Publications by authors named "Angela Pecoraro"

68 Publications

Comparison between small renal masses 0-2 cm vs. 2.1-4 cm in size: A population-based study.

Urol Oncol 2021 Feb 15. Epub 2021 Feb 15.

Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada; Division of Urology, University of Montreal Hospital Center (CHUM), Montreal, Quebec, Canada.

Background: The NCCN guidelines recommend active surveillance (AS) as an option for the initial management of cT1a 0-2 cm renal lesions. However, data about comparison between renal cell carcinoma (RCC) 0-2 cm vs. 2.1-4 cm are scarce.

Methods: Within the Surveillance, Epidemiology, and End Results database (2002-2016), 46,630 T1a NM stage patients treated with nephrectomy were identified. Data were tabulated according to histological subtype, tumor grade (low [LG] vs. high [HG]), as well as age category and gender. Additionally, rates of synchronous metastases were quantified.

Results: Overall, 69.3 vs. 74.1% clear cell, 21.4 vs. 17.6% papillary, 6.9 vs. 6.8% chromophobe, 2.0 vs. 1.1% sarcomatoid dedifferentiation, 0.2 vs. 0.2% collecting duct histological subtype were identified for respectively 0-2 cm and 2.1-4 cm RCCs. In both groups, advanced age was associated with higher rate of HG clear cell and HG papillary histological subtype. In 0-2 cm vs. 2.1-4 cm RCCs, 13.8% vs. 20.2% individuals operated on harbored HG tumors and were more prevalent in males. Lower synchronous metastases rates were recorded in 0-2 cm RCC and ranged from 0 in respectively multilocular cystic to 0.9% in HG papillary histological subtype. The highest synchronous metastases rates were recorded in sarcomatoid dedifferentiation histological subtype (13.8% and 9.7%) in both groups.

Conclusions: Relative to 2.1-4 cm RCCs, 0-2 cm RCCs harbored lower rates of HG tumors, lower rates of aggressive variant histology and lower rates of synchronous metastases. The indications and demographics of patients selected for AS may be expanded in the future to include younger and healthier patients.
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http://dx.doi.org/10.1016/j.urolonc.2021.01.003DOI Listing
February 2021

The impact of sex and age on distribution of metastases in patients with renal cell carcinoma.

Int J Clin Oncol 2021 Jan 30. Epub 2021 Jan 30.

Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, QC, Canada.

Background: Our objective was to investigate age and sex-related discrepancies on distribution of metastases in patients with metastatic renal cell carcinoma (RCC).

Methods: Within the National Inpatient Sample database (2008-2015) we identified 9607 patients with metastatic RCC. Trend test and Chi-square test analyses were used to evaluate the relationship between age and site of metastases, according to sex.

Results: Of 9607 patients with metastatic RCC, 6344 (65.9%) were men and 3263 (34.1%) were women. Thoracic, abdominal, bone and brain metastases were present in 51.1 vs. 52.8%, 42.6 vs. 44.3%, 29.9 vs. 29.2% and 8.6 vs. 8.8% of men vs. women, respectively. Increasing age was associated with decreasing rates of thoracic (from 55.5 to 48.5%) and brain (from 8.6 to 5.8%) metastases in men and with decreasing rates of abdominal (from 48.3 to 39.6%), bone (from 32.6 to 24.9%) and brain (from 8.8 to 5.4%) metastases in women. (all p < 0.05). Rates of concomitant metastatic sites also decreased with increasing age, from 57.1 to 50.8% in men and from 54.1 to 50.2% in women.

Conclusions: Important age and sex-related differences exist in the distribution of RCC metastases. The distribution of metastases is marginally different between sexes. Specifically, more advanced age is associated with lower rates of thoracic and brain metastases in men and with lower rates of abdominal, bone and brain metastases in women. Age and sex should be take into consideration into the staging management strategy, as well as into the follow-up strategy of patients with metastatic RCC.
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http://dx.doi.org/10.1007/s10147-021-01874-3DOI Listing
January 2021

Metabolic syndrome predicts worse perioperative outcomes in patients treated with radical prostatectomy for non-metastatic prostate cancer.

Surg Oncol 2021 Jan 3;37:101519. Epub 2021 Jan 3.

Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, Quebec, Canada.

Objectives: Metabolic syndrome (MetS) and its components (high blood pressure, BMI≥30, altered fasting glucose, low HDL cholesterol and high triglycerides) may undermine early perioperative outcomes after radical prostatectomy (RP). We tested this hypothesis.

Materials & Methods: Within the National Inpatient Sample database (2008-2015) we identified RP patients. The effect of MetS was tested in four separate univariable analyses, as well as in multivariable regression models predicting: 1) overall complications, 2) length of stay, 3) total hospital charges and 4) non-home based discharge. All models were weighted and adjusted for clustering, as well as all available patient and hospital characteristics.

Results: Of 91,618 patients: 1) 50.2% had high blood pressure, 2) 8.0% had BMI≥30, 3) 13.0% had altered fasting glucose, 4) 22.8% had high triglycerides and 5) 0.03% had low HDL cholesterol. Respectively, one vs. two vs. three vs. four MetS components were recorded in 36.2% vs. 19.0% vs. 5.5% vs. 0.8% patients. Of all patients, 6.3% exhibited ≥3 components and qualified for MetS diagnosis. The rates of MetS increased over time (EAPC:+9.8%; p < 0.001). All four tested MetS components (high blood pressure, BMI≥30, altered fasting glucose and high triglycerides) achieved independent predictor status in all four examined endpoints. Moreover, a highly statistically significant dose-response was also confirmed for all four tested endpoints.

Conclusion: MetS and its components consistently and strongly predict early adverse outcomes after RP. Moreover, the strength of the effect was directly proportional to the number of MetS components exhibited by each individual patient, even if formal MetS diagnosis of ≥3 components has not been met.
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http://dx.doi.org/10.1016/j.suronc.2020.12.013DOI Listing
January 2021

Contemporary rates and predictors of open conversion during minimally invasive partial nephrectomy for kidney cancer.

Surg Oncol 2021 Mar 11;36:131-137. Epub 2020 Dec 11.

Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, Quebec, Canada.

Objectives: To test contemporary rates and predictors of open conversion at minimally invasive partial nephrectomy (MIPN: laparoscopic or robotic partial nephrectomy).

Materials And Methods: Within the National Inpatient Sample database (2008-2015) we identified all MIPN patients and patients that underwent open conversion at MIPN. First, estimated annual percentage changes (EAPC) tested temporal trends of open conversion. Second, univariable and multivariable logistic regression models predicted open conversion at MIPN. All models were weighted and adjusted for clustering, as well as all available patient and hospital characteristics.

Results: Of 7649 MIPN patients, 287 (3.8%) underwent open conversion. The rates of open conversion decreased over time (from 12 to 2.4%; EAPC: 24.8%; p = 0.004). In multivariable logistic regression models predicting open conversion, patient obesity achieved independent predictor status (OR:1.80; p < 0.001). Moreover, compared to high volume hospitals, medium volume (OR:1.48; p = 0.02) and low volume hospitals (OR:2.11; p < 0.001) were associated with higher rates of open conversion. Last but not least, when the effect of obesity was tested according to hospital volume, the rates of open conversion ranged from 2.2 (non obese patients treated at high volume hospitals) to 9.8% (obese patients treated at low volume hospitals).

Conclusion: Overall contemporary (2008-2015) rate of open conversion at MIPN was 3.8% and it was strongly associated with patient obesity and hospital surgical volume. In consequence, these two parameters should be taken into account during preoperative patients counselling, as well as in clinical and administrative decision making.
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http://dx.doi.org/10.1016/j.suronc.2020.12.004DOI Listing
March 2021

Anastomosis quality score during robot-assisted radical prostatectomy: a new simple tool to maximize postoperative management.

World J Urol 2021 Jan 3. Epub 2021 Jan 3.

