Preoperative nomogram to predict the likelihood of complications after radical nephroureterectomy

The Impact of Venous Thromboembolism on Upper Tract Urothelial Carcinomas Undergoing Open or Minimally Invasive Radical Nephroureterectomy in the USA: Perioperative Outcomes and Health Care Costs from Insurance Claims Data

BACKGROUND AND OBJECTIVE

Venous thromboembolism (VTE) is a significant predictor of worse postoperative morbidity in cancer surgeries. No data have been available for patients with preoperative VTE and upper tract urothelial carcinoma (UTUC) undergoing radical nephroureterectomy (RNU). Our aim was to assess the impact of a preoperative VTE diagnosis on perioperative outcomes in the RNU context.

METHODS

Patients aged 18 yr or older with a UTUC diagnosis undergoing RNU were identified in the Merative Marketscan Research deidentified databases between 2007 and 2021. Multivariable logistic regression adjusted by relevant perioperative confounders was used to investigate the association between a diagnosis of VTE prior to RNU and 90-d complication rates, postoperative VTE, rehospitalization, and total costs. A sensitivity analysis on VTE severity (pulmonary embolism [PE] and/or deep venous thrombosis [DVT]) was examined.

KEY FINDINGS AND LIMITATIONS

Within the investigated cohort of 6922 patients, history of any VTE preceding RNU was reported in 568 (8.21%) cases, including DVT (n = 290, 51.06%), PE (n = 169, 29.75%), and superficial VTE (n = 109, 19.19%). The history of VTE before RNU was predictive of higher rates of complications, the most prevalent being respiratory complications (odds ratio [OR]: 1.78, 95% confidence interval [CI]: 1.43-2.22). Preoperative VTE was found to be associated with an increased risk of VTE following RNU (OR: 14.3, 95% CI: 11.48-17.82), higher rehospitalization rates (OR: 1.26, 95% CI 1.01-1.56) other than home discharge status (OR: 1.44, 95% CI: 1.18-1.77), and higher costs (OR 1.42, 95% CI: 1.20-1.68). Limitations include the retrospective nature and the use of an insurance database that relies on accurate coding and does not include information such as pathologic staging.

CONCLUSIONS AND CLINICAL IMPLICATIONS

The presented findings will contribute to the counseling process for patients. These patients may benefit from enhanced pre/postoperative anticoagulation. More research is needed before the following results can be used in the clinical setting.

PATIENT SUMMARY

Patients aged 18 yr or older with an upper tract urothelial carcinoma (UTUC) diagnosis undergoing radical nephroureterectomy (RNU) were identified in the Merative Marketscan Research deidentified databases between 2007 and 2021. Multivariable logistic regression adjusted by relevant perioperative confounders was used to investigate the association between a diagnosis of venous thromboembolism (VTE) prior to RNU and 90-d complication rates, postoperative VTE, rehospitalization, and total costs. A sensitivity analysis on VTE severity (pulmonary embolism and/or deep venous thrombosis) was examined. The presented findings will contribute to the counseling of patients with UTUC and preoperative VTE.

Machine learning identifies the risk of complications after laparoscopic radical gastrectomy for gastric cancer

BACKGROUND

Laparoscopic radical gastrectomy is widely used, and perioperative complications have become a highly concerned issue.

AIM

To develop a predictive model for complications in laparoscopic radical gastrectomy for gastric cancer to better predict the likelihood of complications in gastric cancer patients within 30 days after surgery, guide perioperative treatment strategies for gastric cancer patients, and prevent serious complications.

METHODS

In total, 998 patients who underwent laparoscopic radical gastrectomy for gastric cancer at 16 Chinese medical centers were included in the training group for the complication model, and 398 patients were included in the validation group. The clinicopathological data and 30-d postoperative complications of gastric cancer patients were collected. Three machine learning methods, lasso regression, random forest, and artificial neural networks, were used to construct postoperative complication prediction models for laparoscopic distal gastrectomy and laparoscopic total gastrectomy, and their prediction efficacy and accuracy were evaluated.

RESULTS

The constructed complication model, particularly the random forest model, could better predict serious complications in gastric cancer patients undergoing laparoscopic radical gastrectomy. It exhibited stable performance in external validation and is worthy of further promotion in more centers.

