ORCID Profile
0000-0001-8241-4386
Current Organisations
The University of Auckland
,
Counties Manukau District Health Board
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Publisher: Springer Science and Business Media LLC
Date: 05-08-2016
DOI: 10.1007/S00345-016-1915-2
Abstract: The benefits of robotic-assisted radical cystectomy (RARC) are unclear, especially in patients with high-risk disease (pT3/T4). We evaluated pathological and postoperative outcomes of RARC versus open radical cystectomy (ORC) in these patients. We identified bladder cancer patients treated with RARC or ORC from January 2010-August 2014. Clinicodemographic factors were examined for potential confounding. Our primary outcome of interest was positive soft-tissue surgical margins (STSMs). Secondary outcomes included post-operative complications and length of stay (LOS). We used logistic regression to define the association between clinical factors with outcomes of interest, focusing on patients with locally advanced disease. We identified 472 patients treated with ORC (407, 86.2 %) or RARC (65, 13.8 %) of which 215 (45.6 %) were high-risk cases based on advanced pathologic stage (pT3/4). RARC patients were more commonly men (96.9 vs. 73.2 %, p < 0.01), had better performance status (ECOG 0, 78.5 vs. 59.7 %, p = 0.031), and received less neoadjuvant chemotherapy (21.5 vs. 39.3 %, p = 0.006). Total (52.3 vs. 59.7 %, p = 0.26) and high-grade complication rates (13.8 vs. 19.7 %, p = 0.27) were similar, but median LOS was shorter after RARC (6 vs. 7 days, p < 0.01). On multivariate analysis, prior pelvic radiation (OR: 4.78, 95 % CI: 2.16-10.57), and advanced tumor stage (OR: 3.06, 95 % CI: 1.56-6.03) were independently associated with positive STSMs in high-risk patients but robotic surgical approach was not (OR: 0.81, 95 % CI: 0.29-2.30 p = 0.69). RARC had similar short-term postoperative outcomes compared to ORC and did not compromise oncological control in patients with extravesical disease.
Publisher: Wiley
Date: 22-10-2021
DOI: 10.1111/ANS.17263
Abstract: Prostate cancer (Pca) is the most frequently diagnosed cancer in New Zealand (NZ) men and the third leading cause of cancer deaths. Temporal changes in Pca incidence and mortality have not been reported despite changes in the Pca landscape. This study aims to analyse the temporal trends in Pca with focus on ethnic and regional variations. The study cohort was identified from the NZ Cancer Registry and the mortality collection databases. Men who were diagnosed with Pca between 2000 and 2018 were included in the incidence analysis. Men who died from Pca between 2000 and 2015 were included in the mortality analysis. Other data collected were ethnicity and geographical information. Pca incidence and mortality were calculated as age‐standardized rates using the 2001 World Health Organization population. A total of 58 966 men were diagnosed (incidence: 105.2 per 100 000) and 14 749 men died (mortality: 49.3 per 100 000) from Pca. When compared to European men, Māori and Asian men had significantly lower Pca incidence. Mortality rates demonstrated a steady decline, which was more prominent until 2010. Māori and Pacific men had higher mortality rates when compared to European men. In most recent years, the difference in mortality is decreasing for Māori but increasing for Pacific men. There were no regional differences in mortality. Pca incidence in NZ has fluctuated over the last 20 years, while mortality rates have shown to steadily decline. Pca mortality was shown to disproportionately affect Māori and Pacific men.
Publisher: Springer Science and Business Media LLC
Date: 29-03-2018
DOI: 10.1007/S00345-018-2279-6
Abstract: To identify clinical and stone-related factors predicting the need for surgical intervention in patients who were clinically considered appropriate for non-surgical intervention. We conducted a retrospective review of a contemporary cohort of patients who were selected for surveillance following presentation with acute ureteric colic. Data on patient demographic and stone variables, inpatient management and long-term outcomes were evaluated. Multivariate logistic regression was used to generate a nomogram predicting need for surgical intervention. The accuracy of the nomogram was subsequently validated with an independent cohort of patients presenting with ureteric colic. Of 870 study eligible patients presenting with acute ureteric colic, 527 were initially treated non-surgically and included in the analysis. 113 of these eventually required surgical intervention. Median time from first presentation to acute surgery was 11 (IQR 4-82) days. In our final MVA analysis, duration of symptoms more than 3 days, not receiving alpha-blockers, positive history of previous renal calculi and stone location, burden and density were independent predictors of need for surgical intervention. Patients who required opioid analgesia were more likely to have surgical intervention however, this did not reach statistical significance. The area under the curve (AUC) of the final model was 0.802. The nomogram was validated with a cohort of 210 consecutive colic patients with AUC of 0.833 (SE 0.041, p < 0.001). We have identified independent predictors of the need for surgical intervention during an episode of renal colic and formulated a nomogram. Combined with the diligent use of acute ureteroscopy at our centre, this nomogram may have clinical utility when making decisions regarding treatment options with potential healthcare cost savings.
Publisher: Elsevier BV
Date: 05-2011
DOI: 10.1016/J.JSS.2010.12.043
Abstract: At the present, no fully validated instrument is available for the assessment of general postoperative recovery. Such an instrument would form a useful patient-centered outcome measure in studies evaluating surgical and perioperative interventions. The aim of our study is to develop and validate a summary score based on the Identity Consequence Fatigue Scale (ICFS), for the specific purpose of reliably measuring functional patient recovery following surgery. Patients who underwent elective open or laparoscopic colonic resection between June 2006 and June 2009 were included. The 31 item ICFS was administered at baseline and postoperative d 3, 7, 30, and 60. Item reduction was applied based on defined parameters, to derive a single summary score capable of predicting >90% of the variance present in the original ICFS and maximizing sensitivity to changes over time. The final score was then validated against published criteria as set out by Terwee et al. [2]. Data from 150 patients were included in the analysis. Application of the item reduction process retained 13 items. These items form the Surgical Recovery Scale (SRS). The SRS was able to predict 94% (89.4%-98.1%) of the ICFS subscale variances, and was successfully validated against seven out of eight published validation criteria. The new SRS is a simple and sensitive tool for the assessment of functional recovery following major surgery. Seven of the eight Terwee et al. validation criteria have been addressed, making this the most broadly validated measure of surgical recovery available.
Publisher: Future Science Ltd
Date: 03-2016
DOI: 10.4155/FSO.15.72
Abstract: Prostate cancer (PCa) has variable biological potential with multiple treatment options. A more personalized approach, therefore, is needed to better define men at higher risk of developing PCa, discriminate indolent from aggressive disease and improve risk stratification after treatment by predicting the likelihood of progression. This may improve clinical decision-making regarding management, improve selection for active surveillance protocols and minimize morbidity from treatment. Discovery of new biomarkers associated with prostate carcinogenesis present an opportunity to provide patients with novel genetic signatures to better understand their risk of developing PCa and help forecast their clinical course. In this review, we examine the current literature evaluating biomarkers in PCa. We also address current limitations and present several ideas for future studies.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2015
DOI: 10.1016/J.JURO.2015.10.133
Abstract: We assessed survival dependent on pathological response after neoadjuvant chemotherapy in a large multicenter patient cohort, with a particular focus on the difference between the absence of residual cancer (pT0) and the presence of only nonmuscle invasive residual cancer (pTa, pTis, pT1). We retrospectively reviewed records of patients with urothelial cancer who received neoadjuvant chemotherapy and underwent radical cystectomy at 19 contributing institutions from 2000 to 2013. Patients with cT2-4aN0M0 and eventual pN0 disease were selected for this analysis. Estimated overall survival was compared between patients with pT0 and pTa/Tis/T1 disease. A multivariable Cox proportional hazards regression model for overall survival was generated to evaluate hazard ratios for variables of interest. Of 1,543 patients treated with neoadjuvant chemotherapy and radical cystectomy during the study period 257 had pT0N0 and 207 had pTa/Tis/T1N0 disease. The Kaplan-Meier mean estimates of overall survival for pT0 and pTa/Tis/T1 cases were 186.7 months (95% CI 145.9-227.6, median 241.1) and 138 months (95% CI 118.2-157.8, median 187.4), respectively (p=0.58). In the Cox proportional hazards regression model for overall survival pTa/Tis/T1N0 status (HR 0.36, 95% CI 0.23-0.67) and pT0N0 status (HR 0.28, 95% CI 0.17-0.47) compared to pT2N0 pathology, positive surgical margin (HR 1.75, 95% CI 1.07-2.86), and receiving a methotrexate, vinblastine, doxorubicin and cisplatin regimen compared to an "other" regimen (HR 0.45, 95% CI 0.27-0.76) were predictors of overall survival. pTa/Tis/T1N0 and pT0N0 stage on the final cystectomy specimen are strong predictors of survival in patients treated with neoadjuvant chemotherapy and radical cystectomy. We did not discern a statistically significant difference in overall survival when comparing these 2 end points.
