| 1. |
- Bobjer, Johannes, et al.
(författare)
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Location of retroperitoneal lymph node metastases in upper tract urothelial carcinoma : results from a prospective lymph node mapping study
- 2023
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Ingår i: European Urology Open Science. - : Elsevier. - 2666-1691 .- 2666-1683. ; 57, s. 37-44
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Tidskriftsartikel (refereegranskat)abstract
- Background: There is limited information on the distribution of retroperitoneal lymph node metastases (LNMs) in upper tract urothelial carcinoma (UTUC).Objective: To investigate the location of LNMs in UTUC of the renal pelvis or proximal ureter and short-term complications after radical nephroureterectomy (RNU) with lymph node dissection (LND).Design, setting, and participants: This was a prospective Nordic multicenter study (four university hospitals, two county hospitals). Patients with clinically suspected locally advanced UTUC (stage >T1) and/or clinical lymph node–positive (cN+) disease were invited to participate. Participants underwent RNU and fractionated retroperitoneal LND using predefined side-specific templates.Outcome measurements and statistical analysis: The location of LNMs in the LND specimen and retroperitoneal lymph node recurrences during follow-up was recorded. Postoperative complications within 90 d of surgery were ascertained from patient charts. Descriptive statistics were used.Results and limitations: LNMs were present in the LND specimen in 23/100 patients, and nine of 100 patients experienced a retroperitoneal recurrence. Distribution per side revealed LNMs in the LND specimen in 11/38 (29%) patients with right-sided tumors, for whom the anatomically larger, right-sided template was used, in comparison to 12/62 (19%) patients with left-sided tumors, for whom a more limited template was used. High-grade complications (Clavien grade ≥3) within 90 d of surgery were registered for 13/100 patients. The study is limited in size and not powered to assess survival estimates.Conclusions: The suggested templates that we prospectively applied for right-sided and left-sided LND in patients with advanced UTUC included the majority of LNMs. High-grade complications directly related to the LND part of the surgery were limited.Patient summary: This study describes the location of lymph node metastases in patients with cancer in the upper urinary tract who underwent surgery to remove the affected kidney and ureter. The results show that most metastases occur within the template maps for lymph node surgery that we investigated, and that this surgery can be performed with few severe complications.
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| 2. |
- Brändstedt, Johan, et al.
(författare)
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Urosymphyseal fistula after pelvic radiotherapy in a tertial referral centre : a rare entity with significant comorbidity requiring multidisciplinary management
- 2023
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Ingår i: Scandinavian journal of urology. - : Medical Journals Sweden AB. - 2168-1805 .- 2168-1813. ; 58, s. 4-10
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Tidskriftsartikel (refereegranskat)abstract
- Objective: To report population-based clinical presentation and outcomes in patients with urosymphyseal fistula (USF) after pelvic radiotherapy (RT).Patients and methods: A retrospective chart review was performed in 33 consecutive patients diagnosed with suspicion of USF in a tertial referral center from 2014–2022 to ascertain information about diagnostic delay, clinical presentation, precipitating causes, treatments received and outcomes during the median 22 months follow-up. Out of 33 consecutive patients with suspicion of USF, one female with vesicovaginal fistula, one patient developing RT-associated bladder angiosarcoma, four patients with short follow-up (<3 months), and three patients that during chart review not were considered to have a USF were excluded.Results: In all, 24 males with a median age of 77 years were diagnosed with USF. Local pain was the predominating symptom in 17/24 (71%) patients. Endourologic manipulations preceded the diagnosis of USF in 16 patients. Five patients had a diagnostic delay of more than 3 months. At diagnosis, 20/24 patients had radiological signs of osteomyelitis, and five had a concomitant rectourethral fistula. Due to comorbidity, five patients were not amenable to any other interventions than urinary catheter or suprapubic tube in conjunction with long-term antibiotics, of which three died from infections related to the USF. Out of the remaining 19 patients receiving some form of urinary diversion, five had recurrent osteomyelitis, of which four did not undergo cystectomy in conjunction with surgery for the USF.Conclusions: Urethral endourologic interventions in patients previously subjected to pelvic RT should be performed cautiously.
