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1.  Is Vascular Endothelial Growth Factor Modulation a Predictor of the Therapeutic Efficacy of Gefitinib for Bladder Cancer? 
The Journal of urology  2008;180(3):1146-1153.
Purpose
The epidermal growth factor receptor inhibitor gefitinib (Iressa®) is currently being studied in patients with bladder cancer and it has significant anti-angiogenic activity. We investigated the relationship between the modulation of vascular endothelial growth factor (Santa Cruz Biotechnology, Santa Cruz, California) expression and the biological efficacy of gefitinib for bladder cancer.
Materials and Methods
In vitro the 4 bladder cancer cell lines 253JB-V, UMUC-3, KU-7 and UMUC-13 were treated with gefitinib and vascular endothelial growth factor secretion was measured. The effects of gefitinib on vascular endothelial growth factor promoter, proliferation, cell cycle and downstream signals were evaluated. In vivo 253JB-V and UMUC-13 were injected into nude mice and tumors were treated with 2 mg gefitinib per day. Tumor kinetics were determined and the levels of phospho-epidermal growth factor receptor (Biosource™), vascular endothelial growth factor, phospho-vascular endothelial growth factor (Cell Signaling Technology®), angiogenesis and apoptosis were measured.
Results
Epidermal growth factor receptor (Neomarkers, Fremont, California) phosphorylation was blocked efficiently in all cell lines at concentrations of 0.5 µM or greater. Gefitinib (1 µM) induced an accumulation of cells in G0/G1 without apoptosis in 253J B-V cells, whereas it had no effect in other cell lines. Gefitinib inhibited vascular endothelial growth factor secretion in 253JB-V and UMUC-13 (concentration inhibiting a 50% response 0.5 and 0.1 µM, respectively) but not in UMUC-3 or KU-7. Gefitinib decreased vascular endothelial growth factor promoter activity in 253JB-V and UMUC-13 by 40% to 60%. In vivo the growth of 253JB-V tumors was significantly inhibited by gefitinib, whereas no effect was demonstrated in UMUC-13 tumors. Vascular endothelial growth factor expression and vascular endothelial growth factor receptor activation were significantly decreased in 253JB-V tumors and to a greater extent in resistant UMUC-13 tumors. Gefitinib inhibited angiogenesis and induced apoptosis in sensitive 253JB-V tumors only.
Conclusions
Epidermal growth factor receptor blockade exerts an anti-angiogenic effect on bladder cancer cells, in part by modulating vascular endothelial growth factor expression. However, down-regulation of vascular endothelial growth factor expression is not sufficient to inhibit bladder cancer growth and it should not be used as a predictor of the therapeutic efficacy of gefitinib.
doi:10.1016/j.juro.2008.05.001
PMCID: PMC5190512  PMID: 18639280
urinary bladder; carcinoma; transitional cell; gefitinib; vascular endothelial growth factor; angiogenesis inhibitors
2.  PROSTATIC URETHRAL BIOPSY HAS LIMITED UTILITY IN COUNSELING PATIENTS REGARDING FINAL URETHRAL MARGIN STATUS DURING ORTHOTOPIC NEOBLADDER RECONSTRUCTION 
The Journal of urology  2008;180(1):164-167.
Purpose
To determine the value of preoperative transurethral (TUR) prostatic urethral biopsy in predicting final distal urethral margin status at radical cystectomy.
Materials and Methods
Out of 1006 patients undergoing radical cystectomy at our institution between 1990 and 2004, 252 were male patients who underwent ileal neobladder and form the basis of this report. Variable collected include pathology of prostatic urethral biopsies, final pathology of the prostate, frozen section of the distal urethra, final urethral margins, and survival data.
Results
Median age of patients was 61. Of 252 patients, 245 had data regarding pre-operative TUR prostatic urethral biopsy and/or frozen section of urethra at time of surgery: 127 patients had TUR of the prostatic urethra alone, 68 had urethral frozen section alone, 50 had both. The incidence of positive distal urethral margin (on final pathology) was 1.1% (3/252) and urethral recurrence was 0.7% (2/252). The correlation between TUR findings and frozen section margins was only 68%; 16 patients with positive TUR findings had negative frozen section margins. The negative predictive value of TUR biopsy with respect to final margins was 99.4% and that of frozen section was 100%.
