EAU guidelines on renal cell carcinoma: the 2010 update. Final results of the European Advanced Renal Cell Carcinoma Sorafenib (EU-ARCCS) expanded-access study: a large open-label study in diverse community settings. Systemic Therapy for Non-Clear Cell Renal Cell Carcinoma. Improved prognostication of renal cell carcinoma using an integrated staging system. Randomized trial of adjuvant thalidomide versus observation in patients with completely resected high-risk renal cell carcinoma. Combination transurethral resection, systemic chemotherapy, and pelvic radiotherapy for invasive (T2-T4) bladder cancer unsuitable for cystectomy: a phase I/II Southwestern Oncology Group study. Methods for Development of the European Commission Initiative on Breast Cancer Guidelines Key Steps in Conducting Systematic Reviews for Underpinning Clinical Practice Guidelines: Methodology of the European Association of Urology. Prognostic factors for survival in patients with advanced renal cell carcinoma treated with recombinant interleukin-2. A preoperative prognostic model for patients treated with nephrectomy for renal cell carcinoma. Robot-assisted radical cystectomy with intracorporeal urinary diversion versus open radical cystectomy (iROC): protocol for a randomised controlled trial with internal feasibility study The effectiveness of a clinical practice guideline for the management of presumed uncomplicated urinary tract infection in women. Body size and risk of renal cell carcinoma in the European Prospective Investigation into Cancer and Nutrition (EPIC). Autologous CIK Cell Immunotherapy in Patients with Renal Cell Carcinoma after Radical Nephrectomy Diagnostic accuracy of computed tomography-guided percutaneous biopsy of renal masses. Combined modality treatment with bladder preservation for muscle invasive bladder cancer. Conservative treatment of invasive bladder carcinoma by transurethral resection, protracted intravenous infusion chemotherapy, and hyperfractionated radiotherapy
CONTEXT AND OBJECTIVES The European Association of Urology Guideline Group for renal cell carcinoma ( RCC ) has prepared these guidelines to help clinicians assess the current evidence -based management of RCC and to incorporate the present recommendations into daily clinical practice . EVIDENCE ACQUISITION The recommendations provided in the current up date d guidelines are based on a thorough review of available RCC guidelines and review articles combined with a systematic literature search using Medline and the Cochrane Central Register of Controlled Trials . EVIDENCE SYNTHESIS A number of recent prospect i ve r and omised studies concerning RCC are now available with a high level of evidence , whereas earlier publications were based on retrospective analyses , including some larger multicentre validation studies , meta-analyses , and well- design ed controlled studies . CONCLUSIONS These guidelines contain information for the treatment of an individual patient according to a current st and ardised general approach . Up date d recommendations concerning diagnosis , treatment , and follow-up can improve the clinical h and ling of patients with RCC BACKGROUND The European Advanced Renal Cell Carcinoma Sorafenib ( EU-ARCCS ) exp and ed-access study provided sorafenib to advanced renal cell carcinoma ( RCC ) patients in whom previous systemic therapy had failed . The study assessed the safety and use of sorafenib for the treatment of advanced RCC in a large community-based patient population across 11 countries in Europe . PATIENTS AND METHODS EU-ARCCS was a single-arm , open-label trial of  sorafenib in advanced RCC patients . End points included safety , time to progression , progression-free survival ( PFS ) , and disease control rate ( DCR ) . Subgroup analyses included age , Eastern Cooperative Oncology Group performance status , histology , prior therapy , and number and sites of metastases . RESULTS About 1159 advanced RCC patients were enrolled . Most patients ( 94 % ) experienced drug-related adverse events ( AEs ) of any grade , with the most common grade ≥3 AEs including h and -foot skin reaction ( 13 % ) , diarrhea ( 7 % ) , fatigue ( 7 % ) , hypertension ( 6 % ) , and rash/desquamation ( 5 % ) . The incidence of AEs in the subgroups was similar to that in the overall population . Median PFS was 6.6 months ; DCR at ≥8 and ≥12 weeks was 85 % and 78 % , respectively . CONCLUSIONS The sorafenib safety profile in European community-based practice setting s was similar to that reported in clinical trials . The heterogeneous advanced RCC patient population in EU-ARCCS permitted assessment of sorafenib in important sub population s of advanced RCC patients Treatment options for metastatic clear cell renal cell carcinoma ( ccRCC ) have evolved markedly over the past decade , with multiple targeted therapies approved for the disease . In contrast , little improvement has been made in the