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1.  Postoperative mortality and complications after radical cystectomy for bladder cancer in Quebec: A population-based analysis during the years 2000–2009 
Introduction:
Radical cystectomy (RC) is a very complex urologic procedure. Despite improvements in practice, technique and process of care, it is still associated with significant complications, including death, with reported postoperative mortality rates ranging from 0.8% to 8%. We examine the quality of surgical care indicators and document the mortality rates at 30, 60 and 90 days after RC across Quebec.
Methods:
Within the Régie de l’assurance maladie du Québec (RAMQ) administrative database (this database provides prospectively collected universal data on all medical services) and the Institut de la statistique du Québec (ISQ) database (this provides vital status data), we used procedure codes to identify patients who underwent RC for bladder cancer in Quebec over 10 years (between 2000 and 2009), as well as RC outcomes and dates of death. Data obtained were retrospectively analyzed in relation to multiple parameters, including patient characteristics and health-care providers’ volumes. The outcomes analyzed included postoperative complications and mortality rates at 30, 60 and 90 days.
Results:
A total of 2778 RC were performed in 48 hospitals by 122 urologists across Quebec. Among them, 851 (30.6%) patients had at least one postoperative complication and 350 (12.6%) patients had more than one complication. The overall mortality rates at 30, 60 and 90 days were 2.8%, 5.3% and 7.5%, respectively, with significantly elevated 90-day mortality rates in some centres. In the multivariate analysis, increased age was associated with increased risk of post-RC complications and mortality. For example, patients over 75 had more chance of having at least one postoperative complication (odds ratio [OR] 1.66, 95% confidence interval [CI]: 1.31–2.11) and mortality at 90 days (OR 3.28, 95% CI: 2.05–5.26). Provider volume effect on outcomes was statistically significant, with large hospitals having decreased risk of 30-day mortality (OR 0.29, 95% CI: 0.12–0.70), 60-day mortality (OR 0.41, 95% CI: 0.26–0.82) and 90-day mortality (OR 0.52, 95% CI: 0.29–0.93) when compared to smaller hospitals. Surgeon volume showed weak, but not statistically significant, evidence of reduced odds of mortality for the high-volume surgeon. Limitations to our study include reliance on administrative data, which lack some relevant clinical information (such as patient functional status and tumour pathological characteristics) to perform risk adjustment analysis.
Conclusion:
Our study demonstrates that postoperative outcomes after RC in Quebec varies based on several parameters. In addition, 30-day postoperative mortality after RC in Quebec appears acceptable. However, 90-day postoperative mortality rates remain significantly elevated in some centres, particularly in the elderly. This requires further research.
doi:10.5489/cuaj.1997
PMCID: PMC4137011  PMID: 25210550
2.  Royal College surgical objectives of urologic training: A survey of faculty members from Canadian training programs 
Introduction:
According to the Royal College objectives of training in urology, urologic surgical procedures are divided as category A, B and C. We wanted to determine the level of proficiency required and achieved by urology training faculty for Royal College accreditation.
Methods:
We conducted a survey that was sent electronically to all Canadian urology training faculty. Questions focused on demographics (i.e., years of practice, geographic location, subspecialty, access to robotic surgery), operating room contact with residents, opinion on the level of proficiency required from a list of 54 surgical procedures, and whether their most recent graduates attained category A proficiency in these procedures.
Results:
The response rate was 43.7% (95/217). Among respondents, 92.6% were full timers, 21.1% practiced urology for less than 5 years and 3.2% for more than 30 years. Responses from Quebec and Ontario formed 69.4% (34.7% each). Of the respondents, 37.9% were uro-oncologists and 75.7% reported having access to robotic surgery. Sixty percent of faculty members operate with R5 residents between 2 to 5 days per month. When respondents were asked which categories should be listed as category A, only 8 procedures received 100% agreement. Also, results varied significantly when analyzed by sub-specialty. For example, almost 50% or more of uro-oncologists believed that radical cystectomy, anterior pelvic exenteration and extended pelvic lymphadenectomy should not be category A. The following procedures had significant disagreement suggesting the need for re-classification: glanular hypospadias repair, boari flap, entero-vesical and vesicovaginal fistulae repair. Overall, more than 80% of faculty reported that their recent graduating residents had achieved category A proficiency, in a subset of procedures. However, more than 50% of all faculty either disagreed or were ambivalent that all of their graduating residents were Category A proficient in several procedures.