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| 3. |
- Carlsson, Sigrid, et al.
(författare)
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Screening for Prostate Cancer Starting at Age 50-54 Years. A Population-based Cohort Study
- 2017
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Ingår i: European Urology. - : Elsevier BV. - 0302-2838 .- 1873-7560. ; 71:1, s. 46-52
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Tidskriftsartikel (refereegranskat)abstract
- Background: Current prostate cancer screening guidelines conflict with respect to the age at which to initiate screening. Objective: To evaluate the effect of prostate-specific antigen (PSA) screening versus zero screening, starting at age 50-54 yr, on prostate cancer mortality. Design, setting, and participants: This is a population-based cohort study comparing 3479 men aged 50 yr through 54 yr randomized to PSA-screening in the Göteborg population-based prostate cancer screening trial, initiated in 1995, versus 4060 unscreened men aged 51-55 yr providing cryopreserved blood in the population-based Malmö Preventive Project in the pre-PSA era, during 1982-1985. Outcome measurements and statistical analysis: Cumulative incidence and incidence rate ratios of prostate cancer diagnosis, metastasis, and prostate cancer death. Results and limitations: At 17 yr, regular PSA-screening in Göteborg of men in their early 50s carried a more than two-fold higher risk of prostate cancer diagnosis compared with the unscreened men in Malmö (incidence rate ratio [IRR] 2.56, 95% confidence interval [CI] 2.18, 3.02), but resulted in a substantial decrease in the risk of metastases (IRR 0.43, 95% CI 0.22, 0.79) and prostate cancer death (IRR 0.29, 95% CI 0.11, 0.67). There were 57 fewer prostate cancer deaths per 10. 000 men (95% CI 22, 92) in the screened group. At 17 yr, the number needed to invite to PSA-screening and the number needed to diagnose to prevent one prostate cancer death was 176 and 16, respectively. The study is limited by lack of treatment information and the comparison of the two different birth cohorts. Conclusions: PSA screening for prostate cancer can decrease prostate cancer mortality among men aged 50-54 yr, with the number needed to invite and number needed to detect to prevent one prostate cancer death comparable to those previously reported from the European Randomized Study of Screening for Prostate Cancer for men aged 55-69 yr, at a similar follow-up. Guideline groups could consider whether guidelines for PSA screening should recommend starting no later than at ages 50-54 yr. Patient summary: Guideline recommendations about the age to start prostate-specific antigen screening could be discussed. Guideline recommendations about the age to start prostate-specific antigen screening could be discussed.
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| 4. |
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| 5. |
- Gerdtsson, Axel, et al.
(författare)
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Initial surveillance in men with marker negative clinical stage IIA non-seminomatous germ cell tumours
- 2024
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Ingår i: BJU INTERNATIONAL. - : John Wiley & Sons. - 1464-4096 .- 1464-410X.
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Tidskriftsartikel (refereegranskat)abstract
- Objectives To assess whether extended surveillance with repeated computed tomography (CT) scans for patients with clinical stage IIA (CS IIA; <2 cm abdominal node involvement) and negative markers (Mk-) non-seminomatous germ cell tumours (NSGCTs) can identify those with true CS I. To assess the rate of benign lymph nodes, teratoma, and viable cancer in retroperitoneal lymph node dissection (RPLND) histopathology for patients with CS IIA Mk- NSGCT. Patients and methods Observational prospective population-based study of patients diagnosed 2008-2019 with CS IIA Mk- NSGCT in the Swedish and Norwegian Testicular Cancer Group (SWENOTECA) registry. Patients were managed with surveillance, with CT scans, and tumour markers every sixth week for a maximum of 18 weeks. Patients with radiological regression were treated as CS I, if progression with chemotherapy, and remaining CS IIA Mk- disease with RPLND. The end-point was the number and percentage of patients down-staged to CS I on surveillance and rate of RPLND histopathology presented as benign, teratoma, or viable cancer. Results Overall, 126 patients with CS IIA Mk- NSGCT were included but 41 received therapy upfront. After surveillance for a median (range) of 6 (6-18) weeks, 23/85 (27%) patients were in true CS I and four (5%) progressed. Of the remaining 58 patients with lasting CS IIA Mk- NSGCT, 16 received chemotherapy and 42 underwent RPLND. The RPLND histopathology revealed benign lymph nodes in 11 (26%), teratoma in two (6%), and viable cancer in 29 (70%) patients. Conclusions Surveillance with repeated CT scans can identify patients in true CS I, thus avoiding overtreatment. The RPLND histopathology in patients with CS IIA Mk- NSGCT had a high rate of cancer and a low rate of teratoma.
