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Giudici N, Blarer J, Sathianathen N, Burkhard FC, Wuethrich PY, Thalmann GN, Seiler R, Furrer MA. Diagnostic Value of Urine Cytology in Pharmacologically Forced Diuresis for Upper Tract Urothelial Carcinoma Diagnosis and Follow-Up. Cancers (Basel) 2024; 16:758. [PMID: 38398151 PMCID: PMC10886451 DOI: 10.3390/cancers16040758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/02/2024] [Accepted: 02/08/2024] [Indexed: 02/25/2024] Open
Abstract
We performed a urine cytology analysis of a pharmacologically induced diuresis for the diagnosis of upper tract urothelial carcinoma. To evaluate the diagnostic value of cytology of pharmacologically forced diuresis, an initial cohort of 77 consecutive patients with primary upper tract urothelial carcinoma treated via radical surgery was enrolled. To evaluate pharmacologically forced diuresis cytology as a follow-up procedure, a second cohort of 1250 patients who underwent a radical cystectomy for bladder cancer was selected. In the first cohort, the sensitivity of cytology of pharmacologically forced diuresis in patients with invasive, high-grade, low-grade, and concomitant carcinoma in situ was 8%, 9%, 0%, and 14%, respectively. In the second cohort, cytology of pharmacologically forced diuresis was positive in 30/689 (4.3%) patients, in whom upper urinary tract recurrence was present in 21/30 (70%) of cases, and urethral recurrence was present in 8/30 (26%) of cases. As a follow-up tool, cytology of pharmacologically forced diuresis showed a sensitivity, specificity, and positive and negative predictive values of 60%, 99%, 70%, and 98%, respectively. Overall, as a diagnostic tool, the sensitivity of cytology of pharmacologically forced diuresis is slightly better in patients with invasive upper tract urothelial carcinoma and concomitant carcinoma in situ. As a follow-up method, positive cytology of pharmacologically forced diuresis is strongly related to cancer recurrence and can reveal urethral recurrence. Cytology of pharmacologically forced diuresis might be useful in cases with contraindications for imaging or when achieving endoscopic access to the upper urinary tract is difficult.
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Affiliation(s)
- Nicola Giudici
- Department of Urology, Hospital Center Biel, Vogelsang 84, 2501 Biel, Switzerland; (N.G.); (J.B.); (R.S.)
| | - Jennifer Blarer
- Department of Urology, Hospital Center Biel, Vogelsang 84, 2501 Biel, Switzerland; (N.G.); (J.B.); (R.S.)
| | - Niranjan Sathianathen
- Department of Urology, The University of Melbourne, Royal Melbourne Hospital, Parkville, VIC 3052, Australia;
| | - Fiona C. Burkhard
- Department of Urology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (F.C.B.); (G.N.T.)
| | - Patrick Y. Wuethrich
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland;
| | - George N. Thalmann
- Department of Urology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (F.C.B.); (G.N.T.)
| | - Roland Seiler
- Department of Urology, Hospital Center Biel, Vogelsang 84, 2501 Biel, Switzerland; (N.G.); (J.B.); (R.S.)
- Department for BioMedical Research, Translational Organoid Resource Core, University of Bern, 3010 Bern, Switzerland
| | - Marc A. Furrer
- Department of Urology, The University of Melbourne, Royal Melbourne Hospital, Parkville, VIC 3052, Australia;
- Department of Urology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (F.C.B.); (G.N.T.)
