ID

7481

Description

S1011 Intra-Op Surgical Assessment Form Standard Versus Extended LND (#10689) Standard or Extended Pelvic Lymphadenectomy in Treating Patients Undergoing Surgery for Invasive Bladder Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=940453E3-434E-BBC7-E040-BB89AD431F9F

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=940453E3-434E-BBC7-E040-BB89AD431F9F

Keywords

Versions (2)
  1. 8/26/12 8/26/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
Uploaded on

January 9, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Bladder Cancer NCT01224665 Treatment - S1011 Intra-Op Surgical Assessment Form Standard Versus Extended LND (#10689) - 3153877v1.0

English

Instructions: To be completed by attending surgeon. Please complete post surgery, on the day of surgery. Surgeons should be provided with this form prior to the surgical event. All dates are MONTH, DAY, YEAR. Explain any blank fields or blank dates in the Comments section. Place an X in appropriate boxes. Circle AMENDED items in red and write AMENDED across top of form

1 forms  
Header
Description

Header

SWOG Patient ID
Description

Trial subject ID SWOG

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C1519429
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25699
SWOG Study No.
Description

Protocol ID SWOG

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3274381
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C1519429
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25699
Registration Step
Description

Registration Number

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C1514821
NCI Thesaurus ObjectClass
C25646
UMLS CUI-2
C0237753
NCI Thesaurus Property
C16154
NCI Thesaurus ValueDomain-2
C16154
Patient Initials (L, F M)
Description

Patient Initials

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Protocol Surgery Date (MM DD YYYY)
Description

ProtocolSurgeryDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C15329
UMLS 2011AA ObjectClass
C0543467
NCI Thesaurus ObjectClass-2
C42651
UMLS 2011AA ObjectClass-2
C0442711
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ValueDomain-2
C25367
Institution/Affiliate
Description

Institution Name

Data type

text

Alias
NCI Thesaurus ObjectClass
C25454
UMLS CUI-1
C1301943
NCI Thesaurus ObjectClass-2
C21541
NCI Thesaurus Property
C25364
NCI Thesaurus ValueDomain
C25191
NCI Thesaurus ValueDomain-2
C21541
Physician
Description

Investigator Name

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2826892
NCI Thesaurus Property
C25364
NCI Thesaurus ObjectClass
C17089
NCI Thesaurus ObjectClass-2
C25644
Participating Group Name
Description

Participating Group

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2347449
NCI Thesaurus ObjectClass
C25608
NCI Thesaurus ObjectClass-2
C17005
NCI Thesaurus Property
C25364
Participating Group Study No.
Description

Study Number Participating Group

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3274381
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C2347449
NCI Thesaurus Property
C25608
NCI Thesaurus Property-2
C25364
Participating Group Patient ID
Description

Trial subject ID Participating Group

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C2347449
NCI Thesaurus Property
C25608
NCI Thesaurus Property-2
C25364
Intra-operative Extent-of-disease Assessment
Description

Intra-operative Extent-of-disease Assessment

Clinical T4b (fixed or involvement of pelvic side wall, abdominal wall, or adjacent viscera e.g. colon, small bowel)
Description

BladderCarcinomaTStagePresentInd-2

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus Property
C25626
UMLS 2011AA Property
C0150312
NCI Thesaurus ObjectClass
C4912
UMLS 2011AA ObjectClass
C0699885
NCI Thesaurus Property-2
C25728
UMLS 2011AA Property-2
C0475455
Specify location of tumor (select all that apply)
Description

BladderMalignantNeoplasmAdjacentTissueMetastaticInvolvementSite

Data type

text

Alias
NCI Thesaurus ObjectClass
C12414
UMLS 2011AA ObjectClass
C0005682
NCI Thesaurus ObjectClass-2
C9305
UMLS 2011AA ObjectClass-2
C0006826
NCI Thesaurus Property
C14174
UMLS 2011AA Property
C0036525
NCI Thesaurus Property-2
C12801
UMLS 2011AA Property-2
C0040300
NCI Thesaurus Property-3
C25548
UMLS 2011AA Property-3
C1314939
NCI Thesaurus Property-4
C25408
UMLS 2011AA Property-4
C0205117
NCI Thesaurus ValueDomain
C13717
UMLS 2011AA ValueDomain
C1515974
Other specify
Description

