Sarcopenia as a predictor of postoperative outcomes after urologic oncology surgery: A systematic review and meta-analysis

AimSarcopenia as a reliable prognostic predictor in urologic oncology surgery remains controversial, and no consensus amongst researchers exists regarding the management of patients with sarcopenia. This meta-analysis was conducted to investigate the association between sarcopenia and postoperative outcomes after urologic oncology surgery.MethodsA systematic search in MEDLINE (via PubMed), Embase, Web of Science and Cochrane Library databases was conducted to identify the potential studies published before August 2019. Odds ratios and hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated through inverse variance with random or fixed effects models.ResultsSeventeen retrospective cohorts comprising 3,948 patients were included with sarcopenia prevalence between 25% and 68.9%. Patients with sarcopenia had significantly shorter overall survival (OS; HR = 2.06, 95% CI: 1.44–2.95; P < 0.001; I-square (I²) = 86%) and cancer-specific survival (HR = 2.16, 95% CI: 1.60–2.92; P < 0.001; I² = 49.4%) than those without sarcopenia. Sarcopenia was independently associated with increased all-cause mortality (HR = 1.50, 95% CI: 1.26–1.80; P < 0.001; I² = 0%) and cancer-specific mortality (HR = 1.50, 95% CI: 1.12–2.01; P = 0.006; I² = 0%). No prognostic difference was observed in the postoperative risk of total complications and systemic progression except lymphovascular invasion status.ConclusionsSarcopenia is an independent poor prognostic factor for patients undergoing urologic oncology surgery, particularly postoperative risks of short survival and increased mortality. Thus, preoperative sarcopenia evaluation can provide clinicians with important information to guide and individualise patient management and improve surgical outcomes.     

Identification of molecular targets in urologic oncology

Objectives  

Molecular targets in cancer diagnosis and therapy have come to the fore of the oncology field in the last decade. Their identification is rooted in basic science investigation and enhanced knowledge in the fields of genetics, biochemistry, molecular and tumor biology, and pathology among others.     

Erythropoietin in urologic oncology

OBJECTIVES: The use of erythropoietin (EPO) for the treatment of anemia associated with urological malignancies is not well defined. The rate of anemia is dependent on the type of cancer and on the different types of treatment. Only with a substantial risk for blood transfusion is substitution treatment by EPO justified. Additionally, the long-term risks of blood transfusions have to be balanced against the costs of EPO treatment. METHODS: Different experts have reviewed the literature on anemia and EPO regarding the four main tumor entities. RESULTS/CONCLUSIONS: In prostate cancer, EPO treatment may be justified before radical prostatectomy and in patients with advanced, hormone-refractory disease. In bladder cancer, significant treatment-related anemia mainly occurs in patients who have to undergo radical cystectomy and in patients who will be treated with polychemotherapy for metastatic disease. Patients with renal cell carcinoma rarely suffer from anemia and thus are usually not candidates for EPO treatment. Testis cancer patients only have a substantial risk for blood transfusions if they belong to the intermediate or poor prognosis group according to IGCCCG or if they need salvage chemotherapy or salvage surgery. However, in testis cancer patients EPO treatment should generally be preferred to blood transfusions since cure rates are excellent and thus the potential risks of transfusion-related infections are significant.     

Controversies in urologic oncology

The persistent controversies that characterize urologic oncology reflect the significant advances that have been made in our understanding of genitourinary malignancy and the objective posture that has been taken both by those active in this area and by those whose interests are more indirect. Ultimately, the beneficiaries of these controversies are the patients and their physicians. As continued problems are recognized and investigations are designed to explore them, controversy and skepticism become a healthy concomitant so that true knowledge and understanding can be achieved and such issues ultimately resolved.     

Follow-up strategies and management of recurrence in urologic oncology bladder cancer: invasive bladder cancer

A surveillance program following cystectomy should consider a patient's individual risk for the development of local and distant recurrences and any specific needs related to the urinary tract reconstruction performed (Table 1). Well-documented recurrence patterns following cystectomy are available from many large surgical series and provide the background information needed for tailoring follow-up based on pathologic criteria. Economic issues also must be considered, given that the health care-related expenses of treating and following patients with bladder cancer is twice as much as that expended for the treatment of prostate cancer. Because of the ever-increasing fiscal constraints placed on clinicians, risk-adjusted follow-up strategies are reasonable, but will require prospective evaluation to validate their appropriateness.     

Lymphadenectomy in urologic oncology: pathologic considerations

Lymphadenectomy (LAD) is an important staging and treatment modality of oncologic surgery. LAD in genitourinary malignancies presents inherent difficulties to the urologist and pathologist because of the differences in anatomic sites and primary histologic type. This review focuses on pathologic evaluation and how communication between urologist and pathologist is necessary to provide optimal care. Recommendations covering general specimen submission and processing are discussed, as well as more specific recommendations concerning the kidney, upper urinary tract, urinary bladder, prostate, testes, and penis. Emerging areas of prognostic significance and the impact that improved molecular techniques are contributing to diagnostic interpretation are highlighted.     

