Nivolumab plus Gemcitabine-Cisplatin in Advanced Urothelial Carcinoma

BACKGROUND

No new agent has improved overall survival in patients with unresectable or metastatic urothelial carcinoma when added to first-line cisplatin-based chemotherapy.

METHODS

In this phase 3, multinational, open-label trial, we randomly assigned patients with previously untreated unresectable or metastatic urothelial carcinoma either to receive intravenous nivolumab (at a dose of 360 mg) plus gemcitabine-cisplatin (nivolumab combination) every 3 weeks for up to six cycles, followed by nivolumab (at a dose of 480 mg) every 4 weeks for a maximum of 2 years, or to receive gemcitabine-cisplatin alone every 3 weeks for up to six cycles. The primary outcomes were overall and progression-free survival. The objective response and safety were exploratory outcomes.

RESULTS

A total of 608 patients underwent randomization (304 to each group). At a median follow-up of 33.6 months, overall survival was longer with nivolumab-combination therapy than with gemcitabine-cisplatin alone (hazard ratio for death, 0.78; 95% confidence interval [CI], 0.63 to 0.96; P = 0.02); the median survival was 21.7 months (95% CI, 18.6 to 26.4) as compared with 18.9 months (95% CI, 14.7 to 22.4), respectively. Progression-free survival was also longer with nivolumab-combination therapy than with gemcitabine-cisplatin alone (hazard ratio for progression or death, 0.72; 95% CI, 0.59 to 0.88; P = 0.001). The median progression-free survival was 7.9 months and 7.6 months, respectively. At 12 months, progression-free survival was 34.2% and 21.8%, respectively. The overall objective response was 57.6% (complete response, 21.7%) with nivolumab-combination therapy and 43.1% (complete response, 11.8%) with gemcitabine-cisplatin alone. The median duration of complete response was 37.1 months with nivolumab-combination therapy and 13.2 months with gemcitabine-cisplatin alone. Grade 3 or higher adverse events occurred in 61.8% and 51.7% of the patients, respectively.

CONCLUSIONS

Combination therapy with nivolumab plus gemcitabine-cisplatin resulted in significantly better outcomes in patients with previously untreated advanced urothelial carcinoma than gemcitabine-cisplatin alone. (Funded by Bristol Myers Squibb and Ono Pharmaceutical; CheckMate 901 ClinicalTrials.gov number, NCT03036098.).

Creation of bladder assembloids mimicking tissue regeneration and cancer

Current organoid models are limited by their inability to mimic mature organ architecture and associated tissue microenvironments1,2. Here we create multilayer bladder 'assembloids' by reconstituting tissue stem cells with stromal components to represent an organized architecture with an epithelium surrounding stroma and an outer muscle layer. These assembloids exhibit characteristics of mature adult bladders in cell composition and gene expression at the single-cell transcriptome level, and recapitulate in vivo tissue dynamics of regenerative responses to injury. We also develop malignant counterpart tumour assembloids to recapitulate the in vivo pathophysiological features of urothelial carcinoma. Using the genetically manipulated tumour-assembloid platform, we identify tumoural FOXA1, induced by stromal bone morphogenetic protein (BMP), as a master pioneer factor that drives enhancer reprogramming for the determination of tumour phenotype, suggesting the importance of the FOXA1-BMP-hedgehog signalling feedback axis between tumour and stroma in the control of tumour plasticity.

Erdafitinib or Chemotherapy in Advanced or Metastatic Urothelial Carcinoma

BACKGROUND

Erdafitinib is a pan-fibroblast growth factor receptor (FGFR) inhibitor approved for the treatment of locally advanced or metastatic urothelial carcinoma in adults with susceptible FGFR3/2 alterations who have progression after platinum-containing chemotherapy. The effects of erdafitinib in patients with FGFR-altered metastatic urothelial carcinoma who have progression during or after treatment with checkpoint inhibitors (anti-programmed cell death protein 1 [PD-1] or anti-programmed death ligand 1 [PD-L1] agents) are unclear.

METHODS

We conducted a global phase 3 trial of erdafitinib as compared with chemotherapy in patients with metastatic urothelial carcinoma with susceptible FGFR3/2 alterations who had progression after one or two previous treatments that included an anti-PD-1 or anti-PD-L1. Patients were randomly assigned in a 1:1 ratio to receive erdafitinib or the investigator's choice of chemotherapy (docetaxel or vinflunine). The primary end point was overall survival.