Conclusions:
There is sufficient disagreement among Canadian urology faculty to suggest another revision of the current Royal College list of category A procedures.
doi:10.5489/cuaj.1720
PMCID: PMC4081244  PMID: 25024784
3.  Enhanced recovery pathway for radical prostatectomy: Implementation and evaluation in a universal healthcare system 
Introduction:
Enhanced recovery pathways are standardized, multidisciplinary, consensus-based tools that provide guidelines for evidence-based decision-making. This study evaluates the impact of the implementation of a clinical care pathway on patient outcomes following radical prostatectomy in a universal healthcare system.
Methods:
Medical charts of 200 patients with prostate cancer who underwent open and minimally invasive radical prostatectomy at a single academic hospital from 2009 to 2012 were reviewed. A group of 100 consecutive patients’ pre-pathway implementation was compared with 99 consecutive patients’ post-pathway implementation. Duration of hospital stay, complications, post-discharge emergency department visits and readmissions were compared between the 2 groups.
Results:
Length of hospital stay decreased from a median of 3 (inter-quartile range [IQR] 4 to 3 days) days in the pre-pathway group to a median of 2 (IQR 3 to 2 days) days in the post-pathway group regardless of surgical approach (p < 0.0001). Complication rates, emergency department visits and hospital readmissions were not significantly different in the pre- and post-pathway groups (17% vs. 21%, p = 0.80; 12% vs. 12%, p = 0.95; and 3% vs. 7%, p = 0.18, respectively). These findings were consistent after stratification by surgical approach. Limitations of our study include lack of assessment of patient satisfaction, and the retrospective study design.
Conclusions:
The implementation of a standardized, multidisciplinary clinical care pathway for patients undergoing radical prostatectomy improved efficiency without increasing complication rates or hospital readmissions.
doi:10.5489/cuaj.2114
PMCID: PMC4277521  PMID: 25553155
4.  Drug costs in the management of metastatic castration-resistant prostate cancer in Canada 
Background
For Canadian men, prostate cancer (PCa) is the most common cancer and the 3rd leading cause of cancer mortality. Men dying of PCa do so after failing castration. The management of metastatic castration-resistant prostate cancer (mCRPC) is complex and the associated drug treatments are increasingly costly. The objective of this study was to estimate the cost of drug treatments over the mCRPC period, in the context of the latest evidence-based approaches.
Methods
Two Markov models with Monte-Carlo microsimulations were developed in order to simulate the management of the disease and to estimate the cost of drug treatments in mCRPC, as per Quebec’s public healthcare system. The models include recently approved additional lines of treatment after or before docetaxel (i.e. abiraterone and cabazitaxel). Drug exposure and survival were based on clinical trial results and clinical practice guidelines found in a literature review. All costs were assigned in 2013 Canadian dollars ($). Only direct drug costs were estimated.
Results
The mean cost of mCRPC drug treatments over an average period of 28.1 months was estimated at $48,428 per patient (95% Confidence Interval: $47,624 to $49,232). The mean cost increased to $104,071 (95% CI: $102,373 - $105,770) per patient when one includes abiraterone initiation prior to docetaxel therapy. Over the mCRPC period, luteinizing hormone-releasing hormone agonists (LHRHa) prescribed to maintain castrate testosterone levels accounted for 20.4% of the total medication cost, whereas denosumab prescribed to decrease bone-related events accounted for 30.5% of costs. When patients received cabazitaxel in sequence after abiraterone and docetaxel, the mCRPC medications cost per patient per month increased by 60.2%. The total cost of medications for the treatment of each annual Canadian cohort of 4,000 mCRPC patients was estimated at $ 193.6 million to $416.3 million.
Conclusions
Our study estimates the direct drug costs associated with mCRPC treatments in the Canadian healthcare system. Recently identified effective yet not approved therapies will become part of the spectrum of mCRPC treatments, and may potentially increase the cost.
doi:10.1186/1472-6963-14-252
PMCID: PMC4099156  PMID: 24927758
Metastatic castration-resistant prostate cancer; Treatments for advanced prostate cancer; Cost of treatments; Markov model; Cost of drugs for metastatic castration-resistant prostate cancer in Canada
5.  Robotic-assisted radical nephrectomy for renal angiomyolipoma with inferior vena cava thrombus extension 
Urology Annals  2014;6(2):176-178.