BladderMalignantNeoplasmAdjacentTissueMetastaticInvolvementSpecify

Data type

text

Alias
NCI Thesaurus ObjectClass
C12414
UMLS 2011AA ObjectClass
C0005682
NCI Thesaurus ObjectClass-2
C9305
UMLS 2011AA ObjectClass-2
C0006826
NCI Thesaurus Property
C14174
UMLS 2011AA Property
C0036525
NCI Thesaurus Property-2
C12801
UMLS 2011AA Property-2
C0040300
NCI Thesaurus Property-3
C25548
UMLS 2011AA Property-3
C1314939
NCI Thesaurus Property-4
C25408
UMLS 2011AA Property-4
C0205117
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Gross Lymphadenopathy (Note: if in the extended template, must be frozen)
Description

AbnormalLymphNodePresentInd-2

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus Property
C25626
UMLS 2011AA Property
C0150312
NCI Thesaurus ObjectClass
C25401
UMLS 2011AA ObjectClass
C0205161
NCI Thesaurus ObjectClass-2
C12745
UMLS 2011AA ObjectClass-2
C0024204
Location of gross lymphadenopathy (Please complete if the answer was "Yes" to Gross Lymphadenopathy. Select all that apply)
Description

BladderCarcinomaDiseaseExtentType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus Property
C2991
UMLS 2011AA Property
C0012634
NCI Thesaurus ObjectClass
C4912
UMLS 2011AA ObjectClass
C0699885
NCI Thesaurus Property-2
C25332
UMLS 2011AA Property-2
C0439792
Pathologic Lymph Node Assessment (if selected please specify)
Description

LymphNodePathologicInvolvementType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus Property
C25610
UMLS 2011AA Property
C1521733
NCI Thesaurus ObjectClass
C12745
UMLS 2011AA ObjectClass
C0024204
NCI Thesaurus Property-2
C25548
UMLS 2011AA Property-2
C1314939
Description Of How Nodal Packets Were Submitted To Your Pathologist
Description

Description Of How Nodal Packets Were Submitted To Your Pathologist

Did the participant have surgery per protocol treatment?
Description

ProtocolSurgeryPerformedInd-3

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus ObjectClass
C15329
UMLS 2011AA ObjectClass
C0543467
NCI Thesaurus ObjectClass-2
C42651
UMLS 2011AA ObjectClass-2
C0442711
Reason surgery not performed (If no)
Description

SurgeryNotPerformedReason

Data type

text

Alias
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
NCI Thesaurus Property
C25594
UMLS 2011AA Property
C1518422
NCI Thesaurus Property-2
C38000
UMLS 2011AA Property-2
C0884358
NCI Thesaurus ObjectClass
C15329
UMLS 2011AA ObjectClass
C0543467
Extent of pelvic lymph node dissection
Description

PelvicLymphNodeDissectionType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C12745
UMLS 2011AA ObjectClass
C0024204
NCI Thesaurus Property
C15227
UMLS 2011AA Property
C0012737
NCI Thesaurus ObjectClass-2
C25399
UMLS 2011AA ObjectClass-2
C0030797
Cranial extent of dissection (If "Extended,")
Description

BladderCarcinomaNodalDissectionExtentType

Data type

text

Alias
NCI Thesaurus ObjectClass
C4912
UMLS 2011AA ObjectClass
C0699885
NCI Thesaurus Property
C15227
UMLS 2011AA Property
C0012737
NCI Thesaurus Property-2
C25323
UMLS 2011AA Property-2
C0443268
NCI Thesaurus Property-3
C25332
UMLS 2011AA Property-3
C0439792
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Specify
Description

PatientSurgicalResectionAnatomicSiteSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25698
NCI Thesaurus Property-2
C15232
UMLS 2011AA Property
C0728940
Surgical Assessment Of Nodal Dissection
Description

Surgical Assessment Of Nodal Dissection

Which lymph node areas were dissected (Please check all that apply Boundaries for "pelvic" are defined by the Standard node dissection)
Description

LymphNodeDissectionAnatomicSite

Data type

text

Alias
NCI Thesaurus ValueDomain
C13717
UMLS 2011AA ValueDomain
C1515974
NCI Thesaurus ObjectClass
C12745
UMLS 2011AA ObjectClass
C0024204
NCI Thesaurus Property
C15227
UMLS 2011AA Property
C0012737
Other specify
Description

LymphNodeDissectionSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C12745
UMLS 2011AA ObjectClass
C0024204
NCI Thesaurus Property
C15227
UMLS 2011AA Property
C0012737
Reconstruction
Description

Reconstruction

Surgical Reconstruction
Description

SurgeryReconstructionType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C15329
UMLS 2011AA ObjectClass
C0543467
NCI Thesaurus Property
C25351
UMLS 2011AA Property
C0524865
Other specify
Description

SurgeryReconstructionSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C15329
UMLS 2011AA ObjectClass
C0543467
NCI Thesaurus Property
C25351
UMLS 2011AA Property
C0524865
Anastomosis Performed Type
Description

