516 Background: Radical cystectomy for bladder cancer is a complex surgical oncology procedure. Centralization of this procedure to high volume, fellowship-trained surgeons may improve clinical outcomes. Our objective was to compare outcomes of radical cystectomy before and after centralization of care. Methods: A retrospective analysis of data from the University of Alberta Radical Cystectomy Database was performed. Eligible subjects were those with histologically proven urothelial carcinoma of the bladder (cTanyN1-3M0) undergoing curative intent surgery. Patients were classified into pre-centralization era (1994-2007; N = 523) and post-centralization era (2013-present; N = 134) cohorts for analyses. Pre-centralization era patients were treated by 1 of 11 urologic surgeons at 2 academic teaching hospitals. Post-centralization era patients were treated by 1 of 2 fellowship-trained urologic oncologists at 1 academic teaching hospital. Outcomes were overall survival, 90-day mortality rate, positive surgical margin (R1) resection rate, total number of lymph nodes evaluated, and 90-day blood product transfusion rate. The Kaplan-Meier method and multivariable regression analyses were used to analyze survival outcomes. Statistical tests were two-sided (p≤0.05). Results: The median follow-up duration in the pre- and post-centralization era was 33 months and 16 months, respectively. The predicted 2-year overall survival rate was 62% in the pre-centralization era and 84% in the post-centralization era (Log rank P = 0.0007; multivariable HR 0.40, 95% CI 0.24 to 0.68, P < 0.0001). Treatment in the post-centralization era was associated with lower 90-day mortality (6.3% versus 1.5%, multivariable OR 0.23, 95% CI 0.06 to 0.99, P = 0.049), R1 resection (13.0% versus 1.5%; multivariable OR 0.07, 95% CI 0.01 to 0.51, P = 0.009), and 90-day blood product transfusion (59% versus 6%, P < 0.0001) as well as higher total number of lymph nodes evaluated (7 versus 30 lymph nodes, P < 0.0001). Conclusions: Surgical treatment in the post-centralization era was associated with superior survival, cancer control, and perioperative outcomes.

You have accessJournal of UrologyBladder Cancer: Epidemiology & Evaluation III1 Apr 2017PD57-08 CENTRALIZATION OF RADICAL CYSTECTOMY FOR BLADDER CANCER IN A UNIVERSAL HEALTHCARE SYSTEM: EARLY RESULTS FROM A CANADIAN ACADEMIC CENTER Jan Rudzinski, Niels Jacobsen, Eric Estey, Sunita Ghosh, Scott North, Naveen Basappa, Michael Kolinsky, and Adrian Fairey Jan RudzinskiJan Rudzinski More articles by this author , Niels JacobsenNiels Jacobsen More articles by this author , Eric EsteyEric Estey More articles by this author , Sunita GhoshSunita Ghosh More articles by this author , Scott NorthScott North More articles by this author , Naveen BasappaNaveen Basappa More articles by this author , Michael KolinskyMichael Kolinsky More articles by this author , and Adrian FaireyAdrian Fairey More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2610AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Radical cystectomy for bladder cancer is a complex surgical oncology procedure. Accumulating data suggest variation in outcomes based on hospital and surgeon characteristics. Centralization of this procedure to high volume, fellowship-trained surgeons may improve clinical outcomes. High quality data examining the impact of radical cystectomy centralization are lacking. At the University of Alberta, radical cystectomy was centralized at a single institution and performed by 1 of 2 urologic oncologists starting in August 2013. Our objective was to compare outcomes of radical cystectomy before and after centralization of care. METHODS A retrospective analysis of data from the University of Alberta Radical Cystectomy Database was performed. Eligible subjects were those with histologically proven urothelial carcinoma of the bladder (cTanyN1-3M0) undergoing curative intent surgery. Patients were classified into pre-centralization era (1994-2007; N=523) and post-centralization era (2013-present; N=134) cohorts for analyses. Pre-centralization era patients were treated by 1 of 11 urologic surgeons at 2 academic teaching hospitals. Post-centralization era patients were treated by 1 of 2 fellowship-trained urologic oncologists at 1 academic teaching hospital. Outcomes were overall survival, 90-day mortality rate, positive surgical margin (R1) resection rate, total number of lymph nodes evaluated, and 90-day blood product transfusion rate. The Kaplan-Meier method and multivariable regression analyses were used to analyze survival outcomes. Statistical tests were two-sided (p≤0.05). RESULTS The median follow-up duration in the pre- and post-centralization era was 33 months and 16 months, respectively. The predicted 2-year overall survival rate was 62% in the pre-centralization era and 84% in the post-centralization era (Log rank P=0.0007; multivariable HR 0.40, 95% CI 0.24 to 0.68, P<0.0001). Treatment in the post-centralization era was associated with lower 90-day mortality (6.3% versus 1.5%, multivariable OR 0.23, 95% CI 0.06 to 0.99, P=0.049), R1 resection (13.0% versus 1.5%; multivariable OR 0.07, 95% CI 0.01 to 0.51, P=0.009), and 90-day blood product transfusion (59% versus 6%, P<0.0001) as well as higher total number of lymph nodes evaluated (7 versus 30 lymph nodes, P<0.0001). CONCLUSIONS Surgical treatment in the post-centralization era was associated with superior survival, cancer control, and perioperative outcomes. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e1124 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Jan Rudzinski More articles by this author Niels Jacobsen More articles by this author Eric Estey More articles by this author Sunita Ghosh More articles by this author Scott North More articles by this author Naveen Basappa More articles by this author Michael Kolinsky More articles by this author Adrian Fairey More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