Publisher: Elsevier BV
Date: 02-2010
Publisher: Springer Science and Business Media LLC
Date: 2015
DOI: 10.1007/S00345-014-1471-6
Abstract: Lymphadenectomy (LND) is part of the surgical management of penile cancer but causes significant perioperative morbidity. We determined whether sarcopenia, a novel marker of nutritional status, is a predictor of postoperative complications after LND. Seventy-nine patients underwent LND for penile cancer from 1999 to 2014, and 43 had available preoperative abdominal imaging. Skeletal muscle index (SMI) was calculated on axial computed tomography images at the third lumbar vertebrae, and an SMI of 55 cm(2)/m(2) was used to classify patients as sarcopenic versus not. This classification was then correlated with postoperative complications and survival. Median lumbar SMI was 54.7 cm(2)/m(2) with 22 (51.2 %) patients categorized as sarcopenic versus 21 (48.8 %) who were not. Twenty-seven postoperative complications occurred in 20 patients within 30 days, of which 11 (40.7 %) were major (Clavien score ≥IIIa) and 16 (59.3 %) were minor. The most common complications were wound dehiscence (25.9 %), wound infection (18.5 %), lymphocele (18.5 %), and flap necrosis (14.8 %). On univariate analysis, the presence of sarcopenia, nodal disease, and lymphovascular invasion were predictors of postoperative complications. On multivariate analysis, only sarcopenia was an independent predictor of 30-day complications [p = 0.038 95 % confidence interval (CI) 1.1-21.1]. Although sarcopenia was not statistically associated with worse overall survival (OS), there was a trend toward poorer outcomes in these patients. Sarcopenia can be a useful prognostic tool to predict the likelihood of postoperative complications after LND for penile cancer. Preoperative nutritional supplementation may help reduce complication rates in the future.
Publisher: Elsevier BV
Date: 02-2010
Publisher: Elsevier BV
Date: 08-2016
Publisher: Journal of Biological Methods
Date: 22-04-2015
Abstract: Objective: To evaluate the clinical utilization patterns and outcomes of alvimopan, a peripherally-acting µ-opioid receptor antagonist, after radical cystectomy (RC) and urinary ersion at a high-volume cancer center.Patients and Methods: We retrospectively identified 130 consecutive patients who underwent RC and urinary ersion for bladder cancer at our institution from October 2013 to September 2014. Demographic, clinical, and postoperative outcomes were compared between patients who did and did not receive alvimopan using the Kruskal-Wallis test for medians and the chi-square test for proportions. Predictors of 30-day complications and prolonged length of stay (LOS) were analyzed using multivariate logistic regression analysis. Results: Perioperative alvimopan was given to 81 patients (62.3%) during the study period although in 17 patients (13.1%) it was indicated but not given. The most common absolute or relative contraindication for alvimopan usage was prior consumption of opioids for more than 7 consecutive days (n=18 13.8%). Patients who received alvimopan had a better performance status (p=0.06), less comorbidities (p=0.08), and were more likely to have minimally-invasive surgery (p=0.07) although these differences did not reach statistical significance. Alvimopan usage was independently associated with less postoperative 30-day complications (odds ratio [OR]: 0.35, 95% confidence interval [CI]: 0.15 – 0.82 p=0.015), less high-grade complications (OR: 0.12, 95% CI: 0.044 – 0.34 p .01), and less prolonged hospitalization days (OR: 0.28, 95% CI: 0.11 – 0.72 p=0.008). Conclusions: Despite its clinical benefits, alvimopan was under-utilized in RC patients, especially in those with worse baseline health. We recommend its incorporation into standardized protocols to optimize perioperative care.
Publisher: Springer Science and Business Media LLC
Date: 19-08-2015
DOI: 10.1007/S00345-015-1667-4
Abstract: Several disease characteristics have been identified as potential predictors for pathological node involvement (pN+) following radical cystectomy (RC). However, these have not been assessed in patients treated with neoadjuvant chemotherapy (NAC). We endeavored to assess factors predicting adverse pathology in clinically node-negative patients treated with NAC and RC. Patients from four North American institutions with cT2-4aN0M0 UC who received three or four cycles of NAC followed by RC were selected. Logistic regression was used to predict pN+, <pT2 and pT4 disease. One hundred and ninety-six patients were included. The clinical stage was cT2 in 115 (61 %), cT3 in 62 (33 %) and cT4 in 12 (6 %) cases. NAC regiments were gemcitabine-cisplatin (GC)-4 cycles 57 (29 %), GC-3 cycles 77 (39 %), methotrexate, vinblastine, adriamycin, cisplatin (MVAC)-3 cycle 22 (11 %) and MVAC-4 cycles 40 (21 %). pN+ was seen in 35 (18 %) patients. In the logistic regression analysis, cT4 stage (OR 7.50 95 % CI 1.58-33.3) and three compared to four cycles of GC (OR 3.44 95 % CI 1.09-10.9) were significant predictors of pN+ status. Additionally, when controlling for clinical stage, three cycles of GC, compared to four, were significantly associated with higher rates of pT4 disease and lower rates of downstaging to non-muscle-invasive disease. The results suggest that four cycles of neoadjuvant GC may be superior to three cycles, and the latter regimen may be associated with adverse pathological findings. Although this would require validation in a prospective trial, it does encourage the completion of the conventional four cycles GC whenever possible.
Publisher: Elsevier BV
Date: 04-2018
Publisher: Elsevier BV
Date: 05-2015
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2015
Publisher: Medknow
Date: 2016
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2012
DOI: 10.1016/J.IJSU.2012.10.003
Abstract: Preoperative glucocorticoid (GC) administration attenuates the physiological response to surgery and improves clinical outcomes. However, GC use is not yet universally implemented. A propensity score analysis was performed to evaluate preoperative GC use in elective colectomy. A retrospective review of prospectively collected data was conducted for all patients who had undergone elective colectomy within an established Enhanced Recovery After Surgery (ERAS) programme at our institution from January 2006 to 2010. Demographic data, surgery type, glucocorticoid administration and clinical outcomes including complication rates and length of hospital stay (LOS) were investigated. Univariate and propensity score analyses were conducted with statistical significance identified as p ≤ 0.05. There were 253 patients included in the analysis, of which 146 received preoperative GC. There were significant baseline differences between those who received GC and those who did not in male gender (GC: 56 (38%) non-GC: 58 (54%) p = 0.02) and American Society of Anesthesiologists (ASA) III (GC: 40 (27%) non-GC: 43 (40%) p = 0.04). On univariate analysis, there were no significant differences in the incidence of total complications, major complication, anastomotic leak and infectious complication. On propensity score analysis, preoperative GC administration was found to be independently associated with a reduction in LOS (GC: 5 Non-GC: 6 p = 0.04). Preoperative GC administration is associated with a reduction in LOS without an increase in postoperative complications.
Publisher: Wiley
Date: 06-2017
DOI: 10.1111/ANS.13975
Publisher: Elsevier BV
Date: 10-2018
DOI: 10.1016/J.UROLONC.2017.10.010
Abstract: Biomarkers are increasingly used in the diagnosis and management of various malignancies. Selected biomarkers may also play a role in management of certain cases of penile carcinoma. In this article, we provide an overview of the clinical role of such markers in the management of penile cancer. This is a nonsystematic review of relevant literature assessing biomarkers in penile carcinoma. Evidence of infections with human papillomavirus and its surrogate markers may have important prognostic value in patients with localized or metastatic penile cancer. Squamous cell carcinoma antigen, p53, C-reactive protein, Ki-67, proliferating cell nuclear antigen, cyclin D1, as well as other markers have been studied with various degree of evidence in support of clinical utility in penile cancer. No single marker may have all the answers, and future research should focus on genomic analysis of in idual penile tumors, attempting to identify specific targets for treatment.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 02-2012
Publisher: Elsevier BV
Date: 09-2005
DOI: 10.1016/J.TRANSPROCEED.2005.07.054
Abstract: Spontaneous renal allograft rupture is one of the most dangerous complications of kidney transplantation, which can result in graft loss. This condition needs immediate surgical intervention. Conservative management has dismal results. Its prevalence varies from 0.3% to 3%. Rupture occurs in first few weeks after transplantation. Predisposing factors for graft rupture are acute rejection, acute tubular necrosis, and renal vein thrombosis. There are growing reports about successful results of repairing these ruptured kidneys. In this study, we reviewed the medical records of 1682 patients who received kidney allografts from living donors from 1986 through 2003. There were six (0.35%) cases of renal allograft rupture. All were preceded by acute graft rejection. They were treated with antirejection medications. In first three cases, the kidney allografts were removed because the procedure of choice in this situation is graft nephrectomy but in three next cases we repaired the ruptured grafts with good results in two of them. In conclusion, the procedure of choice for kidney allograft rupture is graft repair.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2015
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2015
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2015
Publisher: Wiley
Date: 21-08-2008
DOI: 10.1111/J.1445-2197.2008.04647.X
Abstract: Early laparoscopic cholecystectomy has been shown to be the treatment of choice for acute presentations of gallstone disease. However, currently this practice is not common in many centres. The aim of the study was to evaluate surgical management of patients presenting with acute symptomatic gallstone disease to Middlemore Hospital in 2005. A retrospective case review of acute presentations of symptomatic gallstone disease was carried out between 1 January and 31 December 2005. Four hundred and two patients were included in the final analysis. Forty-six of these patients were unfit for surgery, 26 were solely admitted to the emergency department without being referred to a surgical team and 25 declined surgery. Therefore, 305 patients (76%) were eligible for surgery at index admission (IA). Two hundred and four (67%) received surgery during IA with a median time to surgery of 3 days. From the 198th patient who did not have acute surgery at IA, 112 had delayed surgery. When comparing those with surgery at IA with those who did not receive surgery at IA, median length of stay for IA was significantly longer in acute surgical group (5 vs 3 P = 0.05) however, there was no significant difference in duration of total hospital stay (6 vs 6 P > 0.05). For those who had acute surgery the conversion rate was 3% (six) compared with 7% (seven) in delayed surgery group (P = 0.09). Acute surgery remains the treatment of choice for acute biliary disease. This approach requires a committed team approach but is safe and effective.