Conclusion
While patients with no tumor on TUR biopsy of the prostatic urethra have a high likelihood of negative urethral margins on final pathologic evaluation, optimal negative predictive value is obtained with frozen sections. Furthermore, a positive TUR prostatic urethral biopsy does not correlate with final margin and should not exclude patients from consideration for an orthotopic diversion.
doi:10.1016/j.juro.2008.03.037
PMCID: PMC5154171  PMID: 18485384
bladder cancer; cystectomy; neobladder; prostatic urethral biopsy; counsel
3.  Multicenter Assessment of Neoadjuvant Chemotherapy for Muscle-invasive Bladder Cancer 
European urology  2014;67(2):241-249.
Background
The efficacy of neoadjuvant chemotherapy (NAC) for muscle-invasive bladder cancer (BCa) was established primarily with methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC), with complete response rates (pT0) as high as 38%. However, because of the comparable efficacy with better tolerability of gemcitabine and cisplatin (GC) in patients with metastatic disease, GC has become the most commonly used regimen in the neoadjuvant setting.
Objective
We aimed to assess real-world pathologic response rates to NAC with different regimens in a large, multicenter cohort.
Design, setting, and participants
Data were collected retrospectively at 19 centers on patients with clinical cT2–4aN0M0 urothelial carcinoma of the bladder who received at least three cycles of NAC, followed by radical cystectomy (RC), between 2000 and 2013.
Intervention
NAC and RC
Outcome measurements and statistical analysis
The primary outcome was pathologic stage at cystectomy. Univariable and multivariable analyses were used to determine factors predictive of pT0N0 and ≤pT1N0 stages.
Results and limitations
Data were collected on 935 patients who met inclusion criteria. GC was used in the majority of the patients (n = 602; 64.4%), followed by MVAC (n = 183; 19.6%) and other regimens (n = 144; 15.4%). The rates of pT0N0 and ≤pT1N0 pathologic response were 22.7% and 40.8%, respectively. The rate of pT0N0 disease for patients receiving GC was 23.9%, compared with 24.5% for MVAC (p = 0.2). There was no difference between MVAC and GC in pT0N0 on multivariable analysis (odds ratio: 0.89 [95% confidence interval, 0.61–1.34]; p = 0.6).
Conclusions
Response rates to NAC were lower than those reported in prospective randomized trials, and we did not discern a difference between MVAC and GC. Without any evidence from randomized prospective trials, the best NAC regimen for invasive BCa remains to be determined.
Patient summary
There was no apparent difference in the response rates to the two most common presurgical chemotherapy regimens for patients with bladder cancer.
doi:10.1016/j.eururo.2014.09.007
PMCID: PMC4840190  PMID: 25257030
Neoadjuvant chemotherapy; MVAC; GC; Cystectomy; Complete pathologic response; Partial pathologic response; Urothelial cancer
4.  Enumerating pelvic recurrence following radical cystectomy for bladder cancer: A Canadian multi-institutional study 
Introduction:
We aimed to enumerate the rate of pelvic recurrence following radical cystectomy at university-affiliated hospitals in Canada.
Methods:
Canadian, university-affiliated hospitals were invited to participate. They were asked to identify the first 10 consecutive patients undergoing radical cystectomy starting January 1, 2005, who had urothelial carcinoma stages pT3/T4 N0-2 M0. The first 10 consecutive cases starting January 1, 2005 who met these criteria were the patients submitted by that institution with information regarding tumour stage, age, number of nodes removed, and last known clinical status in regard to recurrence and patterns of failure.
Results:
Of the 111 patients, 80% had pT3 and 20% pT4 disease, with 62% being node-negative, 14% pN1, and 27% pN2; 57% had 10 or more nodes removed. Cumulative incidence of pelvic relapse was 40% among the entire group
Conclusions:
This review demonstrates a high rate of pelvic tumour recurrence following radical cystectomy for pT3/T4 urothelial cancer.
doi:10.5489/cuaj.3456
PMCID: PMC4840007  PMID: 27217852
6.  Evaluation of RNA-binding motif protein 3 expression in urothelial carcinoma of the bladder: an immunohistochemical study 
Background
RNA-binding motif protein 3 (RBM3), involved in cell survival, has paradoxically been linked to both oncogenesis as well as an increased survival in several cancers, including urothelial carcinoma (UCA).
Methods
The putative prognostic role of RBM3 was studied using cystectomy specimens with 152 invasive UCA with 35 matched metastases, 65 carcinomas in situ (CIS), 22 high-grade papillary UCAs (PAP), and 112 benign urothelium cases.