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.

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy VI1 Apr 2016PD43-05 PROSPECTIVE COMPARISON OF OPEN VERSUS ROBOT-ASSISTED RADICAL PROSTATECTOMY FOR CLINICALLY LOCALIZED PROSTATE CANCER: ANALYSIS OF 1806 CONSECUTIVE MEN TREATED IN A UNIVERSAL HEALTHCARE SYSTEM Adrian Fairey, Sunita Ghosh, Niels Jacobsen, Lucas Dean, Derek Bochinski, Michael Chetner, Howard Evans, Michael Hobart, David Mador, Blair St. Martin, Keith Rourke, and Eric Estey Adrian FaireyAdrian Fairey More articles by this author , Sunita GhoshSunita Ghosh More articles by this author , Niels JacobsenNiels Jacobsen More articles by this author , Lucas DeanLucas Dean More articles by this author , Derek BochinskiDerek Bochinski More articles by this author , Michael ChetnerMichael Chetner More articles by this author , Howard EvansHoward Evans More articles by this author , Michael HobartMichael Hobart More articles by this author , David MadorDavid Mador More articles by this author , Blair St. MartinBlair St. Martin More articles by this author , Keith RourkeKeith Rourke More articles by this author , and Eric EsteyEric Estey More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1783AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES There are limited prospective data comparing outcomes of Open Radical Prostatectomy (ORP) and Robot-Assisted Radical Prostatectomy (RARP) for clinically localized prostate cancer (CLPC). Our primary objective was to compare ORP and RARP with respect to cancer control outcomes in men treated within a universal healthcare system. METHODS A prospective analysis of data from the University of Alberta Radical Prostatectomy Database was performed. Between September 2007 and January 2013, 1,806 consecutive men underwent radical prostatectomy for CLPC. The surgeon selected the surgical approach. The primary end point was biochemical recurrence (BCR). BCR was defined as a PSA≥0.2 µg/L followed by a subsequent confirmatory value or initiation of salvage therapy. Secondary endpoints included positive surgical margin (R1) rate, 1-year urinary and erectile function preservation rate, 90-day complication rate, and 90-day return to emergency room or readmission to hospital rate. The Kaplan-Meier method and multivariable Cox regression analyses were used to analyze BCR. Statistical tests were two-sided (p<0.05). RESULTS Complete data were evaluable for 1,769 out of 1,806 patients. 333 patients underwent ORP and 1,436 patients underwent RARP. The median follow-up duration was 48 months. Baseline age (62 years vs. 61 years, p=0.07), BMI (29 kg/m2 vs. 29 kg/m2, p=0.29), and D'Amico risk stratification score (low risk: 50% vs. 45%; intermediate risk: 42% vs. 46%; high risk: 8% vs. 9%, p=0.15) were similar between the ORP and RARP groups. The 5-year freedom from BCR rate differed between the ORP and RARP groups (79% vs. 86%, log rank p=0.006). In multivariable Cox regression analysis that adjusted for surgical margin status, pathologic Gleason score, pathologic T stage, and preoperative PSA, ORP was independently associated with an increased risk of BCR (HR 1.62, 95% CI 1.21 to 2.18, p=0.001). The 1-year urinary function preservation rate (60% vs. 72%, p=0.004), 1-year erectile function preservation rate (10% vs. 17%, p=0.007), and blood transfusion rate (4% vs. 1%, p<0.001) differed between the ORP and RARP groups. There were no significant differences between groups for R1 rate (24% vs. 26%, p=0.57) 90-day complication rate (27% vs. 27%, p=0.27), return to emergency room rate (21% vs. 20%, p=0.54), or readmission to hospital rate (3% vs. 4%, p=0.15). CONCLUSIONS In men treated at a Canadian academic center within a universal healthcare system, RARP provided superior cancer control, functional preservation, and blood product transfusions rates compared to ORP. Further analyses designed to examine mechanisms of differences in cancer control and functional preservation is needed. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e994 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Adrian Fairey More articles by this author Sunita Ghosh More articles by this author Niels Jacobsen More articles by this author Lucas Dean More articles by this author Derek Bochinski More articles by this author Michael Chetner More articles by this author Howard Evans More articles by this author Michael Hobart More articles by this author David Mador More articles by this author Blair St. Martin More articles by this author Keith Rourke More articles by this author Eric Estey More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