Division of Urology, Department of Oncology, School of Medicine, University of Turin, San Luigi Hospital, Regione Gonzole 10, 10043, Orbassano, Turin, Italy.

Purpose: The urethro-vesical anastomosis represents one of the most challenging steps of robotic prostatectomy (RARP). To maximize postoperative management, we specifically designed our anastomosis quality score (AQS), based on the intraoperative characteristics of the urethra and bladder neck.

Methods: This is a prospective study, conducted from April 2019 to March 2020. All the patients were classified into three different AQS categories (low, intermediate, high) based on the quality of the anastomosis. The postoperative management was modulated accordingly.

Results: We enrolled 333 patients. According to AQS, no differences were recorded in intraoperative complications (p = 0.9). Median hospital stay and catheterization time were longer in AQS 1 group (p < 0.001). Additionally, the occurrence of postoperative complication was higher in AQS 1 category (p = 0.002) but, when focusing on the complications related to the quality of the anastomosis, no differences were found neither for acute urinary retention (p = 0.12) nor urine leakage (p = 0.11). Finally, concerning the continence recovery, no significant differences were found among the three groups for each time point. The highest potency recovery rate at one month of follow-up was recorded in AQS 3 category (p = 0. 03).

Conclusion: The AQS proposed revealed to be a valid too to intraoperatively categorize patients who underwent RARP on the basis of the urethral and bladder neck features. The modulated postoperative management for each specific score category allowed to limit the occurrence of complications and to maximize the functional outcomes.
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http://dx.doi.org/10.1007/s00345-020-03549-6DOI Listing
January 2021

The importance of anatomical reconstruction for continence recovery after robot assisted radical prostatectomy: a systematic review and pooled analysis from referral centres.

Minerva Urol Nefrol 2020 Nov 17. Epub 2020 Nov 17.

Division of Urology, Department of Oncology, School of Medicine, University of Turin, San Luigi Hospital, Orbassano, Turin, Italy.

Introduction: Urinary incontinence is one of the most scared sequelae of robot assisted radical prostatectomy (RARP). Therefore, different surgical modifications, aimed to restore the original anatomy, were proposed to overcome this issue. The purpose of this study is to assess which is the best reconstruction technique (posterior only: PR; anterior only: AR; total: TR) compared to the standard approach for continence recovery after RARP in a tertiary care centre.

Evidence Acquisition: After establishing an a priori protocol, a systematic electronic literature search was conducted in May 2019. The article selection proceeded in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and was registered (PROSPERO registry number 131667). The risk of bias and the quality assessment of the included studies were performed. Simple pooled analysis was performed for continence rates according to the definition of continence (0 pad vs. 0-1 pad) and the different types of reconstruction at 1, 4, 12, 24, 52 weeks after RARP. Complication rate, operative and console time and estimated blood loss were pooled. Two-side test of proportion and T-test were used to compare rates and mean, respectively.

Evidence Synthesis: Six studies meeting the inclusion criteria were found and included in the analysis. All the included studies were of "poor" or "good" quality. A high or moderate risk of bias was recorded. TR showed higher continence recovery rates, compared to their anterior reconstruction counterpart at 1, 4, 12, 24, 52 weeks (p <0.001 at all time-points). At 12 weeks TR showed the highest continence rates (p<0.001), followed by AR and PR. No statistically significant differences were recorded regarding anastomosis-related complication rates (anastomosis stricture p=0.08; urine leakage p=0.1).

Conclusions: In patients undergoing RARP, TR facilitates a faster and higher continence recovery compared to standard approach or PR or AR only.
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http://dx.doi.org/10.23736/S0393-2249.20.04146-6DOI Listing
November 2020

Prognostic factors in patients with small renal masses: a comparison between <2 vs. 2.1-4 cm renal cell carcinomas.

Cancer Causes Control 2021 Feb 9;32(2):119-126. Epub 2020 Nov 9.

Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, Quebec, Canada.

Background: Few data factually support the prognostic distinction between renal cell carcinomas (RCC) < 2 vs. 2.1-4 cm, in terms of cancer-specific mortality (CSM). We investigated CSM rates over time in <2 vs. 2.1-4 cm RCC, according to patient and tumor characteristics.

Methods: Within the Surveillance, Epidemiology and End Results (SEER) database, we focused on patients with TNM RCC who underwent either radical or partial nephrectomy between 2000 and 2015. Temporal trends, Kaplan-Meier plots and multivariable Cox-regression analyses assessed CSM.

Results: Of 43,147 TNM patients, 12,238 (28.4%) harbored RCC < 2 cm and 30,909 (71.6%) 2.1-4 cm RCC. The distribution of histological subtypes according to 2 cm cut-off was as follows: a). clear-cell G1/G2: 64.5 vs. 61.8%; b). papillary G1/G2 15.9 vs. 11.1%; c). clear-cell G3/G4: 9.9 vs. 16.1%; d). papillary G3/G4 4.9 vs. 5.4%; and e). chromophobe 4.9 vs. 5.2%. Five-year CSM rates were invariably lower in RCC < 2 cm than in 2.1-4 cm, for all histological subtypes and grade groups (a-e), even after additional multivariable adjustment for age and residual tumor size differences. 5-year CSM rates improved in more contemporary years, in both tumor size groups (< 2 vs. 2.1-4 cm), but to a greater extent in 2.1-4 cm renal masses.

Conclusion: Our results validate the presence of prognostically more favorable CSM outcomes in RCC < 2 cm vs. 2.1-4 cm, across all histological subtypes and grades. Moreover, temporal improvements were also recorded in both <2 and 2.1-4 cm RCC groups, with more pronounced improvements in patients with 2.1-4 cm renal masses. However, prospective randomized trials are needed to further confirm our results.
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http://dx.doi.org/10.1007/s10552-020-01364-3DOI Listing
February 2021

Prostate Cancer Grade and Stage Misclassification in Active Surveillance Candidates: Black Versus White Patients.

J Natl Compr Canc Netw 2020 11 2;18(11):1492-1499. Epub 2020 Nov 2.

1Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, Quebec, Canada.

Background: Misclassification rates defined as upgrading, upstaging, and upgrading and/or upstaging have not been tested in contemporary Black patients relative to White patients who fulfilled criteria for very-low-risk, low-risk, or favorable intermediate-risk prostate cancer. This study aimed to address this void.

Methods: Within the SEER database (2010-2015), we focused on patients with very low, low, and favorable intermediate risk for prostate cancer who underwent radical prostatectomy and had available stage and grade information. Descriptive analyses, temporal trend analyses, and multivariate logistic regression analyses were used.

Results: Overall, 4,704 patients with very low risk (701 Black vs 4,003 White), 17,785 with low risk (2,696 Black vs 15,089 White), and 11,040 with favorable intermediate risk (1,693 Black vs 9,347 White) were identified. Rates of upgrading and/or upstaging in Black versus White patients were respectively 42.1% versus 37.7% (absolute Δ = +4.4%; P<.001) in those with very low risk, 48.6% versus 46.0% (absolute Δ = +2.6%; P<.001) in those with low risk, and 33.8% versus 35.3% (absolute Δ = -1.5%; P=.05) in those with favorable intermediate risk.

Conclusions: Rates of misclassification were particularly elevated in patients with very low risk and low risk, regardless of race, and ranged from 33.8% to 48.6%. Recalibration of very-low-, low-, and, to a lesser extent, favorable intermediate-risk active surveillance criteria may be required. Finally, our data indicate that Black patients may be given the same consideration as White patients when active surveillance is an option. However, further validations should ideally follow.
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http://dx.doi.org/10.6004/jnccn.2020.7580DOI Listing
November 2020

The effect of sex on disease stage and survival after radical cystectomy: a population-based analysis.

Urol Oncol 2020 Oct 6. Epub 2020 Oct 6.

Division of Urology, Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada.