Results
The H-score (HS, staining intensity × % of positive cells) was used for RBM3 immunoexpression. CIS showed the highest HS (mean = 140) followed by benign urothelium (mean = 97). Metastases showed higher HS than primary invasive UCA (P ≤ 0.0001), and high HS was associated with a lower pT stage (P ≤ 0.0001) and a trend toward the absence of lymphovascular invasion (LVI, P = 0.09), but not pN stage (P = 0.35) and surgical margin status (P = 0.81). Univariate analysis (UVA) of disease recurrence only showed an association between pN stage and LVI (P = 0.005 and 0.03, respectively). On UVA of mortality, pT stage was strongly associated with death (P = 0.01) while pN stage, LVI, surgical margin status, and HS were not. Multivariate analysis confirmed the lack of HS association with recurrence (P = 0.08) and death (P = 0.32).
Conclusions
Stronger RBM3 immunoexpression correlated with lower stage tumors and a diminished risk for LVI. However, RBM3 does not seem to carry a prognostic significance for clinical outcome (recurrence and mortality). The exact prognostic role of RBM3 in UCA is yet to be determined.
doi:10.1186/s12957-015-0730-3
PMCID: PMC4650614  PMID: 26577765
RBM3; Expression; Urothelial; Carcinoma; Prognosis; Metastasis
7.  Assessing the quality of studies on the diagnostic accuracy of tumor markers 
Urologic oncology  2014;32(7):1051-1060.
Objectives
With rapidly increasing numbers of publications, assessments of study quality, reporting quality, and classification of studies according to their level of evidence or developmental stage have become key issues in weighing the relevance of new information reported. Diagnostic marker studies are often criticized for yielding highly discrepant and even controversial results. Much of this discrepancy has been attributed to differences in study quality. So far, numerous tools for measuring study quality have been developed, but few of them have been used for systematic reviews and meta-analysis. This is owing to the fact that most tools are complicated and time consuming, suffer from poor reproducibility, and do not permit quantitative scoring.
Methods
The International Bladder Cancer Network (IBCN) has adopted this problem and has systematically identified the more commonly used tools developed since 2000.
Results
In this review, those tools addressing study quality (Quality Assessment of Studies of Diagnostic Accuracy and Newcastle-Ottawa Scale), reporting quality (Standards for Reporting of Diagnostic Accuracy), and developmental stage (IBCN phases) of studies on diagnostic markers in bladder cancer are introduced and critically analyzed. Based upon this, the IBCN has launched an initiative to assess and validate existing tools with emphasis on diagnostic bladder cancer studies.
Conclusions
The development of simple and reproducible tools for quality assessment of diagnostic marker studies permitting quantitative scoring is suggested.
doi:10.1016/j.urolonc.2013.10.003
PMCID: PMC4524775  PMID: 25159014
Diagnostic accuracy; Study quality; IBCN classification; Oxford levels of evidence; QUADAS; NOS; STARD
9.  Health-care services utilization and costs associated with radical cystectomy for bladder cancer: a descriptive population-based study in the province of Quebec, Canada 
Background
Bladder cancer (BC) has the highest lifetime treatment costs per patient of all cancers. The objective of this study was to characterize the use of health-care services and costs associated with BC among patients who underwent radical cystectomy (RC) in the province of Quebec.
Methods
We conducted a descriptive study in a retrospective cohort of patients who underwent RC for BC between 2000 and 2009. Data was obtained from two health administrative databases (RAMQ and ISQ). We calculated average costs per patient and total costs in 2014 Canadian dollars for the following components of costs: 1) Pre-surgery costs (pre and post-urologist consultations, urologist consultations, cystoscopies, TURBTs, imaging procedures); 2) Costs of radical cystectomy and 3) Post-surgery costs (urologist consultations, post-operative consultations, medical oncologist consultations, imaging procedures and post-operative complication management). ARIMA models were used to evaluate trends in average costs per patient over the study period.
Results
Among 2759 patients included in the study (75 % men), average pre-surgery costs, RC costs, and post-surgery costs were estimated at 3762$, 18979$ and 4770$, respectively. RC cost was responsible for 69 % of total costs, followed by post-operative consultations (7.8 %), post-operative complications and TURBTs (6 % of total costs, each). Academic hospitals performed RC at a lower average cost, compared to community hospitals (difference of $1000, p < .0001). A decreased trend in post-surgery costs was detected in the year 2009.
