistry on a tissue microarray in 3117 patients treated with RP for prostate cancer at five institutions. Univariable and multivariable Cox proportional hazards regression models assessed the association of Caveolin-1 status with BCR. Harrell's c-index quantified prognostic accuracy. Caveolin-1 was overexpressed in 644 (20.6%) patients and was associated with higher pathological Gleason sum (P = 0.002) and lymph node metastases (P = 0.05). Within a median (interquartile range) follow-up of 38 (21-66) months, 617 (19.8%) patients experienced BCR. Patients with overexpression of Caveolin-1 had worse BCR-free survival than those with normal expression (log-rank test, P = 0.004). Caveolin-1 was an independent predictor of BCR in multivariable analyses that adjusted for the effects of standard clinicopathological features (hazard ratio 1.21, P = 0.037). Addition of Caveolin-1 in a model for prediction of BCR based on these standard prognosticators did not significantly improve the predictive accuracy of the model. In subgroup analyses, Caveolin-1 was associated with BCR in patients with favourable pathological features (pT2pN0 and Gleason score = 6; P = 0.021). We confirmed that overexpression of Caveolin-1 is associated with adverse pathological features in prostate cancer and independently predicts BCR after RP, especially in patients with favourable pathological features. However, it did not add prognostically relevant information to established predictors of BCR, limiting its use in clinical practice.

Abstract 3419: VEGFA and SLC2A1 are prognostic biomarkers for patients with resectable colorectal cancer liver metastases

Abstract Background: Colorectal cancer (CRC) is the second leading cause of cancer mortality in developed countries, which is mainly due to hematogenous dissemination to the liver. Resection of CRC liver metastases (CRCLM) is the only treatment option with curative intent. Patient eligibility relies on standard prognostic clinicopathological variables, however, 5-year survival rates hardly exceed 40% indicating the need for better prognostic biomarkers to improve clinical management of CRCLM patients. Overexpression of hypoxia-inducible factor 1α (HIF1α), glucose transporter 1 (SLC2A1; also known as GLUT1) and vascular endothelial growth factor A (VEGFA) have been associated with tumor progression and poor prognosis of CRC patients. Aim: To investigate the individual and combined prognostic value of HIF1α, SLC2A1 and VEGFA in a multi-institutional cohort of patients with resected colorectal cancer liver metastasis (CRCLM). Methods: Tissue microarrays were generated using CRCLM and patient-matched primary CRC from patients who underwent CRCLM resection between 1990 and 2010. Prognostic value of HIF1α, SLC2A1 and VEGFA was determined by immunohistochemistry. A 500-fold cross-validated hazard rate ratio (HRRav) for overall survival was calculated. Results: Protein expression of HIF1α, SLC2A1 and VEGFA could be evaluated in 328, 350 and 335 patients, respectively. HIF1α expression was not associated with survival. High SLC2A1 expression was associated with good prognosis (HRRav0.67; P(HRR&amp;gt;1)&amp;lt;.01) and high VEGFA expression to poor prognosis (HRRav1.84; P(HRR&amp;lt;1) = .02), also after multivariate analysis including established clinicopathological prognostic variables (HRRav0.67; P(HRR&amp;gt;1)&amp;lt;.01 and HRRav1.50; P(HRR&amp;lt;1) = .02, respectively). SLC2A1 showed prognostic value in patients who were treated with systemic therapy (P&amp;lt;.01), while the prognostic value of VEGFA expression was mainly observed in patients who were not treated with systemic therapy (P&amp;lt;.01). Poorest prognosis was observed in patients with both low SLC2A1 and high VEGFA expression (P&amp;lt;.01). Conclusions: VEGFA and SLC2A1 expression are prognostic molecular biomarkers for CRCLM patients with added value to established clinicopathological variables. VEGFA is a key molecular target for anti-angiogenesis therapy in metastatic CRC patients, and SLC2A1 increases the uptake of glucose which is visualized by 18FDG-PET imaging. Therefore, these biomarkers provide opportunities to improve clinical management of CRCLM patients. Citation Format: Jeroen A.C.M. Goos, Erienne M.V. de Cuba, Veerle M.H. Coupe, Begona Diosdado, Pien M. Delis-van Diemen, Cemile Karga, Jeroen A.M. Belien, C. Willemien Menke - Van der Houven van Oordt, Albert A. Geldof, Gerrit A. Meijer, Otto S. Hoekstra, Remond J. A. Fijneman, on behalf of the DeCoDe PET group. VEGFA and SLC2A1 are prognostic biomarkers for patients with resectable colorectal cancer liver metastases. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 3419. doi:10.1158/1538-7445.AM2015-3419