management of metastatic non-clear cell RCC ( nccRCC ) . Non-clear cell disease is an umbrella term that encompasses multiple biologically distinct entities , including but not limited to papillary , chromophobe , and sarcomatoid RCC . To date , prospect i ve studies have largely explored treatments for ccRCC ( e.g. , VEGF- and mTOR-directed therapies ) in trials that aggregate non-clear cell histologies . However , the studies do not acknowledge the varying biology of each non-clear cell subtype . Emerging studies in nccRCC should examine individual histologies and apply biologically relevant therapies . An example of this is SWOG 1500 , a r and omized phase II study that will compare a  VEGF-inhibitor  to one of three  MET-directed therapies  in patients with metastatic papillary RCC . Until the biologic diversity of nccRCC is appreciated , outcomes are likely to remain dismal PURPOSE To integrate stage , grade , and Eastern Cooperative Oncology Group ( ECOG ) performance status ( PS ) into a clinical ly useful tool capable of stratifying the survival of renal cell carcinoma ( RCC ) patients . PATIENTS AND METHODS The medical records of 661 patients undergoing nephrectomy at University of California Los Angeles between 1989 and 1999 were evaluated . Median age was 61 years , male-to-female ratio was 2.2:1 , and median follow-up was 37 months .  Survival time was the primary end point assessed . Sixty-four possible combinations of stage , grade , and ECOG PS were analyzed and collapsed into distinct groups . The internal validity of the categorized was challenged by a univariate analysis and a multivariate analysis testing for the accountability of each UCLA Integrated Staging System ( UISS ) category against independent variables shown to have impact on survival . RESULTS Combining and stratifying 1997 tumor-node-metastasis stage , Fuhrman 's grade and ECOG PS result ed in five survival stratification groups design ated UISS , and numbered I to V. The projected 2- and 5-year survival for the UISS groups are as follows for the groups : I , 96 % and 94 % ; II , 89 % and 67 % ; III , 66 % and 39 % ; IV , 42 % and 23 % ; and V , 9 % and 0 % , respectively . UISS accounted for the significant variables in the variate analysis . CONCLUSION A novel system for staging and predicting survival for RCC integrating clinical variables is offered . UISS is simple to use and is superior to stage alone in differentiating patients ' survival . Our data suggests that UISS is an important prognostic tool for counseling patients with various stages of kidney cancer . Further prospect i ve large-scale validation with external data is awaited OBJECTIVES To evaluate the effect of adjuvant thalidomide on recurrence-free survival ( RFS ) after nephrectomy for high-risk metastatic renal cell carcinoma ( RCC ) . METHODS Eligibility criteria for enrollment on this r and omized trial included any histologic subtype , T2 ( high grade , any N ) , T3/T4 ( any grade , any N ) , or node-positive ( any grade , any T ) RCC . We r and omized eligible patients to observation or to receive thalidomide 300 mg daily for 24 months . Patients were observed until disease recurrence or death . RESULTS After we enrolled 46 patients , we stopped the trial at a median follow up of 43.9 months ( range , 9.7 - 74.2 months ) . Patients on the thalidomide arm had inferior 2- and 3-year probabilities of RFS , compared with controls ( 47.8 % vs 69.3 % and 28.7 % vs 69.3 % , respectively ; P = .022 ) . The 2- and 3-year cancer-specific survival was similar for both groups . All observed deaths were attributable to RCC ( P = .392 ) . By multivariate analysis , tumor size and grade predicted recurrence ( P = .001 and .013 ) and kidney cancer-specific death ( P = .002 and .014 ) . Thalidomide treatment , however , was not an independent predictor of recurrence or cancer-specific mortality . CONCLUSIONS In this small , r and omized , controlled trial , adjuvant thalidomide therapy after complete resection of high-risk RCC did not improve the 2- and 3-year RFS rates or cancer-specific death rates OBJECTIVES Primarily to evaluate the toxicity and , secondarily , the tumor response and patient survival associated with a three-phase combined modality treatment plan for patients with invasive transitional cell carcinoma ( TCC ) of the bladder ( T2-T4,NX-N2 , MO ) who are medically unsuitable for or who refuse cystectomy . METHODS Eligible patients initially underwent extensive transurethral resection ( TUR ) of the primary tumor with the attempt to resect disease totally . Subsequently , they received systemic combination chemotherapy consisting of two cycles of methotrexate , cisplatin , and vinblastine ( MCV ) , followed by cystoscopic re-evaluation of the bladder tumor . Patients then received 6480 cGy radiotherapy to the bladder with concurrent systemic cisplatin .  