Search

Enhanced Recovery After Surgery (ERAS) is a perioperative approach to managing surgical patients. The impact of ERAS on radical cystectomy (RC) outcomes remains understudied.To review the literature regarding ERAS protocols and RC outcomes. The primary outcome was hospital length of stay (LOS).A systematic review of the articles published from 1970 through 2018 was conducted. Individual patient data (IPD) were requested and a meta-analysis was performed.A total of 4197 articles were retrieved and 22 (reporting 4048 patients) were selected for the review. LOS followed by 30-d and that followed by 90-d complications were the most common endpoints. ERAS use was associated with reduced morbidity, quicker bowel recovery, and shorter LOS, without affecting mortality. IPD were obtained for 2077 patients from 11 studies. In multivariable models, LOS was associated with ERAS use (regression coefficient: -4.54 [95% confidence interval {CI}: -5.79 to -3.28] d with ERAS p 0.001) and Charlson Comorbidity Index (+1.64 [1.38-1.90] d for each point increase, p 0.001), and varied between hospitals (from -1.59 [-3.03 to -0.14] to +4.55 [1.89-7.21] d, p 0.03). Individual ERAS components associated with shorter LOS included no nasogastric (NG) tube (-8.70 [-11.9 to -5.53] d, p 0.001) and local anesthesia blocks compared with regional anesthesia (-3.29 [-6.31 to -0.27] d, p = 0.03).ERAS protocols were associated with reduced LOS and postoperative complication rate. Avoidance of NG tubes and use of local anesthesia blocks were significantly associated with reduced LOS. These findings reflect different components of recovery, which ERAS can optimize and further support documentation of the use of ERAS components when reporting RC outcomes.Use of enhanced recovery in patients undergoing surgery to remove the bladder is associated with fewer surgical complications and a shorter hospital stay. Avoidance of nasogastric tubes and use of local anesthesia after the operation were associated with a shorter length of stay.

Background Primary robot-assisted retroperitoneal lymph node dissection (R-RPLND) has been studied as an alternative to open RPLND in single-institution series for patients with low-stage nonseminomatous germ cell tumors (NSGCT). Objective To evaluate a multicenter series of primary R-RPLND for low-stage NSGCT. Design, setting, and participants Between 2011 and 2015, 47 patients underwent primary R-RPLND at four centers for Clinical Stage (CS) I-IIA NSGCT. Surgical procedure R-RPLND was performed using the da Vinci surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA). Outcome measurements and statistical analysis Data were collected regarding patient demographics, primary tumor characteristics, pathologic findings, and clinical outcomes. Results and limitations Forty-two patients (89%) were CS I and five (11%) were CS IIA. The median operative time was 235min (interquartile range [IQR]: 214–258min), estimated blood loss was 50ml (IQR: 50–100ml), node count was 26 (IQR: 18–32), and length of stay was 1 d. There were two intraoperative complications (4%), four early postoperative complications (9%), no late complications, and the rate of antegrade ejaculation was 100%. Of the eight patients (17%) with positive nodes (seven pN1and one pN2), five (62%) received adjuvant chemotherapy. The one recurrence was out of template in the pelvis after adjuvant chemotherapy (resected teratoma). The median follow-up was 16 mo and the 2-yr recurrence-free survival rate was 97% (95% confidence interval: 82–100%). Limitations include retrospective design and limited follow-up. Conclusions Our multicenter experience supports R-RPLND as a potential option at experienced centers in select patients with low-stage NSGCT. Informal comparison to open and laparoscopic series suggests R-RPLND has an acceptably low morbidity profile, but oncologic efficacy evaluation requires further evaluation. Patient summary We examined outcomes after robot-assisted retroperitoneal lymph node dissection for patients with low-stage nonseminomatous testicular cancer with our data suggesting the robotic approach has acceptable morbidity and early oncologic outcomes.