Renal angiomyolipoma with inferior vena caval venous extension is rare with only 40 cases reported in the literature. We report a case of a 35-year-old lady with angiomyolipoma with inferior vena caval thrombus that was managed surgically with robotic-assisted radical nephrectomy.
doi:10.4103/0974-7796.130663
PMCID: PMC4021665  PMID: 24833837
Angiomyolipoma; inferior vena caval venous extension; robotic assisted radical nephrectomy
6.  Active surveillance for low-risk prostate cancer compared with immediate treatment: a Canadian cost comparison 
CMAJ Open  2014;2(2):E60-E68.
Background
Clinical consequences of active surveillance compared with immediate treatment have been evaluated in patients with low-risk prostate cancer; yet, its financial benefits have not been adequately studied in Canada or elsewhere. Our study objective was to evaluate the direct costs associated with active surveillance and immediate treatment in the Canadian context.
Methods
We developed a Markov model with Monte Carlo microsimulations to estimate the Canadian cost of prostate cancer associated with immediate treatment and active surveillance strategies. The patients receiving active surveillance were assumed to receive delayed treatment at a rate of 8.35%, 4.17% and 2.1% per year for the first 2 years, years 3 to 5, and years 6 to 10 of follow-up, respectively. All costs were assigned in Canadian dollars and reflect Quebec’s health system.
Results
With active surveillance, the mean cost of prostate cancer management over the first year and 5 years of follow-up was estimated at $6200 (95% confidence interval [CI] $6083–$6317) per patient. The mean cost corresponding to immediate treatment was estimated at $13 735 (95% CI $13 615–$13 855) per patient. We estimated that patients receiving active surveillance who received delayed treatment incurred higher costs of $16 257 per patient.
Interpretation
Active surveillance could offer important economic benefits to the Canadian health system, estimated at $96.1 million for each annual cohort of incident prostate cancer. These results add to the economic rationale advocating active surveillance for eligible men with low-risk prostate cancer.
doi:10.9778/cmajo.20130037
PMCID: PMC4084746  PMID: 25077131
7.  Are Canadian urology residency programs fulfilling the Royal College expectations?: A survey of graduated chief residents 
Introduction:
We assess outgoing Canadian urology chief residents’ well-being, their satisfaction with their surgical training, and their proficiency in surgical procedures throughout their residency program.
Methods:
In 2012 an anonymous survey was sent by email to all 29 graduated urology chief residents across Canada. The survey included a list of all urologic surgical procedures listed by the Royal College of Physicians and Surgeons of Canada (RCPSC). According to the A/B/C classification used to assess competence in these procedures (A most competent, C least competent), we asked chief residents to self-classify their competence with regards to each procedure and we compared the final results to the current RCPSC classification.
Results:
The overall response rate among chief residents surveyed was 97%. An overwhelming majority (96.4%) of residents agreed that the residency program has affected their overall well-being, as well as their relationships with their families and/or partners (67.8%). Overall, 85.7% agreed that research was an integral part of the residency program and 78.6% have enrolled in a fellowship program post-graduation. Respondents believed that they have received the least adequate training in robotic surgery (89.3%), followed by female urology (67.8%), andrology/sexual medicine/infertility (67.8%), and reconstructive urology (61.4%). Interestingly, in several of the 42 surgical procedures classified as category A by the RCPSC, a significant percentage of residents felt that their proficiency was not category A, including repair of urinary fistulae (82.1%), pediatric indirect hernia repair and meatal repair for glanular hypospadias (67.9%), open pyeloplasty (64.3%), anterior pelvic exenteration (61.6%), open varicocelectomy (60.7%) and radical cystoprostatectomy (33.3%). Furthermore, all respondents (100%) believed they were deficient in at least 1 of the 42 category A procedures, while 53.6 % believed they were deficient in at least 10 of the 42 procedures.
