Adjuvant chemotherapy after radical cystectomy:Do all patients who need chemotherapy after surgery actually receive it?

Background:Compliance with the guideline recommendations for neoadjuvant chemotherapyin patients with muscle-invasive bladder cancer is incomplete.The adjuvant chemotherapy approach has the advantage of pathology-based decision-making,allowing for patient selection.In addition,radical surgery is not delayed and treatment-related toxicity does not impair surgical fitness.The proportion of patients who completed chemotherapy after cystectomy among those who were fit and in need of treatment were evaluated.The reasons for not completing adjuvant chemotherapy were determined.Materials and methods:We retrospectively evaluated all patients who had undergone radical cystectomy at our center over thelast 7 years.Indications for adjuvant chemotherapy included pathological T>2,any node+,or surgical margin involvement.Only patients who were fit for chemotherapy before surgery were included in the study.Results:Of the 52 patients with muscle-invasive bladder cancer,14 received neoadjuvant chemotherapy or unfit for chemotherapy were excluded.Of the remaining 38 patients,14(37%)had bladder-confined cancers and did not require additional chemotherapy.Of the 24 patients who needed chemotherapy and were fit to receive it,8 patients completed treatment(33%),and 3 discontinued treatment due to toxicity.Twelve patients(50%)declined chemotherapy,whereas 1 patient became unfit for chemotherapy after surgery.Conclusions:While the adjuvant chemotherapy approach could save unnecessary treatment in 37%of patients,two-thirds of those who needed chemotherapy did not complete it.Patient refusal was the primary reason for not receiving treatment.

When should we give up on expectant management for patients with proximal ureteral stones?

Background:Proximal ureteral stones(PUS)have relatively low rates of spontaneous expulsion.However,some patients do on expectant management.Our aim was to compare risk factors for surgical intervention in patients with PUS who underwent primary intervention to those subjected to expectant management.Materials and methods:We retrospectively reviewed the medical charts of patients presented to the emergency room with symptoms of renal colic and underwent computerized tomography between August 2016 and August 2017.A total of 97 consecutive patients were identified with up to 10 mm PUS.We collected patient demographics,clinical,and imaging data,and performed binary regression analysis for risk of intervention.Results:The average age was 49years(range 17-97)and average stone size was 7.1 mm(range 3-10).Forty-one patients underwent immediate intervention while the remaining 56 patients were treated conservatively.Of the 56 patients treated conservatively,26 underwent delayed intervention while 30 reported spontaneous stone expulsion.On univariate analysis of all 97 patients,statistically significant risk factors for intervention were found based on stone size,age,serum lymphocyte,platelet counts,and stone density.Of these risk factors,stone size≥7mm(p=0.012,odds ratio=5.4)and platelet count?230K/mL(p=0.027,odds ratio=4.9)remained statistically significant on multivariate analysis.Conclusion:Stone size and platelet count were found to be risk factors for surgical intervention in patients with up to 10 mm PUS.These findings may assist in identifying patients who are more suitable for conservative approach.