CONCLUSION

Using the risk factors identified in multicenter datasets, highly sensitive risk prediction models for complications following laparoscopic radical gastrectomy were established. We hope to facilitate the diagnosis and treatment of preoperative and postoperative decision-making by using these models.

Development and validation of a nomogram based on geriatric nutritional risk index for predicting prognosis and postoperative complications in surgical patients with upper urinary tract urothelial carcinoma

BACKGROUND

This study aimed to evaluate the potential role of the Geriatric Nutritional Risk Index (GNRI) in predicting oncological outcomes and postoperative complications in UTUC patients undergoing radical nephroureterectomy (RNU) and to develop a nomogram incorporating GNRI to predict outcomes.

METHODS

A retrospective analysis was performed on 458 consecutive patients who underwent RNU in our center. According to nutritional scores, patients were divided into the following groups: low GNRI (GNRI ≤ 98) and high GNRI (GNRI > 98). Univariable and multivariable logistic regression were performed to investigate the role of GNRI in predicting the perioperative complications. The survival was compared with Kaplan - Meier curve, and test by log-rank tests. Risk factors associated with cancer-specific survival (CSS) and overall survival (OS) were evaluated using Cox proportional hazards regression model and were integrated into a nomogram for individualized risk prediction. The calibration and discrimination ability of the model were evaluated by concordance index (C-index) and risk group stratification.

RESULTS

When compared with high GNRI, low GNRI had significantly lower survival (CSS, p < 0.001; OS, p < 0.001). Across all patients, multivariable analyses revealed that low GNRI was an independent prognostic factor (CSS, p = 0.007; OS, p = 0.005). Nomograms for 1-, 3-, and 5 years of CSS and OS had good performance. Patients can be stratified into different groups based on the nomogram, with significant differences in OS and CSS. Further, GNRI was also found to be an independent risk factor for postoperative complications. The complication - prediction nomogram based on GNRI was also internally validated and showed good performance.

CONCLUSIONS

The GNRI score is an independent predictor for the prognosis and postoperative complications of UTUC following RNU. This study presented a nomogram incorporating preoperative GNRI that might be used as a convenient tool to facilitate the preoperative individualized prediction of short- and long-term outcomes for patients with UTUC.

Reliability of prostate imaging reporting and data system version 2.1 for excluding clinically significant prostate cancer using a 1.5 tesla scanner

INTRODUCTION

Multiparametric magnetic resonance imaging (mpMRI) of the prostate gland is now the recommended initial investigation of choice for the detection of Prostate cancer (PCa). It effectively identifies patients who require prostate biopsies due to the risk of clinically significant PCa. It helps patients with clinically insignificant PCa avoid the invasive biopsies and possible accompanying complications. Large clinical trials have investigated the accuracy of mpMRI in detecting PCa. We performed a local review to examine the reliability of omitting tissue sampling in men with a negative (PIRADS 2 (P2) or less) mpMRI in the primary diagnostic setting.

METHODS

This was a retrospective study of patients with clinical suspicion of PCa within a 2-year period. Patients had a mpMRI prior to having trans-perineal prostate gland biopsies. Clinically significant disease was defined as Gleason 7 and above. The descriptive data was analysed using contingency table methods. A p-value less than 0.05 was statistically significant.

RESULTS

Out of 700 patients 90 had an mpMRI score of PIRADS 2. Seventy-seven (85.5%) of these patients had a negative biopsy, 9(10%) showed Gleason 6, 4 patients showed Gleason 7 or above. 78 patients with PIRADS 2 had a PSA density of < 0.15, none of which had a clinically significant biopsy result. The negative predictive value of mpMRI from this study is 95%.

CONCLUSION

Our results are in line with negative predictive values demonstrated in the current literature. This local study, likely applicable to other district general hospitals, shows that mpMRI is a safe and reliable initial investigation to aid decisions on which patients require biopsies.

