Editor’s Choice
Conflict of Interest
2
None declared.
3
Jesse D. Sammon VUI Center for Outcomes Research Analytics and Evaluation, Henry Ford Health System, Detroit, MI, USA e-mail: [email protected]; [email protected]
4
5
References 1
Hirschhorn AD, Kolt GS, Brook AJ. A multicomponent theory-based intervention improves uptake of pelvic floor muscle training before radical prostatectomy: a before and after cohort study. BJU Int 2014; 113: 383–92
6
7
Donabedian A, Bashshur R. An Introduction to Quality Assurance in Health Care. Oxford; New York: Oxford University Press, 2003 Sammon JD, Karakiewicz PI, Sun M et al. Robot-assisted versus open radical prostatectomy: the differential effect of regionalization, procedure volume and operative approach. J Urol 2013; 189: 1289–94 Cronenwett JL, Likosky DS, Russell MT, Eldrup-Jorgensen J, Stanley AC, Nolan BW. A regional registry for quality assurance and improvement: the Vascular Study Group of Northern New England (VSGNNE). J Vasc Surg 2007; 46: 1093–101; discussion 1101–2 Birkmeyer NJ, Dimick JB, Share D et al. Hospital complication rates with bariatric surgery in Michigan. JAMA 2010; 304: 435–42 Miller DC, Murtagh DS, Suh RS, Knapp PM, Dunn RL, Montie JE. Establishment of a urological surgery quality collaborative. J Urol 2010; 184: 2485–90 Concato J. Is it time for medicine-based evidence? JAMA 2012; 307: 1641–3
Radical cystectomy: how do blood transfusions affect oncological outcomes? Kluth et al. [1] have conducted a large retrospective study from several institutions in North America and Europe to assess the impact of blood transfusion on oncological outcomes after radical cystectomy (RC) for bladder cancer. The hypothesis for a negative impact of transfusion on oncological outcomes stems from the observation that renal allograft survival is prolonged after pre-transplant blood transfusions because of its immuno-modulatory effects [2]. This finding prompted Gantt [3] to express concern about the possible adverse effects of transfusions in patients being treated for cancer. Since then, there have been numerous publications addressing this issue in various surgical journals including those of urology with conflicting messages. Sadeghi et al. [4] queried the Columbia University Urologic Oncology Database. This included 638 patients undergoing RC between 1989 and 2010. Of these, 209 (32.8%) received perioperative blood transfusions. On univariate analysis, the number of units transfused was inversely related to overall and cancer-specific survival. However, on multivariate analysis, it did not prove to be an independent predictor of cancer-specific survival. As the authors highlighted in this paper, Linder et al. [5] reported a large series of patients from the Mayo Clinic, which included 2060 patients undergoing RC over 25 years. Of this large cohort, 1279 (62%) received perioperative blood transfusion with adverse outcomes, not only in terms of overall and cancer-specific mortality, but also postoperative tumour recurrence. RC is one of the most major surgical procedures performed in urological surgery. The vast majority of patients with bladder cancer requiring RC are in their mid-sixties, overweight and
352
© 2014 The Author BJU International © 2014 BJU International
have several co-morbidities. Some of these patients present late and are anaemic at presentation. Blood loss during open RC varies depending upon surgeons’ experience, patients’ body mass index, disease stage and availability of modern equipment, e.g. LigaSure™ or stapling devices. Blood transfusion may be required because of pre-existing anaemia or excessive blood loss during surgery. Variations exist in thresholds of anaesthesiologists and the surgeons for transfusions. All of these factors account for variation in reported frequency of transfusion rates for this operation and this is well reflected in many large series of RC. As there are many confounding factors that may influence overall and cancer-specific survival in patients undergoing RC including stage of the disease, histological nature of the tumour, lymph node status and competing co-morbidities, it is very challenging to control for these factors in retrospective series. Hence, prospective well-controlled multicentre studies are the only way forward to answer this question. While we await robust evidence on the influence of perioperative transfusion on oncological outcomes, several potential options could be explored to avoid homologous blood transfusion. These include preoperative optimisation of haemoglobin levels through iron infusions, administration of erythropoietin where appropriate, and preoperative autologous-banking. Intraoperatively meticulous surgical technique, use of modern devices, e.g. LigaSure/stapler and Cell Savers, could be used to avoid homologous blood transfusion. Fortunately, these studies aimed at raising awareness of potential risks of transfusions are appearing in the urological
Editor’s Choice
literature at a time when urologists are moving away from open to minimally invasive oncological surgery with a steady decline in the need for perioperative blood transfusion. This is one of the important steps in the right direction and will have a major impact on the need for blood transfusion in foreseeable future.