Background: The increased awareness regarding the sex gap in bladder cancer (BCa) care over the last decade may have resulted in more timely-wise referral patterns and treatment of female patients with BCa. Thus, we tested the association of sex with disease stage at presentation, as well as with cancer-specific mortality (CSM) after radical cystectomy (RC) in a contemporary cohort of patients with nonmetastatic urothelial bladder cancer (UCUB).

Methods: Within the Surveillance, Epidemiology, and End Results database (2004-2016), we identified 14,086 patients (10,879 men and 3,207 women) treated with RC for non-metastatic UCUB. Temporal trend, interaction analyses, logistic regression, cumulative incidence, and competing-risks regression analyses were used.

Results: Overall, 10,879 (77.2%) men and 3,207 (22.8%) women underwent RC between 2004 and 2016. Female gender was an independent predictor of non-organ-confined (NOC) UCUB at RC in multivariable analyses (odds ratio: 1.23; 95% confidence intervals [CI] 1.10-1.38; P < 0.001). While NOC rates in men decreased over time (from 54.8% to 45.7%; P < 0.01), NOC rates in women remained stationary (from 60.6% to 57.3%; P = 0.15) and the excess NOC rate between men and women increased from + 5.8% in 2004 to +11.6% in 2016. Moreover, in multivariable analyses adjusted for other covariates, female gender was an independent predictor of higher CSM after RC in NOC UCUB (HR: 1.14; 95%CI 1.04-1.24; P < 0.01), but not in localized UCUB (P = 0.06).

Conclusion: It is worrisome that, while in men the rate of NOC is decreasing, NOC rates in females have not improved over time. Moreover, it is also worrisome that, despite adjustment for both pathological tumor and patient characteristics, female sex remains an adverse prognostic factor for CSM. Reassessment of referral, diagnostic, and treatment patterns aimed at eliminating these sex discrepancies appears warranted.
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http://dx.doi.org/10.1016/j.urolonc.2020.09.004DOI Listing
October 2020

Small Renal Masses With Tumor Size 0 to 2 cm: A SEER-Based Study and Validation of NCCN Guidelines.

J Natl Compr Canc Netw 2020 10 1;18(10):1340-1347. Epub 2020 Oct 1.

1Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada.

Background: The NCCN Clinical Practice Guidelines in Oncology for Kidney Cancer recommend active surveillance as an option for initial management of T1a 0- to 2-cm renal lesions, in addition to partial nephrectomy, radical nephrectomy, and focal ablation. However, contemporary data regarding the distribution of patient and renal cell carcinoma characteristics within this special patient group are scarce.

Methods: Within the SEER database (2002-2016), 13,364 patients with T1aNanyMany 0- to 2-cm renal lesions treated with nephrectomy were identified. Data were tabulated according to histologic subtype, Fuhrman grade (FG1-2 vs FG3-4), age category, and sex. In addition, rates of synchronous metastases were quantified.

Results: Overall, clear-cell (69.3%), papillary (21.4%), chromophobe (6.9%), multilocular cystic (2.0%), sarcomatoid dedifferentiation (0.2%), and collecting-duct histologic subtypes (0.2%) were identified. Advanced age was associated with a lower rate of FG1-2 clear cell histologic subtype (70.8%-50.3%) but higher rates of FG1-2 papillary (11.1%-23.9%) and chromophobe histologic subtypes (6.2%-8.5%). Overall, 14.5% individuals harbored FG3-4 clear cell (9.8%) or FG3-4 papillary histologic subtypes (4.8%), and both were more prevalent in men. FG3-4 clear-cell and FG3-4 papillary histologic subtypes increased with age, more so in women than in men. The overall rate of synchronous metastases was 0.4% and ranged from 0 in the multilocular cystic subtype to 0.9% in the FG3-4 papillary histologic subtype, respectively, except for 13.8% in the sarcomatoid dedifferentiation histologic subtype.

Conclusions: Most T1a 0- to 2-cm renal cell carcinoma represents the low-grade clear-cell or low-grade papillary histologic subtype, with an FG3-4 minority. Even in patients with the FG3-4 histologic subtype, rates of synchronous metastases are virtually zero.
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http://dx.doi.org/10.6004/jnccn.2020.7577DOI Listing
October 2020

Effect of Age on Cancer-specific Mortality in Patients With Urothelial Carcinoma of the Urinary Bladder: A Population-based Competing-risks Analysis Across Disease Stages.

Am J Clin Oncol 2020 12;43(12):880-888

Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, QC, Canada.

Objective: The objective of the study is to test the effect of age on cancer-specific mortality (CSM) in patients with urothelial carcinoma of the urinary bladder (UCUB), across all disease stages.

Materials And Methods: Within the Surveillance, Epidemiology, and End Results (SEER) registry (2004-2016), we identified 207,714 patients. Age was categorized as: below 60 versus 60 to 69 versus 70 to 79 versus 80 years and above. Multivariable competing-risks regression (CRR) models were used according to disease stage (low-risk nonmuscle invasive: TaN0M0 low grade, high-risk nonmuscle invasive: Ta high grade or Tis-1N0M0, muscle invasive: T2-3N0M0, regional: T4N0M0/TanyN1-3M0, and metastatic: TanyNanyM1).

Results: Overall, 33,970 (16.4%) versus 52,173 (25.1%) versus 64,537 (31.1%) versus 57,034 (27.4%) patients were below 60 versus 60 to 69 versus 70 to 79 versus 80 years and above, respectively. In multivariable CRR models that focused on low-risk nonmuscle invasive UCUB, advanced age was associated with higher CSM rates (hazard ratio [HR]: 7.04 in patients aged 80 y and above, relative to below 60 y; P<0.001). Moreover, advanced age was also associated with higher CSM rates in high-risk nonmuscle invasive UCUB (HR: 2.77 in patients aged 80 y and above, relative to below 60 y; P<0.001) and in muscle invasive UCUB patients (HR: 1.38 in patients aged 80 y and above, relative to below 60 y; P<0.001). Conversely, lower CSM rates with advanced age were observed in multivariable CRR that focused on regional (HR: 0.91 for patients aged 80 y and above, relative to below 60 y; P=0.02) or metastatic UCUB (HR: 0.75 for patients aged 80 y and above, relative to below 60 y; P<0.001).

Conclusions: The direction and the magnitude of the association between advanced age and CSM in UCUB patients changes according to tumor stage. In low-risk nonmuscle invasive, high-risk nonmuscle invasive, and muscle invasive UCUB, more advanced age is associated with higher CSM rates. Conversely, in regional and metastatic UCUB patients, more advanced age is associated with lower CSM rates.
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http://dx.doi.org/10.1097/COC.0000000000000766DOI Listing
December 2020

Association of preoperative serum De Ritis ratio with oncological outcomes in patients treated with cytoreductive nephrectomy for metastatic renal cell carcinoma.

Urol Oncol 2020 Dec 19;38(12):936.e7-936.e14. Epub 2020 Sep 19.

Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia; Department of Urology, Weill Cornell Medical College, New York, NY; Department of Urology, University of Texas Southwestern, Dallas, TX; Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic; Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria; Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman, Jordan; European Association of Urology Research Foundation, Arnhem, Netherlands. Electronic address:

Purpose: Identifying which patients are likely to benefit from cytoreductive nephrectomy (CN) for metastatic renal cell carcinoma (mRCC) is important. We tested the association between preoperative serum De Ritis ratio (DRR, Aspartate Aminotransferase/Alanine Aminotransferase) and overall survival (OS) as well as cancer-specific survival (CSS) in mRCC patients treated with CN.

Material And Methods: mRCC patients treated with CN at different institutions were included. After assessing for the optimal pretreatment DRR cut-off value, we found 1.2 to have the maximum Youden index value. The overall population was therefore divided into 2 DRR groups using this cut-off (low, <1.2 vs. high, ≥1.2). Univariable and multivariable Cox regression analyses tested the association between DRR and OS as well as CSS. The discrimination of the model was evaluated with the Harrel's concordance index (C-index). The clinical value of the DRR was evaluated with decision curve analysis.

