Faculty Bibliography

PURPOSE/OBJECTIVE:In marker lesion experiments a single bladder tumor is deliberately left unresected for later ablation by intravesical instillation of a novel agent. While the benefits are clear, eg the opportunity to examine the effect of therapy on measurable disease, the safety and medical ethics of these experiments are less obvious. We review the goals, inclusion criteria, definition of success, agents used, effectiveness, safety and ethics of marker lesion studies, and suggest a framework for future experiments. MATERIALS AND METHODS/METHODS:Published bladder cancer studies using the marker lesion concept were identified with a MEDLINE search through March 2009. RESULTS:A total of 23 well documented marker lesion studies were identified involving more than 1,200 patients. Most agents studied were cytotoxins (mitomycin-C, epirubicin, gemcitabine, valrubicin, apaziquone) or immune response modifiers (bacillus Calmette-Guerin, tumor necrosis factor-alpha, interferon-alpha, granulocyte-macrophage colony-stimulating factor). The highest complete response rate in intermediate risk patients (67%) was attained with apaziquone. Patients who achieved a complete response with this agent also had a prophylactic benefit with a 2-year recurrence-free rate of 45.2% compared to 26.7% in those who did not achieve a complete response. The complete response rate in bacillus Calmette-Guerin trials ranged from 32% to 61%. Marker lesion experiments were deemed safe with progression to T2 disease in only 7 patients (0.6%) and only when high risk patients were selected. CONCLUSIONS:Marker lesion studies are most appropriate for the evaluation of novel anticancer therapeutics. Only patients with multiple recurrent, noninvasive, low grade tumors (intermediate risk) should be recruited. Primary end points should be complete response and recurrence rates after 2 to 3 years.

PURPOSE/OBJECTIVE:Little is known about the health related quality of life of women who have undergone continent urinary diversion. We compared health related quality of life outcomes for women who underwent radical cystectomy with an orthotopic neobladder or Indiana pouch. MATERIALS AND METHODS/METHODS:From 1995 to June 2008 a single surgeon (GDS) performed radical cystectomy with an orthotopic neobladder in 47 women and radical cystectomy with an Indiana pouch in 45. A comprehensive database provided clinical, pathological and outcomes data. The validated Functional Assessment of Cancer Therapy-Vanderbilt Cystectomy Index was mailed to 92 patients. RESULTS:Complete data were available for 87% of patients treated with radical cystectomy with an orthotopic neobladder and 93% of those treated with radical cystectomy with an Indiana pouch, with a median followup of 34 and 24 months, respectively (p = 0.8). Median (IQR) age was 65 (58, 71) and 61.5 (51, 67) years for patients with an orthotopic neobladder and Indiana pouch, respectively (p = 0.03). No significant differences were found for pathological stage, nodal status, blood loss, Clavien grade III or greater complications, adjuvant therapy or hospital stay between the 2 treatment groups, or between respondents and nonrespondents. Five-year survival rates for patients with an orthotopic neobladder and Indiana pouch were 65% and 58%, respectively (p = 0.9). There were 21 (75%) living patients with an orthotopic neobladder and 19 (61%) with an Indiana pouch who completed the Functional Assessment of Cancer Therapy-Vanderbilt Cystectomy Index, and physical (p = 0.53), social (p = 0.97), emotional (p = 0.61), functional (p = 0.55) and radical cystectomy specific (p = 0.54) health related quality of life domains were not significantly different between the groups. CONCLUSIONS:Women undergoing radical cystectomy with an orthotopic neobladder vs an Indiana pouch have similar health related quality of life outcomes. Larger series with longer followup and multiple surgeons are necessary to confirm these findings.

INTRODUCTION/BACKGROUND:With the advent of minimally invasive surgery (MIS) for treating urologic malignancies, emphasis has been placed on reducing patient morbidity and resuming normal activity. We sought to clarify whether open surgeons (OS) have modified their techniques, surgical equipment, and perioperative management in response to this trend. METHODS:A survey sent to all members of the Society of Urologic Oncology assessed changes that OS performing radical retropubic prostatectomy have made in analgesia, operative technique, perioperative management, and follow-up patterns. We also assessed OS sense of competition from MIS. Surgeon perception of the influence MIS had on these changes was scored from 0 to 4 (0 = not at all, 1 = slightly, 2 = moderately, 3 = greatly, 4 =completely). Overall and major influence by MIS included scores 1-4 and 3-4, respectively. RESULTS:Reduced radical retropubic prostatectomy (RRP) case volume because of MIS competition was reported by 20 OS (24%), with 27 OS (32%) starting to perform MIS, and 20 (24%) doing mostly/exclusively MIS. MIS has influenced OS to reduce incision length (overall influence 56%/major influence 33%), operative time (40%/12%), blood loss (31%/17%), and transfusion rate (33%/14%). MIS has influenced OS to use new instruments (48%/44%) or loupes (20%/9%), modify dissection (45%/31%) or anastomotic technique (14%/12%), and increase the use of hemostatic agents (48%/19%). MIS has reduced convalescence in OS patients by reducing length of stay (52%/28%), time to a regular diet (40%/18%), duration of drain (21%/16%) and Foley (32%/15%), time to return to work (49%/25%), and exercise (44%/21%). MIS has changed follow-up of OS patients by increasing the use of clinical pathways (14%/9%) and validated questionnaires (22%/13%). CONCLUSIONS:To date, the influence of MIS on the OS has not been comprehensively assessed. This survey finds that OS report that MIS serves as major competition to the open technique and that it has influenced them to modify their surgical technique, reduce convalescence, and alter follow-up recommendations.