Strategies of Endoscopic Management of Upper Tract Urothelial Carcinoma among Endourologists: A Global Survey

Up-to-date guidelines on the management of upper tract urothelial carcinoma (UTUC) are continuously published. We aim to assess the variability of diagnosis and treatment strategies in the endoscopic management of UTUC and adherence to European Association of Urology and National Comprehensive Cancer Network guidelines. A 15-question survey was designed to query practitioners on approaches to clinical practice and knowledge about endoscopic treatment indications and techniques. It was emailed to all members of the Endourologic Society through the society’s office, and to all Israeli non-member endourologists. Eighty-eight urologists participated in the survey. Adherence to guidelines on indications for endoscopic management was only 51%. Most of the survey respondents (87.5%) use holmium laser for tumor ablation, and ~50% use forceps for biopsy while the other half use baskets. Only 50% stated that they would use Jelmyto® for specific indications. Most (80%) indicated that they repeat the ureteroscopy 3 months after the first one, and 52.3% continue with follow-up ureteroscopy every 3 months during the first year after diagnosis. There is vast variability among endourologists in the technical aspects of UTUC, the indications for endoscopic management, and adherence to the available guidelines for managing UTUC.

Clinical outcomes following laparoscopic radical nephroureterectomy in octogenarians

BACKGROUND

This study aimed to compare the incidence of postoperative complications occurring within 30 days of surgery between octogenarians and younger patients and identify preoperative risk factors for the incidence of postoperative complications. Moreover, we also compared the oncological outcomes between octogenarians and younger patients.

METHODS

This retrospective study included 283 patients who underwent laparoscopic radical nephroureterectomy for upper tract urothelial carcinoma from 2002 to 2020. The patients were divided into octogenarians and younger patients (age: < 80 years), and their clinical characteristics, perioperative parameters, and postoperative complications were evaluated. The predictors of postoperative complications were evaluated using logistic regression models. Recurrence-free survival, cancer-specific survival, and overall survival were measured using the Kaplan-Meier method.

RESULTS

Twelve (17.1%) octogenarians and 40 (18.7%) younger patients had postoperative complications. No significant difference in the incidence of postoperative complications was observed between octogenarians and younger patients (p = 0.14). A high body mass index was a significant risk factor for complications (p = 0.03). The 5-year recurrence-free survival, cancer-specific survival, and overall survival rates for octogenarians and younger patients were 72% and 64% (p = 0.31), 76% and 63% (p = 0.63), and 43% and 63% (p = 0.06), respectively.

CONCLUSION

Laparoscopic radical nephroureterectomy can be performed in octogenarians with complication rates similar to those in younger patients. Similarly, the outcomes of laparoscopic radical nephroureterectomy for oncological control do not differ significantly between octogenarians and younger patients. This procedure is safe and effective for selected octogenarians.

The role of endoscopic management and adjuvant topical therapy for upper tract urothelial cancer

Upper tract urothelial carcinoma (UTUC) has traditionally been managed with radical nephroureterectomy, and while this approach remains the gold standard for high-risk disease, endoscopic, kidney-sparing management has increasingly been adopted for low-risk disease as it preserves kidney function without compromising oncologic outcomes. Ureteroscopy and percutaneous renal access not only provide diagnoses by tumor visualization and biopsy, but also enable treatment with electrocautery or laser ablation. Several modalities exist for laser ablative treatments including thulium:YAG, neodymium:YAG, holmium:YAG, and combinations of the preceding. Furthermore, due to high recurrence rates after endoscopic management, adjuvant intracavitary instillation of various agents such as mitomycin C and bacillus Calmette-Guerin have been used given benefits seen in non-muscle invasive urothelial bladder cancer. Other formulations also being studied include gemcitabine, anthracyclines, and immunotherapies. More recently, Jelmyto, a mitomycin reverse thermal gel, has been developed to allow for adequate drug delivery time and potency since urine flow could otherwise dilute and washout topical therapy. In this article, the authors review techniques, indications, best practices, and areas of current investigation in endoscopic management and adjuvant topical therapy for UTUC.