Results: Among 613 mRCC patients, 239 (39%) patients had a DRR ≥1.2. Median follow-up was 31 (IQR 16-58) months. On univariable analysis, high DRR was significantly associated with OS (hazard ratios [HR]: 1.22, 95% confidence interval [CI]: 1.01-1.46, P = 0.04) and CSS (HR: 1.23, 95% CI: 1.02-1.47, P = 0.03). On multivariable analysis, which adjusted for the effect of established clinicopathologic features, high DRR remained significantly associated with both OS (HR: 1.26, 95% CI: 1.04-1.52, P = 0.02) and CSS (HR: 1.26, 95% CI: 1.05-1.53, P = 0.01). The addition of DRR only minimally improved the discrimination of a base model that included established clinicopathologic features (C-index = 0.633 vs. C-index = 0.629). On decision curve analysis, the inclusion of DRR did not improve the net-benefit beyond that obtained by established subgroup analyses stratified by IMDC risk groups, type of systemic therapy, body mass index and sarcomatoid features, did not reveal any prognostic value to DRR.

Conclusion: Despite the statistically significant association between DRR and OS as well as CSS in mRCC patients treated with CN, DRR does not seem to add any further prognostic value beyond that obtained by currently available features.
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http://dx.doi.org/10.1016/j.urolonc.2020.08.013DOI Listing
December 2020

Assessment of other-cause mortality in localized renal cell carcinoma patients within 15 years: A population-based analysis.

J Surg Oncol 2020 Dec 18;122(7):1506-1513. Epub 2020 Aug 18.

Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Canada.

Background And Objective: Five-year other cause mortality (OCM) after nephrectomy for non-metastatic renal cell carcinoma (RCC) should be marginal in properly selected surgical candidates. We examined 5-year OCM rates as a quality of care indicator for patient selection.

Materials And Methods: Within the Surveillance, Epidemiology, and End Results database (1997-2011), we identified 59267 RCC patients treated with either radical (n = 27 804, 46.9%) or partial nephrectomy (n = 31 463, 53.1%). Temporal trends and multivariable Cox regression analyses assessed 5-year OCM. Data were stratified according to age group, year of diagnosis, race, marital status, gender, and socio-economic status. The overall OCM rates for the entire cohort at 5 years of follow-up was 4.7% and decreased from 9.4% to 5.6% over the study span (-3.8%, P < .001). The greatest decrease in 5-year OCM rates over time was recorded in patients >70 years (17.0%-9.6%, slope, -0.6%/y), as well as in African-Americans (12.0-6.2%; slope, -0.3%/y) and in males (8.9%-4.7%; slope, -0.3%, all P < .001).

Conclusions: An important OCM decrease was recorded over the study span. Nonetheless, further improvement may be accomplished, especially in African-Americans, unmarried and older individuals, who exhibited higher OCM rates than others. These three groups may represent ideal targets for better patient selection based on OCM considerations.
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http://dx.doi.org/10.1002/jso.26149DOI Listing
December 2020

Contemporary Cytoreductive Nephrectomy Provides Survival Benefit in Clear-cell Metastatic Renal Cell Carcinoma.

Clin Genitourin Cancer 2020 Dec 20;18(6):e730-e738. Epub 2020 May 20.

Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, QC, Canada; Division of Urology, University of Montreal Hospital Center (CHUM), Montreal, QC, Canada.

Introduction: A recent randomized trial questioned the role of cytoreductive nephrectomy in clear-cell metastatic renal cell carcinoma (ccmRCC). We reassessed the effect of cytoreductive nephrectomy on survival in a contemporary population-based ccmRCC cohort.

Patients And Methods: Within the Surveillance, Epidemiology, and End Results database (2010-2015), we focused on patients with ccmRCC. The primary endpoint consisted of overall mortality. Univariable and multivariable Cox regression models were applied in the overall cohort and in patients who underwent targeted therapy. Sensitivity analyses included 1:1 propensity score matching, 3- and 6-month landmark analyses, incremental survival benefit analyses, and metastases number and location-based stratifications.

Results: Of 4062 patients with ccmRCC, 2241 (55.1%) received targeted therapy; cytoreductive nephrectomy was performed in 2226 (54.8%) patients and 1168 (52.1%) patients in the overall and targeted therapy cohorts, respectively. Cytoreductive nephrectomy was associated with lower overall mortality in the overall cohort (median survival, 30 vs. 9 months; hazard ratio [HR], 0.43; P < .001), as well as in the targeted therapy cohort (median survival, 28 vs. 12 months; HR, 0.49; P < .001). In sensitivity analyses, cytoreductive nephrectomy was associated with lower overall mortality after 1:1 propensity score-matching (HR, 0.49; P < .001), in 3- and 6-month landmark analyses (HR, 0.49; P < .001 and HR, 0.51; P < .001, respectively), in metastases number and location-based stratifications, except for exclusive liver metastases, as well as in all incremental benefit analyses.

Conclusion: Cytoreductive nephrectomy is associated with better survival in patients with ccmRCC, including those exposed to targeted therapy, after adjustment for multiple potential confounders.
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http://dx.doi.org/10.1016/j.clgc.2020.05.009DOI Listing
December 2020

Bladder cancer incidence rates and trends in young adults aged 20-39 years.

Urol Oncol 2020 Dec 9;38(12):934.e11-934.e19. Epub 2020 Jul 9.

Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada.

Objectives: To assess contemporary gender, race and stage-specific incidence and trends of bladder cancer among young adults in the United States.

Materials And Methods: Within Surveillance, Epidemiology, and End Results database (2001-2016), all patients aged 20 to 39 years-old with histologically confirmed bladder cancer were included. Age-standardized rates (ASR per 100,000 person-years) were estimated. Temporal trends were calculated through joinpoint regression analyses to describe the average annual percent change (AAPC).

Results: From 2000 to 2016, 2,772 new cases were recorded (ASR 0.2, AAPC -1.5%, P = 0.01). ASRs were higher in males than in females (0.3 and 0.1, respectively) and decreased significantly in both genders (AAPC -1.3, P = 0.02 and -2.2% P = 0.03, respectively). non-Hispanic White (NHW) accounted for 70.7% of the cohort and had the highest incidence (ASR 0.3) that decreased over time (AAPC -1.4%, P = 0.02). Conversely, ASRs in other ethnic groups were lower and showed stable trends. The most frequent tumor characteristics were Ta/TisN0M0 stage (71.0%, ASR 0.1, AAPC -1.0%, P = 0.1), low grade (61.6%, ASR 0.1, AAPC -4.3%, P = 0.001) and urothelial histology (95.5%, ASR 0.2, AAPC -1.5%, P = 0.01).

Conclusions: Despite the rarity of bladder cancer in those aged 20 to 39 years, a standard work-up is required to avoid advanced stage at diagnosis. The current data validate initial diagnoses at earliest stage in the vast majority of young adults. Moreover, decreasing ASRs in both genders are encouraging.
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http://dx.doi.org/10.1016/j.urolonc.2020.06.009DOI Listing
December 2020

Renal cell carcinoma incidence rates and trends in young adults aged 20-39 years.

Cancer Epidemiol 2020 08 22;67:101762. Epub 2020 Jun 22.

Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada.

Background: The burden of renal cell carcinoma (RCC) in young adults received marginal attention. We assessed contemporary gender, race and stage-specific incidence and trends of RCC among young adults (20-39 years-old) in the United States.

Methods: Within Surveillance, Epidemiology, and End Results database (2000-2016), patients aged 20-39 years with histologically confirmed RCC were included. Age-standardized incidence rates (ASR per 100,000 person-years) were estimated. Temporal trends were calculated through joinpoint regression analyses to describe the average annual percent change (AAPC).