RESULTS

A total of 266 patients underwent randomization: 136 to the erdafitinib group and 130 to the chemotherapy group. The median follow-up was 15.9 months. The median overall survival was significantly longer with erdafitinib than with chemotherapy (12.1 months vs. 7.8 months; hazard ratio for death, 0.64; 95% confidence interval [CI], 0.47 to 0.88; P = 0.005). The median progression-free survival was also longer with erdafitinib than with chemotherapy (5.6 months vs. 2.7 months; hazard ratio for progression or death, 0.58; 95% CI, 0.44 to 0.78; P<0.001). The incidence of grade 3 or 4 treatment-related adverse events was similar in the two groups (45.9% in the erdafitinib group and 46.4% in the chemotherapy group). Treatment-related adverse events that led to death were less common with erdafitinib than with chemotherapy (in 0.7% vs. 5.4% of patients).

CONCLUSIONS

Erdafitinib therapy resulted in significantly longer overall survival than chemotherapy among patients with metastatic urothelial carcinoma and FGFR alterations after previous anti-PD-1 or anti-PD-L1 treatment. (Funded by Janssen Research and Development; THOR ClinicalTrials.gov number, NCT03390504.).

Percutaneous nephrostomy versus indwelling ureteral stents in the management of extrinsic ureteral obstruction in advanced malignancies: are there differences?

OBJECTIVES

To compare the complications and morbidities after placement of a percutaneous nephrostomy (PCN) tube or an internal ureteral stent (IUS) in the management of malignant ureteral obstruction in patients with advanced malignancy.

METHODS

A retrospective analysis was performed on a total of 148 patients (80 women and 68 men, mean age 57.3 years, range 20 to 84) with malignant ureteral obstruction, who underwent PCN tube placement (n = 80) or IUS placement (n = 68) between January 2000 and December 2002. The incidence of fever and acute pyelonephritis was expressed as the number of episodes per 100 person-days.

RESULTS

The accumulated incidence of fever and acute pyelonephritis was not different in the two groups. The accumulated incidence and the incidence of febrile episodes in the IUS group was 10.3% and 0.0004/100 person-days; the corresponding values for the PCN group were 15.0% and 0.2154/100 person-days. The incidence of acute pyelonephritis in the IUS and PCN groups was 0.0002/100 person-days and 0.0005/100 person-days, respectively. These patients were treated conservatively and recovered uneventfully. The difference in overall stent-related or catheter-related complications between the IUS and PCN groups was not statistically significant. The accumulated incidence of failed diversion due to obstruction was 11% (8 of 68) and 1.3% (1 of 80) in the IUS and PCN groups, respectively (P = 0.012).

CONCLUSIONS

Our results have demonstrated that morbidities after internal or external diversion were minimal in cases of malignant obstruction. However, patients scheduled to receive an IUS should be more carefully monitored for ongoing obstruction than patients scheduled for PCN tube placement.

Adjuvant systemic chemotherapy in the treatment of patients with invasive transitional cell carcinoma of the upper urinary tract

OBJECTIVES

To evaluate the efficacy of adjuvant systemic chemotherapy in conjunction with surgery in patients with invasive transitional cell carcinoma of the upper urinary tract.

METHODS

From January 1991 to May 2001, 36 men and 7 women had invasive (Stage pT2 or worse), but not metastatic, disease and were the subjects of this study. Their median age was 59 years (range 36 to 72). Of these 43 patients, 32 were scheduled to receive more than four courses of cisplatin-based chemotherapy. The median follow-up period of all the evaluated patients was 30.7 months (range 4.7 to 98.8).

RESULTS

Recurrence was observed in 12 patients (37.5%) who underwent chemotherapy and 7 (63.6%) who did not (P = 0.170). The disease-free survival was lower in the nonchemotherapy group than in the chemotherapy group (P = 0.0439). During the follow-up period, 9 patients (28.1%) in the chemotherapy group died and 9 patients (81.8%) in the nonchemotherapy group died (P = 0.004). Multivariate Cox proportional hazard model analysis revealed that the use of adjuvant chemotherapy (P = 0.006, relative risk = 9.19) and node-positive status (P = 0.008, relative risk = 8.28) were strongly associated with overall survival. In the chemotherapy group, 24 (75%) had side effects due to the treatment; however, fever and gastrointestinal symptoms were the chief adverse effects and were well tolerated.

CONCLUSIONS

Our results have indicated that adjuvant systemic chemotherapy may provide therapeutic benefit in patients with invasive transitional cell carcinoma of the upper urinary tract.