Publisher: Elsevier BV
Date: 2015
DOI: 10.1016/J.EURURO.2015.03.027
Abstract: Cryoablation (CA) is a minimally invasive modality with low complication rates, but its use in urology is relatively recent. To summarize available evidence for CA for small renal masses (SRMs) and to assess the selection criteria, complications, and functional and oncologic results based on the latest CA literature. A systematic literature search of the Medline, Embase, and Scopus databases was performed in August 2014 using Medical Subject Headings and free-text protocol. The following search terms were included: kidney cryosurgery, renal cryosurgery, kidney cryoablation, renal cryoablation, kidney cryotherapy, and renal cryotherapy. Due to the relatively recent mainstream utilization of CA and lack of long-term efficacy data from large prospective or randomized studies, most of the data available on CA are limited to treatment of SRMs in patients who are often older or are poor surgical candidates. The rates of major complications across the CA literature remain relatively low. Studies assessing renal function after CA suggest a degree of functional decline following CA because proper application includes freezing of a tumor margin however, often this is not clinically significant. Specific oncologic outcomes should be evaluated in patients with biopsy-proven renal cell carcinoma when SRM series include benign or unbiopsied tumors, the results of these outcomes are skewed. Although earlier series were suggestive of a higher recurrence rate after CA, some studies have challenged this view reporting recurrence rates comparable with extirpative nephron-sparing surgery. CA represents an alternative approach to treatment for patients diagnosed with renal neoplasm. There is no consensus within the literature on the best patient selection criteria. Due to higher rates of treatment failure, it is often not offered to patients with minimal comorbidities and good life expectancy. In terms of functional outcomes, CA signifies a modality with minimum impact on renal function however, well-designed studies precisely assessing this factor are lacking. CA is a minimally invasive modality with suitably low rates of complications, particularly if delivered via the percutaneous route. Cryoablation (CA) represents an alternative approach for treating renal neoplasm. Excellent functional outcomes and low rates of complications make CA an ideal minimally invasive modality. Patient selection criteria and oncologic outcomes require further study.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2015
Publisher: Wiley
Date: 2008
DOI: 10.1111/J.1445-2197.2007.04350.X
Abstract: Enhanced recovery after surgery (ERAS) care pathways are becoming increasingly common in colonic surgery. ERAS is a combination of in idual strategies that have been shown to be effective in improving care. In this article, we review the evidence surrounding core components of enhanced recovery care pathways for patients undergoing open colonic surgery. We will also identify new elements that should be considered as part of ERAS strategy.
Publisher: Oxford University Press (OUP)
Date: 08-2015
Abstract: Accurate pathologic interpretation of testicular germ cell tumors (GCTs) can be problematic due to low incidence and variation in histologic patterns. By analyzing changes in the diagnosis of testicular specimens after secondary review, we hoped to determine how these can affect prognosis and treatment. From 1999 to 2013, a total of 235 patients underwent radical orchiectomy at a referring facility and had pathology specimens reanalyzed by our center’s pathologists with expertise in genitourinary malignancies. We identified discrepancies in pathologic reporting. Fifty (21.3%) patients had variations in interpretation of their orchiectomy specimens. A clinically significant alteration was identified in 16 (6.8%) patients, most commonly due to recognition (or misrecognition) of lymphovascular invasion (LVI) associated with nonseminomatous germ cell tumors (NSGCTs). Changes in LVI status resulted in upstaging or downstaging from clinical stage 1A to stage 1B or vice versa in six patients with NSGCTs, with a subsequent change in therapeutic strategy. In addition, one patient with stage 1 pure seminoma had been misclassified with nonseminoma. Inaccurate interpretation of orchiectomy specimens is not uncommon and may lead to incorrect tumor staging, imprecise assignment of progression risk, and inappropriate management recommendations. Secondary opinions of primary GCT orchiectomy specimens potentially facilitate appropriate counseling and therapeutic strategies.
Publisher: Elsevier BV
Date: 06-2015
Publisher: Elsevier BV
Date: 2020
DOI: 10.1016/J.UROLONC.2019.09.023
Abstract: The neutrophil-to-lymphocyte ratio (NLR) is an attractive marker because it is derived from routine bloodwork. NLR has shown promise as a prognostic factor in muscle invasive bladder cancer (MIBC) but its value in patients receiving neoadjuvant chemotherapy (NAC) before radical cystectomy (RC) is not yet established. Since NLR is related to an oncogenic environment and poor antitumor host response, we hypothesized that a high NLR would be associated with a poor response to NAC and would remain a poor prognostic indicator in patients receiving NAC. A retrospective analysis was performed on patients with nonmetastatic MIBC (cT2-4aN0M0) who received NAC prior to RC between 2000 and 2013 at 1 of 19 centers across Europe and North America. The pre-NAC NLR was used to split patients into a low (NLR ≤ 3) and high (NLR > 3) group. Demographic and clinical parameters were compared between the groups using Student's t test, chi-squared, or Fisher's exact test. Putative risk factors for disease-specific and overall survival were analyzed using Cox regression, while predictors of response to NAC (defined as absence of MIBC in RC specimen) were investigated using logistic regression. Data were available for 340 patients (199 NLR ≤ 3, 141 NLR > 3). Other than age and rate of lymphovascular invasion, demographic and pretreatment characteristics did not differ significantly. More patients in the NLR > 3 group had residual MIBC after NAC than the NLR ≤ 3 group (70.8% vs. 58.3%, P = 0.049). NLR was the only significant predictor of response (odds ratio: 0.36, P = 0.003) in logistic regression. NLR was a significant risk factor for both disease-specific (hazard ratio (HR): 2.4, P = 0.006) and overall survival (HR:1.8, P = 0.02). NLR > 3 was associated with a decreased response to NAC and shorter disease-specific and overall survival. This suggests that NLR is a simple tool that can aid in MIBC risk stratification in clinical practice.
Publisher: Wiley
Date: 03-07-2015
DOI: 10.1111/ANS.13205
Abstract: The aim of the study is to assess the contemporary patterns of utilization of various therapeutic options for the management of nephrolithiasis in our tertiary referral institution in Auckland, New Zealand. A retrospective audit was conducted for all urinary stone procedures between January 2007 and December 2013. Procedure-related information was collected for each year. All elective and emergency procedures were included. Data were collected on the elective waiting lists for each procedure. A total of 5512 stone-related cases were performed during the study period. Six hundred and fifty-three cases were performed in 2007 compared with 945 in 2013. Total number of percutaneous nephrolithotomy (PCNLs) performed, as well as the proportion of PCNL cases, demonstrated a significant decline from 84 (12.9%) in 2007 to 67 (7.1%) in 2013. While the annual numbers of extracorporeal shock wave lithotripsy (ESWLs) have increased, the percentage of ESWLs performed relative to total stone procedures has declined from 33% to 23% over the last 4 years of this audit. There has been a significant rise in the numbers of rigid and flexible ureteroscopies, with these now being the most utilized procedure. The number of patients awaiting elective procedures declined over the duration of this audit, with an associated improvement in meeting annual demand for treatment of nephrolithiasis from 78% in 2007 to 91% in 2013. A proportional decline in PCNL and ESWL utilization with a significant increase in flexible and rigid ureteroscopic procedures has been observed over this time and this pattern has been associated with improved adherence to surgical targets despite an increasing number of cases.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2015
DOI: 10.1016/J.JURO.2015.07.085
Abstract: Selected patients with bladder cancer with pelvic lymphadenopathy (cN1-3) are treated with induction chemotherapy followed by radical cystectomy. However, the data on clinical outcomes in these patients are limited. In this study we assess pathological and survival outcomes in patients with cN1-3 disease treated with induction chemotherapy and radical cystectomy. Data were collected on patients from 19 North American and European centers with cT1-4aN1-N3 urothelial carcinoma who received chemotherapy followed by radical cystectomy between 2000 and 2013. The primary end points were pathological complete (pT0N0) and partial (pT1N0 or less) response rates, with overall survival as a secondary end point. Logistic regression and Cox proportional hazard ratios were used for multivariate analysis of factors predicting these outcomes. The total of 304 patients had clinical evidence of lymph node involvement (cN1-N3). Methotrexate/vinblastine/doxorubicin/cisplatin was used in 128 (42%), gemcitabine/cisplatin in 132 (43%) and other regimens in 44 (15%) patients. The pN0 rate was 48% (cN1-56%, cN2-39%, cN3-39%, p=0.03). The complete and partial pathological response rates for the entire cohort were 14.5% and 27%, respectively. The estimated median overall survival time for the cohort was 22 months (IQR 8.0, 54). On Cox regression analysis overall survival was associated with pN0, negative surgical margins, removal of 15 or more pelvic nodes and cisplatin therapy. Complete pathological nodal response can be achieved in a proportion of patients with cN1-3 disease receiving induction chemotherapy. The best survival outcomes are observed in male patients on cisplatin regimens with subsequent negative radical cystectomy margins and complete nodal response (pN0) with excision of 15 or more pelvic nodes.