Contains fulltext : 220581.pdf (Publisher’s version ) (Closed access) Transurethral resection of bladder tumour is the initial, most critical step in the management of bladder cancer; as such, this is a call to arms for the urological community to it the due diligence it deserves regarding technology and training.

Background Large prostate size, median lobes, and prior benign prostatic hyperplasia (BPH) surgery may pose technical challenges during robot-assisted laparoscopic prostatectomy (RALP). Objective To describe technical modifications to overcome BPH sequelae and associated outcomes. Design, settings, and participants A retrospective study of prospective data on 951 RALP procedures performed from September 2005 to November 2010 was conducted. Outcomes were analyzed by prostate weight, prior BPH surgical intervention ( n =59), and median lobes >1cm ( n =42). Surgical procedure RALP. Measurements Estimated blood loss (EBL), blood transfusions, operative time, positive surgical margin (PSM), and urinary and sexual function were measured. Results and limitations In unadjusted analysis, men with larger prostates and median lobes experienced higher EBL (213.5 vs 176.5ml; p p =0.002), and larger prostates were associated with more transfusions (4 vs 1; p =0.037). Operative times were longer for men with larger prostates (164.2 vs 149.1min; p =0.002), median lobes (185.8 vs 155.0min; p =0.004), and prior BPH surgical interventions (170.2 vs 155.4min; p =0.004). Men with prior BPH interventions experienced more prostate base PSM (5.1% vs 1.2%; p =0.018) but similar overall PSM. In adjusted analyses, the presence of median lobes increased both EBL ( p =0.006) and operative times ( p p =0.014). However, prostate size did not affect EBL, PSM, or recovery of urinary or sexual function. Conclusions Although BPH characteristics prolonged RALP procedure times and increased EBL, prostate size did not affect PSM or urinary and sexual function.

© 2015 European Association of Urology. Published by Elsevier B.V. All rights reserved. Context Multimodal treatment for men with locally advanced prostate cancer (PCa) using neoadjuvant/adjuvant systemic therapy, surgery, and radiation therapy is being increasingly explored. There is also interest in the oncologic benefit of treating the primary tumor in the setting of metastatic PCa (mPCa). Objective To perform a review of the literature regarding the treatment of the primary tumor in the setting of mPCa. Evidence acquisition Medline, PubMed, and Scopus electronic databases were queried for English language articles from January 1990 to September 2014. Prospective and retrospective studies were included. Evidence synthesis There is no published randomized controlled trial (RCT) comparing local therapy and systemic therapy to systemic therapy alone in the treatment of mPCa. Prospective studies of men with locally advanced PCa and retrospective studies of occult node-positive PCa have consistently shown the addition of local therapy to a multimodal treatment regimen improves outcomes. Molecular and genomic evidence further suggests the primary tumor may have an active role in mPCa. Conclusions Treatment of the primary tumor in mPCa is being increasingly explored. While preclinical, translational, and retrospective evidence supports local therapy in advanced disease, further prospective studies are under way to evaluate this multimodal approach and identify the patients most likely to benefit from the inclusion of local therapy in the setting of metastatic disease. Patient summary In this review we explored preclinical and clinical evidence for treatment of the primary tumor in metastatic prostate cancer (mPCa). We found evidence to support clinical trials investigating mPCa therapy that includes local treatment of the primary tumor. Currently, treating the primary tumor in mPCa is controversial and lacks high-level evidence sufficient for routine recommendation.