Prioritizing the patient voice in the development of urologic oncology research

Prioritization of patient and stakeholder engagement in the research process has been realized through increased funding and policy directives at the government level. Particularly, patient engagement in the preparatory research stage has driven development of patient-prioritized research questions. In this article, a successful example of patient-centered research prioritization is reviewed, and effective strategies and opportunities for patient engagement in urologic oncology research are described.     

Immunosuppressive strategies to improve outcomes of kidney transplantation

The introduction of several immunosuppressive agents over the past decade has reduced the rate of acute rejection significantly and has improved short-term renal allograft survival. However, their impact on long-term outcomes remains unclear. Current immunosuppressive strategies are focused on improving long-term graft and patient survival along with maintaining allograft function. The approval of the new immunosuppressive agents: rabbit antithymocyte globulin, basiliximab, daclizumab, tacrolimus, mycophenolate, and sirolimus, also has facilitated the development of steroid- and calcineurin inhibitor-sparing regimens in kidney transplantation. We discuss the impact of various immunosuppressive regimens on the outcome measures of kidney transplantation: acute rejection episodes, allograft survival, and renal function.     

Intraoperative ultrasonography in urologic oncology

Ultrasonography is a powerful nonionizing imaging modality that has generally been underused by American Urologists in the past. Innovative investigators and clinicians, however, are realizing the great potential of ultrasonography and are applying it increasingly not only in the clinic but in the operating room. In this commentary we outline some of the current and future uses of intraoperative ultrasonography in urologic oncology.     

Intraoperative autotransfusion in urologic oncology

The value of autotransfusion is widely recognized in the surgical community and may be of increasing importance in prevention of acquired immunodeficiency syndrome and hepatitis. The concern of potential contamination of the blood with viable tumor cells has resulted in limited use of autotransfusion in cancer surgery. The objective of this study was to examine the benefits and safety of autotransfusion in patients undergoing major surgery of genitourinary tumors. Autotransfusion was used in 49 consecutive patients. Twenty-four patients had radical cystectomy, ten had radical prostatectomy, 13 had radical nephrectomy, and two had other types of operations. An autotransfusion machine (Haemonetics Cell Saver) was used. The follow-up included physical examination, chest roentgenogram every three months, and bone scan and computed tomographic scan if clinically indicated. Liver and renal profiles were routinely performed every three months. Five of 49 patients developed metastases during follow-up examination from 12 to 23 months. The low incidence of metastatic spread and the pattern of spread fall to implicate autotransfusion as a cause of tumor dissemination. Autotransfusion and predeposited blood banking may result in elimination of or significant reduction in homologous transfusions.     

Flow cytometry in urologic oncology

Flow cytometers have proved to be useful research tools in cellular biology. By using these devices, rapid and objective measurements of a variety of cellular parameters can be made on a cell-by-cell basis. The application of flow cytometers to the study of urologic neoplasms is at present very preliminary. The available literature on the flow cytometric study of urologic tumors is presented and discussed.     

Molecular therapy in urologic oncology

During recent years, significant advances have been made in the field of molecular therapy in urologic oncology, mainly for advanced renal cell carcinoma. In this hitherto largely treatment-refractory disease, several agents have been developed targeting the von Hippel-Lindau metabolic pathway which is involved in carcinogenesis and progression of the majority of renal cell carcinomas. Although cure may not be expected, new drugs, such as the multikinase inhibitors sorafenib and sunitinib and the mammalian target of rapamycine inhibitor temsirolimus, frequently stabilize the disease course and may improve survival. Fewer data are available supporting molecular therapies in prostate, bladder, and testicular cancers. Preliminary data suggest a potential role of high-dose calcitriol and thalidomide in hormone-refractory prostate cancer, whereas targeted therapies in bladder and testicular cancers are still more or less limited to single-case experiences. The great theoretical potential and the multitude of possible targets and drug combinations, however, support further research into this exciting field of medical treatment of urologic malignancies.     

Quantum dots: emerging applications in urologic oncology

Quantum dots (QDs), nanometer-sized fluorescent probes with unique optical and electronic properties, offer a promising and powerful tool for cancer imaging and diagnostics. For the past few years, QDs were actively developed for biomolecular profiling of cancer biomarkers, in vivo tumor imaging, and even targeted drug delivery. These emerging applications are currently being improved and integrated into clinical practice. In this article, we describe the development of multifunctional QDs and their potential applications in oncology, with a particular emphasis on the diagnosis, prognosis, and treatment of urologic cancers.