PURPOSE:To evaluate the impact of concomitant carcinoma in situ (CIS) on upstaging and outcome of patients treated with radical cystectomy with pelvic lymph node dissection.METHODS:We collected and pooled a database of 1,968 patients who have undergone radical cystectomy between 1998 and 2008 in eight academic centers across Canada. Collected variables included patient's age, gender, tumor grade, histology and the presence of concomitant CIS with either cTa-1 or cT2 disease, dates of recurrence and death.RESULTS:In the presence of concomitant CIS, upstaging following radical cystectomy occurred in 48 and 55 % of patients with cTa-1 and cT2 disease, respectively. On univariate analysis, the presence of concomitant CIS with cT2 disease was associated with upstaging (p < 0.0001), and the presence of concomitant CIS with cTa-1 disease was also associated with upstaging but did not reach statistical significance (p = 0.0526). On multivariate analyses, the presence of concomitant CIS with either cTa-1 or cT2 tumors was independently prognostic of disease upstaging (p = 0.0001 and 0.0186, respectively). However, on multivariate analysis that incorporates pathologic stage, concomitant CIS was not significantly associated with worse overall, recurrence-free or disease-specific survival.CONCLUSION:These results demonstrate that while the presence of concomitant CIS on cystectomy specimens does not independently affect outcomes, its presence is significantly predictive of a higher rate of upstaging at radical cystectomy.