To seek differences in gene expression in the primary muscle-invasive bladder cancers of two cohorts of patients having different survival rates. An Italian group treated by transurethral resection of the bladder tumor (TURBT) and neo-adjuvant chemotherapy using methotrexate, vinblastine, adriamycin and cisplatin (M-VAC) followed by TURBT, partial cystectomy or radical cystectomy (75% 3-year survival) was compared to an American cohort treated by radical cystectomy (51% 3-year survival).Immunohistochemistry was used to examine the protein expression levels of three genes that act at the G1/S cell cycle checkpoint, p53, p21/waf-1/cip1 (a downstream effector gene in the p53 pathway) and Rb, plus a major inhibitor of apoptosis, Bcl-2.For the bladder cancers of the Italian patient cohort, there was a significantly higher rate of p53 immunopositivity (93 vs. 63%, p = 0.002) and a significantly lower rate of Rb loss (25 vs. 54%, p = 0.009). In bivariate analysis, 72% of Italian tumors were immunopositive for both p53 and p21 (p53+/p21+) vs. 49% for the American tumors. The subset of Italian patients with p53+/p21+ tumors were more frequently disease-free (stage pT0) following chemotherapy and were less likely to fail therapy than those with p53+/p21- tumors (p = 0.0357). Loss of Rb staining was associated with a decreased 5-year survival in the Italian, but not in the American patients.(1) Significant differences in the expression of the p53, p21 and Rb genes were found between the 2 groups of patients. (2) Italian patients with p53+/p21+ tumors had significantly lower recurrence rates after TURBT and chemotherapy than those having p53+/p21- tumors. (3) Absence of p21 immunopositivity in the Italian tumors may identify alterations in the p53 pathway that predict poor outcome.

Prostate cancer has been singled out as a litmus test for US health care reform with a lack of consensus regarding optimal treatment strategies [1]. Up to 21–37% of men experience biochemical recurrence (BCR) after radical prostatectomy [2]. Radiotherapy after prostatectomy improves prostate cancer–specific survival [3] and significantly decreases overall mortality when used in the adjuvant [4] or salvage setting in selected men with high-risk disease [5]. In the current issue, Briganti et al. provide a novel tool to predict BCR following early salvage radiotherapy (eSRT) after radical prostatectomy (RP) [6]. Prior studies have assessed risk factors for BCR following post-RP adjuvant RT and identified men most likely to benefit from early radiotherapy [4,7]. The current study provides a nomogram to identifymen at greater risk for BCR following eSRT. It has been suggested that self-referral patternsmay lead to increased utilization and costs of medical care [8,9]. With regard to primary RT for prostate cancer, consultation with radiation oncologists and regional variation has a significant impact on the utilization of RT treatment options [10]. The magnitude of RT utilization is significantly increased with the integration of urology and radiation oncology practices into prostate cancer center groups [10]. Furthermore, companies that sell turnkey intensity-modulated radiation treatment (IMRT) programs to US urology practices market the potential for increased IMRT revenue to replace lost earnings from androgen-deprivation therapy, for which reimbursement decreased sharply as part of the 2003 Medicare Modernization Act [10,11].

Robotic technology has enabled urologists to perform a variety of laparoscopic surgeries. Robotic surgery offers enhanced optical magnification and visualization with precise surgical movements. We report the first case series of robot-assisted laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous testicular cancer in three consecutive patients. All procedures were performed using a modified template nerve-sparing approach. The mean patient age was 31 yr. Estimated blood loss was 150-200 ml; operative time was 150-240 min. Length of stay was 2 d, and there were no perioperative complications. This early series in carefully selected and well-informed patients represented a limited experience. These results may not be applicable to all surgeons. Further long-term follow-up with a larger number of patients are warranted to validate these preliminary findings.