Toxicity , primary tumor response , and overall survival were evaluated . RESULTS Of 34 eligible patients , 27 patients completed the treatment series . Twenty-two received 80 % to 100 % of the prescribed doses of MCV and only 2 patients experienced grade 4 hematologic toxicities . The most common toxicities were gastrointestinal ( 23 ) , hematologic ( 21 ) , and renal ( 8) . The complete response ( CR ) rate after all treatment phases was 56 % ( 19 of 34 ) , 10 patients achieving a complete tumor resection of visible tumor at the initial TUR of the bladder ( TURB ) ; 3 , a CR after MCV ; and 6 , after radiotherapy and concomitant cisplatin . The median overall survival was 21 months with 6 of 34 ( 18 % ) alive at 57 months ( range , 36 to 75 ) . Complete resection of tumor by TURB was associated with prolonged overall survival . The bladder was the initial site of recurrence in 85 % of patients who had achieved a CR status . CONCLUSIONS This older age patient group tolerated this combined modality therapy with acceptable toxicities , but the overall survival rate was not improved compared with those reported with radiotherapy alone In December 2003 , the European Council identified best practice as key for ensuring development of high- quality cancer-screening programs . To support national policies on cancer control , the European Union institutions progressed several initiatives on cancer . The European Commission ( EC ) Initiative on Breast Cancer ( ECIBC ) is the most recent of these projects and the most implementation driven . Within this initiative , the European Guidelines for Breast Cancer Screening and Diagnosis ( in short , European Breast Guidelines ) are being developed ( http://ecibc.jrc.ec.europa.eu/ ) . Guidelines are approaches to generally improve prevention , diagnosis , treatment , and follow-up of diseases , overcoming inappropriate variations by providing recommendations for best care . The new era of guidelines promises recommendations that are based on the best available evidence summarized in systematic review s while providing the necessary flexibility needed to individualize decisions . The best methods for development of practice guidelines have experienced intense elaboration and attention during the past decades ( 17 ) . The impetus for this attention has been the change from expert- or consensus-based to evidence -based health care recommendations . Although this change in terminology should express the shift from un systematic development of guidelines to systematic and trustworthy recommendations , it is often misunderstood and misconstrued as meaning that experts are now meaningless in the process or as if consensus through discussion is a matter of the past . Neither is correct . Experts from various disciplines and consensus as a result of deliberation remain a mainstay of health care guideline development ( 810 ) . These experts are responsible for prioritization of questions that should be addressed in guidelines ; judgments that result from interpretation of evidence , including the rating of the certainty of the available evidence ; and decisions about how the judgments on the different criteria bear on recommendations . What has changed over time in guideline development are the rules , the structure and explicitness of the process , and the guideline product . Indeed , review s of guideline development methodology and how guidelines can be improved have led to more structured and documented processes that allow a reduction of bias and provide balanced views of appropriately composed guideline panels ( 2 , 5 , 6 ) . Core components for trustworthy guideline development ( 13 , 5 , 7 , 11 ) include that guidelines be developed by a knowledgeable , multidisciplinary panel of experts and representatives from key affected groups ; be based on a systematic review of the existing evidence ; consider important patient subgroups and patient preferences as appropriate ; be based on an explicit and transparent process that minimizes distortions , biases , and conflicts of interest ( 12 ) ; provide a clear explanation of the logical relationships between alternative care options and health outcomes and provide ratings of both the quality of evidence and the strength of the recommendations ( 1316 ) ; and be reconsidered and revised as appropriate when important new evidence warrants modifications . In addition , greater transparency in linking the considered research evidence and the recommendations , as well as the requirement of making structured expert judgments , represents a shift in the guideline development paradigm ( 5 , 11 , 1719 ) . At the same time , developing guidelines for a large number of member states and those that aim to adapt the guidelines poses challenges , such as the feasibility of implementing strategies that may exist in some member countries but not others ( for example , organized population -based screening in Italy but not Greece ) . Addressing these