Objective: To evaluate the effect of body mass index (BMI) on the outcomes of patients with urinary tract carcinoma treated with radical surgery.Materials and methods: Data were collected from 10 Canadian centers on patients who underwent radical cystectomy (RC) (1998-2008) or radical nephroureterectomy (RNU) (1990-2010). Various parameters among subsets of patients (BMI <25, 25 <= BMI <30, and BMI >= 30 kg/m(2)) were analyzed. Kaplan-Meier and multivariate analyses were performed to assess the effect of BMI on overall survival, disease-specific survival, and recurrence-free survival (RFS).Results: Among the 847 RC and 664 RNU patients, there was no difference in histology, stage, grade, and margin status among the 3 patient subsets undergoing either surgery. However, RC patients with lower BMIs ( <25 kg/m(2)) were significantly older (P = 0.004), had more nodal metastasis (P = 0.03), and trended toward higher stage (P = 0.052). RNU patients with lower BMIs (<25 kg/m(2)) were significantly older (P = 0.0004) and fewer received adjuvant chemotherapy (P = 0.04) compared with those with BMI >= 30 kg/m(2); however, there was no difference in tumor location (P = 0.20), stage (P = 0.48), and management of distal ureter among the groups (P = 0.30). On multivariate analysis, BMI was not prognostic for overall survival, disease-specific survival, and RFS in the RC group. However, BMI >= 30 kg/m(2) was associated with more bladder cancer recurrences and worse RFS in the RNU group (HR = 1.588; 95% CI: 1.148-2.196; P = 0.0052).Conclusions: Increased BMI did not influence survival among RC patients. BMI >= 30 kg/m(2) is associated with worse bladder cancer recurrences among RNU patients; whether this is related to difficulty in obtaining adequate bladder cuff in patients with obesity requires further evaluation. (C) 2014 Elsevier Inc. All rights reserved.

INTRODUCTION:We examined the association between type of urinary diversion and quality of life (QoL) in patients who underwent radical cystectomy for primary bladder cancer using a validated, disease-specific instrument.MATERIALS AND METHODS:A cohort of 314 consecutive patients treated with radical cystectomy and urinary diversion for primary bladder cancer between January 2000 and December 2006 was analyzed. Participants were mailed the validated Functional Assessment of Cancer Therapy-Vanderbilt Cystectomy Index (FACT-VCI) questionnaire. Univariable and multivariable linear regression analyses were used to examine the association between type of urinary diversion (ileal conduit versus orthotopic neobladder) and QoL.RESULTS:Eighty-four out of 168 (50% response rate) evaluable patients completed the FACT-VCI questionnaire. The median follow up duration was 5.6 years (range, 2.1 to 9.3 years). ANOVA showed statistically significant differences favoring orthotopic neobladder urinary diversion with more favorable QoL scores on the FACT-VCI (mean difference 5.6 points, p = .03) and radical cystectomy-specific domain (mean difference 2.9 points, p = .05). However, multivariable linear regression analyses showed no statistically significant association between the type of urinary diversion and QoL (FACT-VCI: β = 4.1 points, p = .177; radical cystectomy-specific: β = 1.5 points, p = .390).CONCLUSIONS:Type of urinary diversion was not associated with QoL after radical cystectomy. Randomized controlled trials comparing types of urinary diversion using validated, disease-specific QoL instruments are needed.

The purpose of this review of clinical guidelines and best practices literature is to suggest prevention options and a treatment approach for intermittent catheter users that will minimize UTI. Recommendations are based both on evidence in the literature and an understanding of what is currently attainable within the Alberta context, through collaboration between both major tertiary care centres (Edmonton and Calgary) and between various professionals who regularly encounter these patients, including nursing, physiatry, and urology. Key references used to prepare this document included Canadian sources such as; SCIRE, along with the American Urological Association (AUA) and European Urological Association (EUA) documents on the topic and resources from Paralyzed Veterans of America. No details on neurogenic bladder management exist in the Canadian Urological Association list of publications. Finally, the impetus for preparing these protocols arose due to concerns identified by a survey of individuals with SCI regarding perceived gaps in knowledge and practice among caregivers and physicians about SCI and UTI prevention and management.

Angiomyofibroblastoma (AMF) is a rare benign tumor of the female genital tract. Three cases of AMF-like tumors of the male genital tract have been reported in the literature. We present the first documented case of an AMF-like soft tissue tumor of the male pelvis excised with robotic assisted laparoscopic surgery.