Pentafecta for Radical Nephroureterectomy in Patients with High-Risk Upper Tract Urothelial Carcinoma: A Proposal for Standardization of Quality Care Metrics

Background: Measuring quality of care indicators is important for clinicians and decision making in health care to improve patient outcomes. Objective: The primary objective was to identify quality of care indicators for patients with upper tract urothelial carcinoma (UTUC) and to validate these in an international cohort treated with radical nephroureterectomy (RNU). The secondary objective was to assess the factors associated with failure to validate the pentafecta. Design: We performed a retrospective multicenter study of patients treated with RNU for EAU high-risk (HR) UTUC. Outcome measurements and statistical analysis: Five quality indicators were consensually approved, including a negative surgical margin, a complete bladder-cuff resection, the absence of hematological complications, the absence of major complications, and the absence of a 12-month postoperative recurrence. After multiple imputations and propensity-score matching, log-rank tests and a Cox regression were used to assess the survival outcomes. Logistic regression analyses assessed predictors for pentafecta failure. Results: Among the 1718 included patients, 844 (49%) achieved the pentafecta. The median follow-up was 31 months. Patients who achieved the pentafecta had superior 5-year overall- (OS) and cancer-specific survival (CSS) compared to those who did not (68.7 vs. 50.1% and 79.8 vs. 62.7%, respectively, all p < 0.001). On multivariable analyses, achieving the pentafecta was associated with improved recurrence-free survival (RFS), CSS, and OS. No preoperative clinical factors predicted a failure to validate the pentafecta. Conclusions: Establishing quality indicators for UTUC may help define prognosis and improve patient care. We propose a pentafecta quality criteria in RNU patients. Approximately half of the patients evaluated herein reached this endpoint, which in turn was independently associated with survival outcomes. Extended validation is needed.

Influence of enhanced recovery after surgery (ERAS) on patients receiving lung resection: a retrospective study of 1749 cases

BACKGROUND

The study aimed to evaluate the outcomes following the implementation of enhanced recovery after surgery (ERAS) for patients undergoing lung cancer surgery.

METHOD

A retrospective cohort study involving 1749 patients with lung cancer undergoing pulmonary resection was conducted. The patients were divided into two time period groups for analysis (routine pathway and ERAS pathway). Logistic regression analysis was performed to assess the risks of developing postoperative pulmonary complications.

RESULTS

Among the 1749 patients, 691 were stratified into the ERAS group, and 1058 in to the routine group. The ERAS group presented with shorter postoperative in-hospital length of stay (LOS) (4.0 vs 6.0, P < 0.001), total LOS (10.0 vs. 13.0 days, P < 0.001), and lower total in-hospital costs (P < 0.001), including material (P < 0.001) and drug expenses (P < 0.001). Furthermore, the ERAS group also presented with a lower occurrence of postoperative pulmonary complications (PPCs) than the routine group (15.2% vs. 19.5%, P = 0.022). Likewise, a significantly lower occurrence of pneumonia (8.4% vs. 14.2%, P < 0.001) and atelectasis (5.9% vs. 9.8%, P = 0.004) was found in the ERAS group. Regarding the binary logistic regression, the ERAS intervention was the sole independent factor for the occurrence of PPCs (OR: 0.601, 95% CI 0.434-0.824, P = 0.002). In addition, age (OR: 1.032, 95% CI 1.018-1.046), COPD (OR: 1.792, 95% CI 1.196-2.686), and FEV1 (OR: 0.205, 95% CI 0.125-0.339) were also independent predictors of PPCs.

CONCLUSION

Implementation of an ERAS pathway shows improved postoperative outcomes, including shortened LOS, lower in-hospital costs, and reduced occurrence of PPCs, providing benefits to the postoperative recovery of patients with lung cancer undergoing surgical treatment.

Development and Validation of a Nomogram Model to Predict Acute Kidney Disease After Nephrectomy in Patients with Renal Cell Carcinoma

Purpose

To develop and validate a nomogram model to predict the occurrence of acute kidney disease (AKD) after nephrectomy.

Patients and Methods

A retrospective cohort including 378 patients with renal cell carcinoma (RCC) who had undergone radical or partial nephrectomy between March 2013 and December 2017 at the First Affiliated Hospital of Zhengzhou University was analyzed. Of these, patients who had undergone surgery in an earlier period of time formed the training cohort (n=265) for nomogram development, and those who had undergone surgery thereafter formed the validation cohort (n=113) to confirm the model's performance. The incidence rate of AKD was measured. Univariate and multivariate logistics regression analysis was used to estimate the independent risk factors associated with AKD. The independent risk factors were incorporated into the nomogram. The accuracy and utility of the nomogram were evaluated by calibration curve and decision curve analysis, respectively.