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland;
- Department of Urology, Solothurner Spitäler AG, Kantonsspital Olten, 4600 Olten, Switzerland
- Department of Urology, Solothurner Spitäler AG, Bürgerspital Solothurn, 4500 Solothurn, Switzerland
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Furrer MA, Soliman C, Wuethrich PY. Meticulous initial clinical and pathological staging with standardized long-term follow-up after radical cystectomy is required to validate and improve overall prognostic performance in patients undergoing neoadjuvant chemotherapy for bladder cancer. Minerva Urol Nephrol 2024; 76:124-126. [PMID: 38193744 DOI: 10.23736/s2724-6051.23.05563-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Affiliation(s)
- Marc A Furrer
- Department of Urology, Bern University Hospital, University of Bern, Bern, Switzerland -
- Department of Urology, Solothurner Spitäler AG, Olten, Switzerland -
- Kantonsspital Olten, Olten, Switzerland -
- Bürgerspital Solothurn, Olten, Switzerland -
- Department of Anesthesiology and Pain Medicine, Bern University Hospital, University of Bern, Bern, Switzerland -
- Department of Urology, Royal Melbourne Hospital, The University of Melbourne, Victoria, Australia -
| | - Christopher Soliman
- Department of Urology, Royal Melbourne Hospital, The University of Melbourne, Victoria, Australia
| | - Patrick Y Wuethrich
- Department of Anesthesiology and Pain Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
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Furrer MA, Sathianathen N, Gahl B, Corcoran NM, Soliman C, Rodriguez Calero JA, Ineichen GB, Gahl M, Kiss B, Thalmann GN. Oncological outcomes after attempted nerve-sparing radical prostatectomy (NSRP) in patients with high-risk prostate cancer are comparable to standard non-NSRP: a longitudinal long-term propensity-matched single-centre study. BJU Int 2024; 133:53-62. [PMID: 37548822 DOI: 10.1111/bju.16126] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
OBJECTIVE To assess the long-term safety of nerve-sparing radical prostatectomy (NSRP) in men with high-risk prostate cancer (PCa) by comparing survival outcomes, disease recurrence, the need for additional therapy, and perioperative outcomes of patients undergoing NSRP to those having non-NSRP. PATIENTS AND METHODS We included consecutive patients at a single, academic centre who underwent open RP for high-risk PCa, defined as preoperative prostate-specific antigen level of > 20 ng/mL and/or postoperative International Society of Urological Pathology Grade Group 4 or 5 (i.e., Gleason score ≥ 8) and/or ≥pT3 and/or pN1 assessing the RP and lymph node specimen. We calculated a propensity score and used inverse probability of treatment weighting to match baseline characteristics of patients with high-risk PCa who underwent NSRP vs non-NSRP. We analysed oncological outcome as time-to-event and calculated hazard ratios (HRs). RESULTS A total of 726 patients were included in this analysis of which 84% (n = 609) underwent NSRP. There was no evidence for the positive surgical margin rate being different between the NSRP and non-NSRP groups (47% vs 49%, P = 0.64). Likewise, there was no evidence for the need for postoperative radiotherapy being different in men who underwent NSRP from those who underwent non-NSRP (HR 0.78, 95% confidence interval [CI] 0.53-1.15). NSRP did not impact the risk of any recurrence (HR 0.99, 95% CI 0.73-1.34, P = 0.09) and there was no evidence for survival being different in men who underwent NSRP to those who underwent non-NSRP (HR 0.65, 95% CI 0.39-1.08). There was also no evidence for the cancer-specific survival (HR 0.56, 95% CI 0.29-1.11) or progression-free survival (HR 0.99, 95% CI 0.73-1.34) being different between the groups. CONCLUSION In patients with high-risk PCa, NSRP can be attempted without compromising long-term oncological outcomes provided a comprehensive assessment of objective (e.g., T Stage) and subjective (e.g., intraoperative appraisal of tissue planes) criteria are conducted.