INTRODUCTION:The objective of this study was to compare referral and treatment rates of neoadjuvant chemotherapy for patients with muscle-invasive bladder cancer before and after publication of a clinical practice guideline.METHODS:This was a retrospective comparative cohort study of 236 patients diagnosed with clinical stage >/= T2 bladder cancer in Alberta, Canada. Patients were divided into 2 groups based on the time of diagnosis relative to the publication of the Alberta Genitourinary Oncology Group Clinical Practice Guideline on Bladder Cancer (CPG), which recommends cisplatin-based neoadjuvant chemotherapy for muscle-invasive disease. The pre-CPG group included patients (n = 129) diagnosed prior to publication of the CPG (November 1, 2002 to October 31, 2004, inclusively). The post-CPG group included patients (n = 107) diagnosed after publication of the CPG (November 1, 2005 to October 31, 2007). There was an accrual blackout period of 6 months before and after the CPG release date. The primary analysis compared the two groups with respect to neoadjuvant chemotherapy referral rates, treatment-offered rates and treatment-administered rates.RESULTS:Referral to medical oncology regarding neoadjuvant chemotherapy occurred in 2.3% and 23.4% of patients in the pre- and post-CPG groups, respectively (p < 0.01). Neoadjuvant chemotherapy was offered to 0.8% and 18.7% of patients in the pre- and post-CPG groups, respectively (p < 0.01). Neoadjuvant chemotherapy was administered to 0.8% and 14.0% of patients in the pre- and post-CPG groups, respectively (p < 0.01).INTERPRETATION:Neoadjuvant referral and treatment rates increased after publication of the CPG. However, overall referral and treatment rates remained low, which warrants additional exploration.

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 (group1), 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.

The purpose of this review of clinical guidelines and best practices literature is to suggest prevention options and a treatment approach for intermittent catheter users that will minimize urinary tract infections (UTI). Recommendations are based both on evidence in the literature and an understanding of what is currently attainable within the Alberta context. This is done through collaboration between both major tertiary care centres (Edmonton and Calgary) and between various professionals who regularly encounter these patients, including nurses, physiatrists and urologists.

BACKGROUND:The present study documents the natural history and outcomes of high-risk bladder cancer after radical cystectomy (RC) in patients who did not receive neoadjuvant chemotherapy during a contemporary time period.METHODS:We analyzed 1180 patients from 1993 to 2008 with >pT3N0 or pT0-4N+ bladder cancer who underwent RC ± standard (sLND) or extended (eLND) lymph node dissection from 8 Canadian centres.RESULTS:Of the 1180 patients, 55% (n = 643) underwent sLND, 34% (n = 402) underwent ePLND and 11% did not undergo a formal LND. Of the total number of patients, 321 (27%) received adjuvant chemotherapy. The median follow-up was 2.1 years (range: 0.6 to 12.9). Overall 30-day mortality was 3.2%. Clinical and pathological stages T3-4 were present in 6.1% and 86.7% of the patients, respectively; this demonstrates a dramatic understaging. Overall survival (OS) at 2 and 5 years was 60% and 43%, respectively. Patients who received adjuvant chemotherapy had a 2- and 5-year disease-specific survival (DSS) of 72% and 57% versus 64% and 51% for those who did not (log-rank p = 0.0039). The 2- and 5-year OS for high-risk node-negative disease was 67% and 52%, respectively, whereas for node-positive patients, the OS was 52% and 32%, respectively (p < 0.001). The OS, DSS and RFS for patients with pN0 were significantly improved compared to those who did not undergo a LND (log-rank p = 0.0035, 0.0241 and 0.0383, respectively).INTERPRETATION:This series suggests that bladder cancer outcomes in advanced disease have improved in the modern era. The need for improved staging investigations, use of neoadjuvant chemotherapy and performance of complete LND is emphasized.