Potential differentiation of human mesenchymal stem cell transplanted in rat corpus cavernosum toward endothelial or smooth muscle cells

One of the causes of erectile dysfunction (ED) is the damaged penile cavernous smooth muscle cells (SMCs) and sinus endothelial cells (ECs). To investigate the feasibility of applying immortalized human mesenchymal stem cells (MSCs) to penile cavernous ECs or SMCs repair in the treatment of ED, the in vivo potential differentiation of the immortalized human MSCs toward penile cavernous endothelial or smooth muscle was investigated. One clone of immortalized human bone marrow mesenchymal stem cell line B10 cells via retroviral vector encoding v-myc were transplanted into the cavernosum of the Sprague-Dawley rats and harvested 2 weeks later. The expression of CD31, von Willebrand factor (vWF), smooth muscle cell actin (SMA), calponin and desmin was determined immunohistochemically in rat penile cavernosum. Multipotency of B10 to adipogenic, osteogenic or chondrogenic differentiation was found. Expression of EC specific markers (CD31 or vWF protein) and expression of SMC specific markers (calponin, SMA or desmin protein) were demonstrated in grafted B10 cells. When human MSCs were transplanted into the penile cavernosum, they have the potential to differentiate toward ECs or SMCs. Human MSCs may be a good candidate in the treatment of penile cavernosum injury.

Tension-free vaginal tape procedure for urinary incontinence with low Valsalva leak point pressure

PURPOSE

We evaluated the outcome of the tension-free vaginal tape (TVT) procedure for stress urinary incontinence with low Valsalva leak point pressure (VLPP) and identified factors predicting the outcome.

MATERIALS AND METHODS

A total of 221 women 29 to 80 years old (mean age 55.2) were included in the study. The TVT procedure was performed mostly using local anesthesia. Mean followup was 10.5 months (range 6 to 52). Patients were divided into 61 with low (less than 60 cm H2O) and 160 with higher (60 cm H2O or greater) VLPP. Cure of incontinence was defined as an absent subjective complaint of leakage and absent objective leakage on stress testing.

RESULTS

The overall cure rate was significantly lower in patients with low vs higher VLPP (82.0% vs 93.1%, p = 0.013). In women with low VLPP multivariate analysis indicated that urge symptoms and low maximal urethral closure pressure were independent factors for treatment failure (OR 15.12, 95% CI 1.90 to 120.61, p = 0.010 and OR 0.92, 95% CI 0.86 to 0.99, p = 0.018, respectively).

CONCLUSIONS

The cure rate after the TVT procedure is lower in women with VLPP less than 60 cm H2O compared to those with higher VLPP. Our findings suggest that women with urge symptoms and low maximal urethral closure pressure should be considered to be at high risk for failure after the TVT procedure.

Voiding diary for the evaluation of urinary incontinence and lower urinary tract symptoms: prospective assessment of patient compliance and burden

AIMS

Voiding diary duration may be related to patient compliance and burden. To test this hypothesis, we evaluated patient compliance and burden.

METHODS

Between January and July 2002, we prospectively evaluated 162 patients (57 males and 105 females, mean age 53.0, range 20-81 years) with stress urinary incontinence or lower urinary tract symptoms. At the initial visit, all patients underwent a detailed clinical evaluation including an International Prostate Symptom Score (I-PSS) assessment and were randomly requested to complete 2-day, 3-day, or 7-day voiding diaries (the three study groups). At the second visit, a simple self-administered questionnaire was completed by all patients. The questionnaire included 11 items on subject demographics and voiding diary-keeping.

RESULTS

No significant differences were found in either the accuracy of diary-keeping or the daily average number of omissions when the three groups were compared. However, as the diary duration increased, the mean burden scores increased (P = 0.005), and the mean preferred duration of the diary in the 7-day group was significantly higher than that of the 2-day or 3-day groups (P < 0.001). After categorizing patients into two groups according to the degree of patient burden, members of the group with a greater perceived burden were found to have a significantly higher I-PSS quality of life score (P = 0.045) and to have kept a diary for a longer time (P = 0.038).

CONCLUSIONS

Our results suggest that keeping a diary for 7 days may increase patient burden and thus, we recommend that the 7-day diary should be reduced to cover fewer days.

Health-related quality of life and sexual function in women with stress urinary incontinence and overactive bladder

BACKGROUND

We evaluated the impact of stress urinary incontinence (SUI) and overactive bladder (OAB) on health-related quality of life (HRQOL) and sexual function.

METHODS

A total of 245 women (SUI; n = 123 and OAB; n = 122) from 21 to 79 years old (mean 50.4) were included in the primary analyses. To obtain HRQOL and sexual function assessments, patients were asked to fill in the 'Bristol Female Lower Urinary Tract Symptoms (BFLUTS)' and the 'Medical Outcomes Study Short Form (SF-36)' questionnaires.