SurgicalProcedureAnastomosisPerformedType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus Property
C15609
UMLS 2011AA Property
C0677554
NCI Thesaurus Property-2
C38000
UMLS 2011AA Property-2
C0884358
NCI Thesaurus ObjectClass
C15329
UMLS 2011AA ObjectClass
C0543467
Operative Information
Description

Operative Information

Duration of Surgery (skin to skin, in hrs: minutes)
Description

Duration of Surgery

Data type

float

Alias
NCI Thesaurus ObjectClass
C15329
UMLS CUI-1
C0488629
NCI Thesaurus Property
C25275
NCI Thesaurus ValueDomain
C25330
Estimated blood loss (ml)
Description

TotalEstimateBloodLossAmount

Data type

float

Alias
NCI Thesaurus ObjectClass
C25304
UMLS 2011AA ObjectClass
C0439810
NCI Thesaurus ObjectClass-2
C25498
UMLS 2011AA ObjectClass-2
C0750572
NCI Thesaurus ObjectClass-3
C12434
UMLS 2011AA ObjectClass-3
C0229664
NCI Thesaurus Property
C25559
UMLS 2011AA Property
C1517945
NCI Thesaurus ValueDomain
C25417
Total units whole blood (in units equivalent to 500 ml whole blood)
Description

WholeBloodTransfusionCount

Data type

float

Alias
NCI Metathesaurus ObjectClass
C0370231
NCI Thesaurus ValueDomain
C25463
UMLS 2011AA ValueDomain
C0750480
NCI Thesaurus Property
C25256
UMLS 2011AA Property
C1265611
NCI Thesaurus ObjectClass
C15408
Total units PRBC (in units equivalent to 500 ml whole blood)
Description

PackedRedBloodCellTransfusionReceivedUnitCount

Data type

float

Alias
NCI Thesaurus ValueDomain
C44278
UMLS 2011AA ValueDomain
C0439148
NCI Thesaurus Property
C25639
UMLS 2011AA Property
C1514756
NCI Thesaurus ValueDomain-2
C25463
UMLS 2011AA ValueDomain-2
C0750480
NCI Thesaurus ObjectClass
C15409
UMLS 2011AA ObjectClass
C0199962
Total units fresh frozen plasma (in units equivalent to 500 ml whole blood)
Description

FreshFrozenPlasmaTransfusionReceivedUnitCount

Data type

float

Alias
NCI Metathesaurus ObjectClass
C0016709
NCI Thesaurus ObjectClass
C15408
NCI Thesaurus Property
C25639
UMLS 2011AA Property
C1514756
NCI Thesaurus ValueDomain
C44278
UMLS 2011AA ValueDomain
C0439148
NCI Thesaurus ValueDomain-2
C25463
UMLS 2011AA ValueDomain-2
C0750480
Total units platelets (in units equivalent to 500 ml whole blood)
Description

PlateletTransfusionReceivedUnitCount

Data type

float

Alias
NCI Thesaurus ValueDomain
C44278
UMLS 2011AA ValueDomain
C0439148
NCI Thesaurus Property
C25639
UMLS 2011AA Property
C1514756
NCI Thesaurus ValueDomain-2
C25463
UMLS 2011AA ValueDomain-2
C0750480
NCI Thesaurus ObjectClass
C15366
UMLS 2011AA ObjectClass
C0086818
Intraoperative vascular injury
Description

AdverseEventIntraoperativeComplicationAnatomicSitePresentInd-2

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C41331
UMLS 2011AA ObjectClass
C0877248
NCI Thesaurus Property
C13717
UMLS 2011AA Property
C1515974
NCI Thesaurus Property-2
C25626
UMLS 2011AA Property-2
C0150312
NCI Thesaurus Property-3
C34735
UMLS 2011AA Property-3
C0021890
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Specify location (If yes)
Description

AdverseEventIntraoperativeComplicationOtherAnatomicSitePresentAdverseEventSpecify

Data type

text

Alias
NCI Thesaurus ObjectClass
C41331
UMLS 2011AA ObjectClass
C0877248
NCI Thesaurus Property
C13717
UMLS 2011AA Property
C1515974
NCI Thesaurus Property-2
C17649
UMLS 2011AA Property-2
C0205394
NCI Thesaurus Property-3
C25626
UMLS 2011AA Property-3
C0150312
NCI Thesaurus Property-4
C34735
UMLS 2011AA Property-4
C0021890
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Perioperative DVT prophylaxis (other than sequential compression device)
Description

Anticoagulation Drugs

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS CUI-1
C0003280
NCI Thesaurus ObjectClass
C263
NCI Thesaurus ObjectClass-2
C25730
NCI Thesaurus Property
C25382
Other, specify
Description