Conclusions:
Most residents agree that their residency program has affected their overall well-being as well as their relationships with their families and/or partners. There is also a clear deficiency in what outgoing residents perceive they have achieved and what the RCPSC mandates. Future work should concentrate on addressing this discrepancy to assure that training and RCPSC expectations are better aligned.
doi:10.5489/cuaj.1339
PMCID: PMC4001631  PMID: 24839479
8.  Regional differences in practice patterns and outcomes in patients treated with radical cystectomy in a universal healthcare system 
Canadian Urological Association Journal  2013;7(11-12):E667-E672.
Introduction
Our objective is to assess differences in practice patterns and outcomes across 3 regions in bladder cancer patients treated with radical cystectomy under a universal healthcare system.
Methods:
In total, we included 2287 patients treated with radical cystectomy at 8 Canadian centres from 1998 to 2008. Variables included various clinico-pathologic parameters, recurrence, and death stratified into different regions.
Results:
In total, 1105 patients were from the east region (group 1), 601 from the centre region (group 2), and 581 from the west region of Canada (group 3). The median follow-up of groups 1, 2, and 3 was 22.1, 17.1, and 28.6 months, respectively. Although the overall rate of neoadjuvant chemotherapy was low (3.1%), rates were higher in group 2 compared with groups 1 and 3 (p = 0.07). Continent diversions and extended lymphadenectomy were performed in 23.5%, 8.5%, 23.9% and 39.7%, 27.7%, 12.6% across groups 1, 2, and 3, respectively. There were statistically significant differences in gender distribution, performance of lymphadenectomy, presence of concomitant carcinoma in situ and lymphovascular invasion across the 3 groups. There were no differences among the 3 geographical locations in terms of stage, surgical margin status, and use of adjuvant chemotherapy. The mean number of days from the transurethral resection of the bladder tumour to cystectomy was 50, 79, 69 days for groups 1, 2, 3, respectively (p = 0.0006). The 5-year overall survival was 53.6%, 66.8%, and 52.4% for groups 1, 2 and 3, respectively (p < 0.0001).
Conclusions:
Significant variations in practice patterns were noted across different geographic regions in a universal healthcare system. Use of continent diversions, extended lymphadenectomy, and neoadjuvant chemotherapy remains low across all 3 regions. Treatment delays are significant.
doi:10.5489/cuaj.201
PMCID: PMC3840506  PMID: 24282454
9.  Does transperitoneal minimally invasive radical prostatectomy increase the amount of small bowel receiving salvage radiation? 
Introduction:
Transperitoneal minimally invasive radical prostatectomy (MIRP) has become first choice for several urologists and patients dealing with localized prostate cancer. We evaluate the effect of postoperative radiation on the small bowel in patients who underwent extraperitoneal open versus transperitoneal MIRP.
Methods:
We reviewed all patients who received postoperative radiation from 2006 to 2010. Planning target volume (PTV) and surrounding organs, including the small bowel, were delineated. The presence of the small bowel in PTV and its volume in receiving each dose level were analyzed.
Results:
A total of 122 patients were included: 26 underwent MIRP and 96 underwent open prostatectomy. The median age of patients was 66 years, with median body mass index 27 kg/m2. The total PTV dose was 66 Gy, with the minimum and maximum doses received by the small bowel 0.4 and 66.4 Gy, respectively. The maximum volume of small bowel that received the safe limit of 40 Gy was 569 cm3. Of the 26 patients who underwent MIRP, 12 (46%) had small bowel identified inside the PTV compared to 57 (59%) among patients who underwent open prostatectomy (p = 0.228). The mean volume of the small bowel receiving 40 Gy was 26 and 67 cm3 in open and MIRP groups, respectively (p = 0.006); the incidence of acute complications was the same in both groups.
Conclusions:
Higher volumes of the small bowel are subjected to significant radiation after MIRP procedures compared to open procedures; however, we could not demonstrate any impact on acute complications. Whether there is a difference in late complications remains to be evaluated.
doi:10.5489/cuaj.265
PMCID: PMC3876447  PMID: 24381666
10.  Human resource assessment of academic urology across Canada: What are the future job prospects? 
Introduction:
Our objective was to capture an overview of anticipated staffing needs at Canadian urology academic centres over the next 5 years to help guide and counsel urology residents in their respective programs.
