Lysine analogue use during cancer surgery: a survey from a Canadian tertiary care centre

Background

When used during surgery, antifibrinolytic hemostatic agents such as lysine analogues are effective at reducing blood loss and the need for transfusions. Despite proven efficacy, use of hemostatic agents remains low during some surgeries. Our objective was to explore surgeon opinions about, and use of lysine analogues in, oncologic surgeries at a large tertiary care academic institution.

Methods

We administered a survey to surgeons who perform high-transfusion-risk oncologic surgeries at a large academic hospital in Ottawa, Ontario. Design and distribution of the survey followed a modified Dillman method. To ensure that the survey questionnaire was relevant, clear, and concise, we performed informant interviews, cognitive interviews, and pilot-testing. The final survey consisted of 19 questions divided into 3 sections: respondent demographics, use of hemostatic agents, and potential clinical trial opinions.

Results

Of 28 surgeons, 24 (86%) participated. When asked to indicate the frequency of lysine analogue use, "never" accounted for 46% of the responses, and "rarely" (<10% of the time) accounted for 23% of the responses. Reasons for never using included "unfamiliar with benefits" and "prefer alternatives." Fifteen surgeons (63%) felt that a trial was needed to demonstrate the efficacy and safety of lysine analogues in their cancer field.

Conclusions

Our survey found that lysine analogues are infrequently used during oncologic surgeries at our institution. Many surgeons are unfamiliar with the benefits and side effects of lysine analogues and, alternatively, use topical hemostatic agents. Our results demonstrate that future trials exploring the efficacy and safety of lysine analogues in oncologic surgery are needed.

The effect of surgery report cards on improving radical prostatectomy quality: the SuRep study protocol

Background

The goal of radical prostatectomy is to achieve the optimal balance between complete cancer removal and preserving a patient’s urinary and sexual function. Performing a wider excision of peri-prostatic tissue helps achieve negative surgical margins, but can compromise urinary and sexual function. Alternatively, sparing peri-prostatic tissue to maintain functional outcomes may result in an increased risk of cancer recurrence. The objective of this study is to determine the effect of providing surgeons with detailed information about their patient outcomes through a surgical report card.

Methods

We propose a prospective cohort quasi-experimental study. The intervention is the provision of feedback to prostate cancer surgeons via surgical report cards. These report cards will be distributed every 3 months by email and will present surgeons with detailed information, including urinary function, erectile function, and surgical margin outcomes of their patients compared to patients treated by other de-identified surgeons in the study. For the first 12 months of the study, pre-operative, 6-month, and 12-month patient data will be collected but there will be no report cards distributed to surgeons. This will form the pre-feedback cohort. After the pre-feedback cohort has completed accrual, surgeons will receive quarterly report cards. Patients treated after the provision of report cards will comprise the post-feedback cohort. The primary comparison will be post-operative function of the pre-feedback cohort vs. post-feedback cohort. The secondary comparison will be the proportion of patients with positive surgical margins in the two cohorts. Outcomes will be stratified or case-mix adjusted, as appropriate. Assuming a baseline potency of 20% and a baseline continence of 70%, 292 patients will be required for 80% power at an alpha of 5% to detect a 10% improvement in functional outcomes. Assuming 30% of patients may be lost to follow-up, a minimum sample size of 210 patients is required in the pre-feedback cohort and 210 patients in the post-feedback cohort.

Discussion

The findings from this study will have an immediate impact on surgeon self-evaluation and we hypothesize surgical report cards will result in improved overall outcomes of men treated with radical prostatectomy.

Electronic supplementary material

The online version of this article (10.1186/s12894-018-0403-y) contains supplementary material, which is available to authorized users.

Fibrous pseudotumor of the epididymis and tunica vaginalis

We present a case of fibrous pseudotumor of the epididymis and tunica vaginalis which is one of the rarest paratesticular tumors. Fibrous pseudotumor presents as a solid scrotal mass with normal serum markers. Pathological examination is the only reliable way to make the diagnosis with these tumors exhibiting characteristic macroscopic and microscopic features. It is important to recognize this entity since local excision is the treatment of choice and orchiectomy is unnecessary.

[Can nomograms derived in the U.S. applied to German patients? A study about the validation of preoperative nomograms predicting the risk of recurrence after radical prostatectomy]

In patients suffering from prostate cancer, preoperative nomograms, which predict the risk of recurrence may provide a helpful tool in regard to the counselling and planning of an appropriate therapy. The best known nomograms were published by the Baylor College of Medicine, Houston and the Harvard Medical School, Boston. We investigated these nomograms derived in the U.S. when applied to German patients. Data from 1003 patients who underwent radical prostatectomy at the University-Hospital Hamburg were used for validation. Nomogram predictions of the probability for 2-years (Harvard nomogram) and 5-years (Kattan nomogram) freedom from PSA recurrence were compared with actual follow-up recurrence data using areas under the receiver-operating-characteristic curves (AUC). The recurrence free survival after 2 and 5 years was 78% and 58%, respectively. The AUC of the Harvard nomogram predicting 2-years probability of freedom from PSA recurrence was 0.80 vs. Kattan-Nomogram 5-years prediction of 0.83. Thereby, the Kattan nomogram showed a significant higher predictive accuracy (p=0.0274). For that reason preoperative nomograms derived in the U.S. can be applied to german patients. However, we would recommend the utilization of the Kattan nomogram due to its higher predictive accuracy.

Ureteropelvic junction disruption secondary to blunt trauma: excretory phase imaging (delayed films) should help prevent a missed diagnosis

PURPOSE

Ureteropelvic junction disruption is a rare condition which is often diagnosed after some delay. The aim of this study is to examine the current status of this entity and to determine if improvements could be made in the diagnosis.

MATERIALS AND METHODS

We evaluated 5 consecutive adult cases of ureteropelvic junction disruption secondary to blunt trauma and compared the findings to those reported in literature.

RESULTS

The diagnosis was delayed by at least 24 hours in 4 of the 5 cases (80%). Compared to the literature, in which most delays in diagnosis were the result of genitourinary tract imaging being omitted, most of our delays (3 cases) were a result of the initial contrast enhanced spiral (helical) computerized tomography (CT) failing to provide the diagnosis. This failure occurred because of either absence of contrast extravasation (2 cases) or only subtle extravasation (1 case), which was not recognized by the radiologist. The delay in diagnosis resulted in added morbidity in all circumstances.

CONCLUSIONS

Ureteropelvic junction disruption continues to be diagnosed late in a large proportion of cases. Absence of gross contrast extravasation on nephrogram phase scanning using spiral CT may not exclude a major injury of the ureteropelvic junction. Addition of delayed CT of the kidney 5 to 8 minutes or longer after contrast material injection (during the excretory phase) may increase the probability of extravasation being demonstrated and, thus, reduce the possibility of missing a ureteropelvic junction disruption.