Results: From 2000-2016, 7767 new RCC cases were recorded (ASR 0.6, AAPC  + 5.0 %, p < 0.001). ASRs were higher in males than in females (0.7 and 0.5, respectively) and increased significantly in both genders (AAPC + 5.0 % and +4.7 % both p < 0.001, respectively). Non-Hispanic American Indian/Alaska Native had the highest incidence (ASR 1.0) vs. non-Hispanic Asian or Pacific Islander the lowest (ASR 0.3). ASRs significantly increased in all ethnic groups. T1aN0M0 and T1bN0M0 stages showed the highest incidence and increase (ASR 0.3, AAPC + 5.9 %, p < 0.001 and ASR 0.1, AAPC + 5.7 %, p < 0.001, respectively). Also regional and distant stages increased (AAPC + 3.7 %, p = 0.001 and AAPC + 1.5 %, p = 0.06). The most frequent tumor characteristics were G2 (44.4 %, ASR 0.3, AAPC + 6.3 %, p < 0.001) and G1 (13.1 %, ASR 0.1, AAPC + 1.1 %, p = 0.2), as well as clear cell histology (54.8 %, ASR 0.3, AAPC  + 7.6 %, p < 0.001).

Conclusions: RCC in young adults is rare, but increasing. This is mainly due to T1aN0M0 tumors. Nonetheless, also regional diseases are significantly increasing. Differences between ethnic groups exist and may warrant further research.
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http://dx.doi.org/10.1016/j.canep.2020.101762DOI Listing
August 2020

Forecasting the Future of Urology Practice: A Comprehensive Review of the Recommendations by International and European Associations on Priority Procedures During the COVID-19 Pandemic.

Eur Urol Focus 2020 Sep 31;6(5):1032-1048. Epub 2020 May 31.

Division of Urology, Department of Oncology, School of Medicine, San Luigi Hospital, University of Turin, Orbassano, Turin, Italy. Electronic address:

Context: The unprecedented health care scenario caused by the coronavirus disease 2019 (COVID-19) pandemic has revolutionized urology practice worldwide.

Objective: To review the recommendations by the international and European national urological associations/societies (UASs) on prioritization strategies for both oncological and nononcological procedures released during the current emergency scenario.

Evidence Acquisition: Each UAS official website was searched between April 8 and 18, 2020, to retrieve any document, publication, or position paper on prioritization strategies regarding both diagnostic and therapeutic urological procedures, and any recommendations on the use of telemedicine and minimally invasive surgery. We collected detailed information on all urological procedures, stratified by disease, priority (higher vs lower), and patient setting (outpatient vs inpatient). Then, we critically discussed the implications of such recommendations for urology practice in both the forthcoming "adaptive" and the future "chronic" phase of the COVID-19 pandemic.

Evidence Synthesis: Overall, we analyzed the recommendations from 13 UASs, of which four were international (American Urological Association, Confederation Americana de Urologia, European Association of Urology, and Urological Society of Australia and New Zealand) and nine national (from Belgium, France, Germany, Italy, Poland, Portugal, The Netherlands, and the UK). In the outpatient setting, the procedures that are likely to impact the future burden of urologists' workload most are prostate biopsies and elective procedures for benign conditions. In the inpatient setting, the most relevant contributors to this burden are represented by elective surgeries for lower-risk prostate and renal cancers, nonobstructing stone disease, and benign prostatic hyperplasia. Finally, some UASs recommended special precautions to perform minimally invasive surgery, while others outlined the potential role of telemedicine to optimize resources in the current and future scenarios.

Conclusions: The expected changes will put significant strain on urological units worldwide regarding the overall workload of urologists, internal logistics, inflow of surgical patients, and waiting lists. In light of these predictions, urologists should strive to leverage this emergency period to reshape their role in the future.

Patient Summary: Overall, there was a large consensus among different urological associations/societies regarding the prioritization of most urological procedures, including those in the outpatient setting, urological emergencies, and many inpatient surgeries for both oncological and nononcological conditions. On the contrary, some differences were found regarding specific cancer surgeries (ie, radical cystectomy for higher-risk bladder cancer and nephrectomy for larger organ-confined renal masses), potentially due to different prioritization criteria and/or health care contexts. In the future, the outpatient procedures that are likely to impact the burden of urologists' workload most are prostate biopsies and elective procedures for benign conditions. In the inpatient setting, the most relevant contributors to this burden are represented by elective surgeries for lower-risk prostate and renal cancers, nonobstructing stone disease, and benign prostatic hyperplasia.
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http://dx.doi.org/10.1016/j.euf.2020.05.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7261455PMC
September 2020

The Effect of Systemic Chemotherapy on Survival in Patients With Localized, Regional, or Metastatic Adenocarcinoma of the Urinary Bladder.

Am J Clin Oncol 2020 08;43(8):567-574

Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, QC, Canada.

Objectives: To test the effect of systemic chemotherapy on cancer-specific mortality (CSM) in patients with adenocarcinoma of the urinary bladder (ADKUB).

Materials And Methods: Within the Surveillance, Epidemiology, and End Results registry (2004 to 2016), we identified patients with localized (T2-3N0M0), regional (T4N0M0/TanyN1-3M0), and metastatic (TanyNanyM1) ADKUB. Temporal trends, Kaplan-Meier plots, and multivariable Cox regression models were used before and after 1:1 propensity score matching and inverse probability of treatment weighting.

Results: Of 1537 patients with ADKUB, 834 (54.0%), 363 (23.5%), and 340 (22.5%) harbored localized, regional, and metastatic disease, respectively. The rates of chemotherapy use increased in localized (estimated annual percentage change [EAPC]: +2.7%; P=0.03) and regional ADKUB (EAPC: +2.4%; P=0.04). Conversely, chemotherapy rates remained stable in metastatic patients (EAPC: +1.6%; P=0.4). In multivariable Cox regression models, chemotherapy use was associated with lower CSM in metastatic ADKUB (hazard ratio [HR]: 0.5; P=0.003), but not in either localized (HR: 0.8; P=0.2) or in regional ADKUB (HR: 1.0; P=0.9). In metastatic ADKUB, the benefit of chemotherapy on CSM persisted after 1:1 propensity score matching (HR: 0.6; P=0.002) and after inverse probability of treatment weighting (HR: 0.4; P<0.001).

Conclusions: Chemotherapy improves survival in metastatic ADKUB. However, only one out of 2 such patients benefit from chemotherapy. In consequence, greater emphasis on chemotherapy use may be warranted in these patients. Conversely, no benefit was identified in localized or regional ADKUB.
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http://dx.doi.org/10.1097/COC.0000000000000704DOI Listing
August 2020

PSA, stage, grade and prostate cancer specific mortality in Asian American patients relative to Caucasians according to the United States Census Bureau race definitions.

World J Urol 2020 May 26. Epub 2020 May 26.

Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada.

Background: The United States Census Bureau recommends distinguishing between "Asians" vs. "Native Hawaiians or Other Pacific Islanders" (NHOPI). We tested for prognostic differences according to this stratification in patients with prostate cancer (PCa) of all stages.

Methods: Descriptive statistics, time-trend analyses, Kaplan-Meier plots and multivariate Cox regression models were used to test for differences at diagnosis, as well as for cancer specific mortality (CSM) according to the Census Bureau's definition in either non-metastatic or metastatic patients vs. 1:4 propensity score (PS)-matched Caucasian controls, identified within the Surveillance, Epidemiology and End Results database (2004-2016).

Results: Of all 380,705 PCa patients, NHOPI accounted for 1877 (0.5%) vs. 23,343 (6.1%) remaining Asians vs. 93.4% Caucasians. NHOPI invariably harbored worse PCa characteristics at diagnosis. The rates of PSA ≥ 20 ng/ml, Gleason ≥ 8, T3/T4, N1- and M1 stages were highest for NHOPI, followed by Asians, followed by Caucasians (PSA ≥ 20: 18.4 vs. 14.8 vs. 10.2%, Gleason ≥ 8: 24.9 vs. 22.1, vs. 15.9%, T3/T4: 5.5 vs. 4.2 vs. 3.5%, N1: 4.4 vs. 2.8, vs. 2.7%, M1: 8.3 vs. 4.9 vs. 3.9%). Despite the worst PCa characteristics at diagnosis, NHOPI did not exhibit worse CSM than Caucasians. Moreover, despite worse PCa characteristics, Asians exhibited more favorable CSM than Caucasians in comparisons that focussed on non-metastatic and on metastatic patients.