RESULTS

Of the eight domains in the SF-36 questionnaire, only 'general health' was significantly different between the groups. Patients with SUI had a better general health than those with OAB (P = 0.016). When comparing the BFLUTS scores in the two groups, the score for 'BFLUTS-filling symptoms' was higher in the OAB group (P = 0.002) but that for 'BFLUTS-incontinence symptoms' was higher in the SUI group (P < 0.001). The score for 'BFLUTS-sex' was higher in the SUI group than in the OAB group but this was not statistically significant (P = 0.096). Of the 169 patients who had a sex life, the SUI group had experienced pain (P = 0.033) and leakage (P = 0.056) more frequently during intercourse than the OAB group.

CONCLUSION

Both SUI and OAB have a detrimental impact on patient HRQOL in Korean women. In addition, our findings suggest that women with SUI had more frequently experienced pain during intercourse and coital incontinence than those with OAB.

Health-related quality of life of patients using clean intermittent catheterization for neurogenic bladder secondary to spinal cord injury

OBJECTIVES

To determine the psychological and social status of patients using clean intermittent catheterization for neurogenic bladder according to health-related quality of life (HRQOL).

METHODS

We conducted a prospective trial involving 132 patients (81 men and 51 women, mean age 41.8 years, range 18 to 80 years) using clean intermittent catheterization because of neurogenic bladder secondary to spinal cord injury. The 150 controls (90 men and 60 women) lived in the same region as the patients and were frequency matched to ensure equal age and sex distributions. HRQOL was measured using the Medical Outcomes Study 36-Item Short-Form General Health Survey (SF-36).

RESULTS

The SF-36 scores did not reveal any significant differences between the men and women in the patient group. The SF-36 scores of the patients were significantly lower than those of the general population. When patients and controls were divided into two groups according to sex and age, the SF-36 scores of the patients were significantly lower than the controls across both sex and all age groups, other than the energy and vitality scale, the differences for which were not statistically significant in women and those younger than 50 years.

CONCLUSIONS

Our findings suggest that patients using clean intermittent catheterization because of neurogenic bladder secondary to spinal cord injury generally exhibit a reduced quality of life in all health domains as assessed by the SF-36.

Tension-free vaginal tape, suprapubic arc sling, and transobturator tape in the treatment of mixed urinary incontinence in women

We evaluated the outcome at least 6 months after tension-free vaginal tape (TVT), suprapubic arc (SPARC) sling, or transobturator tape (TOT) procedure in women with mixed urinary incontinence and identified factors predicting the outcome in these patients. A total of 144 women, 29 to 77 years old (mean age 57.3), were included in the study; TVT (n = 72), SPARC (n = 22), and TOT (n = 50). The mean follow-up time was 10.9 months (range 6 to 52). There were no significant differences in the three groups in terms of the cure rate for stress urinary incontinence (SUI; TVT, 95.8%; SPARC, 90.0%; TOT, 94.0%; P = 0.625) and urinary incontinence (UUI; TVT, 81.9%; SPARC, 86.4%; TOT, 82.0%; P = 0.965). In the multivariate model, there is no influencing factor for treatment failure of SUI, while maximum urethral closure pressure (MUCP) and the diagnosis of uninhibited detrusor contraction during cystometry were independent risk factors for treatment failure of UUI. Decreasing MUCP was associated with an increased likelihood of treatment failure of UUI [odds ratio (OR), 0.974; 95% confidence interval (CI), 0.950-0.998; P = 0.034]. In the same model, uninhibited detrusor contraction was associated with 3.4-fold risk of treatment failure of UUI (OR, 3.351; 95% CI, 1.031-10.887; P = 0.044). Our findings suggest that low MUCP and the presence of uninhibited detrusor contraction during cystometry should be considered to be at high risk of treatment failure of UUI after surgery in these patients.

Late recurrence of renal cell carcinoma >5 years after surgery: clinicopathological characteristics and prognosis

What's known on the subject? and What does the study add? Late recurrence more than five years after the initial treatment is one of the biological behaviours specific for RCC. In our study, late recurrence was observed in 8.8% of the patients. Also, patients with late recurrence had more favorable clinicopathological features and better prognosis with long cancer-specific survival after recurrence. Age and preoperative hs-CRP levels may be independent predictive factors for late recurrence of RCC.

OBJECTIVE

• To evaluate the clinicopathological features and prognosis of late recurrence of renal cell carcinoma (RCC).

PATIENTS AND METHODS

• A total of 747 patients who had undergone curative surgery for RCC with follow-up of >5 years or recurrence within 5 years were included in the study. • The patients were stratified into four groups based on cancer-free intervals: no recurrence (no recurrence >5 years after surgery, n= 425), synchronous metastasis (n= 138), early recurrence (recurrence within 5 years, n= 143), and late recurrence (recurrence after 5 years, n= 41). • Multivariate analysis was performed to identify the clinicopathological factors affecting late recurrence and its clinical outcome.