DVT prevention, specify

Data type

text

Alias
NCI Thesaurus ObjectClass
C49343
UMLS CUI-1
C0853245
NCI Thesaurus ObjectClass-2
C15368
NCI Thesaurus ObjectClass-3
C15405
NCI Thesaurus Property
C25639
UMLS CUI-2
C1521902
NCI Thesaurus ValueDomain
C25685
Epidural anesthesia employed
Description

EpiduralAnestheticAgentAdministeredInd-2

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C245
UMLS 2011AA ObjectClass
C0002932
NCI Thesaurus ObjectClass-2
C15683
UMLS 2011AA ObjectClass-2
C1526986
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Nerve sparing
Description

NervePreservationSurgicalProcedurePerformedInd-2

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C15329
UMLS 2011AA ObjectClass
C0543467
NCI Thesaurus ObjectClass-2
C12466
UMLS 2011AA ObjectClass-2
C0027740
NCI Thesaurus ObjectClass-3
C52243
UMLS 2011AA ObjectClass-3
C0033085
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Laterality (Please complete if the answer was "yes" to nerve sparing. Select all that apply)
Description

NervePreservationSurgicalProcedureLateralityType

Data type

text

Alias
NCI Thesaurus ObjectClass
C15329
UMLS 2011AA ObjectClass
C0543467
NCI Thesaurus ObjectClass-2
C12466
UMLS 2011AA ObjectClass-2
C0027740
NCI Thesaurus ObjectClass-3
C52243
UMLS 2011AA ObjectClass-3
C0033085
NCI Thesaurus Property
C25185
UMLS 2011AA Property
C0332304
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Nerve-sparing status (if selected please specify)
Description

NervePreservationSurgicalProcedurePerformedStatus

Data type

text

Alias
NCI Thesaurus ObjectClass
C15329
UMLS 2011AA ObjectClass
C0543467
NCI Thesaurus ObjectClass-2
C12466
UMLS 2011AA ObjectClass-2
C0027740
NCI Thesaurus ObjectClass-3
C52243
UMLS 2011AA ObjectClass-3
C0033085
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus ValueDomain
C25688
UMLS 2011AA ValueDomain
C0449438
Photographic documentation (required per protocol)
Description

PatientPhotographMalignantNeoplasmAssessmentInd-2

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25367
NCI Thesaurus Property-2
C9305
UMLS 2011AA Property
C0006826
NCI Thesaurus Property-3
C86035
UMLS 2011AA Property-2
C0441468
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Specify
Description

EvaluationNotDoneReasonSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C25214
UMLS 2011AA ObjectClass
C0220825
NCI Thesaurus Property
C49484
UMLS 2011AA Property
C1272696
NCI Thesaurus Property-2
C25365
UMLS 2011AA Property-2
C0678257
Comments
Description

Comments

Comments
Description

Research Comments

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI-1
C0947611
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
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Similar models

Instructions: To be completed by attending surgeon. Please complete post surgery, on the day of surgery. Surgeons should be provided with this form prior to the surgical event. All dates are MONTH, DAY, YEAR. Explain any blank fields or blank dates in the Comments section. Place an X in appropriate boxes. Circle AMENDED items in red and write AMENDED across top of form