Conflict of Interest
References 1
2
3 4
None declared. Muhammed S. Khan Department of Urology, Guy’s Hospital and King’s College London School of Medicine, London, UK e-mail: [email protected]
5
Kluth LA, Xylinas E, Rieken M et al. Impact of perioperative blood transfusion on the outcome of patients undergoing radical cystectomy for urothelial carcinoma of the bladder. BJU Int 2014; 113: 393–8 Opelz G, Sengar DP, Mickey MR, Terasaki PI. Effect of blood transfusions on subsequent kidney transplants. Transplant Proc 1973; 5: 253–9 Gantt CL. Red blood cells for cancer patients. Lancet 1981; 2: 363 Sadeghi N, Badalato GM, Hruby G, Kates M, McKiernan JM. The impact of perioperative blood transfusion on survival following radical cystectomy for urothelial carcinoma. Can J Urol 2012; 19: 6443–9 Linder BJ, Frank I, Cheville JC et al. The impact of perioperative blood transfusion on cancer recurrence and survival following radical cystectomy. Eur Urol 2013; 63: 839–45
Once again Gleason remains the grading system to beat: a comparison with using percentage pattern 4/5 The study by Hansen et al. [1] in the current issue of the BJUI assesses whether percent high grade tumour (HGTV) is superior to or adds to the Gleason scoring system in a group of men with high risk disease. In large part due to the work of John McNeal at Stanford, percentage pattern 4/5 has been proposed as a substitute to the Gleason system both on biopsy and TURP [2]; however, percent pattern 4/5 is only very predictive for prognosis in radical prostatectomy specimens at the extremes of the percentages. The percent of pattern 4/5 on needle biopsy has also been shown to not correlate well with the percent of pattern 4/5 in the corresponding radical prostatectomy [3]. When new grading systems are compared with the Gleason system, it is critical to use the current updated Gleason system and to break down Gleason scores into equivalent prognostic grade groups [4]. In the previous works at Stanford, Gleason score 7 without subdividing into 3+4 or 4+3 was compared with percent pattern 4/5. As the authors noted: ‘For a score of 7, the proportion of Gleason grade 4 cancer may vary between 5% and 95% without altering the score (sum)’. Also, the group from Stanford stated that: ‘fractional areas of tumor less than 5% of the total tumor area should be ignored’ [2]. Currently, even if there is only a very limited amount of high grade cancer on biopsy, it is incorporated into the Gleason score [4]. In the initial submission by Hansen et al., Gleason scores were categorized into ≤3+3 = 6 vs >6. Using this subdivision, the authors concluded that % high grade tumour volume was an independent predictor of early biochemical relapse (BCR) after radical prostatectomy. We have demonstrated that an accurate
Table 1 Addendum to biopsy reports with prostate adenocarcinoma. Gleason score ≤6: Gleason score 3 + 4 = 7: Gleason score 4 + 3 = 7: Gleason score 8: Gleason score 9–10:
Prognostic Grade Group I Prognostic Grade Group II Prognostic Grade Group III Prognostic Grade Group IV Prognostic Grade Group V
The overall Gleason score for this case is based on the core with the highest Gleason score. Gleason scores can be grouped and ranged from Prognostic Grade Group I (most favourable) to Prognostic Grade Group V (least favourable).
grouping of Gleason scores can be accomplished with five prognostic grade groups, which we note in all our biopsy reports (Table 1) [5,6]. Once Hansen et al. refined their Gleason grade grouping accordingly, their results were diametrically opposite, leading them to conclude that ‘sophisticated TV/HGTV measurement does not seem to carry additional benefit for early BCR prediction relative to the use of Gleason grading’. Their findings in a large cohort of men with high-risk prostate cancer help to resolve the issue that percent pattern 4/5 should not be required or recommended as a method of grading.
Conflict of Interest None declared. Jonathan I. Epstein Departments of Pathology, Urology and Oncology, The Johns Hopkins Medical Institutions, Baltimore, MD, USA e-mail: [email protected] © 2014 The Author BJU International © 2014 BJU International
353
Conflict of Interest
2
None declared.