RESULTS

• The subgroups were significantly different in clinicopathological variables, including age, preoperative haemoglobin, platelet count, high-sensitivity C-reactive protein (hs-CRP) levels, pT stage and nuclear grade. • In multiple logistic regression analysis, age (odds ratio [OR] 1.085, 95% confidence interval [CI] 1.012-1.163, P= 0.022), and preoperative hs-CRP levels (OR 6.211, 95% CI 1.590-24.270, P= 0.009) were independent predictive factors for late recurrence. • In patients with synchronous metastasis, early recurrence and late recurrence, 5-year cancer-specific survival rates after recurrence were 27.0%, 41.1% and 73.7%, respectively (P < 0.001). • Multivariate Cox analysis indicated that cancer-free interval, as well as body mass index, initial symptoms, Fuhrman's nuclear grade, sarcomatoid differentiation, lymphovascular invasion and metastasectomy, were independent predictive factors for cancer-related death.

CONCLUSIONS

• Late recurrence of RCC is not a rare event. • Patients with late recurrence had more favourable clinicopathological features and better prognosis with long cancer-specific survival after recurrence. • Age and preoperative hs-CRP levels may be independent predictive factors for late recurrence of RCC.

Risk factors in predicting a poor response to sildenafil citrate in elderly men with erectile dysfunction

OBJECTIVE

To assess the clinical efficacy of sildenafil and the potential predictors of poor response to sildenafil in elderly patients with erectile dysfunction (ED).

PATIENTS AND METHODS

The study included 162 patients (aged > or = 60 years) treated with sildenafil for at least 8 weeks; all patients were evaluated with a history, physical examination, measurement of total testosterone and a pharmacological erection test. Sexual function before and 8 weeks after treatment was assessed using the self-administered International Index of Erectile Function (IIEF). Treatment was considered successful when the patient attained a higher grade on the erectile function (EF) domain score, and an affirmative response to the overall assessment question. Factors influencing treatment outcome were evaluated by univariate and multivariate statistical analysis.

RESULTS

The overall efficacy with sildenafil was 47% (76/162). On univariate analysis, uncontrolled diabetes, current smoking, hypogonadism (<3 microg/L testosterone) and low pretreatment EF domain score (<17) were selected as predictors of a poor response. On multivariate logistic regression, a low pretreatment EF domain score was the strongest independent prognostic factor for a poor response (odds ratio 2.25, 95% confidence interval, 1.45-7.33), and this was followed by hypogonadism (1.89, 1.12-3.16) and current smoking (1.34, 1.04-3.52).

CONCLUSION

In a real clinical setting, sildenafil was effective for about half of the elderly men. The baseline EF domain score, hypogonadism and current smoking were significantly associated with failure of sildenafil. These results suggest that modifying reversible risk factors, e.g. stopping smoking and replacing testosterone, would be beneficial in augmenting the efficacy of sildenafil in elderly men.

The prognostic value of pretreatment of systemic inflammatory responses in patients with urothelial carcinoma undergoing radical cystectomy

BACKGROUND

Systemic inflammatory response (SIR) is important in the relationship between the tumour, the host, and outcome in cancer patients. However, limited data exist regarding the prognostic significance of SIR in bladder cancer. We investigate the utility of pretreatment SIR in patients with urothelial carcinoma undergoing radical cystectomy.

METHODS

The study cohort consisted of 419 patients with a median follow-up of 37.7 months. The SIRs used for each described prognostic nomogram are consistent with previously published data: C-reactive protein, albumin, white cell count, neutrophil count, lymphocyte count, and platelet count. Primary end point was disease-specific survival (DSS) and overall survival (OS) after surgery. Cox regression models were used to determine the time to disease-specific and overall mortality. Multivariate regression coefficients of the predictors were used to develop nomograms for predicting 5-year DSS and OS probability.

RESULTS

Multivariate Cox regression analyses revealed that albumin, lymphocyte count, and platelet count were significantly associated with a significantly increased risk for death from bladder cancer. The nomograms including each index were developed to predict the probability of 5-year DSS and OS after radical cystectomy. The C statistics were 77.8% and 77.3%, respectively, and exceeded the 2002 AJCC (72.0% and 70.3%, respectively). In the decision curve analyses, the nomograms including SIR demonstrated higher net benefit gains compared with the models without SIR.

CONCLUSIONS

Cellular components of SIR have better prognostic values compared with acute-phase protein in patients undergoing radical cystectomy for bladder cancer.

Influence of age, anthropometry, and hepatic and renal function on serum prostate-specific antigen levels in healthy middle-age men

OBJECTIVES

To test the hypothesis of a causal relationship between clinical parameters, including age, anthropometry, and hepatic or renal function tests and serum prostate-specific antigen (PSA) levels and to determine the predictors of high serum PSA concentrations in healthy middle-age men.