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header
Trial subject ID SWOG
Item
SWOG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1519429 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25699 (NCI Thesaurus Property-2)
Protocol ID SWOG
Item
SWOG Study No.
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1519429 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25699 (NCI Thesaurus Property-2)
Registration Number
Item
Registration Step
text
C25337 (NCI Thesaurus ValueDomain)
C1514821 (UMLS CUI-1)
C25646 (NCI Thesaurus ObjectClass)
C0237753 (UMLS CUI-2)
C16154 (NCI Thesaurus Property)
C16154 (NCI Thesaurus ValueDomain-2)
Patient Initials
Item
Patient Initials (L, F M)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
ProtocolSurgeryDate
Item
Protocol Surgery Date (MM DD YYYY)
date
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C42651 (NCI Thesaurus ObjectClass-2)
C0442711 (UMLS 2011AA ObjectClass-2)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
Institution Name
Item
Institution/Affiliate
text
C25454 (NCI Thesaurus ObjectClass)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
C25191 (NCI Thesaurus ValueDomain)
C21541 (NCI Thesaurus ValueDomain-2)
Investigator Name
Item
Physician
text
C25191 (NCI Thesaurus ValueDomain)
C2826892 (UMLS CUI-1)
C25364 (NCI Thesaurus Property)
C17089 (NCI Thesaurus ObjectClass)
C25644 (NCI Thesaurus ObjectClass-2)
Participating Group
Item
Participating Group Name
text
C25191 (NCI Thesaurus ValueDomain)
C2347449 (UMLS CUI-1)
C25608 (NCI Thesaurus ObjectClass)
C17005 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
Study Number Participating Group
Item
Participating Group Study No.
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C2347449 (UMLS CUI-2)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Trial subject ID Participating Group
Item
Participating Group Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C2347449 (UMLS CUI-2)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Item Group
Intra-operative Extent-of-disease Assessment
BladderCarcinomaTStagePresentInd-2
Item
Clinical T4b (fixed or involvement of pelvic side wall, abdominal wall, or adjacent viscera e.g. colon, small bowel)
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C4912 (NCI Thesaurus ObjectClass)
C0699885 (UMLS 2011AA ObjectClass)
C25728 (NCI Thesaurus Property-2)
C0475455 (UMLS 2011AA Property-2)
Item
Specify location of tumor (select all that apply)
text
C12414 (NCI Thesaurus ObjectClass)
C0005682 (UMLS 2011AA ObjectClass)
C9305 (NCI Thesaurus ObjectClass-2)
C0006826 (UMLS 2011AA ObjectClass-2)
C14174 (NCI Thesaurus Property)
C0036525 (UMLS 2011AA Property)
C12801 (NCI Thesaurus Property-2)
C0040300 (UMLS 2011AA Property-2)
C25548 (NCI Thesaurus Property-3)
C1314939 (UMLS 2011AA Property-3)
C25408 (NCI Thesaurus Property-4)
C0205117 (UMLS 2011AA Property-4)
C13717 (NCI Thesaurus ValueDomain)
C1515974 (UMLS 2011AA ValueDomain)
CL.2
Code List
Specify location of tumor (select all that apply)
CL Item
Pelvic Sidewall (Pelvic sidewall)
CL Item
Abdominal Wall (Abdominal wall)
C77608 (NCI Thesaurus)
C0836916 (UMLS 2011AA)
CL Item
Rectosigmoid (Rectosigmoid)
CL Item
Other Specify (Other)
BladderMalignantNeoplasmAdjacentTissueMetastaticInvolvementSpecify
Item
Other specify
text
C12414 (NCI Thesaurus ObjectClass)
C0005682 (UMLS 2011AA ObjectClass)
C9305 (NCI Thesaurus ObjectClass-2)
C0006826 (UMLS 2011AA ObjectClass-2)
C14174 (NCI Thesaurus Property)
C0036525 (UMLS 2011AA Property)
C12801 (NCI Thesaurus Property-2)
C0040300 (UMLS 2011AA Property-2)
C25548 (NCI Thesaurus Property-3)
C1314939 (UMLS 2011AA Property-3)
C25408 (NCI Thesaurus Property-4)
C0205117 (UMLS 2011AA Property-4)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
AbnormalLymphNodePresentInd-2
Item
Gross Lymphadenopathy (Note: if in the extended template, must be frozen)
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C25401 (NCI Thesaurus ObjectClass)
C0205161 (UMLS 2011AA ObjectClass)
C12745 (NCI Thesaurus ObjectClass-2)
C0024204 (UMLS 2011AA ObjectClass-2)
Item
Location of gross lymphadenopathy (Please complete if the answer was "Yes" to Gross Lymphadenopathy. Select all that apply)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C2991 (NCI Thesaurus Property)