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| 6. |
- Gerdtsson, Axel
(författare)
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Retroperitoneal lymph node dissection for non-seminomatous germ cell tumour
- 2022
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: The Swedish and Norwegian Testicular Cancer Group (SWENOTECA) is a multidisciplinary collaboration with an aim to improve the testicular cancer care for patients in Sweden and Norway by publishing guidelines, include patients in the SWENOTECA register and promote research. In 2007, SWENOTECA initiated RETROP, a multicenter study on nonseminomatous germ cell tumour (NSGCT) patients that are operated with post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND). PC-RPLND, a cornerstone in the therapy for metastatic NSGCT, is a challenging procedure with a high risk of post-operative complications. However, in up to 50% of the patients that undergo PC-RPLND, the histopathology result is benign. No viable cancer or teratoma was found and the surgery performed was unnecessary. Paper I, II and III focus on strategies to reduce the negative effects of PC-RPLND using patients included in RETROP. Patients with NSGCT and lymph nodes on CT-scan sized < 20 mm and normalized tumour markers following orchiectomy is defined as CS IIA Mk (-). The survival rate for this patient group is high, and the recommended therapy is either initial surveillance, chemotherapy or primary Retroperitoneal Lymph Node Dissection (RPLND). The evaluation of a surveillance strategy is the focus in Paper IV. Aims: Paper I) To compare the intra- and post-operative complications between a unilateral and a bilateral PC-RPLND; Paper II) To describe the distribution of retroperitoneal metastases on pre-operative CT scans for patients with a residual tumour of 10 – 49 mm following chemotherapy and to correlate it to the histopathological finding for the different areas resected. To assess the rate and location of retroperitoneal recurrences; Paper III) To validate a statistical model that predicts benign histopathology at PC-RPLND; Paper IV) To evaluate a surveillance plan with the aim of reducing overtreatment for patients with NSGCT in CS IIA Mk (-). To assess the RPLND histopathology results and describe the distribution of the metastatic retroperitoneal lymph nodes. Methods: In paper I, patients in the RETROP database that underwent PC-RPLND during 2007–2014, were included (n = 318). A bilateral PC-RPLND was compared to a unilateral PCRPLND for intra- and post-operative complications and retrograde ejaculation using X2-test. In paper II, patients in the RETROP database with a residual tumour of 10-49 mm and normalized or low and declining tumour markers following chemotherapy were included (n =215). Patients were classified depending on the affected testicle (right- or left-sided NSGCT) and the lymph node spread to retroperitoneal lymph nodes on CT-scans (unilateral or bilateral spread) with reference to the aorta. The pathologic lymph nodes detected on CT-scans preand post-chemotherapy were correlated to the findings in the resected lymph nodes. Paper III includes patients in the RETROP database with normalized tumour markers following chemotherapy (n = 284). Variables used to predict outcome were: levels of alpha fetoprotein (AFP), ß- human chorionic gonadotropin (ß-HCG) and lactate dehydrogenase (LDH) before receiving chemotherapy, teratoma component in primary testicular tumour, change in lymph node size pre- and post-chemotherapy and maximal size of residual tumour. Discrimination and calibration analyses including Hosmer-Lameshow test were used to validate the prediction model and clinical