3
Jesse D. Sammon VUI Center for Outcomes Research Analytics and Evaluation, Henry Ford Health System, Detroit, MI, USA e-mail: [email protected]; [email protected]
4
5
References 1
Hirschhorn AD, Kolt GS, Brook AJ. A multicomponent theory-based intervention improves uptake of pelvic floor muscle training before radical prostatectomy: a before and after cohort study. BJU Int 2014; 113: 383–92
6
7
Donabedian A, Bashshur R. An Introduction to Quality Assurance in Health Care. Oxford; New York: Oxford University Press, 2003 Sammon JD, Karakiewicz PI, Sun M et al. Robot-assisted versus open radical prostatectomy: the differential effect of regionalization, procedure volume and operative approach. J Urol 2013; 189: 1289–94 Cronenwett JL, Likosky DS, Russell MT, Eldrup-Jorgensen J, Stanley AC, Nolan BW. A regional registry for quality assurance and improvement: the Vascular Study Group of Northern New England (VSGNNE). J Vasc Surg 2007; 46: 1093–101; discussion 1101–2 Birkmeyer NJ, Dimick JB, Share D et al. Hospital complication rates with bariatric surgery in Michigan. JAMA 2010; 304: 435–42 Miller DC, Murtagh DS, Suh RS, Knapp PM, Dunn RL, Montie JE. Establishment of a urological surgery quality collaborative. J Urol 2010; 184: 2485–90 Concato J. Is it time for medicine-based evidence? JAMA 2012; 307: 1641–3
Radical cystectomy: how do blood transfusions affect oncological outcomes? Kluth et al. [1] have conducted a large retrospective study from several institutions in North America and Europe to assess the impact of blood transfusion on oncological outcomes after radical cystectomy (RC) for bladder cancer. The hypothesis for a negative impact of transfusion on oncological outcomes stems from the observation that renal allograft survival is prolonged after pre-transplant blood transfusions because of its immuno-modulatory effects [2]. This finding prompted Gantt [3] to express concern about the possible adverse effects of transfusions in patients being treated for cancer. Since then, there have been numerous publications addressing this issue in various surgical journals including those of urology with conflicting messages. Sadeghi et al. [4] queried the Columbia University Urologic Oncology Database. This included 638 patients undergoing RC between 1989 and 2010. Of these, 209 (32.8%) received perioperative blood transfusions. On univariate analysis, the number of units transfused was inversely related to overall and cancer-specific survival. However, on multivariate analysis, it did not prove to be an independent predictor of cancer-specific survival. As the authors highlighted in this paper, Linder et al. [5] reported a large series of patients from the Mayo Clinic, which included 2060 patients undergoing RC over 25 years. Of this large cohort, 1279 (62%) received perioperative blood transfusion with adverse outcomes, not only in terms of overall and cancer-specific mortality, but also postoperative tumour recurrence. RC is one of the most major surgical procedures performed in urological surgery. The vast majority of patients with bladder cancer requiring RC are in their mid-sixties, overweight and
352
© 2014 The Author BJU International © 2014 BJU International
have several co-morbidities. Some of these patients present late and are anaemic at presentation. Blood loss during open RC varies depending upon surgeons’ experience, patients’ body mass index, disease stage and availability of modern equipment, e.g. LigaSure™ or stapling devices. Blood transfusion may be required because of pre-existing anaemia or excessive blood loss during surgery. Variations exist in thresholds of anaesthesiologists and the surgeons for transfusions. All of these factors account for variation in reported frequency of transfusion rates for this operation and this is well reflected in many large series of RC. As there are many confounding factors that may influence overall and cancer-specific survival in patients undergoing RC including stage of the disease, histological nature of the tumour, lymph node status and competing co-morbidities, it is very challenging to control for these factors in retrospective series. Hence, prospective well-controlled multicentre studies are the only way forward to answer this question. While we await robust evidence on the influence of perioperative transfusion on oncological outcomes, several potential options could be explored to avoid homologous blood transfusion. These include preoperative optimisation of haemoglobin levels through iron infusions, administration of erythropoietin where appropriate, and preoperative autologous-banking. Intraoperatively meticulous surgical technique, use of modern devices, e.g. LigaSure/stapler and Cell Savers, could be used to avoid homologous blood transfusion. Fortunately, these studies aimed at raising awareness of potential risks of transfusions are appearing in the urological
Editor’s Choice
literature at a time when urologists are moving away from open to minimally invasive oncological surgery with a steady decline in the need for perioperative blood transfusion. This is one of the important steps in the right direction and will have a major impact on the need for blood transfusion in foreseeable future.