Conclusions
Costs of RC, TURBT, consultations and post-operative complications were the most important economic components of total RC cost per patient in Quebec. Academic hospitals performed RC at a lower cost, compared to community hospitals.
doi:10.1186/s12913-015-0972-3
PMCID: PMC4523952  PMID: 26239240
Bladder cancer; Radical cystectomy; Health-services utilization; Costs
11.  The 2015 CUA-CUOG Guidelines for the management of castration-resistant prostate cancer (CRPC) 
Summary
Agents that have shown improvements in survival in mCRPC now include abiraterone, enzalutamide, docetaxel, cabazitaxel and radium-223. Bone supportive agents and palliative radiation continue to play an important role in the overall management of mCRPC. Given the complexity, variety and importance of optimizing the use of these agents, a multidisciplinary team approach is highly recommended.
doi:10.5489/cuaj.2526
PMCID: PMC4455631  PMID: 26085865
13.  The impact of method of distal ureter management during radical nephroureterectomy on tumour recurrence 
Canadian Urological Association Journal  2014;8(11-12):E845-E852.
Introducton:
Radical nephroureterectomy for upper tract urothelial carcinoma (UTUC) must include some form of distal ureter management to avoid high rates of tumour recurrence. It is uncertain which distal ureter management technique has the best oncologic outcomes. To determine which distal ureter management technique resulted in the lowest tumour recurrence rate, we analyzed a multi-institutional Canadian radical nephroureterectomy database.
Methods:
We retrospectively analyzed patients who underwent radical nephroureterectomy with distal ureter management for UTUC between January 1990 and June 2010 at 10 Canadian tertiary hospitals. Distal ureter management approaches were divided into 3 categories: (1) extravesical tenting for ureteric excision without cystotomy (EXTRAVESICAL); (2) open cystotomy with intravesical bladder cuff excision (INTRAVESICAL); and (3) extravesical excision with endoscopic management of ureteric orifice (ENDOSCOPIC). Data available for each patient included demographic details, distal ureter management approach, pathology and operative details, as well as the presence and location of local or distant recurrence. Clinical outcomes included overall recurrence-free survival and intravesical recurrence-free survival. Survival analysis was performed with the Kaplan-Meier method. Multivariable Cox regression analysis was also performed.
Results:
A total of 820 patients underwent radical nephroureterectomy with a specified distal ureter management approach at 10 Canadian academic institutions. The mean patient age was 69.6 years and the median follow-up was 24.6 months. Of the 820 patients, 406 (49.5%) underwent INTRAVESICAL, 316 (38.5%) underwent EXTRAVESICAL, and 98 (11.9%) underwent ENDOSOPIC distal ureter management. Groups differed significantly in their proportion of females, proportion of laparoscopic cases, presence of carcinoma in situ and pathological tumour stage (p < 0.05). Recurrence-free survival at 5 years was 46.3%, 35.6%, and 30.1% for INTRAVESICAL, EXTRAVESICAL and ENDOSCOPIC, respectively (p < 0.05). Multivariable Cox regression analysis confirmed that INTRAVESICAL resulted in a lower hazard of recurrence compared to EXTRAVESICAL and ENDOSCOPIC. When looking only at intravesical recurrence-free survival (iRFS), a similar trend held up with INTRAVESICAL having the highest iRFS, followed by ENDOSCOPIC and then EXTRAVESICAL management (p < 0.05). At last follow-up, 406 (49.5%) patients were alive and free of disease.
Conclusion:
Open intravesical excision of the distal ureter (INTRAVESICAL) during radical nephroureterectomy was associated with improved overall and intravesical recurrence-free survival compared with extravesical and endoscopic approaches. These findings suggest that INTRAVESICAL should be considered the gold standard oncologic approach to distal ureter management during radical nephroureterectomy. Limitations of this study include its retrospective design, heterogeneous cohort, and limited follow-up.
doi:10.5489/cuaj.1985
PMCID: PMC4250251  PMID: 25485014
14.  Optimizing a frail elderly patient for radical cystectomy with a prehabilitation program 
Canadian Urological Association Journal  2014;8(11-12):E884-E887.