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Affiliation(s)
- Marc A Furrer
- Department of Urology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Urology, Solothurner Spitäler AG, Kantonsspital Olten and Bürgerspital Solothurn, Biberist, Switzerland
- Department of Urology, Royal Melbourne Hospital, The University of Melbourne, Melbourne, Victoria, Australia
| | - Niranjan Sathianathen
- Department of Urology, Royal Melbourne Hospital, The University of Melbourne, Melbourne, Victoria, Australia
- Clinical Trials Unit Bern, University of Bern, Bern, Switzerland
| | - Brigitta Gahl
- Clinical Trials Unit Bern, University of Bern, Bern, Switzerland
| | - Niall M Corcoran
- Department of Urology, Royal Melbourne Hospital, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Urology, Western Health, St Albans, Victoria, Australia
| | - Christopher Soliman
- Department of Urology, Royal Melbourne Hospital, The University of Melbourne, Melbourne, Victoria, Australia
- Clinical Trials Unit Bern, University of Bern, Bern, Switzerland
| | | | - Gallus B Ineichen
- Department of Urology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Miriam Gahl
- Department of Urology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Bernhard Kiss
- Department of Urology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - George N Thalmann
- Department of Urology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Sathianathen NJ, Furrer MA, Mulholland CJ, Katsios A, Soliman C, Lawrentschuk N, Peters JS, Zargar H, Costello AJ, Hovens CM, Bishop C, Rao R, Tong R, Steiner D, Moon D, Thomas BC, Dundee P, Calero JAR, Thalmann GN, Corcoran NM. Lymphovascular Invasion at the Time of Radical Prostatectomy Adversely Impacts Oncological Outcomes. Cancers (Basel) 2023; 16:123. [PMID: 38201549 PMCID: PMC10778356 DOI: 10.3390/cancers16010123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 12/01/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
Lymphovascular invasion, whereby tumour cells or cell clusters are identified in the lumen of lymphatic or blood vessels, is thought to be an essential step in disease dissemination. It has been established as an independent negative prognostic indicator in a range of cancers. We therefore aimed to assess the impact of lymphovascular invasion at the time of prostatectomy on oncological outcomes. We performed a multicentre, retrospective cohort study of 3495 men who underwent radical prostatectomy for localised prostate cancer. Only men with negative preoperative staging were included. We assessed the relationship between lymphovascular invasion and adverse pathological features using multivariable logistic regression models. Kaplan-Meier curves and Cox proportional hazard models were created to evaluate the impact of lymphovascular invasion on oncological outcomes. Lymphovascular invasion was identified in 19% (n = 653) of men undergoing prostatectomy. There was an increased incidence of lymphovascular invasion-positive disease in men with high International Society of Urological Pathology (ISUP) grade and non-organ-confined disease (p < 0.01). The presence of lymphovascular invasion significantly increased the likelihood of pathological node-positive disease on multivariable logistic regression analysis (OR 15, 95%CI 9.7-23.6). The presence of lymphovascular invasion at radical prostatectomy significantly increased the risk of biochemical recurrence (HR 2.0, 95%CI 1.6-2.4). Furthermore, lymphovascular invasion significantly increased the risk of metastasis in the whole cohort (HR 2.2, 95%CI 1.6-3.0). The same relationship was seen across D'Amico risk groups. The presence of lymphovascular invasion at the time of radical prostatectomy is associated with aggressive prostate cancer disease features and is an indicator of poor oncological prognosis.
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Affiliation(s)
- Niranjan J. Sathianathen
- Department of Urology, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC 3050, Australia (C.J.M.); (C.S.); (N.L.); (J.S.P.); (H.Z.); (A.J.C.); (R.R.); (R.T.); (D.M.); (B.C.T.); (P.D.); (N.M.C.)
| | - Marc A. Furrer
- Department of Urology, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC 3050, Australia (C.J.M.); (C.S.); (N.L.); (J.S.P.); (H.Z.); (A.J.C.); (R.R.); (R.T.); (D.M.); (B.C.T.); (P.D.); (N.M.C.)
- Department of Urology, University of Bern, 3010 Bern, Switzerland; (A.K.); (G.N.T.)
- Epworth Healthcare, Melbourne, VIC 3121, Australia; (C.M.H.); (C.B.)
- Department of Urology, Solothurner Spitäler AG, Kantonsspital Olten, 4600 Olten, Switzerland
- Department of Urology, Solothurner Spitäler AG, Bürgerspital Solothurn, 4500 Solothurn, Switzerland
| | - Clancy J. Mulholland
- Department of Urology, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC 3050, Australia (C.J.M.); (C.S.); (N.L.); (J.S.P.); (H.Z.); (A.J.C.); (R.R.); (R.T.); (D.M.); (B.C.T.); (P.D.); (N.M.C.)
| | - Andreas Katsios
- Department of Urology, University of Bern, 3010 Bern, Switzerland; (A.K.); (G.N.T.)
| | - Christopher Soliman
- Department of Urology, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC 3050, Australia (C.J.M.); (C.S.); (N.L.); (J.S.P.); (H.Z.); (A.J.C.); (R.R.); (R.T.); (D.M.); (B.C.T.); (P.D.); (N.M.C.)
- Epworth Healthcare, Melbourne, VIC 3121, Australia; (C.M.H.); (C.B.)
| | - Nathan Lawrentschuk
- Department of Urology, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC 3050, Australia (C.J.M.); (C.S.); (N.L.); (J.S.P.); (H.Z.); (A.J.C.); (R.R.); (R.T.); (D.M.); (B.C.T.); (P.D.); (N.M.C.)