challenges requires considerations that extend beyond strictly clinical efforts in guideline development and mastering the many factors that influence recommendations and their implementation . This article describes the rationale , methods , and processes the ECIBC has adopted to develop the European Breast Guidelines in the context of evolving international st and ards . It also describes an innovative approach to presenting , disseminating , and accelerating implementation of recommendations . Guideline Methodology and Development To adhere to the core requirements for guideline development , the EC has taken several steps . First , it selected , via an open call ( https://ecibc.jrc.ec.europa.eu/ guidelines -team ) , a panel with broad representation of expertise , knowledge , and background , which includes patients , health care professionals , epidemiologists , guideline method ologists , and others ( Appendix ) . These individuals voluntarily participate in the ECIBC and compose the guidelines development group ( GDG ) . Second , it ensured that all recommendations were supported by systematic review s of the evidence conducted by independent scientists from Cochrane Iberoamricathe systematic review team (SRT)following st and ard Cochrane Collaboration methods ( 20 , 21 ) . Third , because this is a women-centered initiative , we included women advocates in the GDG as full voting guideline group members . We separately considered important subgroups of women during recommendation development ( for example , different age groups ) , and we specifically focused on evidence that supports best ways of communicating this information to women to inform their decisions . Fourth , we applied EC conflict of interest rules ( http://ecibc.jrc.ec.europa.eu/rules ) , which are consistent with international recommendations , and used GRADE ( Grading of Recommendations Assessment , Development and Evaluation ) Evidence to Decision ( EtD ) frameworks to minimize the influence of competing interests on the recommendations ( 12 , 17 , 18 ) . These EtD frameworks help guideline panels use evidence in a structured , transparent way to inform decisions with a series of criteria , such as anticipated harms and benefits of the options considered , the certainty of the evidence for those effects , and the costs and feasibility of the options , to help them reach their decision . Fifth , using the GRADE approach to guideline development and its EtD frameworks , we focused our questions and recommendations on outcomes that matter to women and provided a rating of the certainty or quality of evidence and the strength of recommendations that is widely accepted as the reference st and ard ( Figures 1 and 2 ) . Sixth , our evidence review s are up to date when the recommendations are formulated , and we engage in international stakeholder feedback to ensure that recommendations remain timely and relevant to public health and clinical practice . The ECIBC is committed to review ing and updating the recommendations as required when new evidence becomes available . The general process is explained in Figure 3 and is based on the Guidelines International NetworkMcMaster Guideline Development Checklist ( https://hei grade .mcmaster.ca/ guideline -development/using-checklist ) ( 5 ) . Figure 1 . According to GRADE , certainty , quality , strength of evidence , or confidence in the estimate of effect is determined on the basis of a systematic review of the evidence for each outcome ( based on the domains risk of bias , indirectness , imprecision , inconsistency , and publication bias that lower certainty and , usually only for nonr and omized studies , large effects , doseresponse relations and opposing plausible residual confounding that may increase the certainty ) . For recommendations , the overall certainty is determined across outcomes based on the lowest certainty outcome among those critical for decision making for the specific context . The guidelines development group applies the GRADE Evidence -to-Decision frameworks to make recommendations that are made available on the European Commission Web site . ( Reproduced from reference 15 , with permission from Schnemann HJ . ) . GRADE = Grading of Recommendations Assessment , Development and Evaluation . Figure 2 . GRADE EtD frameworks . The GRADE EtD frameworks as available in the GRADE pro software ( www . grade pro.org ) . They help with structuring the entire guideline process into 4 sections and support the conduct of guideline group meetings , presentation , and implementation . They clarify the perspective that is taken by the guideline panel or decision maker and the type of question that is asked in the question section . The section on assessment includes the criteria if the problem is a priority , the balance of health benefits and harms , values and preferences related to the outcomes , cost , re sources and cost-effectiveness , equity , acceptability , and feasibility . Conclusions provide the decision or recommendation with a justification and implementation , as well as research considerations . The presentation function supports the conduct of guideline group meetings and facilitates the output of EtD frameworks to other implementation tools , such as Web sites , h and -held apps , and interactive decision aids . EtD = Evidence to Decision ; GRADE = Grading of Recommendations Assessment , Development and Evaluation ; HTA = health technology assessment ; PICO = population , intervention , comparators , and outcomes . Figure 3 . Approach to guideline development used by the European Commission Initiative on Breast Cancer . The European Commission JRC has oversight of the organization , budgeting , planning , and training . The JRC also manages conflicts of interest , documents all aspects of the work , and manages the membership and group processes . The guideline development group and JRC formulate the questions and work with the systematic review team on identifying and assessing the evidence . The guidelines development group is responsible for developing the recommendations . The JRC is responsible for most other aspects as described in the figure under dissemination , implementation , and updating . JRC = Joint Research Centre ; PICO = population , intervention , comparator , and outcomes . ( Reproduced with adaptation to the JRC process from CONTEXT The findings of systematic review s ( SRs ) and meta-analyses ( MAs ) are used for clinical decision making . The European Association of Urology has committed increasing re sources into the development of high quality clinical guidelines based on such SRs and MAs . OBJECTIVE In this paper , we have summarised the process of conducting SRs for underpinning clinical practice guidelines under the auspices of the European Association of Urology Guidelines Office . EVIDENCE ACQUISITION The process involves explicit methods and the findings should be reproducible . When conducting a SR , the essential first step is to formulate a clear and answerable research question . An extensive literature search lays the foundation for evidence synthesis . Data are extracted independently by two review ers and any disagreements are resolved by discussion or arbitration by a third review er . EVIDENCE SYNTHESIS In SRs , data for particular outcomes in individual r and omised controlled trials may be combined statistically in a meta- analysis to increase power when the studies are similar enough . Biases in studies included in a SR/MA can lead to either an over estimation or an under estimation of true intervention effect size , result ing in heterogeneity in outcome between studies . A number of different tools are available such as Cochrane Risk of Bias assessment tool for r and omised controlled trials . In circumstances where there is too much heterogeneity , or when a review has included nonr and omised comparative studies , it is more appropriate to conduct a narrative synthesis . The GRADE tool for assessing quality of evidence strives to be a structured and transparent system , which can be applied to all evidence , regardless of quality . A SR not only identifies , evaluates , and summarises the best available evidence , but also the gaps to be targeted by future studies . CONCLUSIONS SRs and MAs are integral in developing sound clinical practice guidelines and recommendations . PATIENT SUMMARY Clinical practice guidelines should be evidence based , and systematic review s and meta-analyses are essential in their production . We have discussed the key steps of conducting systematic review s and meta-analyses in this paper A data base of 327 patients with advanced Renal Cell Carcinoma ( RCC ) has been analyzed in order to identify potential baseline prognostic factors predicting for survival , following recombinant Interleukin-2 treatment ( rIL-2 ) . All patients received a continuous infusion ( CIV ) . Eligibility criteria were uniform across studies , and included patients with an ambulatory performance status ( PS ) , measurable disease , no CNS metastases , and no major organ compromise . Multivariate analyses identified baseline PS ( ECOG 0 vs. 1 ) , time from diagnosis to treatment ( DTI greater than 24 months vs. less than or equal to 24 months ) , and the number of metastatic sites ( 1 vs. greater than or equal to 2 , where lung , bone and other sites are considered as separate sites ) as important predictors for survival . Patients can be classified into 4 subgroups , which are a function of the number of risk factors present . Median survival for each subgroup is 28 , 17 , 10 and 5 months , respectively . The model was vali date d in an independent cohort of 125 patients with RCC treated with subcutaneous ( s/c ) rIL-2 , and predicted for survival accurately . By determining in which risk group category patients may fall , treating