Patient Characteristics and Perioperative Outcomes of Female Urethral Diverticulectomy: Analysis of a Multi-Institutional Prospective Database

To assess the patient and perioperative characteristics of urethral diverticulectomy using a large multi-institutional prospectively collected database. Female patients were identified using the American College of Surgeons National Surgical Quality Improvement Program participant user files (2007-2012) and current procedural terminology codes for urethral diverticulectomy (53,230). Preoperative variables and 30-day complications were examined. Urethral diverticulectomies were performed on 122 females during the study period. The cohort was relatively healthy; 80% of patients had an American Society of Anesthesiologists score of 1 or 2. The majority of procedures were performed in an outpatient setting (82%). The median procedure length was 77.5 minutes (interquartile range: 50.5-112.5), and the median length of stay was 0 days (interquartile range: 0-1). The overall 30-day complication rate was 3.3% (n = 4): 3 patients developed urinary tract infections (UTIs) and 1 patient developed both a UTI and a superficial wound infection. To our knowledge, our study represents the largest multi-institutional cohort of patients having undergone urethral diverticulectomy. The patients requiring this intervention were relatively healthy, and the procedure itself was short, allowing most patients to be discharged within 24 hours. The 30-day complication rate was very low, with UTI being the most common complication. Thus, patients can continue to be confidently counseled that urethral diverticulectomy is a safe procedure with very few perioperative complications.

MP63-10 MINIMUM 5 YEAR FOLLOW-UP AFTER ROBOTIC PARTIAL NEPHRECTOMY : A MULTI-INSTITUTIONAL ANALYSIS

You have accessJournal of UrologyKidney Cancer: Surgical Therapy IV1 Apr 2015MP63-10 MINIMUM 5 YEAR FOLLOW-UP AFTER ROBOTIC PARTIAL NEPHRECTOMY : A MULTI-INSTITUTIONAL ANALYSIS Homayoun Zargar, Mohamad Allaf, Craig Rogers, Michael Stifelman, Sam Bhayani, Alon Mass, Ravi Barod, Michael H. Johnson, Jeffrey A. Larson, and Jihad H. Kaouk Homayoun ZargarHomayoun Zargar More articles by this author , Mohamad AllafMohamad Allaf More articles by this author , Craig RogersCraig Rogers More articles by this author , Michael StifelmanMichael Stifelman More articles by this author , Sam BhayaniSam Bhayani More articles by this author , Alon MassAlon Mass More articles by this author , Ravi BarodRavi Barod More articles by this author , Michael H. JohnsonMichael H. Johnson More articles by this author , Jeffrey A. LarsonJeffrey A. Larson More articles by this author , and Jihad H. KaoukJihad H. Kaouk More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2342AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The utility of robotic partial nephrectomy (RPN) for the treatment of renal masses has increased in recent years. Although short to intermediate term functional and oncological data have been promising but long term data in this setting is sparse. The aim of the current study was to report the long-term outcomes of RPN in a multi-institutional cohort of patients who underwent the procedure at least 5 years ago. METHODS We retrospectively reviewed the records of 1836 cases of RPN performed in 5 high volume centres across USA from 2007 to mid 2014. We limited our study to cases where RPN was performed at least 5 years prior. Local recurrence, metastasis rate, overall survival (OS) and cancer specific survival (CSS) were assessed. Time from surgery was calculated from the time of study (November 2014) to the date of surgery. Actual follow up time was assessed as the time between latest follow up time and the date of surgery. GFR preservation was calculated as proportion of latest GFR to preoperative GFR. RESULTS Total of 369 patients met our inclusion criteria. The median time from the RPN surgery was 5 years (IQR 5-6). The median age of the cohort was 60.9 years and the median tumor nephrometry score was 7 (IQR 5-8). The median actual follow up time was 54.8 months (IQR 25.1-62.5). For the 274 patients with renal cell carcinoma the local recurrence and metastasis rates were 3.6 and 1.5% respectively. The OS and CSS were 94.2 and 98.9% respectively. The median time to latest renal function assessment was 51 months (IQR 23.5-60) with median GFR preservation of 89.6% (77.2-104). On multivariable cox regression model for identifying factors predicting overall mortality (age, comorbidities, pre-operative GFR, proportion of GFR preservation, tumor stage and surgical margin) positive surgical margin was a strong predictor of overall mortality (HR =38 (95% CI (3-474); p=0.005). CONCLUSIONS RPN in carefully selected cohort of patients provides excellent long-term oncological and functional outcomes. Positive surgical margin was a predictor of overall mortality in our series. Our results need to be validated by other RPN series as the follow up data further matures. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e792 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Homayoun Zargar More articles by this author Mohamad Allaf More articles by this author Craig Rogers More articles by this author Michael Stifelman More articles by this author Sam Bhayani More articles by this author Alon Mass More articles by this author Ravi Barod More articles by this author Michael H. Johnson More articles by this author Jeffrey A. Larson More articles by this author Jihad H. Kaouk More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