METHODS

Between January 1999 and December 2000, 6005 healthy men 40 to 59 years old who visited our hospital for a routine health checkup were entered into the study. The association between the clinical parameters and a high serum PSA level (greater than 2.5, 3.0, 3.5, or 4.0 ng/mL) was studied in three groups: the 10% with low clinical parameters, the 10% with high clinical parameters, and the remainder as a reference group.

RESULTS

The univariate logistic regression analysis indicated that high or low age, body weight, body mass index, creatinine, and creatinine clearance were significant factors in relation to serum PSA concentration compared with the reference group. In the multivariate model used, only older age was positively related to the serum PSA concentration.

CONCLUSIONS

The results of anthropometry and hepatic and renal function tests do not influence the serum PSA level in this population. Our findings suggest that serum PSA may be a reliable marker in middle-age men without severe hepatic or renal disease.

Expression of survivin, a novel inhibitor of apoptosis, in superficial transitional cell carcinoma of the bladder

PURPOSE

We investigated whether the over expression of survivin, a new antiapoptotic protein, might provide prognostic information in patients with superficial bladder cancer.

MATERIALS AND METHODS

Immunohistochemical staining of paraffin sections using a monoclonal antibody for survivin was performed in 88 cases of superficial bladder cancer using the standard avidin-biotin-peroxidase technique. The relationships between the expression of survivin, clinicopathological characteristics and clinical outcome were analyzed.

RESULTS

Survivin expression was found in tumor cells but not in nonneoplastic bladder tissues. High expressions (greater than 20%) of survivin were observed in 51 cases (58.0%) and low expression in 37 cases. No statistically significant association was observed between survivin expression and tumor grade (p = 0.052) or pathological stage (p = 0.131). When clinical data such as sex, age, tumor number, size or shape were examined in conjunction with survivin status no statistically significant relationship was noted. Patients with a high expression of survivin had worse disease-free survival rates than those with low survivin expression (log rank test p = 0.0004). Multivariate Cox proportional hazards model analysis identified survivin expression as an independent prognostic factor of disease-free survival (p = 0.009, relative risk = 3.17).

CONCLUSIONS

Our findings suggest that high survivin expression may be considered a new unfavorable prognostic factor in superficial bladder cancer.

The preventive effect of systemic treatment with interferon-alpha2B for infertility from mumps orchitis

OBJECTIVE

To evaluate the effect of interferon-alpha2B on mumps orchitis, often caused by postpubertal mumps and which can result in permanent testicular atrophy.

PATIENTS AND METHODS

The study included 21 patients with mumps orchitis, treated between May 1990 and June 1997. Patients were randomly assigned into two groups: in group 1, 13 patients received therapy with interferon-alpha2B (3 x 10(6) IU per day) and group 2 did not, acting as controls. All were evaluated by measurements of testis size, mumps virus titre, hormone level and semen analysis.

RESULTS

In group 1, the patients' symptoms resolved within 2-3 days and the volume of the testes returned to normal within 11 days; there was no testicular atrophy in any patient during the follow-up. However, asthenospermia continued to be detected in four patients (unilateral in two, bilateral in two). In group 2, the patients' symptoms resolved within 5-6 days and the volume of the testes returned to normal within 10 days; testes atrophied in three patients (unilateral in two, bilateral in one) during the follow-up. Asthenospermia continued in four patients (unilateral in two, bilateral in two).

CONCLUSION

These results suggest that treatment with systemic interferon-alpha2B is effective in preventing testicular atrophy when combined with standard symptomatic treatment.

The Prognostic Significance of the Early Postoperative Neutrophil-to-Lymphocyte Ratio in Patients with Urothelial Carcinoma of the Bladder Undergoing Radical Cystectomy

PURPOSE

Because the pretreatment neutrophil-to-lymphocyte ratio (NLR) is a reliable prognostic factor, the authors of this study hypothesized that posttreatment NLR also predicts the survival outcome for cancer patients. The study investigated the clinicopathologic features according to postoperative NLR and determined the prognostic significance of early postoperative NLR for bladder cancer patients undergoing radical cystectomy (RC).

METHODS

The study reviewed 385 bladder cancer patients treated with RC and pelvic lymph node dissection at the authors' institution between 1999 and 2012. The primary end points of the study were cancer-specific survival (CSS) and overall survival (OS) estimates from the Kaplan-Meier analysis. Multivariate Cox regression analysis was adopted to identify the independent prognostic factors for oncologic outcomes after surgery.