physicians may be better equipped to decide on patient management . The model may also be of value in order to stratify patients in r and omized clinical trials BACKGROUND Currently two pretreatment prognostic models with limited accuracy ( 65 - 67 % ) can be used to predict survival in patients with localized renal cell carcinoma ( RCC ) . OBJECTIVE We set out to develop a more accurate pretreatment model for predicting RCC-specific mortality after nephrectomy for all stages of RCC . DESIGN , SETTING , AND PARTICIPANTS The data originated from a series of prospect ively recorded contemporary cases of patients treated with radical or partial nephrectomy between 1984 and 2006 . Model development was performed using data from 2474 patients from five centers and external validation was performed using data from 1972 patients from seven centers . MEASUREMENTS The probability of RCC-specific mortality was modeled using Cox regression . The significance of the predictors was confirmed using competing risks analyses , which account for mortality from other causes . RESULTS AND LIMITATIONS Median follow-up in patients who did not die of RCC-specific causes was 4.2 yr and 3.5 yr in the development and validation cohorts , respectively . The freedom from cancer-specific mortality rates in the nomogram development cohort were 75.4 % at 5 yr after nephrectomy and 68.3 % at 10 yr after nephrectomy . All variables except gender achieved independent predictor status . In the external validation cohort the nomogram predictions were 88.1 % accurate at 1 yr , 86.8 % accurate at 2 yr , 86.8 % accurate at 5 yr , and 84.2 % accurate at 10 yr . CONCLUSIONS Our model substantially exceeds the accuracy of the existing pretreatment models . Consequently , the proposed nomogram-based predictions may be used as benchmark data for pretreatment decision making in patients with various stages of RCC Introduction Bladder cancer ( BC ) is a common malignancy and one of the most expensive to manage . Radical cystectomy ( RC ) with pelvic lymphadenectomy is a gold st and ard treatment for high-risk BC . Reductions in morbidity and mortality from RC may be achieved through robot-assisted RC ( RARC ) . Prospect i ve comparisons between open RC ( ORC ) and RARC have been limited by sample size , use of extracorporeal reconstruction and use of outcomes important for ORC . Conversely , while RARC is gaining in popularity , there is little evidence to suggest it is superior to ORC . We are undertaking a prospect i ve r and omised controlled trial ( RCT ) to compare RARC with intracorporeal reconstruction ( iRARC ) and ORC using multimodal outcomes to explore qualitative and quantitative recovery after surgery . Methods and analysis iROC is a multicentre prospect i ve RCT in English National Health Service ( NHS ) cancer centres . We will r and omise 320 patients undergoing RC to either iRARC or ORC . Treatment allocation will occur after trial entry and consent . The primary outcome is days alive and out of hospital within the first 90 days from surgery . Secondary outcomes will measure functional recovery ( activity trackers , chair-to-st and tests and health related quality of life ( HRQOL ) question naires ) , morbidity ( complications and readmissions ) , cost-effectiveness ( using EuroQol-5 Domain-5 levels ( EQ-5D-5L ) and unit costs ) and surgeon fatigue . Patients will be analysed according to intention to treat . The primary outcome will be transformed and analysed using regression . All statistical assumptions will be investigated . Secondary outcomes will be analysed using appropriate regression methods . An internal feasibility study of the first 30 patients will evaluate recruitment rates , acceptance of r and omised treatment choice , compliance outcome collection and to revise our sample size . Ethics and dissemination The study has ethical approval ( REC reference 16/NE/0418 ) . Findings will be made available to patients , clinicians , funders and the NHS through peer- review ed publications , social media and patient support groups . Trial registration numbers IS RCT N13680280 and NCT03049410 PURPOSE Acute uncomplicated urinary tract infection is a common and costly disorder in women . To reduce potentially unnecessary expense and inconvenience , a large staff-model health maintenance organization instituted a telephone-based clinical practice guideline for managing presumed cystitis in which women 18 to 55 years of age who met specific criteria were managed without a clinic visit or laboratory testing . We sought to evaluate the effects of the guideline . SUBJECTS AND METHODS We performed a population -based , before- and -after study with concurrent control groups at 24 primary care clinics to assess the effect of guideline implementation on re source utilization and on the occurrence of potential adverse outcomes . We measured the proportion of patients with presumed uncomplicated cystitis who had a return office visit for cystitis or sexually transmitted disease or who developed pyelonephritis within 60 days of the initial diagnosis .  