Conflict of Interest
References 1
2
3 4
None declared. Muhammed S. Khan Department of Urology, Guy’s Hospital and King’s College London School of Medicine, London, UK e-mail: [email protected]
5
Kluth LA, Xylinas E, Rieken M et al. Impact of perioperative blood transfusion on the outcome of patients undergoing radical cystectomy for urothelial carcinoma of the bladder. BJU Int 2014; 113: 393–8 Opelz G, Sengar DP, Mickey MR, Terasaki PI. Effect of blood transfusions on subsequent kidney transplants. Transplant Proc 1973; 5: 253–9 Gantt CL. Red blood cells for cancer patients. Lancet 1981; 2: 363 Sadeghi N, Badalato GM, Hruby G, Kates M, McKiernan JM. The impact of perioperative blood transfusion on survival following radical cystectomy for urothelial carcinoma. Can J Urol 2012; 19: 6443–9 Linder BJ, Frank I, Cheville JC et al. The impact of perioperative blood transfusion on cancer recurrence and survival following radical cystectomy. Eur Urol 2013; 63: 839–45
Once again Gleason remains the grading system to beat: a comparison with using percentage pattern 4/5 The study by Hansen et al. [1] in the current issue of the BJUI assesses whether percent high grade tumour (HGTV) is superior to or adds to the Gleason scoring system in a group of men with high risk disease. In large part due to the work of John McNeal at Stanford, percentage pattern 4/5 has been proposed as a substitute to the Gleason system both on biopsy and TURP [2]; however, percent pattern 4/5 is only very predictive for prognosis in radical prostatectomy specimens at the extremes of the percentages. The percent of pattern 4/5 on needle biopsy has also been shown to not correlate well with the percent of pattern 4/5 in the corresponding radical prostatectomy [3]. When new grading systems are compared with the Gleason system, it is critical to use the current updated Gleason system and to break down Gleason scores into equivalent prognostic grade groups [4]. In the previous works at Stanford, Gleason score 7 without subdividing into 3+4 or 4+3 was compared with percent pattern 4/5. As the authors noted: ‘For a score of 7, the proportion of Gleason grade 4 cancer may vary between 5% and 95% without altering the score (sum)’. Also, the group from Stanford stated that: ‘fractional areas of tumor less than 5% of the total tumor area should be ignored’ [2]. Currently, even if there is only a very limited amount of high grade cancer on biopsy, it is incorporated into the Gleason score [4]. In the initial submission by Hansen et al., Gleason scores were categorized into ≤3+3 = 6 vs >6. Using this subdivision, the authors concluded that % high grade tumour volume was an independent predictor of early biochemical relapse (BCR) after radical prostatectomy. We have demonstrated that an accurate
Table 1 Addendum to biopsy reports with prostate adenocarcinoma. Gleason score ≤6: Gleason score 3 + 4 = 7: Gleason score 4 + 3 = 7: Gleason score 8: Gleason score 9–10:
Prognostic Grade Group I Prognostic Grade Group II Prognostic Grade Group III Prognostic Grade Group IV Prognostic Grade Group V
The overall Gleason score for this case is based on the core with the highest Gleason score. Gleason scores can be grouped and ranged from Prognostic Grade Group I (most favourable) to Prognostic Grade Group V (least favourable).
grouping of Gleason scores can be accomplished with five prognostic grade groups, which we note in all our biopsy reports (Table 1) [5,6]. Once Hansen et al. refined their Gleason grade grouping accordingly, their results were diametrically opposite, leading them to conclude that ‘sophisticated TV/HGTV measurement does not seem to carry additional benefit for early BCR prediction relative to the use of Gleason grading’. Their findings in a large cohort of men with high-risk prostate cancer help to resolve the issue that percent pattern 4/5 should not be required or recommended as a method of grading.
Conflict of Interest None declared. Jonathan I. Epstein Departments of Pathology, Urology and Oncology, The Johns Hopkins Medical Institutions, Baltimore, MD, USA e-mail: [email protected] © 2014 The Author BJU International © 2014 BJU International
353