Methods:
A 30-question survey was sent by email to all chairmen of academic urology divisions/departments during fall 2012. The first part of the survey solicited basic demographic information regarding number of residents, number of fellows and fellowships, and number of attending staff and affiliated hospitals. The second part of the survey included detailed questions on the number and sub-specialty of urologists needed at each respective institution, as well as the appropriate year of recruitment.
Results:
The response rate was 100%. There are 13 urology training programs across Canada located in 6 out of the 10 provinces. Robotic surgery is available at 9 out of the 13 centres. A total of 68 urologists need to be recruited by academic institutions throughout Canada within the next 5 years. The greatest need is for general urologists, with a total of 13 required. This is followed by 12 urologic oncologists needed, 11 female urology, 7 reconstructive urologists, 6 pediatric urologists, 6 endourologists, 5 transplant surgeons, 4 infertility/andrology, and 4 experts in advanced laparoscopy/robotics. There was no need for any urologic trauma surgeons in any academic institution surveyed.
Conclusions:
A total of 68 urologists need to be recruited into academic urology across Canada within the next 5 years. This crucial information can be used to help guide urology residents in choosing the most appropriate fellowship, in addition to providing them with an overview of future job prospects at academic institutions throughout the country.
doi:10.5489/cuaj.198
PMCID: PMC3699074  PMID: 23826042
11.  Clavien classification in urology: Is there concordance among post-graduate trainees and attending urologists? 
Purpose:
We assess the variations between post-graduate trainees (PGTs) and attending urologists in applying the Revised Clavien-Dindo Classification System (RCCS) to urological complications.
Methods:
Twenty postoperative complications were selected from urology service Quality Assurance meeting minutes spanning 1 year at a tertiary care centre. The cases were from adult and pediatric sites and included minor and major complications. After a briefing session to review the RCCS, the survey was administered to 16 attending urologists and 16 PGTs. Concordance rates between the two groups were calculated for each case and for the whole survey. Inter-rater agreement was calculated by kappa statistics.
Results:
There was good overall agreement rate of 81 % (range: 30–100) when both groups were compared. Thirteen of the 20 cases (65%) held an agreement rate above 80% (k = 0.753, p < 0.001) including 3 (15%) cases with 100% agreement. There were only 2 cases where the scores given by PGTs were significantly different from that given by attending urologists (p ≤ 0.03). There was no significant difference between both groups in terms of overall RCCS grades (p = 0.12). When all participants were compared as one group, there was good overall inter-rater agreement rate of 75% (k = 0.71). Although the percent of overall agreement rate among PGTs was higher than the attending urologists (82% [k = 0.79] vs. 69% [k = 0.64]), this was not significantly different (p = 0.68).
Conclusion:
There was good overall agreement among PGTs and attending urologists in application of the RCCS in urology. Therefore, it is appropriate for PGTs to complete the Quality Assurance meeting reports.
doi:10.5489/cuaj.505
PMCID: PMC3699078  PMID: 23826044
12.  From podium to press: The 10-year publication rate of abstracts presented at the annual meetings of the Quebec Urological Association (QUA) 
Introduction:
Our objective was to determine the proportion of publications arising from abstracts presented at the Quebec Urological Association (QUA). We wanted to analyze differences in publication rates according to certain parameters, and to examine the quality of publications using journal impact factors.
Methods:
All abstracts presented at the annual meetings of the QUA between 2000 and 2010 were obtained from the QUA archives and searched using the PubMed database. Variables included: institute, number of abstracts presented, year of presentation and publication, impact factor of publishing journal (according to 2010 Thomson Reuters report), time to publication (months), research type, presenter and location of research. Kaplan Meier methods were used for analysis.
Results:
By May 2012, 248 out of 439 abstracts (QUA 2000 to 2010) were published in peer-reviewed journals, resulting in a publication rate of 56%. There were significant differences in publication rates according to institution, research type and location of research. Researchers from non-Quebec institutions were twice as likely to publish compared to those from Quebec institutions (Cox HR 2.13, CI 1.20–3.76, p < 0.01).
