Urologic oncology
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To provide a review of high-risk urologic cancers and the feasibility of delaying surgery without impacting oncologic or mortality outcomes. ⋯ The majority of urologic oncologic surgeries can be safely deferred without impacting long-term cancer specific or overall survival. Notable exceptions are muscle-invasive bladder cancer, high-grade upper tract urothelial cell, large renal masses, testicular and penile cancer. Joint decision making among providers and patients should be encouraged. Clinicians must manage emotional anxiety and stress when decisions around treatment delays are necessary as a result of a pandemic.
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Review
Urologic oncology surgery during COVID-19: a rapid review of current triage guidance documents.
The Coronavirus Disease 2019 pandemic placed urologic surgeons, and especially urologic oncologists, in an unprecedented situation. Providers and healthcare systems were forced to rapidly create triage schemas in order to preserve resources and reduce potential viral transmission while continuing to provide care for patients. We reviewed United States and international triage proposals from professional societies, peer-reviewed publications, and publicly available institutional guidelines to identify common themes and critical differences. ⋯ As the need to preserve resources and prevent viral transmission grows, prioritizing only high priority surgical cases is paramount. A similar approach to prioritization will also be needed as nonemergent cases are allowed to proceed in the coming weeks. While these decisions will often be made on a case-by-case basis, more nuanced surgeon-driven consensus guidelines are needed for the near future.
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There is increasing awareness that different anesthetic and analgesic techniques may impact outcomes after oncological surgery, generally through modifying effects on the immune system but potentially via other mechanisms including mitigating the surgical stress response. This narrative review aims to summarize the mechanisms underlying the effect of perioperative factors on oncological outcomes, with an emphasis on the available urologic literature. ⋯ This review highlights the role of regional anesthesia to improve oncoimmunological responses after surgery, potentially through decreased use of volatile anesthetics and opioids, decreased activation of the surgical stress response, and a direct local anesthetic-mediated anti-inflammatory effect. Available urological literature suggests an association of anesthetic type and outcomes for nonmuscle invasive bladder cancer and prostate cancer surgeries but the evidence is limited. Prospective studies are needed to further investigate the relationship between anesthetic technique and urologic oncological outcomes.
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Comparative Study
Survival after radiotherapy vs. radical prostatectomy for unfavorable intermediate-risk prostate cancer.
The optimal treatment for unfavorable intermediate-risk prostate cancer is unknown. Given the lack of randomized evidence, large comparative studies may be useful in guiding clinical decision-making. ⋯ We found no statistically significant difference in survival between RP and EBRT+BT. EBRT and brachytherapy had higher mortality, respectively, compared to RP. When including only radiotherapy patients who received ADT and, in the case of EBRT, a total dose ≥ 7920 cGy, there was no statistically significant difference in survival when comparing RP to EBRT or brachytherapy. These findings should be prospectively studied.
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Immune-related adverse events (irAEs) develop in a subset of patients with metastatic renal cell carcinoma (mRCC) treated with immune checkpoint inhibitors. The relationship between presence of irAEs and prognosis in these patients remains unknown. Thus, we evaluated the prognostic impact of irAEs caused by nivolumab therapy in mRCC patients who had received prior molecular-targeted therapies. ⋯ This retrospective study revealed a significant association between nivolumab-associated irAEs and prognosis in previously treated mRCC. Further prospective studies are necessary to confirm our findings.