Influence and Impact of Cognitive Trajectories on Outcome in Patients Undergoing Radical Cystectomy: an Observational Study

OBJECTIVES To evaluate cognitive trajectories after radical cystectomy and their impact on surgical outcomes, including urinary continence. METHODS Ninety patients received cognitive testing using the Mini Mental State Exam (MMSE) before open radical cystectomy as well as 3 days and 2 weeks after surgery. Based on MMSE changes ≥3 points between the three time points, five cognitive trajectories emerged (stable cognition, persistent or transient deterioration or persistent or transient improvement). Surgical outcomes were assessed 90 days, 6 months and 1 year postoperatively. RESULTS Mean age was 67.9 ± 9.3 years (range 40 - 88 years). Sixty-six patients (73.3%) had stable cognition, nine patients (10.0%) persistent and seven patients (7.8%) transient deterioration, five patients (5.6%) persistent and three patients (3.3%) transient improvement. An impaired preoperative cognition was the only significant risk factor of short-term cognitive deterioration (OR adjusted for age and sex 9.4, 95%CI 1.6-56.5, p=0.014). Cognition showed no associations with 1-year mortality, 90-day complication rate, cancer progression or duration of in-hospital stay. Patients with transient or persistent cognitive deterioration had an increased risk for nighttime incontinence (OR adjusted for age and sex 5.1, 95%CI 1.1-22.4, p=0.032). CONCLUSIONS In this study, the majority of patients showed stable cognition after major abdominopelvic surgery. Cognitive deterioration occurred in a small subgroup of patients, and an impaired preoperative cognition was the only significant risk factor. Postoperative cognitive deterioration was associated with nighttime incontinence.

Incorporation of tissue-based genomic biomarkers into localized prostate cancer clinics.

Localized prostate cancer (PCa) is a clinically heterogeneous disease, which presents with variability in patient outcomes within the same risk stratification (low, intermediate or high) and even within the same Gleason scores. Genomic tools have been developed with the purpose of stratifying patients affected by this disease to help physicians personalize therapies and follow-up schemes. This review focuses on these tissue-based tools. At present, four genomic tools are commercially available: Decipher™, Oncotype DX®, Prolaris® and ProMark®. Decipher™ is a tool based on 22 genes and evaluates the risk of adverse outcomes (metastasis) after radical prostatectomy (RP). Oncotype DX® is based on 17 genes and focuses on the ability to predict outcomes (adverse pathology) in very low-low and low-intermediate PCa patients, while Prolaris® is built on a panel of 46 genes and is validated to evaluate outcomes for patients at low risk as well as patients who are affected by high risk PCa and post-RP. Finally, ProMark® is based on a multiplexed proteomics assay and predicts PCa aggressiveness in patients found with similar features to Oncotype DX®. These biomarkers can be helpful for post-biopsy decision-making in low risk patients and post-radical prostatectomy in selected risk groups. Further studies are needed to investigate the clinical benefit of these new technologies, the financial ramifications and how they should be utilized in clinics.