Discussion:
The QUA publication rate was considerably higher than previously studied by the American Urological Association (37.8%) and British Association of Urological Surgeons (≈42%); however length of follow-up and presentation types differed. Research conducted outside Quebec was more likely to be published, reflecting the multi-institution robust study designs and higher level of evidence. Factors influencing publication deserve further attention, and clinicians are encouraged to conduct research with intent to publish.
doi:10.5489/cuaj.206
PMCID: PMC3699087  PMID: 23826052
13.  Natural history of pT3-4 or node positive bladder cancer treated with radical cystectomy and no neoadjuvant chemotherapy in a contemporary North-American multi-institutional cohort 
Background:
The present study documents the natural history and outcomes of high-risk bladder cancer after radical cystectomy (RC) in patients who did not receive neoadjuvant chemotherapy during a contemporary time period.
Methods:
We analyzed 1180 patients from 1993 to 2008 with >pT3N0 or pT0-4N+ bladder cancer who underwent RC ± standard (sLND) or extended (eLND) lymph node dissection from 8 Canadian centres.
Results:
Of the 1180 patients, 55% (n = 643) underwent sLND, 34% (n = 402) underwent ePLND and 11% did not undergo a formal LND. Of the total number of patients, 321 (27%) received adjuvant chemotherapy. The median follow-up was 2.1 years (range: 0.6 to 12.9). Overall 30-day mortality was 3.2%. Clinical and pathological stages T3-4 were present in 6.1% and 86.7% of the patients, respectively; this demonstrates a dramatic understaging. Overall survival (OS) at 2 and 5 years was 60% and 43%, respectively. Patients who received adjuvant chemotherapy had a 2- and 5-year disease-specific survival (DSS) of 72% and 57% versus 64% and 51% for those who did not (log-rank p = 0.0039). The 2- and 5-year OS for high-risk node-negative disease was 67% and 52%, respectively, whereas for node-positive patients, the OS was 52% and 32%, respectively (p < 0.001). The OS, DSS and RFS for patients with pN0 were significantly improved compared to those who did not undergo a LND (log-rank p = 0.0035, 0.0241 and 0.0383, respectively).
Interpretation:
This series suggests that bladder cancer outcomes in advanced disease have improved in the modern era. The need for improved staging investigations, use of neoadjuvant chemotherapy and performance of complete LND is emphasized.
doi:10.5489/cuaj.11012
PMCID: PMC3529724  PMID: 23283097
14.  Patients with microscopic and gross hematuria: practice and referral patterns among primary care physicians in a universal health care system 
Background:
Hematuria is one of the most common findings on urinalysis in patients encountered by primary care physicians. In many instances it can also be the first presentation of a serious urological problem. As such, we sought to evaluate current practices adopted by primary care physicians in the workup and screening of hematuria.
Methods:
Questionnaires were mailed to all registered primary care physicians across Quebec. Questions covered each physician’s personal approach to men and postmenopausal women with painless gross hematuria or with asymptomatic microscopic hematuria, as well as screening techniques, general knowledge with regards to urine collection and sampling, and referral patterns.
Results:
Of the surveys mailed, 599 were returned. Annual routine screening urinalysis on all adult male and female patients was performed by 47% of respondents, regardless of age or risk factors. Of all the respondents, 95% stated microscopic hematuria was associated with bladder cancer. However, in an older male with painless gross hematuria, only 64% of respondents recommended further evaluation by urology. On the other hand, in a postmenopausal woman with 2 consecutive events of significant microscopic hematuria, only 48.6% recommended referral to urology. Findings were not associated with the gender of the respondent, experience or geographic location of practice (urban vs. rural).
Interpretation:
There seems to be reluctance amongst primary care physicians to refer patients with gross or significant microscopic hematuria to urology for further investigation. A higher level of suspicion and further education should be implemented to detect serious conditions and to offer earlier intervention when possible.
doi:10.5489/cuaj.10059
PMCID: PMC3104421  PMID: 21470533
15.  Radical cystectomy for the treatment of T1 bladder cancer: the Canadian Bladder Cancer Network experience 
Background:
Radical cystectomy may provide optimal survival outcomes in the management of clinical T1 bladder cancer. We present our data from a large, multi-institutional, contemporary Canadian series of patients who underwent radical cystectomy for clinical T1 bladder cancer in a single-payer health care system.