Publisher: Elsevier BV
Date: 02-2011
Publisher: Springer Science and Business Media LLC
Date: 12-04-2016
DOI: 10.1007/S00345-016-1825-3
Abstract: Neoadjuvant chemotherapy (NAC) can downstage invasive bladder cancers prior to radical cystectomy (RC) and improve overall survival. However, the optimal management in patients with persistent non-organ confined disease (pT3-T4 and/or pN+) following RC has not been completely defined. The aim of this study was to describe outcomes associated with the use of adjuvant chemotherapy (AC) in patients with residual non-organ confined cancer at RC following NAC. Using data from a high-volume referral institution, pT3-T4 and/or pN+ patients who received NAC and then also RC were identified. Recurrence-free survival (RFS) and cancer-specific survival (CSS) were assessed with Kaplan-Meier analysis. From 2001 to 2013, 161 patients received NAC and then RC. Eighty-eight pT3-T4 and/or pN+ patients were identified. Twenty-nine (33 %) received AC. Adjuvant chemotherapy in the majority of patients was carboplatin-based (16), followed by cisplatin (8) and other, mainly taxane-containing regimens (5). The median RFS was 17.5 months in the AC and 13.7 months in the non-AC group (p = 0.78). AC remained an insignificant predictor for RFS after adjusting for pT, pN and margin status (HR 0.89, 95 % CI 0.48-1.68]). CSS was 23 and 22 months (p = 0.65) and remained insignificant after adjusting for pathologic confounders. In our current study population, adjuvant conventional cytotoxic chemotherapy was not associated with significant improvements in RFS or CSS. The choice of AC regimens, and incorporation of newer treatments, may be the key for improving outcomes in this high-risk patient group.
Publisher: Elsevier BV
Date: 03-2015
DOI: 10.1016/J.UROLONC.2015.10.001
Abstract: We evaluated sociodemographic and economic differences in overall survival (OS) of patients with penile SCC using the National Cancer Data Base (NCDB). We identified 5,412 patients with a diagnosis of penile squamous cell carcinoma from 1998 to 2011 with clinically nonmetastatic disease and available pathologic tumor and nodal staging. OS was estimated using the Kaplan-Meier method, and differences were determined using the log-rank test. Cox proportional hazard regression was performed to identify independent predictors of OS. Estimated median OS was 91.9 months (interquartile range: 25.8-not reached) at median follow-up of 44.7 months (interquartile range: 17.2-81.0). Survival did not change over the study period (P = 0.28). Black patients presented with a higher stage of disease (pT3/T4: 16.6 vs. 13.2%, P = 0.027) and had worse median OS (68.6 vs. 93.7 months, P<0.01). Patients with private insurance and median income≥$63,000 based on zip code presented with a lower stage of disease (pT3/T4: 11.6 vs. 14.7%, P = 0.002 and 12.0 vs. 14.0%, P = 0.042, respectively) and had better median OS (163.2 vs. 70.8 months, P<0.01 and 105.3 vs. 86.4 months, p = 0.001, respectively). On multivariate analysis, black race (hazard ratio [HR]: 1.39, 95% confidence interval [CI]: 1.21-1.58 P<0.01) was independently associated with worse OS, whereas private insurance (HR = 0.79, 95% CI: 0.63-0.98 P = 0.028) and higher median income≥$63,000 (HR = 0.82 95% CI: 0.72-0.93 P = 0.001) were independently associated with better OS. Racial and economic differences in the survival of patients with penile cancer exist. An understanding of these differences may help minimize disparities in cancer care.
Publisher: Elsevier BV
Date: 08-2015
DOI: 10.1016/J.UROLOGY.2015.05.013
Abstract: To assess the pattern of renal cell carcinoma (RCC) recurrences in nephron-sparing surgery (NSS) patients, and to determine whether current guidelines for surveillance could be modified based on such patterns. Retrospective review of a single-institution NSS database. Pattern of RCC recurrences and factors associated with recurrence were analyzed using univariate and multivariable competing risk regression analyses. Cost of surveillance was estimated based on Medicare charges. A total of 505 patients underwent elective NSS for RCC. Pathologic T stage included 394 pT1a and 79 pT1b lesions. Median follow-up was 38.3 (6-88) months. Recurrence was detected in 26 patients (5.1%) at a median of 18.9 months (2.7% pT1a and 12.7% pT1b). The estimated 5-year cumulative incidence of recurrence for unifocal pT1a lesions was 2.7%. On multivariable analysis, stage higher than pT1a (HR, 5.56 [CI. 2.57-12.0]) and the presence of multifocal or bilateral tumors (HR, 3.32 [CI, 1.45-7.61]) were independent predictors of disease recurrence. For the entire cohort, recurrence was observed in only 10 patients beyond 24 months including only 2 cases with pT1a. Current guidelines adequately capture most clinically significant recurrences, and with longer follow-up, it may be possible to confirm that routine surveillance beyond 2 years may have little clinical significance for patients with asymptomatic unifocal pT1a.
Publisher: AME Publishing Company
Date: 06-2017
Publisher: Wiley
Date: 24-04-2007
Publisher: Elsevier BV
Date: 05-2020
DOI: 10.1016/J.UROLONC.2019.12.009
Abstract: Prostate specific antigen (PSA) utilization in population-based prostate cancer (CaP) screening, has been a controversial area for decades. Current recommendation in our region is for an opportunistic approach to screening, with estimated low prevalence of such practice in the community. However, our clinical observations suggested that the extent is beyond what might be expected from an opportunistic screening practice. This study aims to estimate the current prevalence and the extent of opportunistic CaP screening, and investigate the contemporary patterns of PSA testing in a large population. From 2008 to 2017, all men in the Northern cancer network of New Zealand, who had a screening PSA test performed in a community laboratory were identified. The study variables were accessed from multiple prospectively maintained databases. These included: Age, Ethnicity, Region, Social deprivation, Medical therapy, CaP history, Gleason score, and PSA test information (results and date). Population estimations were obtained from customized an updated national census data. The study cohort constituted 311,725 men, with 1,208,214 PSA tests performed, in the ten-year period. The mean age at first test was 55.2 years and each man received approximately 4 PSA tests. The prevalence of opportunistic CaP PSA screening in men aged 40 to 79 years, was 87% of the region population. In the 50 to 69-year age group, 65% of men in the region had been receiving regular 2-yearly, screening PSA tests. Men who had 3 or more PSA tests, were more likely to be diagnosed with CaP (Odds ratio [OR] 1.85, P < 0.001). PSA based CaP screening, is a highly prevalent practice in the NZ community. This raises concerns regarding the quality of the in idual counseling process and the adequacy of resources allocated to accommodate for such practice.
Publisher: Elsevier BV
Date: 04-2015
Publisher: SAGE Publications
Date: 10-2016
DOI: 10.1177/107327481602300412
Abstract: Although penile cancer is a rare malignancy in developed nations, racial and socioeconomic differences exist in the incidence of the disease and its associated survival-related outcomes. A search of the literature was performed for research published between the years 1990 and 2015. Case reports and non—English-language articles were excluded, instead focusing specifically on large, population-based studies. The incidence of penile cancer is higher in Hispanic and African American men compared with whites and Asians. Men with penile cancer also appear to have a distinct epidemiological profile, including lower educational and income levels, a history of multiple sexual partners and sexually transmitted infections, and lack of circumcision with the presence of phimosis. African American men presented at a younger age with a higher stage of disease and worse survival rates when compared with white men. Rates of cancer-specific mortality increased with age, single marital status, and among those living in regions of lower socioeconomic status. An understanding of sociodemographical differences in the incidence and survival rates of patients with penile cancer can help advance health care policy changes designed to improve access and minimize disparities in cancer care for all men alike.