- Epworth Healthcare, Melbourne, VIC 3121, Australia; (C.M.H.); (C.B.)
| | - Justin S. Peters
- Department of Urology, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC 3050, Australia (C.J.M.); (C.S.); (N.L.); (J.S.P.); (H.Z.); (A.J.C.); (R.R.); (R.T.); (D.M.); (B.C.T.); (P.D.); (N.M.C.)
- Epworth Healthcare, Melbourne, VIC 3121, Australia; (C.M.H.); (C.B.)
| | - Homi Zargar
- Department of Urology, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC 3050, Australia (C.J.M.); (C.S.); (N.L.); (J.S.P.); (H.Z.); (A.J.C.); (R.R.); (R.T.); (D.M.); (B.C.T.); (P.D.); (N.M.C.)
- Epworth Healthcare, Melbourne, VIC 3121, Australia; (C.M.H.); (C.B.)
| | - Anthony J. Costello
- Department of Urology, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC 3050, Australia (C.J.M.); (C.S.); (N.L.); (J.S.P.); (H.Z.); (A.J.C.); (R.R.); (R.T.); (D.M.); (B.C.T.); (P.D.); (N.M.C.)
- Epworth Healthcare, Melbourne, VIC 3121, Australia; (C.M.H.); (C.B.)
- Australian Prostate Centre, North Melbourne, VIC 3051, Australia
| | - Christopher M. Hovens
- Epworth Healthcare, Melbourne, VIC 3121, Australia; (C.M.H.); (C.B.)
- Australian Prostate Centre, North Melbourne, VIC 3051, Australia
| | - Conrad Bishop
- Epworth Healthcare, Melbourne, VIC 3121, Australia; (C.M.H.); (C.B.)
- Department of Urology, Footscray Hospital Western Health, Melbourne, VIC 3011, Australia
| | - Ranjit Rao
- Department of Urology, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC 3050, Australia (C.J.M.); (C.S.); (N.L.); (J.S.P.); (H.Z.); (A.J.C.); (R.R.); (R.T.); (D.M.); (B.C.T.); (P.D.); (N.M.C.)
- Epworth Healthcare, Melbourne, VIC 3121, Australia; (C.M.H.); (C.B.)
| | - Raymond Tong
- Department of Urology, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC 3050, Australia (C.J.M.); (C.S.); (N.L.); (J.S.P.); (H.Z.); (A.J.C.); (R.R.); (R.T.); (D.M.); (B.C.T.); (P.D.); (N.M.C.)
- Epworth Healthcare, Melbourne, VIC 3121, Australia; (C.M.H.); (C.B.)
| | - Daniel Steiner
- Epworth Healthcare, Melbourne, VIC 3121, Australia; (C.M.H.); (C.B.)
| | - Daniel Moon
- Department of Urology, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC 3050, Australia (C.J.M.); (C.S.); (N.L.); (J.S.P.); (H.Z.); (A.J.C.); (R.R.); (R.T.); (D.M.); (B.C.T.); (P.D.); (N.M.C.)
- Genitourinary Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC 3050, Australia
| | - Benjamin C. Thomas
- Department of Urology, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC 3050, Australia (C.J.M.); (C.S.); (N.L.); (J.S.P.); (H.Z.); (A.J.C.); (R.R.); (R.T.); (D.M.); (B.C.T.); (P.D.); (N.M.C.)
- Epworth Healthcare, Melbourne, VIC 3121, Australia; (C.M.H.); (C.B.)
- Department of Urology, Solothurner Spitäler AG, Bürgerspital Solothurn, 4500 Solothurn, Switzerland
| | - Philip Dundee
- Department of Urology, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC 3050, Australia (C.J.M.); (C.S.); (N.L.); (J.S.P.); (H.Z.); (A.J.C.); (R.R.); (R.T.); (D.M.); (B.C.T.); (P.D.); (N.M.C.)
- Epworth Healthcare, Melbourne, VIC 3121, Australia; (C.M.H.); (C.B.)