Conclusions: Our observations corroborate the validity of the distinction between NHOPI and Asian patients according to the Census Bureau's recommendation, since these two groups show differences in PSA, grade and stage characteristics at diagnosis in addition to exhibiting differences in CSM even after PS matching and multivariate adjustment.
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http://dx.doi.org/10.1007/s00345-020-03242-8DOI Listing
May 2020

Contemporary Age-adjusted Incidence and Mortality Rates of Renal Cell Carcinoma: Analysis According to Gender, Race, Stage, Grade, and Histology.

Eur Urol Focus 2020 May 23. Epub 2020 May 23.

Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada.

Background: Recent data showed that North America has the highest incidence of renal cell carcinoma (RCC) worldwide.

Objective: To assess contemporary gender-, race-, and stage-specific incidence; survival rates; and trends of RCC patients in the USA.

Design, Setting, And Participants: Within the Surveillance, Epidemiology, and End Results database (2001-2016), all patients aged ≥18 yr with histologically confirmed renal parenchymal tumors were included.

Outcome Measurements And Statistical Analysis: Age-adjusted incidence rates and 5-yr cancer-specific survival (CSS) rates were estimated. Temporal trends were calculated through Joinpoint regression analyses to describe the average annual percent change (AAPC).

Results And Limitations: The age-adjusted incidence rate of RCC was 11.3/100 000 person years (AAPC+2.0%, p<0.001). Five-year CSS rates increased from 78.4% to 84.5% (AAPC +0.8%, p<0.001). Male incidence was double that of females (15.5 and 7.7, respectively). CSS marginally favored females (84.5% vs 82.0%), but improved equally in both genders (both AAPC +0.8%). The highest incidence (14.1/100 000 person years, AAPC +2.8%) and lowest survival (80.1%) were recorded in non-Hispanic American Indian/Alaska Native populations. T1aN0M0 had the highest incidence rates (4.6/100 000 person years), the highest increase over time (AAPC +3.6%), and the highest CSS (97.6%) of all stages. Limitations include retrospective nature and lack of information on risk factors.

Conclusions: The incidence of RCC increased significantly from 2001 to 2016, and 5-yr CSS after RCC improved. This was mainly due to T1aN0M0 tumors that showed the highest increase in the incidence and highest CSS. Unfavorable outcomes in specific ethnic groups warrant further research.

Patient Summary: We examined contemporary incidence and cancer-specific survival rates of kidney cancer. Males had double the incidence rates of females, but lower survival. Natives showed the highest incidence rates and the lowest survival rates. Small renal masses showed the highest incidence and survival rates.
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http://dx.doi.org/10.1016/j.euf.2020.05.003DOI Listing
May 2020

The vaccine journey for COVID-19: a comprehensive systematic review of current clinical trials in humans.

Panminerva Med 2020 May 26. Epub 2020 May 26.

Department of Oncology, School of Medicine, San Luigi Hospital, University of Turin, Orbassano, Turin, Italy.

Introduction: Since December 2019, there has been an outbreak of a novel beta-coronavirus (SARS-CoV-2) in Wuhan, China. On March the 11th the World Health Organization (WHO) declared COVID-19 as a pandemic, with over 118,000 cases in more than 110 countries around the world. In response to the global coronavirus disease 2019 (COVID-19) emergency, clinical trial research assessing the efficacy and safety of experimental vaccines to prevent COVID-19 are emerging at an unprecedented rate. The aim of this systematic review is to summarize the preliminary experiences and ongoing clinical trials of the major candidates and challenges of the vaccine strategies in humans.

Evidence Acquisition: After a priori protocol registration with PROSPERO (181483), a systematic research of the published literature was conducted on 24 April 2020 using Medline (via PubMed), Embase (via Ovid), and WHO databases. Moreover, to explore the more recent literature we also searched the preprint server medRxiv. Finally, we scrutinized the Cochrane COVID-19 study register and the COVID-19 section of ClinicalTrials.gov database for identifying relevant ongoing clinical trials. Thereafter we selected the articles according to the PRISMA guidelines. Animal or in-vitro experimental studies were excluded. Moreover editorials, commentaries, abstracts, reviews, book chapters, and articles not in English were not included.

Evidence Synthesis: Our search identified 1359 published papers, 478 pre-print articles and 367 ongoing clinical trials. Finally, only ten ongoing clinical trials met the inclusion criteria. Specifically, seven developed vaccines for the S protein of SARS-CoV-2 and three clinical trials assessed the protective role of BCG vaccine against COVID-19. The first group included phase I/II trials with different types of molecules (DNA or mRNA vaccine, bacterial plasmid or viral vectors), the latter were phase III/IV trials designed on the basis of a heterologous lymphocyte activation by the BCG vaccine.

Conclusions: This new disease is pushing the scientific community to develop swiftly a safe and effective vaccine. Notwithstanding the limitations of our analysis, given by the absence of available results, we try to provide a comprehensive view of the ongoing clinical trials in humans. Our analysis reveals a worldwide effort of both scientists and enterprises to achieve one of the most challenging goals of our century.
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http://dx.doi.org/10.23736/S0031-0808.20.03958-0DOI Listing
May 2020

Association Between Systemic Therapy and/or Cytoreductive Nephrectomy and Survival in Contemporary Metastatic Non-clear Cell Renal Cell Carcinoma Patients.

Eur Urol Focus 2020 May 19. Epub 2020 May 19.

Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, Quebec, Canada.

Background: Optimal management of metastatic non-clear cell renal cell carcinoma (non-ccmRCC) remains largely unknown.

Objective: To test the effect of systemic therapy (ST) and/or cytoreductive nephrectomy (CNT) on overall mortality (OM) in patients with non-ccmRCC.

Design, Setting, And Participants: Within the Surveillance, Epidemiology and End Results (SEER) registry (2006-2015), we identified patients with papillary, chromophobe, sarcomatoid, and collecting duct metastatic renal cell carcinoma (mRCC).

Outcome Measurements And Statistical Analysis: Temporal trends (estimated annual percentage change [EAPC]), Kaplan-Meier plots, and multivariable Cox regression models were used.

Results And Limitations: Of 1573 patients with non-ccmRCC, 22%, 25%, 25%, and 28% underwent no treatment, ST, CNT, and CNT with ST, respectively. Between 2006 and 2015, rates of CNT and the combination of CNT and ST decreased (EAPC: -6.3% and -3.2%, respectively). Conversely, rates of no treatment and ST increased over time (EAPC: 4.6% and 7.5%, respectively). In multivariable Cox regression models, relative to no treatment, ST (hazard ratio [HR]: 0.5; p < 0.001), CNT (HR: 0.4; p < 0.001), and CNT with ST (HR: 0.3; p < 0.001) were associated with lower OM. Histological subtypes were associated with OM, relative to papillary renal cell carcinoma (RCC): chromophobe (HR: 0.7; p < 0.01), sarcomatoid (HR: 2.1; p < 0.001), and collecting duct RCC (HR: 1.9; p < 0.001). Limitations include the impossibility to stratify patients according to mRCC risk groups.

Conclusions: Most non-ccmRCC patients are treated with a combination of CNT and ST or CNT alone or ST alone. The rates of ST alone are increasing. Conversely, the rates of combined CNT and ST and CNT alone are decreasing. These observed temporal patterns of treatment rates are counterintuitive with respect to associated OM benefits, where combination of CNT and ST, as well as CNT alone, resulted in the lowest absolute OM, relative to ST alone, or, even worse, no treatment.