International multi-institutional experience with the vessel-sparing technique to reconstruct the proximal bulbar urethra: mid-term results.

To present mid-term outcomes from an international, multi-institutional cohort of patients undergoing vessel-sparing excision and primary anastomosis urethroplasty for the reconstruction of the anterior urethra. From June 2003 to December 2011, 68 patients underwent vessel-sparing anterior urethral reconstruction at five different international institutions using the vessel-sparing technique described by Jordan et al. (J Urol 177(5):1799-1802, 2007). Patients' age range was from 3 to 82 years (mean 51.2). Stricture length ranged from 1 to 3 cm (mean 1.78). After a mean follow-up of 17.6 months, 95.6 % of patients had a widely patent urethral lumen. Three patients failed the procedure, requiring either direct vision internal urethrotomy or urethral dilation, after which all were free of symptoms and did not require further instrumentation. Complications were minimal and as expected following open urethroplasty. Preservation of blood supply is a noble pursuit in surgery; however, it can be technically difficult and often requires more time and effort. This vessel-sparing technique for anterior urethral reconstruction is reproducible and appears to be reliable in this international cohort. Larger studies and longer follow-up are needed to support these encouraging results.

A nomogram to predict overall survival and disease-free survival after curative resection of gastric adenocarcinoma.

The American Cancer Society projects there will be over 22,000 new cases, resulting in nearly 11,000 deaths, related to gastric adenocarcinoma in the US in 2014. The aim of the current study was to find clinicopathologic variables associated with disease-free survival (DFS) and overall survival (OS) following curative resection of gastric adenocarcinoma, and create a nomogram for individual risk prediction. A nomogram to predict DFS and OS following surgical resection of gastric adenocarcinoma was constructed using a multi-institutional cohort of patients who underwent surgery for primary gastric adenocarcinoma at seven major institutions in the US between January 2000 and August 2013. Discrimination and calibration of the nomogram were tested by C-statistic, Kaplan-Meier curves, and calibration plots. A total of 719 patients who underwent surgery for primary gastric adenocarcinoma were included in the study. Using the backward selection of clinically relevant variables with Akaike information criteria, age, sex, tumor site, depth of invasion, and lymph node ratio (LNR) were selected as factors predictive of OS, while age, tumor site, depth of invasion, and LNR were incorporated in the prediction of DFS. A nomogram was constructed to predict OS and DFS using these variables. Discrimination and calibration of the nomogram revealed good predictive abilities (C-index, DFS 0.711; OS 0.702). Independent predictors of recurrence and death following surgery for primary gastric adenocarcinoma were used to create a nomogram to predict DFS and OS. The nomogram was able to stratify patients into prognostic groups, and performed well on internal validation.