Background The efficacy of neoadjuvant chemotherapy (NAC) for muscle-invasive bladder cancer (BCa) was established primarily with methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC), with complete response rates (pT0) as high as 38%. However, because of the comparable efficacy with better tolerability of gemcitabine and cisplatin (GC) in patients with metastatic disease, GC has become the most commonly used regimen in the neoadjuvant setting. Objective We aimed to assess real-world pathologic response rates to NAC with different regimens in a large, multicenter cohort. Design, setting, and participants Data were collected retrospectively at 19 centers on patients with clinical cT2–4aN0M0 urothelial carcinoma of the bladder who received at least three cycles of NAC, followed by radical cystectomy (RC), between 2000 and 2013. Intervention NAC and RC Outcome measurements and statistical analysis The primary outcome was pathologic stage at cystectomy. Univariable and multivariable analyses were used to determine factors predictive of pT0N0 and ≤pT1N0 stages. Results and limitations Data were collected on 935 patients who met inclusion criteria. GC was used in the majority of the patients (n = 602; 64.4%), followed by MVAC (n = 183; 19.6%) and other regimens (n = 144; 15.4%). The rates of pT0N0 and ≤pT1N0 pathologic response were 22.7% and 40.8%, respectively. The rate of pT0N0 disease for patients receiving GC was 23.9%, compared with 24.5% for MVAC (p = 0.2). There was no difference between MVAC and GC in pT0N0 on multivariable analysis (odds ratio: 0.89 [95% confidence interval, 0.61–1.34]; p = 0.6). Conclusions Response rates to NAC were lower than those reported in prospective randomized trials, and we did not discern a difference between MVAC and GC. Without any evidence from randomized prospective trials, the best NAC regimen for invasive BCa remains to be determined. Patient summary There was no apparent difference in the response rates to the two most common presurgical chemotherapy regimens for patients with bladder cancer.

ObjectiveTo predict the ease of perinephric fat surgical dissection at the time of open partial nephrectomy (OPN) using perinepheric fat density characteristics as measured on preoperative computed tomography (CT). Patients and MethodsIn all, 41 consecutive OPN patients with available preoperative imaging and prospectively collected dissection difficulty assessment were identified. Using a scoring system that was adopted for the purposes of this study, the genitourinary surgeon quantified the difficulty of the perinephric fat dissection on the surface of the renal capsule at the time of surgery. On axial CT slice centred on the renal hilum, we measured the quantity and density of perinephric fat whose absorption coefficient was between -190 to -30 Hounsfield units. Correlation between perinephric fat surface density (PnFSD) as noted on preoperative imaging and as observed by the surgeon at time of surgery were correlated in a completely 'double-blinded' fashion. Density comparisons between fat dissection difficulties were made using an ANOVA. Associations between covariates and perinephric fat density were evaluated by univariate and multivariate logistic regression analyses. Receiver-operating characteristic (ROC) curves for six different predictive models were created to visualise the predictive enhancement of PnFSD. ResultsPnFSD was positively correlated with total surgical duration (Pearson's correlation coefficient 0.314, P = 0.04). PnFSD significantly correlated with gender (P = 0.001) and difficulty of perinephric fat surgical dissection (P < 0.001) scores. The mean (SD) PnFSD for a dissection that was not difficult (n = 19) was 5598.32 (1367.77) surface density pixel unit (SDPU), and for a difficult dissection (n = 22) was 10272.23 (3804.67) SDPU. Univariate analysis showed gender (P = 0.002), and PnFSD were predictive of the presence of 'sticky' perinephric fat. A multivariate analysis model showed that PnFSD was the only variable that remained an independent predictor of perinephric fat dissection difficulty (P = 0.01). Of the six ROC models assessed, only PnFSD had a significant capability to predict the difficulty of the perinephric fat dissection due to the presence of highly adherent 'sticky' fat, with an area under the curve of 0.87 (P < 0.001). ConclusionAccurate preoperative assessment of perinephric fat density constitutes a strong indicator of perioperative fat dissection difficulty. Perinephric fat densities can be practically obtained from preoperative CT to identify 'sticky' fat, which may help determine the anticipated ease of surgical dissection, which can guide education, preoperative surgical planning, and potentially the surgical approach offered to patients.

Purpose Information on patterns of lymph node metastases (LNM) for upper tract urothelial carcinoma (UTUC) is sparse. We investigate patterns of LNM in UTUC. Materials/Methods Retrospective multi-institutional study of 73 patients with N+M0 UTUC undergoing template lymphadenectomy during nephroureterectomy. Anatomic locations of tumor, number of lymph nodes removed, positive lymph nodes were analyzed and descriptive statistics performed. Results On right side: renal pelvis tumors (n=20) had LNM to the hilum (22.1%), paracaval (44.1%), retrocaval (10.3%) and interaortocaval (20.6%) regions. Proximal ureter tumors (n=10) had LNM to hilum (46.2%), paracaval (46.2%), and retrocaval (7.7%) regions. Distal ureter tumors (n=2) had LNM equally to paracaval and pelvic regions. On left side: patients with renal pelvis tumors (n=24) had LNM to hilar (50.0%), and paraaortic (30.0%) regions. Proximal ureter tumors (n=8) had LNM to hilar (36.4%) and paraaortic (63.6%) regions. Mid ureter tumors (n=5) had LNM to paraaortic (40%), common iliac (40%) and internal iliac (20%) regions. Distal ureter tumors (n=4) had LNM to paraaortic (33.3%), common iliac (33.3%), and external and internal iliac (16.7% each). Interaortocaval involvement from both sides as well as out-of-field LNM appeared to occur secondarily. Consolidated templates were constructed based on the available data. Conclusion UTUC has characteristic patterns of LNM dependent on the side and anatomic location of the primary tumor, including right to left migration and involvement of interaortocaval nodes in the setting of proximal disease. Standardized dissection templates should be prospectively evaluated in multi-center trials to assess for morbidity and potential clinical benefit.

Objectives To assess the potential complications associated with inguinal lymph node dissection (ILND) across international tertiary care referral centres, and to determine the prognostic factors that best predict the development of these complications. Materials and Methods A retrospective chart review was conducted across four international cancer centres. The study population of 327 patients underwent diagnostic/therapeutic ILND. The endpoint was the overall incidence of complications and their respective severity (major/minor). The Clavien–Dindo classification system was used to standardize the reporting of complications. Results A total of 181 patients (55.4%) had a postoperative complication, with minor complications in 119 cases (65.7%) and major in 62 (34.3%). The total number of lymph nodes removed was an independent predictor of experiencing any complication, while the median number of lymph nodes removed was an independent predictor of major complications. The American Joint Committee on Cancer stage was an independent predictor of all wound infections, while the patient's age, ILND with Sartorius flap transposition, and surgery performed before the year 2008 were independent predictors of major wound infections. Conclusions This is the largest report of complication rates after ILND for squamous cell carcinoma of the penis and it shows that the majority of complications associated with ILND are minor and resolve without prolonged morbidity. Variables pertaining to the extent of disease burden have been found to be prognostic of increased postoperative morbidity.

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