RESULTS

Patients with elevated postoperative NLR (≥2.0) had higher rates of advanced pathologic tumor stage (≥pT3), lymphovascular invasion, and lymph node involvement. Notably, they showed poorer CSS and OS rates than patients with a postoperative NLR lower than 2.0. Additionally, patients with pre- and postoperative elevated NLR (≥2.1 → ≥2.0) demonstrated worse oncologic outcomes than other groups of NLR changes. Multivariate analysis showed that early postoperative NLR remained a key predictor for CSS and OS. When divided by pathologic T or N stage, patients with localized pathologic T stage or pN0 status showed significant differences in survival according to early postoperative NLR.

CONCLUSION

In summary, postoperative NLR in the early recovery period can be a valuable biomarker for predicting oncologic outcomes for bladder cancer patients undergoing RC.

Metastasectomy without systemic therapy in metastatic renal cell carcinoma: comparison with conservative treatment

AIM

The objective of this study was to evaluate the efficacy of metastasectomy after nephrectomy in patients with metastatic renal cell carcinoma who had not received systemic therapy.

PATIENTS AND METHODS

A total of 62 patients were included in the study. The patients were categorized according to their surgical treatment: the metastasectomy group (n = 21) and the nonmetastasectomy group (n = 41).

RESULTS

In the metastasectomy group, the median overall survival was 36.5 (range 4.0-182.7) months, whereas the patients of the nonmetastasectomy group reached a median overall survival of 8.4 (range 0.9-63.7) months (p < 0.001). The 1-, 3-, and 5-year overall survival rates were calculated at 71.4 and 34.1%, 47.6 and 9.8%, and 9.8 and 2.4%, respectively (p < 0.001). When the patients were stratified according to their characteristics, the overall survival was lower in the nonmetastasectomy group than in the metastasectomy group in the younger patients (p = 0.002), in both male (p = 0.001) and female (p = 0.030) patients, in patients with a poor performance status (p = 0.027), in patients with a shorter time between diagnosis of the primary tumor and development of metastases (p < 0.001), and in patients with a solitary metastasis (p = 0.005). Multivariate analysis using the Cox proportional hazards model showed that only the metastasectomy status was an independent predictor of the overall survival (Hazard ratio 2.57, 95% confidence interval 1.21-5.44; p = 0.014).

CONCLUSION

Our findings suggest that for the management of metastatic renal cell carcinoma, complete surgical resection of the metastatic lesions may prolong survival even in patients with some poor prognostic factors who cannot or are not willing to receive systemic therapy.

Pilot study of the clinical efficacy of ejaculatory hood sparing technique for ejaculation preservation in Holmium laser enucleation of the prostate

We explored the effectiveness of ejaculatory hood sparing technique to Holmium laser enucleation of the prostate (HoLEP) for ejaculation preservation. From June 2010 to July 2011, 52 sexually active patients with sufficient ejaculate underwent HoLEP. Twenty-six patients received the ejaulatory hood sparing technique during HoLEP (EH-HoLEP group). The other 26 patients underwent conventional HoLEP (conventional-HoLEP group). In the EH-HoLEP group, paracollicular and supracollicular tissue >1 cm proximal to the verumontanum was preserved. The mean follow-up period was 9.7 months (range 3-12). There was no significant difference in patient characteristics and perioperative parameters, including age, prostate volume, International Index of Erectile Function score, operation time, weight of the enucleated tissue and the amount of laser energy. Semen was unchanged, decreased or vanished in 4 (15.4%), 8 (30.8%) and 17 (53.8%) EH-HoLEP patients, respectively. In the conventional-HoLEP group, semen was unchanged, decreased or vanished in 0 (0.0%%), 7 (26.9%) and 19 (73.1%) patients, respectively. Overall success rate of ejaculation preservation was 46.2% in the EH-HoLEP group and 26.9% in the conventional-HoLEP group (P = 0.249). Application of an ejaculatory hood sparing technique to HoLEP could not improve the success rate for ejaculation preservation. This was likely due to the surgical characteristics of HoLEP, which enable complete removal of the apical tissue. In this condition, simply preserved ejaculatory hood tissue seems not to be sufficient to obviate retrograde ejaculation. For the maintenance of antegrade ejaculation, it is postulated that a part of apical tissue should be preserved as well.

Comparison of retroperitoneal laparoscopic and open nephrectomy for benign renal diseases in children

OBJECTIVES

To compare the results of retroperitoneal laparoscopic versus open nephrectomy for benign renal diseases in children.

METHODS

From January 1999 to February 2003, retroperitoneal nephrectomy or nephroureterectomy was performed in 23 consecutive children (7 girls and 16 boys). The median patient age was 4 years (range 1 to 13). The disease was on the right side in 9 children and on the left side in 14. Operative and convalescence parameters, including operative time, blood loss, transfusion rate, resumption of oral intake, hospital stay, and complication rate, were evaluated in both groups.