- Department of Urology, Solothurner Spitäler AG, Bürgerspital Solothurn, 4500 Solothurn, Switzerland
| | | | - George N. Thalmann
- Department of Urology, University of Bern, 3010 Bern, Switzerland; (A.K.); (G.N.T.)
| | - Niall M. Corcoran
- Department of Urology, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC 3050, Australia (C.J.M.); (C.S.); (N.L.); (J.S.P.); (H.Z.); (A.J.C.); (R.R.); (R.T.); (D.M.); (B.C.T.); (P.D.); (N.M.C.)
- Department of Urology, Solothurner Spitäler AG, Bürgerspital Solothurn, 4500 Solothurn, Switzerland
- Australian Prostate Centre, North Melbourne, VIC 3051, Australia
- Victorian Comprehensive Cancer Centre, Melbourne, VIC 3050, Australia
- Department of Surgery, University of Melbourne, Melbourne, VIC 3050, Australia
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Furrer MA, Sathianathen N, Gahl B, Wuethrich PY, Giannarini G, Corcoran NM, Thalmann GN. Functional Impact of Neuro-Vascular Bundle Preservation in High Risk Prostate Cancer without Compromising Oncological Outcomes: A Propensity-Modelled Analysis. Cancers (Basel) 2023; 15:5839. [PMID: 38136384 PMCID: PMC10741934 DOI: 10.3390/cancers15245839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 11/30/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
Nerve sparing (NS) is a surgical technique to optimize functional outcomes of radical prostatectomy (RP). However, it is not recommended in high risk (HR) cases because of the risk of a positive surgical margin that may increase the risk of cancer recurrence. In the last two decades there has been a change of perspective to the effect that in well-selected cases NS could be an oncologically safe option with better functional outcomes. Therefore, we aim to compare the functional outcomes and oncological safety of NS during RP in men with HR disease. A total of 1340 patients were included in this analysis, of which 12% (n = 158) underwent non-NSRP and 39% (n = 516) and 50% (n = 666) uni- and bilateral NSRP, respectively. We calculated a propensity score and used inverse probability of treatment weighting (IPTW) to balance the baseline characteristics of Pca patients undergoing non-NSRP and those having uni- and bilateral NSRP, respectively. NS improved functional outcomes; after IPTW, only 3% of patients having non-NSRP reached complete erectile function recovery (without erectile aid) at 24 months, whereas 22% reached erectile function recovery (with erectile aid), while 87% were continent. Unilateral NS increased the probability of functional recovery in all outcomes (OR 1.1 or 1.2, respectively), bilateral NS slightly more so (OR 1.1 to 1.4). NSRP did not impact the risk of any recurrence (HR 0.99, 95%CI 0.73-1.34, p = 0.09), and there was no difference in survival for men who underwent NSRP (HR 0.65, 95%CI 0.39-1.08). There was no difference in cancer-specific survival (0.56, 95%CI 0.29-1.11). Our study found that NSRP significantly improved functional outcomes and can be safely performed in carefully selected patients with HR-PCa without compromising long term oncological outcomes.
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Affiliation(s)
- Marc A. Furrer
- Department of Urology, Inselspital, Bern University Hospital, University of Bern, 3012 Bern, Switzerland;
- Department of Urology, Solothurner Spitäler AG, Kantonsspital Olten, 4600 Olten, Switzerland
- Bürgerspital Solothurn, 4500 Solothurn, Switzerland
- Department of Urology, The University of Melbourne, Royal Melbourne Hospital, Parkville, VIC 3050, Australia; (N.S.); (N.M.C.)
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland;
| | - Niranjan Sathianathen
- Department of Urology, The University of Melbourne, Royal Melbourne Hospital, Parkville, VIC 3050, Australia; (N.S.); (N.M.C.)
| | - Brigitta Gahl
- Clinical Trials Unit Bern, University of Bern, 3010 Bern, Switzerland;
| | - Patrick Y. Wuethrich
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland;
| | - Gianluca Giannarini
- Urology Unit, Santa Maria della Misericordia University Hospital, 33100 Udine, Italy;
| | - Niall M. Corcoran
- Department of Urology, The University of Melbourne, Royal Melbourne Hospital, Parkville, VIC 3050, Australia; (N.S.); (N.M.C.)