Publisher: Wiley
Date: 24-04-2007
Publisher: Informa UK Limited
Date: 16-11-2015
DOI: 10.1586/14737140.2015.1115350
Abstract: The most effective intravesical regimen for the treatment of non-muscle invasive bladder cancer (NMIBC) refractory to Bacillus Calmette-Guérin (BCG) has still not been identified or optimized to minimize recurrence-free survival and prevent progression reliably and consistently. Valrubicin, however, is a cytotoxic chemotherapeutic agent that is used as an intravesical agent for BCG-refractory carcinoma in situ (CIS) of the urinary bladder in patients for whom immediate cystectomy would be associated with unacceptable morbidity or mortality. Here we analyze the literature regarding the treatment of non-muscle invasive urothelial malignancies with intravesical valrubicin for refractory bladder cancer, present our opinion on its current clinical impact and speculate on how its utilization will evolve in the near future.
Publisher: Wiley
Date: 27-04-2009
Publisher: Wiley
Date: 15-09-2015
DOI: 10.1111/ANS.13272
Abstract: Management of renal cell carcinoma (RCC) with inferior vena cava thrombus (IVCT) is associated with high morbidity. Chronic kidney disease (CKD) is a known risk factor for perioperative complications in many surgical procedures. The objective of this study was to review the association between preoperative CKD (eGFR < 60 mL/min) and post-operative outcomes in patients with RCC and IVCT undergoing radical nephrectomy (RN) and tumour thrombectomy (TT). A retrospective review of patients with RCC and IVCT treated with RN and TT was carried out. Complications were recorded according to the Clavien-Dindo classification. Multivariable models were fitted using logistic regression analyses for high-grade complications and salvage therapies and linear-regression for intraoperative blood loss (IBL). One hundred and one patients with RCC and IVCT, treated with RN and TT, were identified. Forty per cent of patients had preoperative CKD. Median IBL was higher in CKD arm (2.5 versus 1.6 L, P = 0.04). In a multivariate linear regression analysis, CKD (beta 1.34, P = 0.01) remained an independent predictor of IBL. High-grade complications were more frequent in the CKD group (34% versus 16%, P = 0.09) and in logistic regression analysis, CKD was an independent predictor of high-grade complications (OR 3.33, 95% CI 1.01-10.9). Furthermore, CKD patients were less likely to be considered for salvage therapies (62% versus 38%, P = 0.02). In patients treated with RN and TT, CKD is an independent predictor of perioperative morbidity. This clinical variable should be considered when selecting patients and subsequent efforts should be made to optimize other competing risk factors in order to reduce the incidence of perioperative adverse events in this patient population.
Publisher: Elsevier BV
Date: 08-2017
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2016
Publisher: Elsevier BV
Date: 04-2016
Publisher: Elsevier BV
Date: 11-2012
DOI: 10.1016/J.JSS.2010.10.009
Abstract: There is a sequential, high concentration cytokine response after major abdominal surgery. The magnitude of this response has been directly linked to postoperative metabolic derangement, ileus, adhesions, and oncological outcomes. We aimed to compare the local and systemic cytokine response in laparoscopic and open colonic surgery and relate this to postoperative recovery parameters. Using a prospectively collected patient database, we compared a Study Group (n = 50) of patients undergoing elective laparoscopic colonic resection with a Control Group (n = 25) of patients undergoing equivalent open colonic surgery within an ERAS program. Patients were matched for age, gender, BMI, ASA, Cr Possum, side of resection, diagnosis, and histologic stage. Plasma and peritoneal fluid concentrations of IL-6, IL-8, IL-10, and TNFα were measured at 20-24 h after surgery. The Surgical Recovery Score was determined pre-operatively and at 3, 7, 30, and 60 d postoperatively. All data were prospectively collected, and a priori definitions were used for discharge parameters, complications, and complication severity. Peritoneal fluid IL-6 concentration was lower after laparoscopic surgery. There were no significant differences in the other cytokines measured, or in any postoperative recovery outcomes. Significant correlations were found between cytokine levels and discharge criteria achievement, day stay, postoperative complications, and the Surgical Recovery Score. With the exception of a lower peritoneal IL-6 level, the systemic and peritoneal cytokine response at 20-24 h is similar after laparoscopic versus open colonic resection within an ERAS program, with corresponding equivalent rates of postoperative recovery.
Publisher: AME Publishing Company
Date: 06-2016
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-2011
Publisher: Elsevier BV
Date: 11-2015
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2015
Publisher: Elsevier BV
Date: 12-2015
Publisher: Elsevier BV
Date: 11-2016
DOI: 10.1016/J.UCL.2016.06.012
Abstract: This article discusses the diagnostic and therapeutic options in the management of urethral cancer recurrence in patients treated with urethral sparing cystectomy as well as those who had urethral preservation following primary urethral carcinoma.
Publisher: Elsevier BV
Date: 06-2009
DOI: 10.1016/J.JSS.2008.06.023
Abstract: Enhanced Recovery After Surgery (ERAS) programs have demonstrated significant reduction in hospital stay for patients undergoing colonic surgery however, their impact on long-term outcomes, such as postoperative fatigue (POF), has not been fully established. To assess the impact of an ERAS program on POF and recovery following elective open colonic surgery. In a prospective study, 26 consecutive patients undergoing open colonic surgery under a conventional care plan were compared with 26 consecutive patients in an ERAS program. Demographic and clinical characteristics were comparable at baseline. The median duration of total hospital stay (4 versus 7 d, P < 0.001), rates of urinary tract infections (P = 0.028) and ileus (P = 0.042) were significantly smaller in the ERAS group. Postoperatively, POF significantly increased in both groups. However, peak POF score was significantly lower in the ERAS group (P = 0.001). In the first 30 d after surgery, Fatigue Consequence scores were also significantly smaller in the ERAS group. Overall, the total fatigue experience (P = 0.035) and the total fatigue impact (P = 0.005) were significantly smaller in the ERAS group. The impact of ERAS programs may extend beyond the commonly reported short-term outcomes, and ERAS may accelerate overall recovery and return to normal function.
Publisher: Wiley
Date: 16-08-2006
DOI: 10.1111/J.1445-2197.2006.03875.X
Abstract: Physiologic and operative severity score for the enumeration of mortality and morbidity (POSSUM), 'Portsmouth'-physiologic and operative severity score for the enumeration of mortality and morbidity (P-POSSUM) and 'Colorectal'-physiologic and operative severity score for the enumeration of mortality and morbidity (Cr-POSSUM) are three related scoring systems, which uses in idual patient parameters to predict postoperative mortality. POSSUM overpredicts mortality in low-risk patients and underpredicts mortality in elderly and emergency patients. P-POSSUM was developed to compensate for these weaknesses. Cr-POSSUM was developed specifically for colorectal surgery. We aim to establish which of these scoring systems would be most useful in an Australasian context. Data were collected for 308 patients and predicted mortality risk values were generated using each of the three systems. The Mann-Whitney U-test was then carried out on the scores for each system. Receiver-operator characteristic curves were designed to determine the relative accuracy of each approach at discriminating between death and survival. All three POSSUM scoring systems showed a statistically significant ability to predict postoperative mortality. Additionally, in each system there was a significant difference in the raw physiologic and operative severity scores between survivors and those who died. A risk-stratification model was applied to each set of data, showing a correlation between an increase in risk and an increase in mortality rate. Finally, the receiver-operator characteristic curves generated showed that in this study group POSSUM, P-POSSUM and Cr-POSSUM were all satisfactory predictive tools although the latter tended to be relatively less accurate. Physiologic and operative severity score for the enumeration of mortality and morbidity, P-POSSUM and Cr-POSSUM are all reliable predictors of postoperative mortality in the Australasian context although there was a trend towards POSSUM and P-POSSUM being better predictors than Cr-POSSUM. However, Cr-POSSUM requires fewer in idual patient parameters to be calculated and is thus easier to generate. An ideal preoperative scoring system remains to be developed for predicting mortality in patients undergoing colorectal surgery.
Publisher: Elsevier BV
Date: 09-2019
DOI: 10.1016/J.EUF.2018.02.002
Abstract: Treatment of locoregionally advanced penile squamous cell carcinoma (LAPSCC) is challenging. The exact role (in terms of oncological benefit) of extensive surgery is not well established. Moreover, surgery invariably leads to large defects requiring reconstructive surgery. Rectus abdominis myocutaneous (RAM) and abdominal advancement flaps have an independent and constant blood supply, are easily harvested, and provide substantial skin coverage and soft tissue. To determine the surgical and oncological outcomes in patients with LAPSCC undergoing surgical resection with RAM flaps. From 2002 to 2016, a multi-institutional database identified 15 LAPSCC patients undergoing flap reconstructions. Local surgical resection with RAM or abdominal advancement flap reconstruction. Perioperative and pathologic data were collected. Postoperative complications were identified using the Clavien-Dindo classification for surgical complications. Fifteen patients (median age 61 yr) were treated, ten with curative intent. Thirteen patients received induction chemotherapy. Thirteen of the 15 patients (87%) experienced wound complications, including five Clavien-Dindo grade III complications. In 11/15 patients (73%), the disease recurred (median recurrence-free interval 106 d). The majority of recurrences (91%) were locoregional, and in four cases the patient also had lesions in distant organs. Ten of the 15 patients (67%) died of their disease. The overall median follow-up interval was 10.5 mo. The study was limited by its retrospective design, the absence of quality-of-life measurements, and the cohort size. The results of this study show that surgical resection with reconstruction is associated with a risk of perioperative complications, including high-grade Clavien-Dindo complications. With a cure rate of 27%, surgery must be carefully considered and there is a need for alternative treatments. Lack of robust quality-of-life-data is also a serious shortcoming in the decision process for this patient category. Surgery in locoregionally advanced penile cancer has a low cure rate. Reconstruction of defects is surgically feasible, albeit with a high risk of complications. Furthermore, decision-making lacks robust data on quality of life after surgery.