Relative risks ( RR ) and 95 % confidence intervals ( CI ) were estimated , adjusting for the effects of clustering within clinics . RESULTS A total of 3,889 eligible patients with presumed acute uncomplicated cystitis were evaluated . As compared with baseline , guideline implementation significantly decreased the proportion of patients with presumed cystitis who received urinalysis ( RR = 0.75 ; CI , 0.70 to 0.80 ) , urine culture ( RR = 0.73 ; CI , 0.68 to 0.79 ) , and an initial office visit ( RR = 0.67 ; CI , 0.62 to 0.73 ) , while increasing the proportion who received a guideline -recommended antibiotic 2.9-fold ( CI , 2.4 to 3.7-fold ) . In the prospect i ve comparison of the 22 intervention and two control clinics , the guideline decreased the proportion of patients who had urinalyses performed ( RR = 0.80 ; CI , 0.65 to 0.98 ) and increased the proportion of patients who were prescribed a guideline -recommended antibiotic ( RR = 1.53 ; CI , 1.01 to 2.33 ) . Adverse outcomes did not increase significantly in either comparison . CONCLUSION Guideline use decreased laboratory utilization and overall costs while maintaining or improving the quality of care for patients who were presumptively treated for acute uncomplicated cystitis Previous studies suggest that obesity is related to increased risk of renal cell carcinoma ( RCC ) ; however , only a few studies report on measures of central vs. peripheral adiposity . We examined the association between anthropometric measures , including waist and hip circumference  and  RCC risk among 348,550 men and women free of cancer at baseline from 8 countries of the European Prospect i ve Investigation into Cancer and Nutrition ( EPIC ) . During 6.0 years of follow-up we identified 287 incident cases of RCC . Relative risks were calculated using Cox regression , stratified by age and study center and adjusted for smoking status , education , alcohol consumption , physical activity , menopausal status , and hormone replacement therapy use . Among women , an increased risk of RCC was conferred by body weight ( relative risk [ RR ] in highest vs. lowest quintile = 2.13 ; 95 % confidence interval [ CI ] = 1.16 - 3.90 ; p-trend = 0.003 ) , body mass index ( BMI ) ( RR = 2.25 ; 95 % CI = 1.14 - 4.44 ; p-trend = 0.009 ) , and waist ( RR = 1.67 ; 95 % CI = 0.94 - 2.98 ; p-trend = 0.003 ) and hip circumference ( RR = 2.30 ; 95 % CI = 1.22 - 4.34 ; p-trend = 0.01 ) ; however , waist and hip circumference were no longer significant after controlling for body weight . Among men , hip circumference ( RR = 0.44 ; 95 % CI = 0.20 - 0.98 ; p-trend = 0.03 ) was related significantly to decreased RCC risk only after accounting for body weight . Height was not related significantly to RCC risk . Our findings suggest that obesity is related to increased risk of RCC irrespective of fat distribution among women , whereas low hip circumference is related to increased RCC risk among men . Our data give further credence to public health efforts aim ing to reduce the prevalence of obesity to prevent RCC , in addition to other chronic diseases Objective . To evaluate the efficacy of autologous cytokine-induced killer ( CIK ) cells in patients with renal cell carcinoma ( RCC ) . Methods . 20 patients diagnosed with TNM stage I or II RCC were r and omly divided into two groups , a CIK cell treatment group and a control group . The endpoint was progression-free survival ( PFS ) evaluated by Kaplan-Meier analyses . Results . CD3 + , CD3+/CD8 + , CD3+/CD4 + , and CD3+/CD56 + levels increased after CIK cell culture ( P < 0.01 ) . The median PFS in CIK cell treatment group was significantly longer than that in control group ( PFS , 32.2 months versus 21.6 months ; log-rank , P = 0.032 ) , all patients were alive during the course of followup , and there are no statistically significant differences between two groups in OS ( log-rank , P = 0.214 ) . Grade III or greater adverse events were not observed . Conclusions . CIK cells treatment could prolong survival in patients with RCC after radical nephrectomy and showed acceptable curative effect with potential enhancement of cellular immune function . This trial is registered with Clinical trials.gov NCT01799083 OBJECTIVE Modern imaging modalities increase the detection of small ( < or=4 cm ) renal tumors , of which about 20 % are benign . As a result , minimal invasive treatments , such as radiofrequency ablation and cryotherapy , and surveillance strategies are gaining popularity . Information that would be helpful when choosing the most appropriate management strategy for this patient group could be obtained from pretherapeutic image-guided biopsy . METHODS Under computed tomography (CT)-fluoroscopic guidance  78 patients with solid renal