You have accessJournal of UrologyBladder Cancer: Invasive III1 Apr 20121762 REGIONAL DIFFERENCES IN PRACTICE PATTERNS AND OUTCOMES AFTER RADICAL CYSTECTOMY Bassel G. Bachir, Faysal A. Yafi, Armen Aprikian, Joseph L. Chin, Jonathan Izawa, Yves Fradet, Louis Lacombe, Darrel Drachenberg, Eric Estey, Adrian Fairey, Ricardo Rendon, David Bell, Jean-Baptiste Lattouf, Ilias Cagiannos, and Wassim Kassouf Bassel G. BachirBassel G. Bachir Montreal, Canada More articles by this author , Faysal A. YafiFaysal A. Yafi Montreal, Canada More articles by this author , Armen AprikianArmen Aprikian Montreal, Canada More articles by this author , Joseph L. ChinJoseph L. Chin London, Canada More articles by this author , Jonathan IzawaJonathan Izawa London, Canada More articles by this author , Yves FradetYves Fradet Laval, Canada More articles by this author , Louis LacombeLouis Lacombe Laval, Canada More articles by this author , Darrel DrachenbergDarrel Drachenberg winnipeg, Canada More articles by this author , Eric EsteyEric Estey Edmonton, Canada More articles by this author , Adrian FaireyAdrian Fairey Edmonton, Canada More articles by this author , Ricardo RendonRicardo Rendon Halifax, Canada More articles by this author , David BellDavid Bell Halifax, Canada More articles by this author , Jean-Baptiste LattoufJean-Baptiste Lattouf Montreal, Canada More articles by this author , Ilias CagiannosIlias Cagiannos Ottowa, Canada More articles by this author , and Wassim KassoufWassim Kassouf Montreal, Canada More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1778AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To assess differences in practice patterns and outcomes across three separate regions in a universal health care system in patients who had undergone radical cystectomy. METHODS This multi-institutional series included 2287 patients who had undergone radical cystectomy at eight Canadian centers from 1998 until 2008. Collected variables included various clinical and pathological parameters, recurrence, and death stratified into three sets to account for the different regions (east, center, west). RESULTS Of 2287 patients, there were 1105 patients from eastern (group 1, 49%), 601 patients from central (group 2, 26%), and 581 from western Canada (group 3, 25%). The median follow-up of group 1, 2 and 3 was 22.1, 17.1, and 28.6 months respectively. There were no differences among the three geographical locations in terms of pathologic stage, rate of surgical margin positivity, adjuvant chemotherapy and smoking status. Rates of neoadjuvant chemotherapy were higher in group 2 compared with group 1 and 3 (p=0.07). There were statistically significant differences in clinicopathological parameters across the 3 groups, specifically gender distribution, performance of a lymphadenectomy, type of diversion and rates of concomitant cis, and lymphovascular invasion. The mean number of days to cystectomy from last TURBT was 50 vs. 79 vs. 69 days for groups 1, 2 and 3 respectively (p=0.0006). On Kaplan-Meier survival analysis, there was a statistically significant difference (p<0.0001) in overall survival (53.6% vs. 66.8% vs. 52.4% for groups 1, 2 and 3). CONCLUSIONS Significant variations in practice patterns were noted across different geographic regions in a universal health care system. The use of orthotopic bladder substitutes remains low across all 3 regions. Treatment delays are prolonged across Canada with significant regional variations. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e711 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Bassel G. Bachir Montreal, Canada More articles by this author Faysal A. Yafi Montreal, Canada More articles by this author Armen Aprikian Montreal, Canada More articles by this author Joseph L. Chin London, Canada More articles by this author Jonathan Izawa London, Canada More articles by this author Yves Fradet Laval, Canada More articles by this author Louis Lacombe Laval, Canada More articles by this author Darrel Drachenberg winnipeg, Canada More articles by this author Eric Estey Edmonton, Canada More articles by this author Adrian Fairey Edmonton, Canada More articles by this author Ricardo Rendon Halifax, Canada More articles by this author David Bell Halifax, Canada More articles by this author Jean-Baptiste Lattouf Montreal, Canada More articles by this author Ilias Cagiannos Ottowa, Canada More articles by this author Wassim Kassouf Montreal, Canada More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