Patient Summary: We investigated the effect of treatment modalities on survival of patients with metastatic non-clear cell renal cell carcinoma. The combination of cytoreductive nephrectomy and systemic therapy confers greater benefit with respect to single treatments alone.
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http://dx.doi.org/10.1016/j.euf.2020.04.009DOI Listing
May 2020

Radical cystectomy plus chemotherapy in patients with pure squamous cell bladder carcinoma: a population-based study.

World J Urol 2020 May 18. Epub 2020 May 18.

Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, QC, Canada.

Purpose: To test the effect of perioperative chemotherapy (CHT) on overall mortality (OM) and cancer-specific mortality (CSM) in patients with locally advanced or metastatic squamous cell carcinoma of the urinary bladder (SCC UB).

Methods: Within the Surveillance, Epidemiology and End Results database (1988-2016), we identified 1,018 SCC UB patients (664 TNM, 197 TanyNM and 156 TN or M), who underwent radical cystectomy with or without perioperative chemotherapy administration. Inverse probability of treatment-weighting (IPTW), Kaplan-Meier plots and Cox-regression models (CRMs) were used.

Results: CHT was administrated in 116 (17.5%) TNM, 77 (39.1%) TanyNM and 47 (30.1%) TN or M patients. IPTW-adjusted 2-year cancer-specific survival (CSS) was 66.5 vs. 71.5% (p = 0.19), 60.9 vs. 29.5% (p < 0.001) and IPTW-adjusted 1-year CSS was 46.2 vs. 31.1% (p = 0.03) for CHT vs. no CHT administration in TNM, TanyNM and TN or M, respectively. In multivariable IPTW-adjusted CRMs, chemotherapy was an independent predictor of lower CSM in TanyNM (HR 0.44) and in TN or M (HR 0.60), but not in TNM (p = 0.6) patients. Virtually the same results were obtained on OM, as well as without IPTW-adjustment and after stratification according to age and gender.

Conclusions: The use of perioperative CHT in patients with SCC UB confers survival benefit in the presence of T4b disease, lymph node or distant metastases. Conversely, patients with locally advanced disease but negative lymph node invasion do not benefit from its use. Pending higher quality data from prospective trials, these data should encourage the use of perioperative CHT in those high-risk patient groups.
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http://dx.doi.org/10.1007/s00345-020-03247-3DOI Listing
May 2020

Comparison of survival outcomes in patients with metastatic papillary vs. clear-cell renal cell carcinoma: a propensity-score analysis.

World J Urol 2021 Feb 6;39(2):461-472. Epub 2020 Apr 6.

Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, QC, Canada.

Background: To compare survival outcomes of metastatic patients harbouring either papillary (pRCC) or clear-cell (ccRCC) renal cell carcinoma in overall population and according to treatment modality.

Methods: Within the Surveillance, Epidemiology and End Results database (2006-2015), we identified 6800 patients (585 papillary and 6215 clear-cell) with metastatic RCC. Propensity-score (PS) matching, Kaplan-Meier plots and multivariable Cox-regression models (CRMs) were used.

Results: Overall, 585 (8.6%) patients harboured pRCC. Rates of nodal metastases were higher in patients with pRCC (49.7 vs. 23.3%; p < 0.001). Median overall survival (OS) was 13 vs. 18 months for pRCC vs. ccRCC patients. After multivariable adjustments, no difference in OS was recorded. Furthermore, after propensity-score matching, virtually the same results were recorded. Median OS of pRCC vs. ccRCC was 8 vs. 4 months for no treatment (NT), 11 vs. 12 months for targeted therapy alone (TT), 17 vs. 35 months for cytoreductive nephrectomy alone (CN) and 18 vs. 25 months for combination of CN with TT.

Conclusions: Metastatic pRCC patients exhibit poor survival, regardless of treatment received. Moreover, pRCC patients are more likely to present nodal metastases, compared to ccRCC patients, as demonstrated by twofold higher rates of lymph node invasion at diagnosis. These observations indicate that papillary variant represents more prognostically unfavorable tumor histology, in the context of metastatic RCC.
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http://dx.doi.org/10.1007/s00345-020-03187-yDOI Listing
February 2021

Single-port robot-assisted radical prostatectomy: a systematic review and pooled analysis of the preliminary experiences.

BJU Int 2020 07 1;126(1):55-64. Epub 2020 May 1.

Department of Urology, San Luigi Gonzaga Hospital, University of Turin, Turin, Italy.

Objective: To summarize the clinical experiences with single-port (SP) robot-assisted radical prostatectomy (RARP) reported in the literature and to describe the peri-operative and short-term outcomes of this procedure.

Material And Methods: A systematic review of the literature was performed in December 2019 using Medline (via PubMed), Embase (via Ovid), Cochrane databases, Scopus and Web of Science (PROSPERO registry number 164129). All studies that reported intra- and peri-operative data on SP-RARP were included. Cadaveric series and perineal or partial prostatectomy series were excluded.

Results: The pooled mean operating time, estimated blood loss, length of hospital stay and catheterization time were 190.55 min, 198.4 mL, 1.86 days and 8.21 days, respectively. The pooled mean number of lymph nodes removed was 8.33, and the pooled rate of positive surgical margins was 33%. The pooled minor complication rate was 15%. Only one urinary leakage and one major complication (transient ischaemic attack) were recorded. Regarding functional outcomes, pooled continence and potency rates at 12 weeks were 55% and 42%, respectively.

Conclusions: The present analysis confirms that SP-RARP is safe and feasible. This novel robotic platform resulted in similar intra-operative and peri-operative outcomes to those obtained with the standard multiport da Vinci system. The advantages of single incision can be translated into a preservation of the patient's body image and self-esteem and cosmesis, which have a great impact on a patient's quality of life.
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http://dx.doi.org/10.1111/bju.15069DOI Listing
July 2020

Rates of other-cause mortality after radical cystectomy are decreasing over time-A population-based analysis over two decades.

J Surg Oncol 2020 Jun 4;121(8):1329-1336. Epub 2020 Apr 4.

Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, Quebec, Canada.

Background And Objectives: To investigate other-cause mortality (OCM) rates over time according to several baseline characteristics in bladder cancer (BCa) patients treated with radical cystectomy (RC).

Methods: Within the Surveillance, Epidemiology, and End Results database (1988-2011), we identified 7702 T N M urothelial BCa patients treated with RC. Temporal trends and multivariable Cox regression (MCR) analyses assessed 5-year OCM. Data were stratified according to the year of diagnosis (1988-1995 vs 1996-2000 vs 2001-2004 vs 2005-2008 vs 2009-2011), age group (<60 vs 60-75 vs >75 years), sex, race, marital status, and socioeconomic status.

Results: Overall, OCM rates decreased from 13.9% in 1988-1995 to 8.6% in 2009-2011. The greatest decrease was recorded in elderly (>75) patients (32%-16%, slope: -0.55% per year; P = .01), followed by patients aged 60 to 75 (21%-5%, slope: -0.35% per year; P = .01), unmarried patients (16%-10%, slope: -0.26% per year; P < .001), male patients (14%-8.9%, slope: -0.23% per year), and African Americans (16%-11%, slope: -0.27% per year; P < .001). MCR models corroborated these results.

Conclusions: Most important decrease in OCM after RC over the last decades was recorded in the elderly, unmarried, and male patients. Nonetheless, these three patient groups still represent ideal targets for efforts aimed at minimizing the morbidity and mortality after RC, as their risk of OCM is higher than in others.
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http://dx.doi.org/10.1002/jso.25919DOI Listing
June 2020

Differences in short-term outcomes between open versus robot-assisted radical cystectomy in frail malnourished patients.

Eur J Surg Oncol 2020 07 14;46(7):1347-1352. Epub 2020 Mar 14.

Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada.

Introduction: We tested whether frail patients may benefit from robot-assisted (RARC) relative to open radical cystectomy (ORC).