tumors prospect ively underwent 18-gauge core biopsy . In addition , using the same sheath , fine-needle aspiration was taken in 44 patients and analyzed cytologically . The renal masses were subsequently removed surgically and evaluated histologically . RESULTS Mean patient age was 63+/-13.5 yr ; mean tumor size was 4+/-1.8 cm . The sensitivity of  core biopsy and fine-needle aspiration for the detection of renal cell carcinoma ( RCC ) was 93.5 % and 90.6 % , respectively ; Fuhrman grade was correctly predicted in 76 % and 28 % and the correct histologic subtype was identified 91 % and 86 % , respectively . Cytology from fine-needle aspiration revealed a sensitivity in detecting malignant and benign lesions of 100 % and 75 % , respectively . Two of the renal tumors diagnosed as oncocytomas on core biopsy were hybrid tumors with scattered areas of oncocytomas and chromophobe RCC . Complications of CT-guided biopsy included one marginal pneumothorax , which resolved under conservative management , and four small perirenal hematomas detected at follow-up ultrasonography not requiring further therapy . CONCLUSION CT-guided percutaneous preoperative renal tumor biopsy had a high diagnostic accuracy , particularly in predicting malignancy OBJECTIVE To evaluate the 5-year results of the following trimodal therapy for treatment of some selected cases of muscle invasive bladder cancer . MATERIAL S AND METHODS In this prospect i ve study , we included 104 patients with transitional cell carcinoma ( TCC ) ( T2 and T3a , N0 , M0 ) who were amenable to complete transurethral resection . All patients received adjuvant chemo-radiotherapy ( CRT ) in the form of gemcitabine and cisplatin and conventional radiotherapy after the maximum resection of their tumors . Two weeks later , all cases had radiologic and cystoscopic evaluation . The patients who showed no evidence of the bladder tumors [ complete response ( CR ) ] went on to complete the CRT , while those with recurrent invasive tumors did not receive any more CRT and were assigned to have salvage cystectomy . Thereafter , all patients were subjected to a regular follow-up . RESULTS This trimodal therapy was well tolerated in most of cases with no severe acute toxicities . Complete response was achieved in 78.8 % of cases after the initial CRT , and tumor grade was found to be the most significant risk factor to predict this response ( P = 0.004 ) . With a median follow-up of 71 months for patients with initial CR , 16.2 % of cases showed muscle invasive recurrences , and multifocality was the only significant risk factor for their development ( P = 0.003 ) . Meanwhile , superficial recurrences were detected in 8.1 % of cases with initial CR and were successfully treated with transurethral resection and intravesical bacillus Calmette-Guerin ( BCG ) . On the other h and , we reported distant metastasis in 24.3 % of patients with initial CR , and tumor grade , stage and multifocality were the most significant risk factors for this complication ( P = 0.002 , 0.031 , 0.006 ) . No cases of contracted bladder or late gastrointestinal complications were demonstrated in this series . The 5-year overall survival rate for patients with initial CR was 67.6 % , and for all the patients in this study it was 59.4 % . CONCLUSIONS This trimodal therapy can be considered as a treatment option for patients with localized muscle invasive TCC . The best c and i date s for such therapy are those with solitary T2 , low grade tumors that are amenable to complete transurethral resection Organ preservation has been investigated in patients with muscle‐invasive bladder carcinoma over the past decades as an alternative to radical cystectomy . The majority of studies reported that trimodal schedules , including transurethral resection of bladder tumor ( TURB ) , radiotherapy ( RT ) , and chemotherapy , are a feasible and safe organ‐sparing approach without deferring the survival probability . However , to the authors ' knowledge the best combination of RT and chemotherapy has yet to be well defined . The current study evaluated the long‐term results of a schedule of concurrent cisplatin and 5‐fluorouracil ( 5‐FU ) administered as protracted intravenous infusions ( PVI ) during hyperfractionated radiotherapy ( HFRT ) with organ‐sparing intent in patients with infiltrating transitional cell carcinoma of the bladder ( TCCB )
The 2014 guideline has been up date d by a multidisciplinary panel using the highest method ological st and ards , and provides the best and most reliable contemporary evidence base for RCC management .
CONTEXT The European Association of Urology Guideline Panel for Renal Cell Carcinoma ( RCC ) has prepared evidence -based guidelines and recommendations for RCC management .
OBJECTIVES To provide an up date of the 2010 RCC guideline based on a st and ardised methodology that is robust , transparent , reproducible , and reliable .