- Department of Urology, Western Health, St. Albans, VIC 3021, Australia
| | - George N. Thalmann
- Department of Urology, Inselspital, Bern University Hospital, University of Bern, 3012 Bern, Switzerland;
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Koelker M, Bradtke M, Klemm J, von Deimling M, Gild P, Dahlem R, Fisch M, Rink M, Vetterlein MW. Rational peri-operative management of antithrombotic therapy in patients undergoing radical cystectomy: A 30-day morbidity analysis based on the updated European Association of Urology guidelines for standardized complication reporting. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:107123. [PMID: 37879160 DOI: 10.1016/j.ejso.2023.107123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/14/2023] [Accepted: 10/20/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Radical cystectomy (RC) in bladder cancer patients with cardiovascular comorbidity poses challenges due to the need for antithrombotic therapy and high perioperative risk. We aimed to assess 30-day complications after RC in patients receiving antithrombotic therapy. PATIENTS AND METHODS Retrospective study of 416 bladder cancer patients (2009-2017) undergoing open RC with pelvic lymph node dissection, with or without antithrombotic therapy. Antithrombotic therapy and complication reporting followed European guidelines. Procedure-specific 30-day complications were cataloged, graded (Clavien-Dindo), and quantified using the 30-day Comprehensive Complication Index. Multivariable regressions evaluated antithrombotic therapy's independent effect on key morbidity outcomes. RESULTS Median age was 70 years, 78% were male. Patients on antithrombotic therapy were mostly male, had higher comorbidity burden, worse kidney function, more frequent incontinent diversion, and shorter operative time (all p ≤ 0.027). Bleeding complications occurred in 135 patients (32%; 95%CI = 28-37%), more prevalent with antithrombotic therapy (46% vs. 29%; p = 0.004). Thromboembolic complications occurred in 18 patients (4.3%; 95%CI = 2.6-6.8%), no difference between patients with and without antithrombotic therapy (8.4% vs. 3.3%; p = 0.063). Prevalence of myocardial infarction, new-onset hypertension, acute congestive heart failure, and angina pectoris showed no difference (all p ≥ 0.3). Multivariable analyses indicated no association between antithrombotic therapy and cardiac complications, 30-day major complications, or cumulative morbidity (all p ≥ 0.2). Antithrombotic therapy was associated with bleeding complications (OR = 1.92; 95%CI = 1.07-3.45; p = 0.028), predominantly transfusion-related (75% of 152 bleeding complications). Limitations include retrospective data assessment with biases. CONCLUSIONS RC in patients on antithrombotic therapy exhibits a higher incidence of adverse events due to underlying comorbidities. Adherence to thromboprophylaxis guidelines enables safe RC in patients with significant comorbidities, without substantial increase in major bleeding or severe thromboembolic events.
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Affiliation(s)
- Mara Koelker
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marlon Bradtke
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob Klemm
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Markus von Deimling
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Philipp Gild
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Roland Dahlem
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Margit Fisch
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Rink
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Urology, Katholisches Marienkrankenhaus, Hamburg, Germany
| | - Malte W Vetterlein
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Furrer MA, Soliman C, Wuethrich PY. Detailed reporting of clinical and pathological parameters, and comprehensive depiction of complication-intervention events and grading is required to ensure comparability of survival and morbidity outcomes. World J Urol 2023; 41:3381-3383. [PMID: 37716934 DOI: 10.1007/s00345-023-04609-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 08/28/2023] [Indexed: 09/18/2023] Open
Affiliation(s)
- Marc A Furrer
- Department of Urology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
- Department of Urology, Solothurner Spitäler AG, Kantonsspital Olten, and Bürgerspital Solothurn, Solothurn, Switzerland.
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
- Department of Urology, The University of Melbourne, Royal Melbourne Hospital, Melbourne, VIC, Australia.