The perioperative management of patients necessitating long-term anticoagulation remains controversial because there remains a careful balance between increased risk of bleeding and thromboembolic events. Many of these highrisk patients are on warfarin oral anticoagulation for a mechanical heart valve, chronic atrial fibrillation, or prior history venous thromboembolism [1]. Prior studies have confirmed the safety and efficacy of discontinuation of warfarin with initiation of therapy with intravenous (IV) heparin or low-molecular-weight heparin (LMWH) as ‘‘bridging’’ therapy [2]. The 2008 American College of Chest Physicians consensus statement [1] for the management of patients receiving vitamin K antagonists (ie, warfarin) and who require invasive procedures includes various strategies for discontinuing warfarin therapy and initiating heparin bridging therapy. Exceptions to this recommendation include surgical cases in which the bleeding risk is low (ie, dental, dermatologic, and ophthalmologic procedures) and a decrease in the dose of warfarin to an international normalized ratio (INR) within the therapeutic range is recommended. The concern associated with operations in patients maintained on warfarin is the risk of perioperative bleeding and the duration of warfarin action. However, the use of heparin bridging therapy is not without risks of bleeding. In fact, prior studies in both animals and humans to evaluate the continuation of oral anticoagulation therapy have shown decreased risk of bleeding compared to patients bridged with heparin [3,4]. To date, no convincing evidence supports that discontinuation of warfarin is necessary in patients who may be maintained on warfarin during the perioperative period. The majority of the literature pertaining to perioperative management of patients requiring continuous anticoagulation is derived from other surgical fields. Larson

Apical dissection and control of the dorsal vein complex (DVC) affects blood loss, apical positive margins, and urinary control during robot-assisted laparoscopic radical prostatectomy (RALP).To describe technique and outcomes for athermal DVC division followed by selective suture ligation (DVC-SSL) compared with DVC suture ligation followed by athermal division (SL-DVC).Retrospective study of prospectively collected data from February 2008 to July 2010 for 303 SL-DVC and 240 DVC-SSL procedures.RALP with comparison of DVC-SSL prior to anastomosis versus early SL-DVC prior to bladder-neck dissection.Blood loss, transfusions, operative time, apical and overall positive margins, urine leaks, catheterization duration, and urinary control at 5 and 12 mo evaluated using 1) the Expanded Prostate Cancer Index (EPIC) urinary function scale and 2) continence defined as zero pads per day.Men who underwent DVC-SSL versus SL-DVC were older (mean: 59.9 vs 57.8 yr, p0.001), and relatively fewer white men underwent DVC-SSL versus SL-DVC (87.5% vs 96.7%, p0.001). Operative times were also shorter for DVC-SSL versus SL-DVC (mean: 132 vs 147 min, p0.001). Men undergoing DVC-SSL versus SL-DVC experienced greater blood loss (mean: 184.3 vs 175.6 ml, p=0.033), and one DVC-SSL versus zero SL-DVC were transfused (p=0.442). Overall (12.2% vs 12.0%, p=1.0) and apical (1.3% vs 2.7%, p=0.361) positive surgical margins were similar for DVC-SSL versus SL-DVC. Although 5-mo postoperative urinary function (mean: 72.9 vs 55.4, p0.001) and continence (61.4% vs 39.6%, p0.001) were better for DVC-SSL versus SL-DVC, 12-mo urinary outcomes were similar. In adjusted analyses, DVC-SSL versus SL-DVC was associated with shorter operative times (parameter estimate [PE]±standard error [SE]: 16.84±2.56, p0.001), and better 5-mo urinary function (PE±SE: 19.93±3.09, p0.001) and continence (odds ratio 3.39, 95% confidence interval 2.07-5.57, p0.001).DVC-SSL versus SL-DVC improves early urinary control and shortens operative times due to fewer instrument changes with late versus early DVC control.

Clinical trials of chemotherapy in germ cell cancer have explored the full range of dose intensity. In good risk patients, efforts have been successful in diminishing duration of treatment or number of drugs required to cure the illness reliably. In patients with poor prognosis, efforts to intensify therapy have been undertaken. It has been difficult to demonstrate improved outcome using higher doses of conventional agents in the setting of primary treatment of poor risk disease. It is more likely that improvement will come with the discovery of new active agents. High dose chemotherapy with bone marrow or peripheral blood stem cell support can cure a small portion of selected patients with multiple recurrences of germ cell cancer. The impact of earlier treatment with high dose chemotherapy as initial salvage therapy or even primary treatment is less certain. Clinical trials in these settings have not yet demonstrated a definite advantage over less toxic conventional dose therapies.