Results

Overall, AKD occurred in 27.5% and 28.3% of patients in the training and validation cohorts, separately. The final nomogram included surgery approach, Charlson comorbidity index (CCI), and the decrement of eGFR. This model achieved good concordance indexes of 0.78 (95% CI=0.71-0.84) and 0.76 (95% CI=0.67-0.86) in the training and validation cohorts, respectively. The calibration curves and decision curve analysis (DCA) demonstrated the accuracy and the clinical usefulness of the proposed nomogram, separately.

Conclusion

The nomogram accurately predicts AKD after nephrectomy in patients with RCC. The risk for patients' progress into AKD can be determined, which is useful in guiding clinical decisions.

Perioperative complications and adverse sequelae of radical nephroureterectomy

Radical nephroureterectomy (RNU) has long been considered the standard of care for treatment of upper tract urothelial carcinoma (UTUC). Despite providing oncologic control, RNU is associated with measurable morbidity and mortality. High quality data is lacking as a result of low disease incidence and very few randomized studies. In this article we will review preoperative nomograms that assist with patient counseling, summarize current knowledge about perioperative complications, and discuss adverse sequelae that may result after surgery.

Incidence and preoperative predictors for major complications following radical nephroureterectomy

Background

Radical nephroureterectomy (RNU) is the referent standard for managing bulky, invasive, or high grade upper-tract urothelial carcinoma (UTUC). The UTUC patient population, however, generally harbor medical comorbidities thereby placing them at risk of surgical complications. This study reviews a large international cohort of RNU patients to define the risk of major complications and preoperative factors associated with their occurrence.

Methods

Patients undergoing RNU at 14 academic medical centers between 2002 and 2015 were retrospectively reviewed. Preoperative clinical, demographic, operative, and comorbidity indices were recorded. The modified Clavien-Dindo index was used to grade complications occurring within 30 days of surgery. The association between preoperative variables and major complications occurring after RNU was determined by multivariable logistic regression.

Results

One thousand two hundred and sixty-six patients (707 men; 559 women) with a median age of 70 years and BMI of 27 kg/m² were included. Over three-quarters of the cohort was white, 50.1% had baseline chronic kidney disease (CKD) ≥ stage III, 22.4% had a Charlson comorbidity index (CCI) score >5, and 17.1% had an Eastern Cooperative Oncology Group (ECOG) performance status ≥2. Overall, 413 (32.6%) experienced a complication including 103 (8.1%) with a major event. Specific distribution of major complications included 49 Clavien III, 44 Clavien IV, and 10 Clavien V. On univariate analysis, patient age (P=0.006), hypertension (P=0.002), diabetes mellitus (P=0.023), CKD stage (P<0.001), American Society of Anesthesiologists (ASA) score (P=0.022), ECOG (P<0.001), and CCI (P<0.001) all were associated with major complications. On multivariate analysis, ECOG ≥2 (OR 2.38, 95% CI, 1.46–3.90), P=0.001), CCI >5 (OR 3.45, 95% CI, 1.41–8.33, P=0.007), and CKD stage ≥3 (OR 3.64, P=0.008) were independently associated with major complications.

Conclusions

Major complications following RNU occurred in almost 10% of patients. Impaired preoperative performance status and baseline CKD are preoperative variables associated with these major post-surgical adverse event. These easily measurable indices warrant consideration and discussion prior to proceeding with RNU.

Pure retroperitoneoscopic extravesical standardized seeable (PRESS) excision of distal ureter and bladder cuff in radical nephroureterectomy: step-by-step technique

BACKGROUND

Concerns have been raised regarding the management of bladder cuff with these minimally invasive approaches. The aim of this study was to describe a modified radical nephroureterectomy (RNU) with pure retroperitoneoscopic extravesical standardized seeable (PRESS) bladder cuff excision (BCE) and to assess its outcomes based on a novel concept of intraoperative "trifecta."

METHODS

Twenty-four patients with upper urinary tract urothelial carcinoma underwent retroperitoneoscopic RNU from August 2017 to August 2019. A modified RNU with PRESS BCE and lymph node dissection (LND) was performed. Descriptive analysis of patients' characteristics, surgical technique, perioperative outcomes, and follow-up data was performed. BCE trifecta was defined as en-bloc excision, mucosa-to-mucosa reliable closure and no urine spillage.