| | - Christopher Soliman
- Department of Urology, The University of Melbourne, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Patrick Y Wuethrich
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Furrer MA, Wuethrich PY. Re: Jakob Klemm, Michael Rink, Markus von Deimling, et al. Time-to-complication Patterns After Radical Cystectomy: A Secondary Analysis of a 30-day Morbidity Assessment Using the European Association of Urology Quality Criteria for Standardized Reporting. Eur Urol Focus. In press. https://doi.org/10.1016/j.euf.2023.06.005. Eur Urol Focus 2023:S2405-4569(23)00215-8. [PMID: 37806852 DOI: 10.1016/j.euf.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 08/28/2023] [Indexed: 10/10/2023]
Affiliation(s)
- Marc A Furrer
- Department of Urology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Urology, Solothurner Spitäler AG, Kantonsspital Olten and Bürgerspital Solothurn, Olten/Solothurn, Switzerland; Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Patrick Y Wuethrich
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Furrer MA, Wuethrich PY. A more comprehensive assessment of pre-, intra-, and postoperative patient- and surgery-specific parameters and prehabilitation is required to improve pre-, peri- and postoperative risk estimation to optimize patient management with reduction of morbidity after major urological surgery. Urol Oncol 2023; 41:436-437. [PMID: 37673760 DOI: 10.1016/j.urolonc.2023.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 08/17/2023] [Indexed: 09/08/2023]
Affiliation(s)
- Marc A Furrer
- Department of Urology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Urology, Solothurner Spitäler AG, Kantonsspital Olten, and Bürgerspital Solothurn, Switzerland; Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Patrick Y Wuethrich
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Hjelmdal C, Draegert C, Vester-Andersen M, Kowark A, Coburn M, Rasmussen LS, Lundstrøm LH, Steinmetz J. Intra-operative blood transfusion in elderly patients on antithrombotic therapy. Acta Anaesthesiol Scand 2023; 67:412-421. [PMID: 36636858 DOI: 10.1111/aas.14197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 12/10/2022] [Accepted: 01/06/2023] [Indexed: 01/14/2023]
Abstract
BACKGROUND Many elderly patients are receiving antithrombotics, which may increase intra-operative blood loss. We aimed to assess whether chronic antithrombotic therapy was associated with intra-operative transfusion of packed red blood cells in patients at least 80 years of age undergoing elective procedures. METHODS We performed a secondary analysis of the prospective, observational European multicentre study entitled POSE (peri-interventional outcome study in the elderly) including 9497 surgical patients aged 80 years and older in 177 centres from October 2017 to December 2018. In this secondary analysis we included POSE patients who underwent elective procedures and with available data on chronic antithrombotic therapy. The primary outcome was intra-operative transfusion of packed red blood cells and results were analysed using multiple logistic regression model. We adjusted for the following predetermined explanatory variables: Age, sex, body mass index, American Society of Anaesthesiologists Physical Status Classification System, baseline haemoglobin concentration, disseminated cancer, and type and severity of surgery. RESULTS A total of 7174 patients were included of whom 4073 (56.8%) were on antithrombotic therapy. Among patients on antithrombotic therapy 191 (4.7%) received intra-operative blood transfusion compared with 98 (3.2%) of patients not on chronic antithrombotic therapy (crude odds ratio: 1.51, 95% CI 1.18-1.94). Following multiple logistic regression analysis, the adjusted odds ratio was 0.98; 0.73-1.32. We found that chronic antithrombotic therapy was associated with intra-operative transfusion of packed red blood cells in elderly patients undergoing elective procedures in an unadjusted analysis, but not in a multivariate adjusted model.
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Affiliation(s)
- Caroline Hjelmdal
- Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christina Draegert
- Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Copenhagen, Denmark
| | - Morten Vester-Andersen
- Department of Anesthesiology, Copenhagen University Hospital, Herlev-Gentofte Hospital, Herlev, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Ana Kowark
- Department of Anaesthesia, University Hospital RWTH, Aachen, Germany
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Mark Coburn
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Lars S Rasmussen
- Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Lars H Lundstrøm
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Department of Anaesthesia, Nordsjaellands Hospital, Hillerød, Denmark
| | - Jacob Steinmetz
- Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Danish Air Ambulance, Aarhus, Denmark
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11
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Mulholland C, Soliman C, Furrer MA, Sathianathen N, Corcoran NM, Schramm B, Mertens E, Peters J, Costello A, Lawrentschuk N, Dundee P, Thomas B. Same day discharge for robot-assisted radical prostatectomy: a prospective cohort study documenting an Australian approach. ANZ J Surg 2023; 93:669-674. [PMID: 36637213 DOI: 10.1111/ans.18198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND The introduction of robotic surgical systems has significantly impacted urological surgery, arguably more so than other surgical disciplines. The focus of our study was length of hospital stay - patients have traditionally been discharged day 1 post-robot-assisted radical prostatectomy (RARP), however, during the ongoing COVID-19 pandemic and consequential resource limitations, our centre has facilitated a cohort of same-day discharges with initial success. METHODS We conducted a prospective tertiary single-centre cohort study of a series of all patients (n = 28) - undergoing RARP between January and April 2021. All patients were considered for a day zero discharge pathway which consisted of strict inclusion criteria. At follow-up, each patient's perspective on their experience was assessed using a validated post-operative satisfaction questionnaire. Data were reviewed retrospectively for all those undergoing RARP over the study period, with day zero patients compared to overnight patients. RESULTS Overall, 28 patients 20 (71%) fulfilled the objective criteria for day zero discharge. Eleven patients (55%) agreed pre-operatively to day zero discharge and all were successfully discharged on the same day as their procedure. There was no statistically significant difference in age, BMI, ASA, Charlson score or disease volume. All patients indicated a high level of satisfaction with their procedure. Median time from completion of surgery to discharge was 426 min (7.1 h) in the day zero discharge cohort. CONCLUSION Day zero discharge for RARP appears to deliver high satisfaction, oncological and safety outcomes. Therefore, our study demonstrates early success with unsupported same-day discharge in carefully selected and pre-counselled patients.