Methods:
We collected a pooled database of 2287 patients who underwent radical cystectomy between 1993 and 2008 in 8 different centres across Canada; 306 of these patients had clinical T1 bladder cancer. Survival data were analyzed using Kaplan-Meier method and Cox regression analysis.
Results:
The median age of patients was 67 years with a mean follow-up time of 35 months. The 5-year overall, disease-specific and disease-free survival was 71%, 77% and 59%, respectively. The 10-year overall and disease-specific survival were 60% and 67%, respectively. Pathologic stage distribution was p0: 32 (11%), pT1: 78 (26%), pT2: 55 (19%), pT3: 60 (20%), pT4: 27 (9%), pTa: 16 (5%), pTis: 28 (10%), pN0: 215 (74%) and pN1-3: 78 (26%). Only 12% of patients were given adjuvant chemotherapy. On multivariate analysis, only margin status and pN stage were independently associated with overall, disease-specific and disease-free survival.
Interpretation:
These results indicate that clinical T1 bladder cancer may be significantly understaged. Identifying factors associated with understaged and/or disease destined to progress (despite any prior intravesical or repeat transurethral therapies prior to radical cystectomy) will be critical to improve survival outcomes without over-treating clinical T1 disease that can be successfully managed with bladder preservation strategies.
doi:10.5489/cuaj.10040
PMCID: PMC3104425  PMID: 21470529
16.  Use of Non-Steroidal Anti-Inflammatory Drugs and Prostate Cancer Risk: A Population-Based Nested Case-Control Study 
PLoS ONE  2011;6(1):e16412.
Background
Despite strong laboratory evidence that non-steroidal anti-inflammatory drugs (NSAIDs) could prevent prostate cancer, epidemiological studies have so far reported conflicting results. Most studies were limited by lack of information on dosage and duration of use of the different classes of NSAIDs.
Methods
We conducted a nested case-control study using data from Saskatchewan Prescription Drug Plan (SPDP) and Cancer Registry to examine the effects of dose and duration of use of five classes of NSAIDs on prostate cancer risk. Cases (N = 9,007) were men aged ≥40 years diagnosed with prostatic carcinoma between 1985 and 2000, and were matched to four controls on age and duration of SPDP membership. Detailed histories of exposure to prescription NSAIDs and other drugs were obtained from the SPDP.
Results
Any use of propionates (e.g., ibuprofen, naproxen) was associated with a modest reduction in prostate cancer risk (Odds ratio = 0.90; 95%CI 0.84-0.95), whereas use of other NSAIDs was not. In particular, we did not observe the hypothesized inverse association with aspirin use (1.01; 0.95–1.07). There was no clear evidence of dose-response or duration-response relationships for any of the examined NSAID classes.
Conclusions
Our findings suggest modest benefits of at least some NSAIDs in reducing prostate cancer risk.
doi:10.1371/journal.pone.0016412
PMCID: PMC3030588  PMID: 21297996
17.  Retroperitoneal lymph node dissection for residual masses after chemotherapy in nonseminomatous germ cell testicular tumor 
Background
Retroperitoneal lymph node dissection has been advocated for the management of post-chemotherapy (PC-RPLND) residual masses of non-seminomatous germ cell tumors of the testis (NSGCT). There remains some debate as to the clinical benefit and associated morbidity. Our objective was to report our experience with PC-RPLND in NSGCT.
Methods
We have reviewed the clinical, pathologic and surgical parameters associated with PC-RPLND in a single institution. Between 1994 and 2008, three surgeons operated 73 patients with residual masses after cisplatin-based chemotherapy for a metastatic testicular cancer. Patients needed to have normal postchemotherapy serum tumor markers, no prior surgical attempts to resect retroperitoneal masses and resectable retroperitoneal tumor mass at surgery to be included in this analysis
Results
Mean age was 30.4 years old. Fifty-three percent had mixed germ cell tumors. The mean size of retroperitoneal metastasis was 6.3 and 4.0 cm, before and post-chemotherapy, respectively. In 56% of patients, the surgeon was able to perform a nerve sparing procedure. The overall complication rate was 27.4% and no patient died due to surgical complications. The pathologic review showed presence of fibrosis/necrosis, teratoma and viable tumor (non-teratoma) in 27 (37.0%), 30 (41.1%) and 16 (21.9%) patients, respectively. The subgroups presenting fibrosis and large tumors were more likely to have a surgical complication and had less nerve sparing procedures.
