Real-world outcomes of patients with renal cell carcinoma, surgically treated at regional hospitals, based on a prospective long-term survey of the pre-robotic era

PURPOSE

Renal cancer surgery is frequently performed in small regional hospitals in Japan. This study evaluated the outcomes of renal cancer surgery, comparing results from the pre-robotic surgery era with those obtained with robotic surgery.

METHODS

This prospective cohort study was conducted on patients who underwent renal cancer surgery between 2008 and 2013 at 14 hospitals, comprising 13 regional hospitals and a university hospital, registered in the Tohoku Urological Evidence-Based Medicine Study Group. The patients' backgrounds; perioperative data; annual postoperative renal function; and prognostic surveys, performed over a median follow-up period of 10 years were obtained.

RESULTS

In 930 surgical cases at the 14 registered hospitals, the 10-year recurrence-free survival rates of cT1a, cT1b, cT2, and cT3 were 0.9326, 0.8501, 0.5786, and 0.5101, respectively. Meanwhile, the 10-year overall survival rates were 0.9612, 0.8662, 0.7505, and 0.7209, respectively. Long-term observation in patients with cT1 showed that vessel involvement and high tumor grade were prognostic factors for recurrence. As a noteworthy fact, radical nephrectomy was performed in 53.3% of patients with cT1a at the regional hospitals. However, even in patients with preoperative chronic kidney disease stage 3, radical nephrectomy was not a prognostic factor of renal function. This indicates that compensatory mechanisms had been working for a long time in many patients who underwent radical nephrectomies without hypertension and preoperative proteinuria, which were predictors of end-stage renal disease.

CONCLUSION

Based on a prospective long-term survey of the pre-robotic era, our results suggested no difference of the survival outcomes between the university hospital and regional hospitals. Our study provides baseline data to evaluate the outcomes of renal cancer robotic surgery, performed at regional hospitals.

Impact of relapse site on oncological outcomes after radical nephroureterectomy for upper urinary tract urothelial carcinoma

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Background: Most upper urinary tract urothelial carcinomas (UTUC) are invasive and advanced with a poor prognosis. Patients often relapse after treatment with radical nephroureterectomy (RNU). However, little is known about an association between sites of recurrence after RNU and oncological outcomes. The present study retrospectively evaluated the impact of a first recurrence site on survival. Methods: A total of 650 patients with UTUC treated by RNU at 12 institutions that participated in the Tohoku Urological Evidence-Based Medicine Study Group between 2000 and 2011 were initially enrolled. Patients who experienced relapse other than intravesical recurrence after RNU were included in this study. Those who had metastasis at the time of UTUC diagnosis or missing data regarding the time and location of relapse were excluded. Finally, 173 patients were eligible to participate in this study. Survival rates were analyzed using Kaplan-Meier curves and the log-rank test, and factors predicting survival were assessed using multivariate analyses. Results: The median follow-up after relapse was nine months. The cancer-specific survival rates at one and two years after relapse were 49% and 22%, respectively. Cancer in 59 (34%), 32 (18%), 23 (13%), and 94 (53%) patients recurred in the lung, liver, bone and lymph nodes, and 23 (13%) had local recurrence. The one-year cancer-specific survival rates were 44%, 27%, 22% and 52% among patients with metastasis of the lungs, liver, bone and lymph nodes respectively, and 41% among those with local recurrence. The survival rate was worse among 48 patients with metastasis at multiple sites, than in those with metastasis at a single site. Fourteen (8%) patients with a single lymph, lung or local recurrence survived for over three years after a first relapse. Multivariate analyses selected the liver, bone and local recurrence as critical factors for cancer-specific survival. Conclusions: Liver or bone metastasis was a negative prognostic factor for UTUC with relapse after RNU. Information about recurrence sites might be helpful for patient counseling.

[Giant phyllodes tumor of the prostate]

A 55 year-old man complained dysuria and visited to our hospital. Physical examination showed firm large mass occupying whole abdomen. Computed tomography (CT) demonstrated a huge retroperitoneal tumor which compressed intestine, liver, kidney, and urinary bladder. We performed extirpation of the tumor (8.6 kg, largest diameter 60 cm) which was composed of myxoid stromal region associated with cystic pattern. Histological examination revealed that the epithelium of the cystic region was positive for prostate specific antigen (PSA) immunostaining. The tumor was diagnosed phyllodes tumor of the prostate (prostatic stromal proliferation of uncertain malignancy, PSTUMP). Serum PSA was declined 3.9 ng/ml to 0.9 ng/ml; however, magnetic resonance imaging (MRI) demonstrated a residual (recurrent?) tumor in the pelvis one month after the operation. We carried out total prostatectomy and residual tumor resection. Phyllodes tumor of the prostate is histologically characterized with biphasic pattern of hyperplastic epithelial cysts and variably cellular spindle stroma. The tumor is considered to have malignant potential and several histological factors including cellularity, atypia, etc. are utilized to assess it. However diagnostic criteria and subsequent treatment modalities are not established thus far. Previous reports showed efficacy of total surgical removal rather than partial resection and that we performed radical extirpation of the entire tumor. Close follow up is needed against this frequently recurrent disease.