RESULTS

In 23 out of 24 cases (95.8%) the procedure was successfully completed. One patient was converted to open distal ureterectomy with a Gibson incision due to peritoneum rupture during dissection of the distal ureter. BCE trifecta was achieved in 95.7% (22/23) cases of all patients finished with PRESS technique. Median OT was 260 min (IQR: 220-305) with median EBL of 100 mL (IQR: 100-250). Median OT for distal ureterectomy was 52 min (IQR: 40-69). No positive surgical margin occurred. Median postoperative hospital stay was 6 d (IQR: 5-7). Median follow-up time was 7 mo (IQR: 5-17). One patient (4.3%) experienced bladder recurrence and no patient developed distant metastasis or died of the disease.

CONCLUSIONS

Herein, we demonstrate a standardized retroperitoneoscopic RNU technique that is safe and reproducible, enabling the visual confirmation of complete BCE and facilitating LND. BCE trifecta should be a routine goal in minimally invasive RNU. Prospective comparison with the standard open surgical technique is warranted.

Development and validation of a nomogram incorporating selected systemic inflammation-based prognostic marker for complication prediction after vascularized fibula flap reconstruction

OBJECTIVE

To develop and validate a nomogram incorporating systemic inflammatory markers (the Albumin/NLR Score [ANS]) to predict postoperative complications after vascularized fibula flap reconstruction.

PATIENTS AND METHODS

A total of 238 patients who underwent vascularized fibula flap reconstruction between March 2012 and December 2016 were collected as the primary cohort. Univariable and multivariable analysis were performed to identify independent risk factors for postoperative complications. Backward stepwise logistic regression analysis was then applied with and without the ANS; and nomograms were established based on these criteria. Independent validation of these nomograms was carried out in an independent validation cohort including 106 consecutive patients from December 2016 and January 2018.

RESULTS

Radiotherapy history (odds ratio [OR] = 0.336; 95% CI, 0.157-0.717; P = 0.005), the ANS (OR = 0.248; 95% CI, 0.093-0.661; P = 0.005) and fluid infusion rate over 24 h (OR = 0.671; 95% CI, 0.479-0.94; P = 0.02) were identified as independent risk factors for postoperative complications. A higher C-index was found in both the primary (0.759; 95% CI, 0.719-0.739) and validation cohort (0.704; 95% CI, 0.613-0.659) for the nomogram incorporating the ANS, and NRI was 0.496 (95% CI, 0.072-0.920; P = 0.022) comparing of these nomograms. Furthermore, a wider threshold probability (0.2-0.9) and superior clinical value were observed in the nomogram incorporating the ANS on the decision curve.

CONCLUSION

The ANS was an independent risk factor for postoperative complications associated with vascularized fibula flap reconstruction. The nomogram incorporating the ANS was established with better accuracy and showed more potential clinical benefit for the estimation of postoperative complications.

A Model for the Prediction of Survival in Patients With Upper Tract Urothelial Carcinoma After Surgery

Objective:

We aimed to formulate and validate prognostic nomograms that can be used to predict the prognosis of patients with upper tract urothelial carcinoma (UTUC).

Methods:

By consulting the Surveillance, Epidemiology, and End Results (SEER) database, we identified patients who were surgically treated for UTUC between 2004 and 2013. Variables were analyzed in both univariate and multivariate analyses. Nomograms were constructed based on independent prognostic factors. The prognostic nomogram models were established and validated internally and externally to determine their ability to predict the survival of patients with UTUC.

Results:

A total of 4990 patients were collected and enrolled in our analyses. Of these, 3327 patients were assigned to the training set and 1663 to the validation set. Nomograms were effectively applied to predict the 3- and 5-year survivals of patients with UTUC after surgery. The nomograms exhibited better accuracy for predicting overall survival (OS) and cancer-specific survival (CSS) than the tumor-node-metastasis (TNM) staging system and the SEER stage in both the training and validation sets. Calibration curves indicated that the nomograms exhibited high correlation to actual observed results for both OS and CSS.