utility expressed as net benefit was calculated. Paper IV CS IIA Mk (-) patients diagnosed 2008-2019 were identified in the Swedish part of the SWENOTECA database. The surveillance plan consisted of repeated CT-scans and tumour markers every 6th week up to 18 weeks before therapy decision. Information obtained from the SWENOTECA register and chart review were: Royal Marsden clinical stage, CTscan results, presence of lymphovascular invasion (LVI) and teratoma in the orchiectomy histopathology, number and type of chemotherapy courses, areas dissected at RPLND, histopathology for each area dissected, lymph node yield and complications, operating time, hemorrhage and length of stay following RPLND, recurrence and cause of death. Follow-up was continued until August 2021. Results: Paper I. 318 patients underwent PC-RPLND (73% unilateral and 27% bilateral PC-RPLND). Patients that were operated with a bilateral PC-RPLND had a larger metastatic burden and received more chemotherapy courses than patients operated with a unilateral PC-RPLND. Bilateral PC-RPLND compared to unilateral PC-RPLND had more intra-operative complications (14% vs. 4%), post-operative complications (45% vs. 25%) and a higher incidence of retrograde ejaculation (59% vs. 32%). Paper II. For 65% of the patients, the retroperitoneal metastases were located unilateral to the aorta on CT-scans. For these patients, the risk of finding a retroperitoneal teratoma or viable cancer contralateral to the aorta were 2% and 3% for a right-sided and a left-sided testicular NSGCT respectively. Furthermore, the risk of recurrence for that group were 0% and 4% for right- and left-sided testicular NSGCT respectively. Paper III. Validation was completed with good reproducibility (AUC of 0.82 [95% CI 0.77 –0.87]) and calibration [Hosmer- Lemeshow test (p = 0.37)]. Using a decision threshold of 70%, the net benefit was 0.098 and 21% patients could have been spared surgery. Surgery would have been correctly avoided in 39% of all patients with a benign histopathology. On the other hand, teratoma or cancer would have been left untreated in 6% out of all patients with teratoma or cancer. Paper IV includes 57 CS IIA Mk (-) patients. During the observational period, 12% were downgraded to CS I and 4% progressed to CS IVA. The remaining patients received either chemotherapy (47%) or primary RPLND (37%). The RPLND histopathology results revealed that 24% had benign lymph nodes, 5% had teratoma, and 71% of the patients had viable cancer. Only one patient with unilateral cancer spread on CT-scan had a contralateral lymph node containing viable cancer. Conclusions: Paper I. A unilateral PC-RPLND is more favourable than a bilateral PC-RPLND concerning the intra- and post-operative complications. However, patients selected for a bilateral PCRPLND had a larger metastatic burden and received more chemotherapy courses. Paper II. It was concluded that patients with unilateral retroperitoneal metastases on CTscans are the most suitable to select for a unilateral PC-RPLND. These patients have a low risk of contralateral metastases and retroperitoneal recurrences. Paper III. The prediction model was validated with good reproducibility and calibration. If the model is used in a clinical setting, the patients that are spared surgery need thorough follow-up to find recurrences at early stages. Paper IV. This study supports an initial surveillance period for NSGCT patients in CS IIA Mk (-), to find patients in CSI and avoid overtreatment. A primary unilateral RPLND is recommended in case of unilateral spread on pre-operative CT-scan.
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| 7. |
- Gerdtsson, Axel, et al.