The purpose of this case report is to discuss the positive impact of a multimodal prehabilitation program on postoperative recovery of a frail patient undergoing radical cystectomy. An 85-year-old man with significant history for poorly controlled type II diabetes, anemia, chronic renal failure, and glaucoma was found to have muscle invasive urothelial carcinoma of the bladder with hydronephrosis. He was scheduled for elective radical cystoprostatectomy and ileal conduit diversion. He was enrolled in a multimodal prehabilitation program in view of his frailty (Fried score = 5), 15% body weight loss, weak grip strength, severe depression and moderate anxiety, poor nutritional status (patient-generated subjective global assessment [PG-SGA] = B), low functional walking capacity (6-minute walking test [6MWT] = 210 metres, predicted 621 metres). The 4-week program included moderate aerobic and resistant exercises, nutritional counselling with whey protein supplementation (20 g/day), and relaxation exercises. Surgery and the postoperative period were uneventful, although he required treatment of his hyperglycemia and hypomagnesemia. He left the hospital on postoperative day 7 and returned home where he continued the multimodal program for 8 weeks. Measurements of 6MWT, Health-Related Quality of Life (SF-36), physical activity, Hospital Anxiety and Depression Scale (HADS), were conducted at baseline, before surgery and at 4 and 8 weeks after surgery. These tests revealed a progressive remarkable improvement before surgery that continued after surgery.
doi:10.5489/cuaj.2025
PMCID: PMC4250260  PMID: 25485023
15.  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
16.  First case of invasive squamous cell carcinoma in a stoma of a Monti ileovesicostomy 
Canadian Urological Association Journal  2014;8(9-10):E654-E656.
We report a very rare case of invasive squamous cell carcinoma (SCC) in the abdominal stoma of a Monti ileovesicostomy. Our patient underwent an uncomplicated Monti ileovesicostomy at age 16 for a neurogenic bladder. She presented 10 years later with difficulty catheterizing the stoma. A biopsy of peristomal tissue showed moderately differentiated SCC. A cystoscopy did not reveal any bladder tumours or suspicious lesions. A computed tomography (CT) scan of the abdomen and pelvis did not demonstrate metastasis. The patient underwent a complete en bloc resection of the stomal site, the Monti, a partial cuff of bladder, and 2 loops of bowel that were adherent to the Monti. Final pathology revealed pure invasive SCC arising around the stoma and negative surgical margins. Six months later, a follow-up CT scan showed no evidence of malignancy, while a cystoscopy revealed a small erythematous area in the posterior bladder wall. Urinary cytology was positive for SCC. Transurethral resection of the erythematous lesion with random bladder biopsies showed SCC in situ in the erythematous lesion and right lateral bladder wall. Staging workup was negative. The patient subsequently underwent a radical cystectomy and ileal conduit diversion with bilateral pelvic lymph node dissection. Final pathology on cystectomy specimen was SCC in situ without evidence of invasive carcinoma. The patient has remained in remission at the 3-year follow-up.
doi:10.5489/cuaj.2093
PMCID: PMC4164558  PMID: 25295141
17.  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
18.  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
19.  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
20.  Uptake of neoadjuvant chemotherapy for invasive bladder cancer 
doi:10.5489/cuaj.2077
PMCID: PMC4001665  PMID: 24839504
21.  Aldehyde dehydrogenase 1 expression in primary and metastatic renal cell carcinoma: an immunohistochemistry study 
Background
ALDH1 has been shown to be a cancer stem cell marker, and its expression correlates with prognosis in a number of malignancies. We aimed to evaluate the expression of ALDH1 in a cohort of primary and metastatic RCC specimens, and to correlate expression with pathological outcomes such as tumor stage and grade, and clinical outcomes such as progression free survival.
Methods
Three tissue microarrays were constructed from 244 RCC specimens, taken from 1985 to 2006. Samples were stained using an ALDH1 monoclonal antibody and expression was quantified by degree of staining. Membrane and cytoplasm staining were considered separately. A retrospective chart review enabled correlation with clinical outcomes.
Results
ALDH1 expression did not vary significantly based on tumor stage (P = 0.6274) or grade (P = 0.1666). ALDH1 showed significantly more membranous expression in clear cell RCC versus other subtypes (P < 0.0001), as well as in the primary setting compared to metastases (P = 0.0216). In terms of progression free survival, no significant differences were seen based on ALDH1 expression levels. In a subanalysis of clear cell tumors, ALDH1 membranous expression was decreased in tumors of higher stage (P = 0.0233).
Conclusions
ALDH1 may be useful in characterizing RCC tumors as clear cell subtype. However, unlike in other malignancies, ALDH1 may not be useful in prognosticating renal cancers. The clinical significance of decreased ALDH1 expression in the high stage and metastatic setting remains to be determined in further investigations.
doi:10.1186/1477-7819-11-298
PMCID: PMC3842840  PMID: 24266898
ALDH1; Renal cell carcinoma; Prognosis; Immunohistochemistry
22.  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
23.  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

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