Conclusions:

The nomogram models showed stronger predictive ability than the TNM staging system and the SEER stage. Precise estimates of the prognosis of UTUC might help doctors to make better treatment decisions.

Developing a prediction model for disease-free survival from upper urinary tract urothelial carcinoma in the Korean population

Background

In this study, we aimed to propose a validated prediction model for disease‐free survival (DFS) after radical nephroureterectomy (RNU) in a Korean population with upper urinary tract urothelial carcinoma (UTUC).

Methods

We performed a retrospective review of 1561 cases of UTUC who underwent either open RNU (ONU, n = 906) or laparoscopic RNU (LNU, n = 615) from five tertiary Korean institutions between January 2000 and December 2012. Data were used to develop a prediction model using the Cox proportional hazards model. Prognostic factors were selected using the backward variable selection method. The prediction model performance was investigated using Harrell's concordance index (C‐index) and Hosmer‐Lemeshow type 2 statistics. Internal validation was performed using a bootstrap approach, and the National Cancer Center data set (n = 128) was used for external validation.

Results

A best‐fitting prediction model with seven significant factors was developed. The C‐index and two Hosmer‐Lemeshow type statistics of the prediction model were 0.785 (95% CI, 0.755‐0.815), 4.810 (P = 0.8506), and 5.285 (P = 0.8088). The optimism‐corrected estimate through the internal validation was 0.774 (95% CI, 0.744‐0.804) and the optimism‐corrected calibration curve was close to the ideal line with mean absolute error = 0.012. In external validation, the discrimination was 0.657 (95% CI, 0.560‐0.755) and the two calibration statistics were 0.790 (P = 0.9397) and 3.103 (P = 0.5408), respectively.

Conclusion

A validated prediction model based on a large Korean RNU cohort was developed with acceptable performance to estimate DFS in patients with UTUC.

[Presurgical assessments]

For the estimation of perioperative risks and mortality in the context of radical urological tumor surgery in elderly patients, the guidelines meanwhile require the use of geriatric assessments. The aim of this work is therefore to explain frequently used geriatric assessments and to give an overview of their predictive significance in radical urological tumor surgery. Comprehensive geriatric assessments provide a good description of the patient's state of health, but are hardly feasible in clinical routine due to their complexity. It is more reasonable to use screening tools with subsequent targeted examination of high-risk patients. Special tools allow the standardized assessment of functional status, mobility, cognition, mood, nutrition, frailty, comorbidities and polypharmacy and have different prognostic significance. Evidence on the predictive value of assessments prior to radical urological tumor surgery is mainly described for the systematic classification of comorbidities. In cystectomy, the Charlson Comorbidity Index (CCI) and the American Society of Anesthesiologists (ASA) score allow an estimation of the risk of complications and mortality. The focus of assessments prior to prostatectomy is to identify patients with sufficient life expectancy to benefit from radical surgery. CCI and ASA scores as well as the Eastern Co-operative Oncology Group (ECOG) score can help to assess the risk of perioperative complications in kidney tumor surgery.

Nomogram for predicting the likelihood of postoperative surgical complications in patients treated with partial nephrectomy: a prospective multicentre observational study (the RECORd 2 project)

OBJECTIVE

To identify meaningful predictors and to develop a nomogram of postoperative surgical complications in patients treated with partial nephrectomy (PN).

PATIENTS AND METHODS

We prospectively evaluated 4308 consecutive patients who had surgical treatment for renal tumours, between 2013 and 2016, at 26 Italian urological centres (RECORd 2 project). A multivariable logistic regression for surgical complications was performed. A nomogram was created from the multivariable model. Internal validation processes were performed using bootstrapping with 1000 repetitions.

RESULTS

Overall, 2584 patients who underwent PN were evaluated for the final analyses. The median (interquartile [IQR]) American Society of Anesthesiologists (ASA) score was 2 (2-3). In all, 72.4% of patients had clinical T1a (cT1a) stage tumours. The median (IQR) Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score was 7 (6-8). Overall, 34.3%, 27.7%, 38% of patients underwent open PN (OPN), laparoscopic PN (LPN), and robot-assisted PN (RAPN). Overall and major postoperative surgical complications were recorded in 10.2% and 2.5% of patients, respectively. At multivariable analysis, age, ASA score, cT2 vs cT1a stage, PADUA score, preoperative anaemia, OPN and LPN vs RAPN, were significant predictive factors of postoperative surgical complications. We used these variables to construct a nomogram for predicting the risk of postoperative surgical complications. At decision curve analysis, the nomogram led to superior outcomes for any decision associated with a threshold probability of >5%.

