AUA 2017: Journal of Urology 2016: Top Papers: Bladder and Renal Cancer
In kidney cancer, some of the most interesting and novel research is being done with regard to the effect of sarcopenia (decreased muscle mass) on oncologic and postsurgical outcomes. Using computed tomography-guided measurements of sarcopenia, Psutka et al. published their data from the Mayo Clinic showing that sarcopenic patients have worse long-term survival following surgery than those who are nonsarcopenic. This includes those who are obese but have radiographic evidence of sarcopenia. Fukushima et al. published a parallel paper demonstrating similar survival effects of sarcopenia on individuals with metastatic renal cell carcinoma. More data in this field are sure to come, and they promise to be useful clinical tools for interventions and management of these patients in the future.
Azawi et al. published their series on patients undergoing same-day-surgery laparoscopic nephrectomies. The researchers prospectively operated on a highly selected cohort of individuals who were at low risk for complications. They were able to discharge 92% of them within 6 hours postoperatively, with another 6% discharged within 24 hours. There were few major complications. They standardized the treatment algorithm: transperitoneal laparoscopy, preoperative administration of gabapentin, paracetamol, and ibuprofen, minimizing postoperative narcotic intake, and utilizing the surgeon as the case manager. The key to success in this setting is appropriate patient selection and the use of evidence-based enhanced recovery after surgery (ERAS) pathways that are shown to improve postoperative outcomes. Understandably, it may be difficult for most urologists to jump on this bandwagon right now, but the proof of concept is important.
In bladder cancer (BC), there were multiple important contributions to the literature in 2016. Park et al. published their findings targeting delays in receiving radical cystectomy (RC) after initial diagnosis. Prior work had demonstrated that delays of more than 12 weeks from transurethral resection of bladder tumors (TURBTs) to RC may portend worse survival. In this study, patients were administered neoadjuvant chemotherapy, and the time to RC was measured along multiple time points (diagnosis to TURBT, TURBT to chemotherapy, chemotherapy to RC). They found there were significant delays to RC (>20 weeks), but that this did not impact survival. Therefore, they concluded that neoadjuvant chemotherapy is still appropriate, even if it delays time to RC. This is welcome news for most healthcare practitioners who have made the shift to giving neoadjuvant chemotherapy prior to RC.
Albissini et al. evaluated disease recurrence in a large cohort of patients undergoing minimally invasive RC. Some 8.7% of patients recurred in fewer than 24 months, and the patterns of recurrence were quite varied. Compared with a standard RC, they concluded that their data suggest an increased risk of early recurrence following minimally invasive RC. They proposed multiple potential reasons for this finding, such as the use of pulsatile pneumoperitoneum or decreased systemic pH from absorbed CO2. Realistically, as more patients undergo minimally invasive RC, we will have more data to delineate whether this increased risk is real. Of course, urologic oncologists will be paying very close attention to this space.
Smith et al. published a fascinating bird’s-eye-view of BC mortality trends in the United States starting in the mid-20th Century. They looked at historic time periods and geographic distributions of BC mortality and identified risks associated with higher frequencies of BC. Risks included some well-known factors such as smoking and well-water use. However, air pollution, unemployment, and lack of insurance were also risk factors—a point that is particularly poignant given the current political discourse regarding environmental and health insurance policies.
Sharma et al. published a highly cited paper showing that preoperative patient-reported mental health is associated with postoperative high-grade complications following RC. Poorer patient-reported mental health portends worse complication rates. The effect of psychological states on perioperative outcomes is virtually unknown, and it will be exciting to see where this research leads in the future.
Finally, Anderson et al. published the Memorial Sloan Kettering Cancer Center-developed and validated checklist for surgeons performing transurethral resection of bladder tumors (TURBT. The aim was to standardize biopsy technique, reporting, and measurement parameters to improve the quality of this extremely common procedure. This is a colossal step in the right direction for improving the quality and efficacy of such a common urologic procedure and, hopefully, it will gain widespread acceptance.
Presented By: Badrinath Konety, MD, University of Minnesota, Minneapolis, MN
Written By: Shreyas Joshi, MD, Fox Chase Cancer Center, Philadelphia, PA
at the 2017 AUA Annual Meeting - May 12 - 16, 2017 – Boston, Massachusetts, USA