C0012634 (UMLS 2011AA Property)
C4912 (NCI Thesaurus ObjectClass)
C0699885 (UMLS 2011AA ObjectClass)
C25332 (NCI Thesaurus Property-2)
C0439792 (UMLS 2011AA Property-2)
CL.4
Code List
Location of gross lymphadenopathy (Please complete if the answer was "Yes" to Gross Lymphadenopathy. Select all that apply)
CL Item
Above Common Illiac Bifurcation (Above common illiac bifurcation)
CL Item
Below Common Illiac Bifurcation (Below common illiac bifurcation)
Item
Pathologic Lymph Node Assessment (if selected please specify)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25610 (NCI Thesaurus Property)
C1521733 (UMLS 2011AA Property)
C12745 (NCI Thesaurus ObjectClass)
C0024204 (UMLS 2011AA ObjectClass)
C25548 (NCI Thesaurus Property-2)
C1314939 (UMLS 2011AA Property-2)
CL.5
Code List
Pathologic Lymph Node Assessment (if selected please specify)
CL Item
Negative (negative)
C25247 (NCI Thesaurus)
C0205160 (UMLS 2011AA)
CL Item
Positive (positive)
C25246 (NCI Thesaurus)
C1446409 (UMLS 2011AA)
Item Group
Description Of How Nodal Packets Were Submitted To Your Pathologist
ProtocolSurgeryPerformedInd-3
Item
Did the participant have surgery per protocol treatment?
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C42651 (NCI Thesaurus ObjectClass-2)
C0442711 (UMLS 2011AA ObjectClass-2)
SurgeryNotPerformedReason
Item
Reason surgery not performed (If no)
text
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
C25594 (NCI Thesaurus Property)
C1518422 (UMLS 2011AA Property)
C38000 (NCI Thesaurus Property-2)
C0884358 (UMLS 2011AA Property-2)
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
Item
Extent of pelvic lymph node dissection
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C12745 (NCI Thesaurus ObjectClass)
C0024204 (UMLS 2011AA ObjectClass)
C15227 (NCI Thesaurus Property)
C0012737 (UMLS 2011AA Property)
C25399 (NCI Thesaurus ObjectClass-2)
C0030797 (UMLS 2011AA ObjectClass-2)
CL.7
Code List
Extent of pelvic lymph node dissection
CL Item
Protocol Defined Standard (Protocol defined Standard)
CL Item
Extended (Extended)
Item
Cranial extent of dissection (If "Extended,")
text
C4912 (NCI Thesaurus ObjectClass)
C0699885 (UMLS 2011AA ObjectClass)
C15227 (NCI Thesaurus Property)
C0012737 (UMLS 2011AA Property)
C25323 (NCI Thesaurus Property-2)
C0443268 (UMLS 2011AA Property-2)
C25332 (NCI Thesaurus Property-3)
C0439792 (UMLS 2011AA Property-3)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.8
Code List
Cranial extent of dissection (If "Extended,")
CL Item
Aorta Bifurcation (Aortic Bifurcation)
C90367 (NCI Thesaurus)
C12669 (NCI Thesaurus-2)
C0003483 (UMLS 2011AA)
CL Item
Between Aortic Bifurcation And Ima (Between Aortic Bifurcation and IMA)
CL Item
Inferior Mesenteric Artery (IMA)
CL Item
Above Inferior Mesenteric Artery (Above IMA)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
PatientSurgicalResectionAnatomicSiteSpecify
Item
Specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25698 (NCI Thesaurus Property)
C15232 (NCI Thesaurus Property-2)
C0728940 (UMLS 2011AA Property)
Item Group
Surgical Assessment Of Nodal Dissection
Item
Which lymph node areas were dissected (Please check all that apply Boundaries for "pelvic" are defined by the Standard node dissection)
text
C13717 (NCI Thesaurus ValueDomain)
C1515974 (UMLS 2011AA ValueDomain)
C12745 (NCI Thesaurus ObjectClass)
C0024204 (UMLS 2011AA ObjectClass)
C15227 (NCI Thesaurus Property)
C0012737 (UMLS 2011AA Property)
CL.9
Code List
Which lymph node areas were dissected (Please check all that apply Boundaries for "pelvic" are defined by the Standard node dissection)
CL Item
Right Pelvis (Right pelvic)
C25228 (NCI Thesaurus)
C0205090 (UMLS 2011AA)
C12767 (NCI Thesaurus-3)
C0030797 (UMLS 2011AA-4)
CL Item
Left Pelvis (Left pelvic)
C25229 (NCI Thesaurus)
C0205091 (UMLS 2011AA)
C12767 (NCI Thesaurus-3)
C0030797 (UMLS 2011AA-4)
CL Item
Right Obturator (Right obturator)
CL Item
Left Obturator Lymph Node (Left obturator)
C25229 (NCI Thesaurus)
C0205091 (UMLS 2011AA)
C88141 (NCI Thesaurus-3)
CL Item
Right External Iliac (Right external iliac)
CL Item
Left External Iliac Lymph Node (Left external iliac)
C25229 (NCI Thesaurus)
C0205091 (UMLS 2011AA)
C88143 (NCI Thesaurus-3)
CL Item
Right Internal Iliac (Right internal iliac)