Conclusion
PC-RPLND is a relatively safe procedure. The presence of fibrosis and large residual masses are associated with surgical complications and non-nerve-sparing procedure.
doi:10.1186/1477-7819-8-97
PMCID: PMC2991320  PMID: 21062470
21.  DEVELOPMENT AND VALIDATION OF A NOMOGRAM PREDICTING THE OUTCOME OF PROSTATE BIOPSY BASED ON PATIENT AGE, DIGITAL RECTAL EXAMINATION AND SERUM PROSTATE SPECIFIC ANTIGEN 
The Journal of urology  2005;173(6):1930-1934.
Purpose
We developed and validated a nomogram which predicts presence of prostate cancer (PCa) on needle biopsy.
Materials and Methods
We used 3 cohorts of men who were evaluated with sextant biopsy of the prostate and whose presenting prostate specific antigen (PSA) was not greater than 50 ng/ml. Data from 4,193 men from Montreal, Canada were used to develop a nomogram based on age, digital rectal examination (DRE) and serum PSA. External validation was performed on 1,762 men from Hamburg, Germany. Data from these men were subsequently used to develop a second nomogram in which percent free PSA (%fPSA) was added as a predictor. External validation was performed using 514 men from Montreal. Both nomograms were based on multivariate logistic regression models. Predictive accuracy was evaluated with areas under the receiver operating characteristic curve and graphically with loess smoothing plots.
Results
PCa was detected in 1,477 (35.2%) men from Montreal, 739 (41.9%) men from Hamburg and 189 (36.8%) men from Montreal. In all models all predictors were significant at 0.05. Using age, DRE and PSA external validation AUC was 0.69. Using age, DRE, PSA and %fPSA external validation AUC was 0.77.
Conclusions
A nomogram based on age, DRE, PSA and %fPSA can highly accurately predict the outcome of prostate biopsy in men at risk for PCa.
doi:10.1097/01.ju.0000158039.94467.5d
PMCID: PMC1855288  PMID: 15879784
prostatic neoplasms; biopsy; nomograms; validation studies
22.  Subsequent prostate cancer detection in patients with prostatic intraepithelial neoplasia or atypical small acinar proliferation 
Introduction:
To evaluate the predictors of prostate cancer in follow-up of patients diagnosed on initial biopsy with high-grade prostatic intraepithelial neoplasia (HGPIN) or atypical small acinar proliferation (ASAP).
Methods:
We studied 201 patients with HGPIN and 22 patients with ASAP on initial prostatic biopsy who had subsequent prostatic biopsies. The mean time of follow-up was 17.3 months (range 1–62). The mean number of biopsy sessions was 2.5 (range 2–6), and the median number of biopsy cores was 10 (range 6–14).
Results:
On subsequent biopsies, the rate of prostate cancer was 21.9% (44/201) in HGPIN patients. Of these, 32/201 patients (15.9%), 9/66 patients (13.6%) and 3/18 patients (16.6%) were found to have cancer on the first, second and third follow-up biopsy sessions, respectively. In ASAP patients, the cancer detection rate was 13/22 (59.1%), all of whom were found on the first follow-up biopsy. There was a statistically significant difference between the cancer detection rate in ASAP and HGPIN patients (p < 0.001). Multivariate analysis showed that the independent predictors of cancer were the number of cores in the initial biopsy, the number of cores (> 10) in the follow-up biopsy and a prostate specific antigen (PSA) density of ≥ 0.15 (odds ratio 0.77, 3.46 and 2.7,8 respectively; p < 0.04). Conversely, in ASAP patients none of these variables were found to be associated with cancer diagnosis.
Conclusion:
ASAP is a strong predictive factor associated with cancer when compared with HGPIN. The factors predictive of cancer on follow-up biopsy of HGPIN are number of cores on initial biopsy, more than 10 cores in rebiopsy and elevated PSA density. As the cancer detection rate on repeated biopsy of HGPIN patients is the same as that of patients without HGPIN, perhaps the standard of repeat biopsy in all patients with HGPIN should be revisited.
PMCID: PMC2422970  PMID: 18542796

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