(författare)
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Surgical Complications in Postchemotherapy Retroperitoneal Lymph Node Dissection for Nonseminoma Germ Cell Tumour : A Population-based Study from the Swedish Norwegian Testicular Cancer Group
- 2020
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Ingår i: European Urology Oncology. - : Elsevier BV. - 2588-9311. ; 3:3, s. 382-389
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Reports on perioperative complications after postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) for nonseminoma germ cell tumour (NSGCT) are from experienced single centres, with a lack of population-based studies. OBJECTIVE: To assess the complications of bilateral and unilateral PC-RPLND. DESIGN, SETTING, AND PARTICIPANTS: A prospective, population-based, observational multicentre study included all patients with NSGCT who underwent PC-RPLND in Norway and Sweden during 2007-2014. Of a total of 318 patients, 87 underwent bilateral PC-RPLND and 231 underwent unilateral PC-RPLND. The median follow-up was 6 yr. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Bilateral and unilateral PC-RPLND were compared for the outcomes of intra- and postoperative complications (graded by Clavien-Dindo) and retrograde ejaculation (with or without nerve-sparing surgery). Complications were reported as absolute counts and percentages. The χ2 test was used for comparisons. RESULTS AND LIMITATIONS: The incidence of intraoperative complications was higher for bilateral PC-RPLND than for unilateral PC-RPLND (14% vs 4.3%, p = 0.003), with ureteral injury as the most frequent reported complication (2% of the patients). Postoperative complications were more common after bilateral than after unilateral PC-RPLND (45% vs 25%, p = 0.001) with Clavien ≥3b reported in 8.3% and 2.2%, respectively (p = 0.009). Lymphatic leakage was the most common complication occurring in 11% of the patients. Retrograde ejaculation occurred more frequently after bilateral than after unilateral surgery (59% vs 32%, p < 0.001). Limitations of the study include reporting of retrograde ejaculation, which was based on a chart review. CONCLUSIONS: Intra- and postoperative complications including retrograde ejaculation are more frequent after bilateral PC-RPLND than after unilateral PC-RPLND. PATIENT SUMMARY: Lymph node dissection in patients with testicular cancer puts them at risk of complications. In this study, we present the complications after lymph node dissection.
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| 8. |
- Gerdtsson, Axel, et al.
(författare)
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Unilateral or Bilateral Retroperitoneal Lymph Node Dissection in Nonseminoma Patients with Postchemotherapy Residual Tumour? Results from RETROP, a Population-based Mapping Study by the Swedish Norwegian Testicular Cancer Group
- 2022
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Ingår i: European Urology Oncology. - : Elsevier BV. - 2588-9311. ; 5:2, s. 235-243
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: The distribution of retroperitoneal lymph node metastases for patients with nonseminoma and a residual tumour of 10-49 mm in a population-based setting is unknown. This information is needed to justify selection of patients for a unilateral template resection. OBJECTIVE: To describe the location of retroperitoneal metastases and recurrences in patients with nonseminoma germ cell tumour (NSGCT) with a residual tumour of 10-49 mm. DESIGN, SETTING, AND PARTICIPANTS: RETROP is a population-based prospective observational mapping study of 213 patients in Sweden and Norway with a retroperitoneal residual tumour of 10-49 mm who underwent postchemotherapy retroperitoneal lymph node dissection for metastatic NSGCT during 2007-2014 with median follow-up of 100 mo. Patients were classified according to the testis primary tumour and the distribution of unilateral or bilateral lymph node metastases (with reference to the aorta) present on pre- and/or postchemotherapy computed tomography (CT) scans. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The distribution and rate of teratoma or cancer in unilateral or bilateral retroperitoneal fields and the location and rate of retroperitoneal recurrence were measured. RESULTS AND LIMITATIONS: In total, 65% of the patients had unilateral retroperitoneal lymph node metastases (RLNMs) on CT scans. Patients with unilateral RLNMs had a low risk of contralateral teratoma or cancer (1.6% for right- and 2.6% for left-sided NSGCT) or retroperitoneal recurrence (0% for right- and 4% for left-sided NSGCT). A weakness of the study is that the pathology specimen could not be fully designated to one specific area for some of the patients. CONCLUSIONS: Men with postchemotherapy residual disease of 10-49 mm and unilateral metastases on pre- and postchemotherapy CT scans have a low risk of contralateral disease and should be considered for a unilateral template resection. PATIENT SUMMARY: The surgeon can use computed tomography (CT) scans in deciding on the extent of lymph node dissection in patients with testicular cancer.
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| 9. |
- Gerdtsson, Axel, et al.