CONCLUSION

Several clinical predictors have been associated with postoperative surgical complications after PN. We used this information to develop and internally validate a nomogram to predict such risk.

Preoperative prognostic nutritional index and nomogram predicting recurrence-free survival in patients with primary non-muscle-invasive bladder cancer without carcinoma in situ

Background and objectives

Among the cancers of the urogenital system, bladder cancer is ranked second both in incidence and mortality, and hence, a more accurate estimate of the prognosis for individual patients with non-muscle-invasive bladder cancer (NMIBC) is urgently needed. Prognostic nutritional index (PNI) which is based on serum albumin levels and peripheral lymphocyte count has been confirmed to have prognostic value in various cancers. The aim of this study was to clarify the prognostic value of PNI in patients with NMIBC.

Methods

Data of 329 patients with NMIBC were evaluated retrospectively. Recurrence-free survival (RFS) was assessed using the Kaplan–Meier method, and the equivalences of survival curves were tested by log-rank tests. The univariate and multivariate analyses were performed using the Cox proportional hazards regression model. Discrimination of the nomogram was measured by the concordance index. A p-value of <0.05 was considered statistically significant.

Results

In univariate analysis, age, tumor focality, tumor size, tumor grade, pathological T stage and preoperative PNI were significantly associated with RFS. Multivariate analysis identified PNI as an independent predictor of RFS in patients with NMIBC. According to these independent predictors, a nomogram for the prediction of recurrence was developed.

Conclusion

PNI can be regarded as an independent prognostic factor for predicting RFS in NMIBC. The nomogram could be useful to improve personalized therapy for patients with NMIBC.

Survival outcomes for patients with localised upper tract urothelial carcinoma managed with non-definitive treatment

OBJECTIVE

To investigate the outcomes of patients with upper tract urothelial carcinoma (UTUC) with non-definitive therapy, which currently remains unknown.

PATIENTS AND METHODS

We used the Surveillance, Epidemiology, and End Results (SEER) database to identify individuals with a localised, histologically confirmed kidney/renal pelvis and ureteric UC. Survival analysis using the Kaplan-Meier method was performed. A competing risk model evaluated the cumulative incidence and predictors of cancer-specific mortality (CSM).

RESULTS

We identified 633 (7.6%) individuals who did not receive surgery. These individuals were significantly older (median age 81 vs 71 years, P < 0.001) than surgically managed patients. The median overall survival (OS) was significantly shorter compared to the surgical cohort (1.9 vs 7.8 years, P < 0.001). The 3-year disease-specific survival (DSS) for patients without surgery was significantly lower compared to those with surgery, at 73.7% vs 92.4%, respectively (P < 0.001). The 3-year DSS for patients with high-grade tumours was worse when compared to patients with low-grade tumours, at 65.1% vs 82.9%, respectively (P < 0.001). The 3-year cumulative CSM was 26.3%. On multivariable analysis, older age (hazard ratio [HR] 1.05, P < 0.001) and high tumour grade (HR 1.88, P < 0.001) were predictors of worse outcomes.

CONCLUSIONS

In this population-based cohort, 7.6% of patients with UTUC were managed with a non-definitive approach. The median OS for the untreated cohort was significantly shorter compared to the surgical cohort (1.9 vs 7.8 years, respectively). These data may be helpful in counselling patients who are poor surgical candidates, as non-definitive therapy may provide reasonable oncological outcomes.

Complications Following Radical Nephroureterectomy

Radical nephroureterectomy (RNU) is the gold standard treatment strategy for bulky, high-grade, or muscle-invasive upper tract urothelial carcinoma (UTUC). Many patients with UTUC who require RNU are elderly, comorbid, and at risk for perioperative complications. Recognition of likelihood and extent of such complications guides preoperative counseling, decision-making process for major surgery, and perioperative care. A critical review of such data is essential, given the inevitable impact of complications on hospital duration, need for readmission, resource utilization, and costs associated with management.