Publisher: Elsevier BV
Date: 08-2015
DOI: 10.1016/J.UROLONC.2015.01.011
Abstract: Cytoreductive nephrectomy (CN) is a therapeutic consideration in patients with metastatic renal cell carcinoma (mRCC). We hypothesized that sarcopenia, a novel marker of nutritional status, is a predictor of survival after CN. Of 105 patients who underwent CN at our institution for mRCC, 93 had preoperative imaging available for analysis. Skeletal muscle index was calculated on axial images at the third lumbar vertebrae, and a threshold skeletal muscle index of<43 cm(2)/m(2) in men with a body mass index (BMI)<25 kg/m(2), 25 kg/m(2), and 2 (hazard ratio = 2.09, 95% CI: 1.24-3.53 P = 0.006). Sarcopenia can be an important prognostic factor associated with worse OS after CN for mRCC.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2018
DOI: 10.1016/J.JURO.2017.12.062
Abstract: Level I evidence supports the usefulness of neoadjuvant cisplatin based chemotherapy for muscle invasive bladder cancer. Since dose dense MVAC (methotrexate, vinblastine, doxorubicin and cisplatin) has mostly replaced traditional MVAC, we compared pathological response and survival rates in patients with locally advanced bladder cancer who received neoadjuvant chemotherapy with dose dense MVAC vs gemcitabine and cisplatin. We retrospectively reviewed the records of patients with urothelial cancer who received neoadjuvant chemotherapy and underwent cystectomy at a total of 20 contributing institutions from 2000 to 2015. Patients with cT3-4aN0M0 disease were selected for this analysis. The rates of ypT0N0 and ypT1N0 or less were compared between the gemcitabine and cisplatin, and dose dense MVAC regimens. Two multivariable Cox proportional hazards regression models of overall mortality were generated using preoperative and postoperative data. Of the patients who underwent neoadjuvant chemotherapy and radical cystectomy during the study period 319 met our inclusion criteria. A significantly lower rate of ypT0N0 was observed in the gemcitabine and cisplatin arm than in the dose dense MVAC arm (14.6% vs 28.0%, p = 0.005). The rate of ypT1N0 or less was 30.1% for gemcitabine and cisplatin compared to 41.0% for dose dense MVAC (p = 0.07). The mean Kaplan-Meier estimates of overall survival in the gemcitabine and cisplatin, and dose dense MVAC groups were 4.2 and 7.0 years, respectively (p = 0.001). On multivariable cox regression analysis based on preoperative data patients who received gemcitabine and cisplatin were at higher risk for death than patients who received dose dense MVAC (HR 2.07, 95% CI 1.25-3.42, p = 0.003). Lymph node invasion (HR 1.97, 95% CI 1.15-3.36, p = 0.01) and hydronephrosis (HR 2.18, 95% CI 1.43-3.30, p <0.001) were also associated with higher risk of death. In our retrospective cohort of patients with locally advanced bladder cancer dose dense MVAC was associated with higher complete pathological response and improved survival rates compared to gemcitabine and cisplatin. A clinical trial is warranted to validate these hypothesis generating results to test the superiority of neoadjuvant dose dense MVAC in patients with locally advanced bladder cancer.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2015
Publisher: Elsevier BV
Date: 02-2014
Publisher: Oxford University Press (OUP)
Date: 21-10-2009
DOI: 10.1002/BJS.6744
Abstract: Recent data have suggested a relationship between postoperative fatigue and the peritoneal cytokine response after surgery. The aim of this study was to test the hypothesis that preoperative administration of glucocorticoids before surgery would decrease fatigue and enhance recovery, by reducing the peritoneal production of cytokines. In a double-blind randomized controlled study, patients undergoing elective, open colonic resection were administered 8 mg dexamethasone or normal saline. Patients were treated within an enhanced recovery after surgery programme. Primary outcomes were cytokine levels in peritoneal drain fluid and fatigue as measured by the Identity–Consequence Fatigue Scale (ICFS). Baseline parameters were similar for 29 patients in the dexamethasone group and 31 in the placebo group. Patients who received dexamethasone had lower ICFS scores on days 3 and 7. Dexamethasone was associated with significantly lower peritoneal fluid interleukin (IL) 6 and IL-13 concentrations on day 1, and these correlated with changes in the ICFS score. There was no significant increase in adverse events in the dexamethasone group. Preoperative administration of dexamethasone resulted in a significant reduction in early postoperative fatigue, associated with an attenuated early peritoneal cytokine response. Peritoneal production of cytokines may therefore be important in postoperative recovery. Registration number: ACTRN12607000066482 (www.anzctr.org.au/).
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2015
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2015
Publisher: Elsevier BV
Date: 07-2010
DOI: 10.1016/J.JSS.2010.02.008
Abstract: Enhanced Recovery after Surgery (ERAS) programs have gained popularity with potential to accelerate recovery and reduce morbidity after colectomy. We were interested in comparing recovery after open right colectomy within an ERAS program compared with laparoscopic right colectomy in a standard care perioperative environment. Between October 2005 and June 2009, prospective data were collected on consecutive patients undergoing elective open right colectomy within an established ERAS setting (OpERAS). Similarly, between March 2008 and June 2009, data were collected on consecutive patients undergoing laparoscopic right hemicolectomy with conventional care (LapCon). Exclusion criteria for both groups were: ASA >or= 4, formation of a stoma, and dementia or mental illness rendering the patient unable to comply with instructions. Perioperative variables were collected. The surgical recovery score (SRS) was used as a validated means to measure convalescence on d 1, 3, 7, 30, and 60 postoperatively. There were 74 patients in the OpERAS and 39 patients in the LapCon groups. At baseline, there were no significant demographic differences except that more patients had malignancy in OpERAS group. Mean operating time was longer in the LapCon group. Median day stay was 4 (3-28) in OpERAS and 5 (2-18) in LapCon (P = 0.032). There was no statistical difference in the incidence of complications or the severity of complications. There were no significant differences in SRS after surgery at any time point. When perioperative care is optimized, recovery after elective open right hemicolectomy is comparable with laparoscopic resection. Studies looking at the combination of laparoscopy and ERAS are warranted.
Publisher: Springer Berlin Heidelberg
Date: 2016
Publisher: Elsevier BV
Date: 2017
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2017
DOI: 10.1016/J.JURO.2017.03.011
Abstract: Careful selection is critical to identify those with metastatic renal cell carcinoma who are most likely to benefit from cytoreductive nephrectomy. Surgery in patients who have metastatic renal cell carcinoma with tumor thrombus is complex and may not benefit some patients with poor overall survival. We evaluated whether preoperative variables or risk stratification systems could predict overall survival following cytoreductive nephrectomy. Prognostic factors for overall survival after surgery were evaluated in patients who had metastatic renal cell carcinoma with venous tumor thrombus at 5 institutions from 2000 to 2014. Prognostic variables, including metastatic renal cell carcinoma risk models, were evaluated for associations with overall survival. Multivariable analysis was used to determine independent associations of preoperative variables with overall survival. A total of 427 patients with metastatic renal cell carcinoma were identified with tumor thrombus. Patients with inferior vena cava thrombus above the diaphragm had shorter median overall survival vs those with renal vein only thrombus (9.2 months, IQR 4.2-30.8, vs 21.7, IQR 7.7-42.8, p = 0.0165). In idual risk factors from prognostic models were evaluated among other preoperative characteristics for associations with overall survival in 122 patients (32%) who died within 270 days of surgery. Independent predictors of overall survival included lactate dehydrogenase greater than the upper limit of normal (p = 0.003), systemic symptoms (p = 0.003), inferior vena cava thrombus above the diaphragm (p = 0.02) and sarcomatoid features (p = 0.005). Poor overall survival following cytoreductive nephrectomy in patients with metastatic renal cell carcinoma with tumor thrombus is associated with inferior vena cava thrombus above the diaphragm, poor risk group, systemic symptoms or sarcomatoid dedifferentiation. Patients with expected poor overall survival should be considered for preoperative systemic therapy clinical trials.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2009
DOI: 10.1016/J.IJSU.2008.11.004
Abstract: Multimodal care or Enhanced Recovery after Surgery (ERAS) protocols are gaining popularity in order to modify surgical stress responses after colonic resection. However, these protocols are not straightforward to implement as peri-operative care is varied. We aimed to identify areas that may need attention in order to successfully change practice. The literature was reviewed for current practice, methods and issues in implementing ERAS. Based on this and our own experience we discuss several important areas that need particular attention in developing and sustaining an ERAS program. International surveys have shown that current peri-operative care in colorectal resection is not evidence based. Important aspects of the ERAS philosophy including patient counselling, teamwork and attitude change are identified and discussed. Implementing evidence-based peri-operative care into practice is challenging. Barriers to multimodal recovery pathways should be addressed.