CL Item
Left Internal Iliac Lymph Node (Left internal iliac)
C25229 (NCI Thesaurus)
C0205091 (UMLS 2011AA)
C88142 (NCI Thesaurus-3)
CL Item
Paravesical (Paravesical)
CL Item
Right Node Of Cloquet (Right node of cloquet)
CL Item
Left Node Of Cloquet (Left node of cloquet)
CL Item
Right Common Iliac (Right common iliac)
CL Item
Left Common Iliac (Left common iliac)
CL Item
Pre-sacral (Pre-sacral)
CL Item
Right Fossa Of Marcille (Right fossa of Marcille)
CL Item
Left Fossa Of Marcille (Left fossa of Marcille)
CL Item
Aorta (Aortic)
C12669 (NCI Thesaurus)
C0003483 (UMLS 2011AA)
CL Item
Pre-aortic (Pre-aortic)
CL Item
Para-aortic (para-aortic)
CL Item
Caval (Caval)
CL Item
Pre-caval (Pre-caval)
CL Item
Para-caval (Para-caval)
CL Item
Other Specify (other)
LymphNodeDissectionSpecify
Item
Other specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C12745 (NCI Thesaurus ObjectClass)
C0024204 (UMLS 2011AA ObjectClass)
C15227 (NCI Thesaurus Property)
C0012737 (UMLS 2011AA Property)
Item Group
Reconstruction
Item
Surgical Reconstruction
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C25351 (NCI Thesaurus Property)
C0524865 (UMLS 2011AA Property)
CL.10
Code List
Surgical Reconstruction
CL Item
Ileal Conduit (Ileal Conduit)
CL Item
Neobladder (Neobladder)
CL Item
Continent Catheterizable Reservoir (Continent Catheterizable Reservoir)
CL Item
Other, Specify (Other specify)
SurgeryReconstructionSpecify
Item
Other specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C25351 (NCI Thesaurus Property)
C0524865 (UMLS 2011AA Property)
Item
Anastomosis Performed Type
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C15609 (NCI Thesaurus Property)
C0677554 (UMLS 2011AA Property)
C38000 (NCI Thesaurus Property-2)
C0884358 (UMLS 2011AA Property-2)
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
CL.11
Code List
Anastomosis Performed Type
CL Item
Entirely Stapled (Entirely stapled)
CL Item
Hand-sewn (Hand-sewn)
CL Item
Partially Stapled And Partially Hand-sewn (Partially stapled and partially hand-sewn)
Item Group
Operative Information
Duration of Surgery
Item
Duration of Surgery (skin to skin, in hrs: minutes)
float
C15329 (NCI Thesaurus ObjectClass)
C0488629 (UMLS CUI-1)
C25275 (NCI Thesaurus Property)
C25330 (NCI Thesaurus ValueDomain)
TotalEstimateBloodLossAmount
Item
Estimated blood loss (ml)
float
C25304 (NCI Thesaurus ObjectClass)
C0439810 (UMLS 2011AA ObjectClass)
C25498 (NCI Thesaurus ObjectClass-2)
C0750572 (UMLS 2011AA ObjectClass-2)
C12434 (NCI Thesaurus ObjectClass-3)
C0229664 (UMLS 2011AA ObjectClass-3)
C25559 (NCI Thesaurus Property)
C1517945 (UMLS 2011AA Property)
C25417 (NCI Thesaurus ValueDomain)
WholeBloodTransfusionCount
Item
Total units whole blood (in units equivalent to 500 ml whole blood)
float
C0370231 (NCI Metathesaurus ObjectClass)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
C25256 (NCI Thesaurus Property)
C1265611 (UMLS 2011AA Property)
C15408 (NCI Thesaurus ObjectClass)
PackedRedBloodCellTransfusionReceivedUnitCount
Item
Total units PRBC (in units equivalent to 500 ml whole blood)
float
C44278 (NCI Thesaurus ValueDomain)
C0439148 (UMLS 2011AA ValueDomain)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C25463 (NCI Thesaurus ValueDomain-2)
C0750480 (UMLS 2011AA ValueDomain-2)
C15409 (NCI Thesaurus ObjectClass)
C0199962 (UMLS 2011AA ObjectClass)
FreshFrozenPlasmaTransfusionReceivedUnitCount
Item
Total units fresh frozen plasma (in units equivalent to 500 ml whole blood)
float
C0016709 (NCI Metathesaurus ObjectClass)
C15408 (NCI Thesaurus ObjectClass)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C44278 (NCI Thesaurus ValueDomain)
C0439148 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain-2)
C0750480 (UMLS 2011AA ValueDomain-2)
PlateletTransfusionReceivedUnitCount
Item
Total units platelets (in units equivalent to 500 ml whole blood)
float
C44278 (NCI Thesaurus ValueDomain)
C0439148 (UMLS 2011AA ValueDomain)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C25463 (NCI Thesaurus ValueDomain-2)
C0750480 (UMLS 2011AA ValueDomain-2)
C15366 (NCI Thesaurus ObjectClass)
C0086818 (UMLS 2011AA ObjectClass)
AdverseEventIntraoperativeComplicationAnatomicSitePresentInd-2
Item
Intraoperative vascular injury
boolean