Pure prostatic papillary adenocarcinoma with ductal features

Papillary adenocarcinoma resembling ductal carcinoma and arising in the peripheral zone is extremely rare. We report a case of prostatic papillary adenocarcinoma with ductal features. The patient was a 68-year-old man who initially presented with dysuria and sensation of residual urine after voiding. Prostatic needle biopsy findings supported pathological diagnosis of prostatitis. The symptoms were improved by medication for prostatitis, and prostate-specific antigen (PSA) level of 22.6 ng/ml descreased to 9.9 ng/ml. It remained between 7.2 ng/ml and 9.9 ng/ml for 2 years. However, it gradually increased to 11.9 ng/ml. Transrectal digital examination, T2-weighted magnetic resonance imaging (MRI) of the prostate and transrecral ultrasound showed a mass in the enlarged right side of the prostate. Transrectal needle biopsy of the mass was performed, and papillary adenocarcinoma was suspected by histological examination. Radical prostatectomy was performed. Histological and immunohistochemical examination of the prostatectomy specimen revealed pure prostatic papillary adenocarcinoma with ductal features.

Health-related quality of life after radical prostatectomy in Japanese men with localized prostate cancer

PURPOSE

We evaluated retrospectively health-related quality of life (HRQOL) after radical prostatectomy (RP) in Japanese men with localized prostate cancer.

METHODS

The study was based on self-reported HRQOL of 280 patients. Patients were divided into seven groups: time 0 (T0), baseline before operation; T1, 1-3 months after RP; T2, 4-6 months after RP; T3, 7-12 months after RP; T4, 13-24 months after RP; T5, 25-36 months after RP; and T6, more than 36 months after RP. We measured the general and disease-specific HRQOL using the RAND 36-item Health Survey 1.0 (SF-36) and the University of California, Los Angeles Prostate Cancer Index (UCLA PCI).

RESULTS

The general HRQOL of the postoperative groups was assessed by SF-36. The postoperative groups showed almost the same or higher scores than those of the baseline group. Urinary function scores decreased substantially after surgery. In contrast, there was no difference in urinary bother between the baseline and postoperative groups. Sexual function deteriorated substantially in all postoperative groups. Similarly, the sexual bother score significantly deteriorated after RP. The sexual bother score of men aged 65-years or younger was significantly worse than that of their counterparts in the T1-2 groups.

CONCLUSION

Despite reports of problems with sexual activity and urinary continence, general HRQOL was mostly unaffected by RP. Although there was a substantial decrease in urinary function, recovery from urinary bother was rapid. Since the deterioration of sexual function was marked through the postoperative period, careful attention should be paid to this issue during preoperative counseling, especially for younger patients.

Urethral recurrence following neobladder in bladder cancer patients

Risk factors of urethral recurrence after neobladder in bladder cancer patients were studied. Between 1977 and 2001, 73 patients (male 58, female 15) underwent neobladder as a treatment for bladder cancer. The observation time after cystectomy ranged from 2 to 254 months (median 60.5). Ten (17.2%) of 58 male patients had urethral recurrence and of the 10, 8 patients had multiple bladder cancers including bladder neck. Urethral recurrence was found by macrohematuria, follow-up cystourethroscopy, and inguinal lymph node swelling. Only one who complained of macrohematuria had positive urinary cytology. Of 58 male patients, 5 underwent total nephroureterectomy for renal pelvic or ureteral cancer before radical cystectomy, and 3 of the 5 had urethral recurrence. Two of 10 patients with urethral recurrence died with cancer, and they had renal pelvic or ureteral cancer. The five-year cause specific survival was 83% for patients with urethral recurrence, and 79% for those without urethral recurrence, respectively. Urethral recurrence did not have a significant effect on survival. The patients with multiple bladder cancers including bladder neck, and renal pelvic or ureteral cancer before radical cystectomy, have high risks for urethral recurrence. Urinary cytology has limited value for the detection of urethral recurrence.

[Urinary incontinence in children with primary vesicoureteral reflux--urinary incontinence and function of refluxing kidney]

The interrelation among urinary incontinence (nocturnal enuresis, urge incontinence), history of urinary tract infection and renal function was investigated in 153 children with primary vesicoureteral reflux who were more than three years old. Of them, 98 children (64%) had the chief complaint of urinary tract infection (UTI) and 43 children (28%), urinary incontinence. Of the children whose chief complaint was UTI, 44 (45%) had incontinence. Thus, 87 children (57%) with VUR had urinary incontinence. Almost all the children who had urinary incontinence and no previous UTI had good renal function. Renal dysfunction was found in children with previous UTI history. These studies on children with primary VUR more than three years old indicate that, although urinary incontinence could be a factor for recurrence of UTI and a probable cause of worsening of renal function, there is no direct correlation between urinary incontinence and renal dysfunction accompanied by VUR.