Publisher: Wiley
Date: 27-04-2009
Publisher: Elsevier BV
Date: 03-2015
DOI: 10.1016/J.UROLONC.2014.11.015
Abstract: Surgery for renal cell carcinoma with tumor thrombus has a high potential morbidity rate, and the current classification system based on proximal tumor thrombus level (TTL) has not been shown to consistently predict outcomes. To assess the prognostic value of inferior vena cava tumor thrombus volume (IVC-TV) for determining the perioperative complications as well as with survival end points. From June 2001 to June 2012, we identified 147 patients who underwent radical nephrectomy with venous thrombi. In total, 66 patients had IVC involvement and available imaging for review. IVC-TV was measured by cross-sectional area and height measurement for each axial slice. Linear, logistic models and Cox proportional hazard was used for analysis. Median IVC-TV was 16.5 cm(3), and 18 patients had TTL≥III. In total, 57 Clavien I-V complications were documented in 32 patients including 3 deaths. On multivariate analysis, age>65 years, American Society of Anesthesiologists>3, and IVC-TV>15 cm(3) were independent predictors for perioperative complications. Disease progression (PoD) occurred in 78% of patients, and metastatic disease (hazard ratio [HR] = 3.33, P 15 cm(3), and TTL III/IV were significantly associated with overall survival. As a preoperative variable, IVC-TV>15 cm(3) was shown to be an independent predictor of PoD (HR = 2.3, P = 0.01) and overall survival (HR = 2.21, P = 0.03). IVC-TV has value as a prognostic indicator, which is superior to TTL in the setting of renal cell carcinoma with IVC venous thrombus.
Publisher: Springer Science and Business Media LLC
Date: 12-01-2017
Publisher: Medknow
Date: 2016
Publisher: Elsevier BV
Date: 02-2015
DOI: 10.1016/J.CLGC.2015.08.006
Abstract: We assessed 126 patients with cT1-4, N0-2 urothelial carcinoma of the bladder who were treated with neoadjuvant chemotherapy followed by radical cystectomy. Twenty patients (16%) had squamous or glandular histological variation (HV). Significant pathologic downstaging (pT<2, N0) was seen in the HV patients (60% vs. 32% P [ .02) and this difference remained significant after controlling for other clinical and pathological confounders. To assess the pathological response rates and survival outcomes in patients with squamous or glandular histological variation (HV) treated with neoadjuvant chemotherapy (nCT) and radical cystectomy (RC), and compare these with patients with pure urothelial carcinoma of the bladder (PUCB). We performed a retrospective review of patients with clinical stage T1-4, N0-2 urothelial cancer treated with cisplatin-based nCT and RC in a single institution setting. Patients who received neoadjuvant carboplatin-based regimens were excluded. The primary end point was pathological response. Overall survival (OS) was a secondary end point. Logistic regression and Cox proportional hazard models were used for multivariate analyses. We evaluated 126 patients, including 20 (16%) with HV. Median estimated glomerular filtration rate (79.6 vs. 73.6 mL/min P = .07) and the rate of complete endoscopic resection (75% vs. 40% P = .01) were higher in the HV patients. Complete pathological response was similar between the groups (21% PUCB vs. 25% HV P = .77). However, a significantly higher rate of pathologic downstaging (pT<2, N0 [pDS]) was seen in the HV patients (60% vs. 32% P = .02). In a logistic regression model to predict pDS, in which clinically relevant confounding variables were included, HV (odds ratio, 4.01 95% confidence interval, 1.16-13.9) remained an independent predictor of pDS. OS was similar between the 2 groups (HV: 45.7 vs. PUCB: 48.3 months P = .73). When controlling for confounding factors, improved pDS rates were seen in the HV patients although there were no significant differences in the OS stratified according to histology. These results support the continued use of systemic nCT for this subgroup of patients.
Publisher: Springer International Publishing
Date: 2016
Publisher: Wiley
Date: 17-02-2021
DOI: 10.1111/IJU.14519
Publisher: Springer Science and Business Media LLC
Date: 03-02-2009
DOI: 10.1007/S00268-008-9906-0
Abstract: Postoperative fatigue (POF) significantly impacts well-being after major surgery. However, this topic has received little emphasis. We conducted a comprehensive search on major databases with a focus on studies relevant to assessment and etiology of POF. POF has been measured by a number of different and inadequate instruments. It has a complicated etiology, with a number of biological and psychological factors implicated. However, the etiology of this condition has not been fully explained. The role of local inflammation in the development of POF requires further research. Multimodal interventions should be conducted with a focus on addressing various factors that contribute to the development and progression of POF.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2018
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2015
Publisher: Elsevier BV
Date: 07-2020
Publisher: Springer Science and Business Media LLC
Date: 21-08-2009
DOI: 10.1007/S00384-008-0540-Y
Abstract: Mortality from cancer recurrence in Dukes B patients is approximately 25-30%. Outcome in Dukes B patients improves in direct relation to the number of lymph nodes examined. Examining fewer lymph nodes risks understaging and also such patients are less likely to receive chemotherapy. The aim of this study was to assess the impact of the number of lymph nodes examined on recurrence and mortality in Dukes B colon cancers. A retrospective database was constructed of 328 consecutive patients who underwent resection for Dukes B colorectal cancer between January 1993 and December 2001 at Middlemore Hospital. Patients with incomplete data, previous colorectal cancer, or perioperative deaths were excluded as were cases of rectal cancer. Data for the remaining 216 patients was subjected to multivariate and logistic regression analysis with 'patient death' or 'cancer recurrence' (CRec5) within 5 years as endpoints. A graph was constructed depicting CRec5 as broken down by lymph node strata. Receiver operator characteristic (ROC) curves were constructed for mortality and CRec5. The mean number of lymph nodes examined was 16.0 (median 14 range 2-48). The mean number of lymph nodes examined in those who died within 5 years was 12.8 vs. 17.5 in those who remained alive (p = 0.0027). The mean number of lymph nodes examined in those with evidence of recurrence within 5 years was 11.8 vs. 17.1 in those without recurrence (p = 0.0007). Analysis at various lymph node strata showed a sharp and statistically significant drop in the recurrence rate after the 16th node mark. The ROC curve for CRec5 showed that examination of 12 lymph nodes provided maximum sensitivity (0.60) and specificity (0.64). Examination of more than 16 lymph nodes is associated with a significant reduction in cancer recurrence. This supports the current clinical practice of harvesting and analysing as many nodes as possible during surgical resection and pathological analysis.
Publisher: Elsevier BV
Date: 2017
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2016
Publisher: Wiley
Date: 07-08-2020
DOI: 10.1111/BJU.15155
Abstract: To investigate the presence of ethnic and socio‐economic disparities in prostate cancer (PCa) screening and identify its impact on cancer outcomes. From January 2008 to December 2017, all men in the Northern region of New Zealand who had a prostate‐specific antigen (PSA) test performed in the community were identified from the electronic laboratory reports database. Asymptomatic men, with no known diagnosis of PCa, were included. Variables collected were age, ethnicity, social deprivation, medical therapy, PSA test information and cancer data. Disparities were investigated by comparing the frequency of PSA testing, proportions of men screened, and rates of cancer detection, between Māori (indigenous) and non‐Māori ethnic groups. The study cohort included 248 491 men, who each received approximately 3.45 PSA tests over the 10‐year study period. Māori men were less likely to be tested compared to non‐Māori men (25.4% vs 46.1% of the total aged‐matched region population P 0.001). Moreover, they received less frequent PSA testing irrespective of their deprivation status (mean difference of 0.97 PSA tests per person P 0.001). The higher testing frequency in non‐Māori men was associated with increased PCa diagnosis rates. Nevertheless, cancers detected in Māori men were 73% more likely to be of high grade (Gleason 8 or above), compared to those in non‐Māori men. There were significant ethnic disparities in PCa screening rates in the Northern region of New Zealand. Māori men, regardless of other demographic factors, were disproportionately affected. The difference in the rates of screening by ethnicity had influenced the incidence and clinical significance of the diagnosed cancers.