Materials And Methods: Frail patients treated with RC were identified within the National Inpatient Sample database (2008-2015). The effect of RARC vs. ORC was tested in five separate multivariable models predicting: complications, failure to rescue (FTR), in-hospital mortality, length of stay (LOS) and total hospital charges (THCs). As internal validity measure, analyses were repeated among non-frail patients. All models were weighted and adjusted for clustering, as well as all available patient and hospital characteristics.

Results: Of 11,578 RC patients, 3477 (30.0%) were frail. RARC was performed in 488 (14.0%) frail patients and 1386 (17.1%) non-frail patients. Among frail, RARC was only independently associated with shorter LOS (median 8 vs. 9 days, relative ratio [RR] 0.79, p < 0.001). Conversely, among non-frail, RARC was independently associated with lower complications (57.3 vs. 59.1%, odds ratio [OR] 0.82, p = 0.004) and shorter LOS (median 6 vs. 7 days, RR 0.88, p < 0.001), but also predicted higher THCs (+2850.3 US dollars, p = 0.001).

Conclusions: In frail patients, the use of RARC did not result in better short-term outcomes except for one-day advantage in LOS. Conversely, in non-frail patients, the use of RARC resulted in lower complication rates and shorter LOS at the cost of higher THCs. In consequence, the benefit of RARC appears relatively marginal in frail patients and our data do not suggest a clear and clinically-meaningful benefit of RARC over ORC in frail radical cystectomy population.
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http://dx.doi.org/10.1016/j.ejso.2020.03.204DOI Listing
July 2020

Contemporary Rates and Predictors of Open Conversion During Minimally Invasive Radical Prostatectomy for Nonmetastatic Prostate Cancer.

J Endourol 2020 05 14;34(5):600-607. Epub 2020 Apr 14.

Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, Quebec, Canada.

To test contemporary rates and predictors of open conversion at minimally invasive (laparoscopic or robotic) radical prostatectomy (MIRP). Within the National Inpatient Sample database (2008-2015), we identified all MIRP patients and patients who underwent open conversion at MIRP. First, estimated annual percentage changes (EAPCs) tested temporal trends of open conversion. Second, multivariable logistic regression models predicted open conversion at MIRP. All models were weighted and adjusted for clustering, as well as all available patient and hospital characteristics. Of 57,078 MIRP patients, 368 (0.6%) underwent open conversion. The rates of open conversion decreased over time (from 1.80% to 0.38%; EAPC: -26.0%;  = 0.003). In multivariable logistic regression models predicting open conversion, patient obesity (odds ratio [OR]: 2.10;  < 0.001), frailty (OR: 1.45;  = 0.005), and Charlson comorbidity index (CCI) ≥2 (OR: 1.57;  = 0.03) achieved independent predictor status. Moreover, compared with high-volume hospitals, medium-volume (OR: 2.03;  < 0.001) and low-volume hospitals (OR: 3.86;  < 0.001) were associated with higher rates of open conversion. Last but not least, when the interaction between the number of patient risk factors (obesity and/or frailty and/or CCI ≥2) and hospital volume was tested, a dose-response effect was observed. Specifically, the rates of open conversion ranged from 0.3% (patients with zero risk factors treated at high-volume hospitals) to 2.2% (patients with two to three risk factors treated at low-volume hospitals). Overall contemporary (2008-2015) rate of open conversion at MIRP was 0.6% and it was strongly associated with patient obesity, frailty, CCI ≥2, and hospital surgical volume. In consequence, these parameters should be taken into account during preoperative patients counseling, as well as in clinical and administrative decision making.
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http://dx.doi.org/10.1089/end.2020.0074DOI Listing
May 2020

Histologic Subtype, Tumor Grade, Tumor Size, and Race Can Accurately Predict the Probability of Synchronous Metastases in T2 Renal Cell Carcinoma.

Clin Genitourin Cancer 2020 10 8;18(5):e610-e618. Epub 2020 Feb 8.

Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, QC, Canada; Division of Urology, University of Montreal Hospital Center, Montreal, QC, Canada.

Background: We investigated the association between synchronous metastases (SMs), histologic subtype (HS), tumor size (TS), and tumor grade (TG) in surgically treated stage T2 renal cell carcinoma (RCC).

Materials And Methods: Within the Surveillance, Epidemiology, and End Results database (2005-2015), 8344 patients with T2 RCC who had undergone radical nephrectomy were identified. The SM rates were tabulated according to the HS, TG, and TS and tested in multivariable logistic regression models.

Results: According to the HS, the average SM rates were 0%, 1.4%, 4.6%, 6.4%, 12.7%, 20.0%, and 32.7% for multilocular cystic, chromophobe, papillary, TG 1-2 clear cell, TG 3-4 clear cell, collecting duct, and sarcomatoid dedifferentiation RCC, respectively. In multivariable logistic regression models predicting for SMs, HS represented the strongest predictor, followed by TG, TS, and race. When combined, HS, TG, TS, and race predicted for SMs with 70.2% accuracy compared with 62.5% with HS, 60.2% with TG, 57.8% with TS, and 53.0% with race alone. Lung only was the most common metastatic site (43.6%), followed by bone only (27.6%), liver only (4.4%), and brain only (4.4%). Of all the patients with SMs, 78.9% had a single metastatic site.

Conclusions: The SM rates showed very wide variation according to the HS, TG, and TS. When HS was combined with TG, TS, and race, SMs could be accurately predicted in individual patients better than with TS alone. Thus, renal mass biopsy-derived HS and TG could improve the prediction of SMs compared with using TS alone.
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http://dx.doi.org/10.1016/j.clgc.2020.02.001DOI Listing
October 2020

Adherence to guideline recommendations for multimodality treatment of patients with pT2-3 M0 non-urothelial carcinoma of the urinary bladder: Temporal trends and survival outcomes.

Int J Urol 2020 May 14;27(5):402-407. Epub 2020 Mar 14.

Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Québec, Canada.

Objectives: To analyze contemporary multimodality treatment rates, defined as radical cystectomy plus chemotherapy and/or radiotherapy, for pT2-3 any N-stage M0 non-urothelial carcinoma of urinary bladder patients. Additionally, we tested for the effect of multimodality treatment versus radical cystectomy alone on cancer-specific mortality.

Methods: Within the Surveillance, Epidemiology and End Results database (2004-2015), 887 pT2-3 any N-stage M0 non-urothelial carcinoma of urinary bladder patients treated with radical cystectomy were identified. Kaplan-Meier plots, and univariable and multivariable Cox regression analyses focused on cancer-specific mortality rates.

Results: Squamous cell carcinoma was recorded in 499 (56.3%) patients, neuroendocrine carcinoma in 246 (27.7%) and adenocarcinoma in 142 (16.0%). The highest proportion of multimodality treatment patients was recorded in neuroendocrine carcinoma (69.1%), relative to adenocarcinoma (34.5%) and squamous cell carcinoma (26.4%). A statistically significant annual increase was recorded in multimodality treatment rates in neuroendocrine carcinoma patients (46.7-74.2%, P < 0.01), but not in adenocarcinoma or squamous cell carcinoma patients. The 5-year cancer-specific mortality rate in neuroendocrine carcinoma patients was significantly lower after multimodality treatment versus radical cystectomy alone (37.0% vs 51.5%; P < 0.01), but no statistically significant differences were recorded in both adenocarcinoma (46.1% vs 35.5%; P = 0.8) and squamous cell carcinoma (41.4% vs 31.1%; P = 0.8) patients. In multivariable analyses, for neuroendocrine carcinoma patients, multimodality treatment was an independent predictor of a lower cancer-specific mortality rate (hazard ratio 0.58, P = 0.03).

Conclusions: Multimodality treatment has been increasingly used during the study period in neuroendocrine carcinoma patients, and it has translated into a cancer-specific mortality benefit. This is not the case for other non-urothelial carcinoma of urinary bladder patients, such as adenocarcinoma or squamous cell carcinoma.
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http://dx.doi.org/10.1111/iju.14206DOI Listing
May 2020