C41331 (NCI Thesaurus ObjectClass)
C0877248 (UMLS 2011AA ObjectClass)
C13717 (NCI Thesaurus Property)
C1515974 (UMLS 2011AA Property)
C25626 (NCI Thesaurus Property-2)
C0150312 (UMLS 2011AA Property-2)
C34735 (NCI Thesaurus Property-3)
C0021890 (UMLS 2011AA Property-3)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
AdverseEventIntraoperativeComplicationOtherAnatomicSitePresentAdverseEventSpecify
Item
Specify location (If yes)
text
C41331 (NCI Thesaurus ObjectClass)
C0877248 (UMLS 2011AA ObjectClass)
C13717 (NCI Thesaurus Property)
C1515974 (UMLS 2011AA Property)
C17649 (NCI Thesaurus Property-2)
C0205394 (UMLS 2011AA Property-2)
C25626 (NCI Thesaurus Property-3)
C0150312 (UMLS 2011AA Property-3)
C34735 (NCI Thesaurus Property-4)
C0021890 (UMLS 2011AA Property-4)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item
Perioperative DVT prophylaxis (other than sequential compression device)
text
C25284 (NCI Thesaurus ValueDomain)
C0003280 (UMLS CUI-1)
C263 (NCI Thesaurus ObjectClass)
C25730 (NCI Thesaurus ObjectClass-2)
C25382 (NCI Thesaurus Property)
CL.13
Code List
Perioperative DVT prophylaxis (other than sequential compression device)
CL Item
Heparin (Heparin)
C539 (NCI Thesaurus)
C0019134 (UMLS 2011AA)
CL Item
Lovenox (Lovenox)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
DVT prevention, specify
Item
Other, specify
text
C49343 (NCI Thesaurus ObjectClass)
C0853245 (UMLS CUI-1)
C15368 (NCI Thesaurus ObjectClass-2)
C15405 (NCI Thesaurus ObjectClass-3)
C25639 (NCI Thesaurus Property)
C1521902 (UMLS CUI-2)
C25685 (NCI Thesaurus ValueDomain)
EpiduralAnestheticAgentAdministeredInd-2
Item
Epidural anesthesia employed
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C245 (NCI Thesaurus ObjectClass)
C0002932 (UMLS 2011AA ObjectClass)
C15683 (NCI Thesaurus ObjectClass-2)
C1526986 (UMLS 2011AA ObjectClass-2)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
NervePreservationSurgicalProcedurePerformedInd-2
Item
Nerve sparing
boolean
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C12466 (NCI Thesaurus ObjectClass-2)
C0027740 (UMLS 2011AA ObjectClass-2)
C52243 (NCI Thesaurus ObjectClass-3)
C0033085 (UMLS 2011AA ObjectClass-3)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
Item
Laterality (Please complete if the answer was "yes" to nerve sparing. Select all that apply)
text
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C12466 (NCI Thesaurus ObjectClass-2)
C0027740 (UMLS 2011AA ObjectClass-2)
C52243 (NCI Thesaurus ObjectClass-3)
C0033085 (UMLS 2011AA ObjectClass-3)
C25185 (NCI Thesaurus Property)
C0332304 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.16
Code List
Laterality (Please complete if the answer was "yes" to nerve sparing. Select all that apply)
CL Item
Left (Left)
C25229 (NCI Thesaurus)
C0205091 (UMLS 2011AA)
CL Item
Right (Right)
C25228 (NCI Thesaurus)
C0205090 (UMLS 2011AA)
Item
Nerve-sparing status (if selected please specify)
text
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C12466 (NCI Thesaurus ObjectClass-2)
C0027740 (UMLS 2011AA ObjectClass-2)
C52243 (NCI Thesaurus ObjectClass-3)
C0033085 (UMLS 2011AA ObjectClass-3)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
CL.17
Code List
Nerve-sparing status (if selected please specify)
CL Item
Partial (Partial)
C25378 (NCI Thesaurus)
C0728938 (UMLS 2011AA)
CL Item
Complete (Complete)
C25250 (NCI Thesaurus)
C0205197 (UMLS 2011AA)
PatientPhotographMalignantNeoplasmAssessmentInd-2
Item
Photographic documentation (required per protocol)
boolean
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C9305 (NCI Thesaurus Property-2)
C0006826 (UMLS 2011AA Property)
C86035 (NCI Thesaurus Property-3)
C0441468 (UMLS 2011AA Property-2)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
EvaluationNotDoneReasonSpecify
Item
Specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25214 (NCI Thesaurus ObjectClass)
C0220825 (UMLS 2011AA ObjectClass)
C49484 (NCI Thesaurus Property)
C1272696 (UMLS 2011AA Property)
C25365 (NCI Thesaurus Property-2)
C0678257 (UMLS 2011AA Property-2)
Item Group
Comments
Research Comments
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C0947611 (UMLS CUI-1)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
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