Objectives: The role of advanced age as an independent prognostic factor for clinical outcomes after radical cystectomy is controversial. The objective of the current study was to assess the associations between age and clinical outcomes in a large, multi-institutional series of patients treated with radical cystectomy for bladder cancer.Materials and methods: Institutional radical cystectomy databases containing detailed information on bladder cancer patients treated between 1993 and 2008 were obtained from 8 academic centers in Canada. Data were collected on 2,287 patients and combined into a relational database formatted with patient characteristics, pathologic characteristics, recurrence status, and survival status. Patient age was coded as <60 years, 60-69 years, 70-79 years, or >= 80 years. Clinical outcomes were 30-day mortality, 90-day mortality, overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS). Logistic regression and Cox proportional hazards regression analysis were used to analyze survival data.Results: Five hundred fifty-seven (24.6%), 679 (30.0%), 846 (37.4%), and 181 (8.0%) patients were <60 years, 60-69 years, 70-79 years, and >= 80 years, respectively. Increased age was associated with decreased utilization rates of neoadjuvant chemotherapy (P = 0.0143), adjuvant chemotherapy (P < 0.0001), and continent urinary diversion (P < 0.0001) as well as advanced pathologic tumor stage (P = 0.0003), increased positive surgical margins (P < 0.0001), and lymphovascular invasion (P = 0.0335). Compared with patients < 60 years, multivariate regression analysis showed that age >= 80 years was independently associated with 90-day mortality (OR 2.98, 95% CI 1.22-7.30), OS (HR 2.03, 95% Cl 1.51-2.75), DSS (HR 1.56, 95% Cl 1.09-2.24), and RFS (HR 2.06, 95% CI 1.57-2.70).Conclusions: Age >= 80 years at the time of radical cystectomy was independently associated with adverse survival outcomes. These data suggest that increased chronologic age should be considered in clinical trial design and in nomograms predicting survival. (C) 2012 Elsevier Inc. All rights reserved.

Study Type – Prognosis (cohort) Level of Evidence 2a What's known on the subject? and What does the study add? Radical cystectomy with pelvic lymph node dissection is recognized as the standard of care for carcinoma invading bladder muscle and for refractory non-muscle-invasive bladder cancer. Owing to high recurrence and progression rates, a two-pronged strict surveillance regimen, consisting of both functional and oncological follow-up, has been advocated. It is also well recognized that more aggressive tumours with extravesical disease and node-positive disease recur more frequently and have worse outcomes. This study adds to the scant body of literature available regarding surveillance strategies after radical cystectomy for bladder cancer. In the absence of any solid evidence supporting the role of strict surveillance regimens, this extensive examination of recurrence patterns in a large multi-institutional project lends further support to the continued use of risk-stratified follow-up and emphasizes the need for earlier strict surveillance in patients with extravesical and node-positive disease. To review our data on recurrence patterns after radical cystectomy (RC) for bladder cancer (BC). To establish appropriate surveillance protocols. We collected and pooled data from a database of 2287 patients who had undergone RC for BC between 1998 and 2008 in eight different Canadian academic centres. Of the 2287 patients, 1890 had complete recurrence information and form the basis of the present study. A total of 825 patients (43.6%) developed recurrence. According to location, 48.6% of recurrent tumours were distant, 25.2% pelvic, 14.5% retroperitoneal and 11.8% to multiple regions such as pelvic and retroperitoneal or pelvic and distant. The median (range) time to recurrence for the entire population was 10.1 (1–192) months with 90 and 97% of all recurrences within 2 and 5 years of RC, respectively. According to stage, pTxN+ tumours were more likely to recur than ≥pT3N0 tumours and ≤pT2N0 tumours (5-yr RFS 25% vs. 44% vs. 66% respectively, P < 0.001). Similarly, pTxN+ tumours had a shorter median time to recurrence (9 months, range 1–72 months) than ≥pT3N0 tumours (10 months, range 1–70 months) or ≤pT2N0 tumours (14 months, range 1–192 months, P < 0.001). Differences in recurrence patterns after RC suggest the need for varied follow-up protocols for each group. We propose a stage-based protocol for surveillance of patients with BC treated with RC that captures most recurrences while limiting over-investigation.