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Affiliation(s)
- Clancy Mulholland
- Department of Urology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Christopher Soliman
- Department of Urology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Marc A Furrer
- Department of Urology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Urology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Surgery, Royal Melbourne Hospital, University of Melbourne, The Australian Medical Robotics Academy, Melbourne, Victoria, Australia
| | | | - Niall M Corcoran
- Department of Urology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Surgery, University of Melbourne, Parkville, Victoria, Australia
| | - Belinda Schramm
- Department of Anaesthesia, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Evie Mertens
- Department of Urology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Justin Peters
- Department of Urology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Surgery, Royal Melbourne Hospital, University of Melbourne, The Australian Medical Robotics Academy, Melbourne, Victoria, Australia
- Department of Surgery, University of Melbourne, Parkville, Victoria, Australia
| | - Anthony Costello
- Department of Urology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Surgery, Royal Melbourne Hospital, University of Melbourne, The Australian Medical Robotics Academy, Melbourne, Victoria, Australia
- Department of Surgery, University of Melbourne, Parkville, Victoria, Australia
| | - Nathan Lawrentschuk
- Department of Urology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Surgery, University of Melbourne, Parkville, Victoria, Australia
| | - Philip Dundee
- Department of Urology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Surgery, Royal Melbourne Hospital, University of Melbourne, The Australian Medical Robotics Academy, Melbourne, Victoria, Australia
- Department of Surgery, University of Melbourne, Parkville, Victoria, Australia
| | - Benjamin Thomas
- Department of Urology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Surgery, Royal Melbourne Hospital, University of Melbourne, The Australian Medical Robotics Academy, Melbourne, Victoria, Australia
- Department of Surgery, University of Melbourne, Parkville, Victoria, Australia
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Moster M, Bolliger D. Perioperative Guidelines on Antiplatelet and Anticoagulant Agents: 2022 Update. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-021-00511-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Abstract
Purpose of Review
Multiple guidelines and recommendations have been written to address the perioperative management of antiplatelet and anticoagulant drugs. In this review, we evaluated the recent guidelines in non-cardiac, cardiac, and regional anesthesia. Furthermore, we focused on unresolved problems and novel approaches for optimized perioperative management.
Recent Findings
Vitamin K antagonists should be stopped 3 to 5 days before surgery. Preoperative laboratory testing is recommended. Bridging therapy does not decrease the perioperative thromboembolic risk and might increase perioperative bleeding risk. In patients on direct-acting oral anticoagulants (DOAC), a discontinuation interval of 24 and 48 h in those scheduled for surgery with low and high bleeding risk, respectively, has been shown to be saved. Several guidelines for regional anesthesia recommend a conservative interruption interval of 72 h for DOACs before neuraxial anesthesia. Finally, aspirin is commonly continued in the perioperative period, whereas potent P2Y12 receptor inhibitors should be stopped, drug-specifically, 3 to 7 days before surgery.
Summary
Many guidelines have been published from various societies. Their applicability is limited in emergent or urgent surgery, where novel approaches might be helpful. However, their evidence is commonly based on small series, case reports, or expert opinions.
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