RESULTS

All laparoscopic cases were completed successfully without conversion to open surgery. The median operative time and estimated blood loss were not statistically different between the two groups. No major perioperative complications occurred in any child, but a wound site complication occurred in 1 child who had undergone open surgery. The median hospital stay of the open group was 4 days (range 3 to 14), significantly longer than that of the laparoscopic group (median 2.5 days, range 2 to 6; P = 0.018). The cosmetic results of the laparoscopic group were excellent; the scars from the trocar sites were barely discernible at the initial postoperative visit. Convalescence was uneventful in all patients.

CONCLUSIONS

Retroperitoneal laparoscopic nephrectomy and nephroureterectomy may be performed for benign disease in children with minimal morbidity, improved cosmetic results, and a short hospital stay. Our findings indicate that retroperitoneal laparoscopic nephrectomy is appropriate in children and superior, in some instances, to open surgery.

Presence of lymphovascular invasion in urothelial bladder cancer specimens after transurethral resections correlates with risk of upstaging and survival: a systematic review and meta-analysis

OBJECTIVES

This study aimed to elucidate the relationship between lymphovascular invasion (LVI) at transurethral resection of bladder tumor (TURBT) and the risk of pathologic upstaging as well as the clinical outcomes.

MATERIALS AND METHODS

PubMed, Scopus, Web of Science, and Cochrane Library databases were searched from the respective dates of inception until November 11, 2013.

RESULTS

A total of 16 articles met the eligibility criteria for this systematic review, which included a total of 3,905 patients. LVI was detected in 18.6% of TURBT specimens. A significant association was found between LVI at TURBT and pathologic upstaging of bladder cancer (odds ratio = 2.21, 95% CI: 1.44-3.39) without heterogeneity (I(2) = 45%, P = 0.14). The pooled hazard ratio (HR) was statistically significant for recurrence-free survival (HR = 1.47, 95% CI: 1.24-1.74), progression-free survival (HR = 2.28, 95% CI: 1.45-3.58), and disease-specific survival (HR = 1.35, 95% CI: 1.01-1.81), but not for overall survival (HR = 1.55, 95% CI: 0.90-2.67). Tests of inconsistency for disease-specific survival (I(2) = 66%, P = 0.007) and overall survival (I(2) = 72%, P = 0.03) could not exclude a significant heterogeneity. The results of the Begg and the Egger tests showed that there was evidence of publication bias on pathologic upstaging and progression-free survival.

CONCLUSIONS

The data obtained in this meta-analysis indicate that the presence of LVI at TURBT portends the increased risk of pathologic upstaging and may provide additional prognostic information. However, a large, well-designed, prospective study is needed to investigate potential treatment options for bladder cancer with LVI.

Sarcomatoid differentiation as a prognostic factor for immunotherapy in metastatic renal cell carcinoma

BACKGROUND

The objective of the current study was to determine the significance of sarcomatoid differentiation as a prognostic factor for immunotherapy in metastatic renal cell carcinoma (RCC).

METHODS

Patients with metastatic RCC were included in this study and were categorized according to sarcomatoid differentiation.

RESULTS

Patients with sarcomatoid differentiation had more aggressive tumor characteristics than those without sarcomatoid differentiation. After immunotherapy, the median progression-free survival was 9.0 months (95% confidence interval [CI] 1.4-52.7) for patient without sarcomatoid differentiation and 3.2 months (95% CI 0.4-42.9) for patients with sarcomatoid differentiation, respectively (P=0.0001). The median overall survival was 22.2 months (95% CI 3.2-75.4) and 10.0 months (95% CI 0.7-60.1) in both groups. When comparing patients with sarcomatoid differentiation, there was no significant difference of overall survival in the immunotherapy group and the no immunotherapy group. Multivariate Cox proportional hazards model analysis showed that T stage (Hazard ratio [HR] 1.71; 95% CI 1.07-2.74; P=0.024), sarcomatoid differentiation (HR 2.18; 95% CI 1.30-3.66; P = 0.003), and the number of metastasis sites (HR 1.81; 95% CI 1.14-2.88; P=0.012) were independent predictors of progression-free survival. Sarcomatoid differentiation and the number of metastasis sites were independent prognostic predictors of overall survival. The estimated relative risks of sarcomatoid differentiation and the number of metastasis sites were 2.83 (95% CI 1.49-5.40; P=0.002) and 2.31 (95% CI 1.29-4.16; P=0.005), respectively.

CONCLUSIONS

Our findings suggest that sarcomatoid differentiation is an important prognostic factor for immunotherapy in metastatic RCC.