Publisher: Elsevier BV
Date: 04-2015
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-2009
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-2008
DOI: 10.1007/S10350-008-9386-1
Abstract: Fast-track (enhanced recovery) care pathways for colonic surgery are becoming increasingly popular however, there have been concerns regarding protocol compliance, high readmission rates, and also the true impact on morbidity rates with these protocols. This study was conducted to assess the impact of a fast-track program for colonic surgery on hospital stay, complications, and readmission rates. From December 2005 to March 2007, consecutive patients undergoing colonic surgery were prospectively studied. The comparison group consisted of a comorbidity-matched group of patients who had undergone similar surgery before establishment of the fast-track program. Fifty patients were included in each group. Groups were comparable at baseline. The fast-track group received significantly smaller amounts of intraoperative and postoperative intravenous fluids, were fed earlier, mobilized earlier, passed flatus earlier, and were discharged earlier than the comparison group (4 vs. 6.5 days, P < 0.001). The numbers of patients with urinary infections (2 vs. 12, P = 0.008), ileus (5 vs. 18, P = 0.005), and cardiopulmonary complications (11 vs. 21, P = 0.032) were significantly lower in the fast-track group. There was no difference in the rate of readmission. Fast-track is a safe and effective approach for reducing hospital stay and morbidity following major colonic surgery.
Publisher: Springer Science and Business Media LLC
Date: 17-06-2017
DOI: 10.1007/S00345-017-2065-X
Abstract: Our primary endpoint was to assess pathological response rate (pT0N0 and ≤pT1N0) for patients with BCa treated with the accelerated or dose dense MVAC (ddMVAC) chemotherapy followed by radical cystectomy (RC) in this real-word multi-institutional cohort. We retrospectively reviewed records of patients with urothelial cancer who underwent ddMVAC and RC at seven contributing institutions from 2000 to 2015. Patients with cT2-4a, M0 BCa were included. Presence of cT3-4 disease, hydronephrosis, lymphovascular invasion and/or existence of sarcomatoid, or micropapillary features on the initial transurethral resection of bladder tumor specimen was defined as high-risk disease. Logistic regression models for prediction of pT0N0 and ≤pT1N0 were generated for the entire cohort as well as for the cN0 subgroup. The multivariable Cox proportional hazards regression model for survival using post RC data was used to assess hazard ratios (HRs) for the variables of interest. A total of 345 patients received ddMVAC chemotherapy during the study period 85% had high-risk features. The median number of chemotherapy cycles was 4 (IQR 4-4) >90% of patients completed all scheduled cycles. The observed rates of pT0N0 and ≤pT1N0 were 30.4 and 49.3%, respectively, among cN0 patients. On the multivariable regression model, the presence of more than one clinical high-risk element was associated with 70% [OR 0.30 95% CI (0.10-0.86) p = 0.02] reduction in the odds of achieving partial pathological response. A complete response (pT0N0) was observed in one-third of patients after neoadjuvant ddMVAC therapy, and a partial response (≤pT1N0) was observed in nearly half of the cases in this real-world experience with this regimen. To our knowledge, this represents the largest experience outside clinical trial settings.
Publisher: Wiley
Date: 19-10-2023
DOI: 10.1111/ANS.18740
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2016
Publisher: Elsevier BV
Date: 02-2012
Publisher: Elsevier BV
Date: 06-2015
DOI: 10.1016/J.CLGC.2014.12.001
Abstract: The objective of this study was to determine if the percentage of sarcomatoid differentiation (%Sarc) in renal cell carcinoma (RCC) can be used for prognostic risk stratification, because sarcomatoid RCC (sRCC) is an aggressive variant of kidney cancer. We performed a retrospective analysis of patients who underwent surgery for RCC at our institution between 1999 and 2012. Pathology slides for all sRCC cases were reexamined by a single pathologist and %Sarc was calculated. %Sarc was analyzed as a continuous variable and as a categorical variable at cut points of 5%, 10%, and 25%. Potential prognostic factors associated with overall survival (OS) were determined using the Cox regression model. OS curves were generated using Kaplan-Meier methods and survival differences compared using the log-rank test. One thousand three hundred seven consecutive cases of RCC were identified, of which 59 patients had sRCC (4.5%). As a continuous variable %Sarc was inversely associated with OS (P = .023). Predictors of survival on multivariable analysis included pathologic (p) T status, tumor size, clinical (c) M status and %Sarc at the 25% level. OS was most dependent on the presence of metastatic disease (4 months vs. 21.2 months P = .001). In cM0 patients with locally advanced (≥ pT3) tumors, OS was significantly diminished in patients with > 25 %Sarc (P = .045). However, %Sarc did not influence OS in patients with cM1 disease. Patients with sRCC have a poor overall outcome as evidenced by high rates of recurrence and death, indicating the need for more effective systemic therapies. In nonmetastatic patients, the incorporation of %Sarc in predictive nomograms might further improve risk stratification.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2016
DOI: 10.1097/DCR.0000000000000598
Abstract: Accumulating evidence suggests that peritoneal cytokine concentrations may predict anastomotic leak after colorectal surgery, but previous studies have been underpowered. We aimed to test this hypothesis by using a larger prospectively collected data set. This study is an analysis of prospectively collected data. This study was conducted at 3 public hospitals in Auckland, New Zealand. Patients undergoing colorectal surgery recruited as part of 3 previous randomized controlled trials were included. Data on peritoneal and plasma levels of interleukin-6, interleukin-8, interleukin-10, and tumor necrosis factor-α on day 1 after colorectal surgery were reanalyzed to evaluate their predictive value for clinically important anastomotic leak. Area under receiver operating characteristic curve analysis was performed. A total of 206 patients with complete cytokine data were included. The overall anastomotic leak rate was 8.3%. Concentration levels of peritoneal interleukin-6 and interleukin-10 on day 1 after colorectal surgery were predictive of anastomotic leak (area under receiver operating characteristic curve, 0.72 and 0.74 p = 0.006 and 0.004). Plasma cytokine levels of interleukin-6 were higher on day 1 after colorectal surgery in patients who had an anastomotic leak, but this was a poor predictor of anastomotic leak. Levels of other peritoneal and plasma cytokines were not predictive. The study was not powered a priori for anastomotic leak prediction. Although the current data do suggest that peritoneal levels of interleukin-6 and interleukin-10 are predictive of leak, the discriminative value in clinical practice remains unclear. Peritoneal levels of interleukin-6 and interleukin-10 on day 1 after colorectal surgery can predict clinically important anastomotic leak.
Publisher: Wiley
Date: 27-04-2009
Publisher: Wiley
Date: 22-10-2015
DOI: 10.1111/BJU.12841
Abstract: To analyse the outcomes of emergency ureteroscopy (URS) cases performed in Auckland City Hospital. We conducted a retrospective review of all emergency URS procedures performed at Auckland City Hospital between 1 January 2010 and 31 December 2011. Data on patients, stones and procedures were collected and analysed. Emergency URS failure was defined as fragments >3 mm or the need for a repeat procedure. A total of 499 URS procedures were identified. Of these 394 (79%) were emergency procedures. The mean (sd range) patient age was 48 (16 13-88) years. In all, 83% of emergency URS cases had an American Society of Anesthesiologists (ASA) score of 1 or 2, 25% of stones were >9 mm, with a mean (sd) size of 8 (4) mm, and 285 procedures (72%) were successful. These patients were younger (47 vs 51 years), were more likely to have an ASA score of 1 (103 patients in the successful treatment group vs 26 in the failed treatment group), had smaller stones (7 vs 9 mm) and were more likely to have distal stones (P < 0.05). A total of 20 complications (5%) were recorded including six false passages and three mucosal injuries, one of which required radiological intervention, and 50 patients (13%) re-presented, for pain (76%), bleeding (10%) or infection (14%). We showed that emergency URS is a feasible approach for the routine management of acute ureteric colic with a low complications rate. A subgroup of younger, healthier patients may benefit the most from the procedure.
Publisher: Elsevier BV
Date: 04-2015
Publisher: Wiley
Date: 24-03-2011
DOI: 10.1111/J.1463-1318.2010.02228.X
Abstract: Enhanced recovery after surgery (ERAS) programmes have been shown to accelerate and enhance functional recovery after colonic surgery. We analysed prospectively collected data to investigate potentially modifiable factors that may influence the length of stay (LOS) in the ERAS setting at a single institution. Between October 2005 and November 2008, prospective data were collected on consecutive patients who underwent elective colonic surgery without a stoma. Patients with rectal cancer, those unable to participate in preoperative ERAS components because of their inability to communicate effectively in English, those with cognitive impairment and those with an American Society of Anesthesiologists (ASA) grade of ≥ 4 were excluded. Statistical analyses were performed using the Mann-Whitney U-test and Cox regression modelling. A total of 100 (79 malignancies) patients underwent elective colon resection during the study period. There were 57 right-sided, 41 left-sided and two total colectomies. The median age of the patients was 67.5 (range 31-92) years and the median day stay was 4 (range 3-46) days. Factors with significant correlations for reduced LOS were female gender, the surgeon, operative severity, high-dependency unit (HDU) admission and incision type favouring laparoscopic and transverse approaches. Age, operation site, indication for surgery and body mass index were not significant predictors of hospital stay. Gender, operative severity, HDU admission and surgeon did not have any independent correlation with LOS in contrast to the ASA score and the type of incision, which did. Lower ASA score, transverse incision laparotomy and laparoscopy correlated independently with reduced postoperative LOS within the ERAS setting.
No related grants have been discovered for Kamran Zargar Shoshtari.