(författare)
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Validation of a prediction model for post-chemotherapy fibrosis in nonseminoma patients
- 2023
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Ingår i: Bju International. - 1464-4096 .- 1464-410X. ; 132:3, s. 329-336
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Tidskriftsartikel (refereegranskat)abstract
- Objective To validate Vergouwe's prediction model using the Swedish and Norwegian Testicular Cancer Group (SWENOTECA) RETROP database and to define its clinical utility. Materials and methods Vergouwe's prediction model for benign histopathology in post-chemotherapy retroperitoneal lymph node dissection (PCRPLND) uses the following variables: presence of teratoma in orchiectomy specimen; pre-chemotherapy level of alphafetoprotein; b-Human chorionic gonadotropin and lactate dehydrogenase; and lymph node size pre- and postchemotherapy. Our validation cohort consisted of patients included in RETROP, a prospective population-based database of patients in Sweden and Norway with metastatic nonseminoma, who underwent PC-RPLND in the period 2007-2014. Discrimination and calibration analyses were used to validate Vergouwe's prediction model results. Calibration plots were created and a Hosmer-Lemeshow test was calculated. Clinical utility, expressed as opt-out net benefit (NBopt-out), was analysed using decision curve analysis. Results Overall, 284 patients were included in the analysis, of whom 130 (46%) had benign histology after PC-RPLND. Discrimination analysis showed good reproducibility, with an area under the receiver-operating characteristic curve (AUC) of 0.82 (95% confidence interval 0.77-0.87) compared to Vergouwe's prediction model (AUC between 0.77 and 0.84). Calibration was acceptable with no recalibration. Using a prediction threshold of 70% for benign histopathology, NBopt-out was 0.098. Using the model and this threshold, 61 patients would have been spared surgery. However, only 51 of 61 were correctly classified as benign. Conclusions The model was externally validated with good reproducibility. In a clinical setting, the model may identify patients with a high chance of benign histopathology, thereby sparing patients of surgery. However, meticulous follow-up is required.
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| 10. |
- Ljungquist, Oskar, et al.
(författare)
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Increasing rates of urinary- and bloodstream infections following transrectal prostate biopsy in South Sweden
- 2022
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Ingår i: BJU International. - : Wiley. - 1464-4096 .- 1464-410X. ; 130:4, s. 478-485
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Tidskriftsartikel (refereegranskat)abstract
- ObjectiveTo report trends and characteristics of post-biopsy infections, with regard to etiology and resistance patterns, in a large unique cohort from a single-centre using the same antibiotic prophylactic regimens during a 15-year period.MethodsThis is an observational cross sectional cohort study, including all patients who underwent transrectal prostate biopsy (TR PBx) guided by ultrasound for the suspicion of prostate cancer at the Department of Urology, Skåne University Hospital between 1st May 2003 and 31st December 2017. Positive blood and urinary cultures were considered markers of bloodstream infection (BSI) and urinary tract infection (UTI), respectively. For all patients, details regarding blood or urine cultures from the date of the prostate biopsy and 14 days onwards were retrieved.ResultsIn total, 8,973 transrectal biopsy procedures were performed in 6,597 men during the study period. Over time, there was a trend towards a changing case-mix, with biopsy procedures increasingly being performed in older patients, patients with lower PSA values and higher prostate volume. During the study period, the number of biopsy procedures performed increased for each time period and we found an increasing rate of infectious complications in the last period. Overall, the rates of BSI and UTI with at least one relevant pathogen were 1 % (88/8,973) and 1.8% (159/8,973), respectively. In total, 16 of 90 strains (18%) were ESBL-producing, with an increasing proportion over time. The proportion of ciprofloxacin-resistant pathogens did not increase over time.ConclusionDuring the 15 years of this study, BSI and UTI after TR PBx increased. The rise of infectious complications post TR PBx in this population is unlikely to be explained by quinolone-resistance, as ciprofloxacin-resistance did not increase in the blood and urinary samples obtained during the study period. Future longitudinal studies are warranted to investigate why infectious complications after TR PBx are increasing.
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