Comparison of Perioperative Outcomes Between Open and Robotic Radical Cystectomy: A Population-Based Analysis

INTRODUCTION

Radical cystectomy represents the standard of care for muscle-invasive bladder cancer (MIBC). Due to its novelty the use of robotic radical cystectomy (RARC) is still under debate. We examined intraoperative and postoperative morbidity and mortality in addition to impact on length of stay (LOS) and total hospital charges (THCGs) of RARC compared with open radical cystectomy (ORC).

MATERIALS AND METHODS

Within National Inpatient Sample (2008-2013), we identified patients with nonmetastatic bladder cancer treated with either ORC or RARC. We relied on inverse probability of treatment weighting to reduce the effect of inherent differences between ORC vs RARC. Multivariable logistic regression (MLR) and multivariable Poisson regression (MPR) models were used.

RESULTS

Of all 10,027 patients, 12.6% underwent RARC. Between 2008 and 2013, RARC rates increased from 0.8% to 20.4% [estimated annual percentage change (EAPC): +26.5%, 95% confidence interval (CI): +11.1 to +48.3; p = 0.035] and RARC THCGs decreased from 45,981 to 31,749 United States dollars (EAPC: -6.8%, 95% CI: -9.6 to -3.9; p = 0.01). In MLR models RARC resulted in lower rates of overall complications [odds ratio (OR): 0.6; p < 0.001] and transfusions (OR: 0.44; p < 0.001). In MPR models, RARC was associated with shorter LOS (relative risk 0.91; p < 0.001). Finally, higher THCGs (OR: 1.09; p < 0.001) were recorded for RARC. Data are retrospective and no tumor characteristics were available.

CONCLUSION

RARC is related to lower rates of overall complications and transfusions rates. In consequence, RARC is a safe and feasible technique in select MIBC patients. Moreover, RARC is associated with shorter LOS, although higher THCGs.

Surgically Treated Retroperitoneal Sarcoma: A Population-based Competing Risks Analysis

BACKGROUND

Data regarding the relationship between non-disease-specific (NDSM) and disease-specific mortality (DSM) in patients with surgically treated nonmetastatic retroperitoneal sarcoma (nmRPS) are lacking.

OBJECTIVE

To examine the rates of NDSM and DSM among patients with surgically treated nmRPS.

DESIGN, SETTING AND PARTICIPANTS

We used the Surveillance, Epidemiology and End Results (SEER) database (2004-2014) to obtain data for patients with surgically treated nonmetastatic RPS.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSES

The 5-yr DSM and NDSM rates were generated via competing risks regression (CRR) methodologies. Multivariable CRR models were used to test the effects of age, histologic subtype, grade, size, and radiotherapy (RT) status on NDSM and DSM.

RESULTS AND LIMITATIONS

Overall, 231 (26.8%) and 57 patients (6.7%) died from DSM and NDSM, respectively. Following stratification according to age, histologic subtype, grade, size, and RT status, the proportion of patients who succumbed to NDSM was higher for patients with age above the median, liposarcoma histologic subtype, low grade, and tumor size ≥17cm. DSM rates were also higher among patients with age above the median, leiomyosarcoma histologic subtype, high grade, and tumor size ≥17cm. Multivariable CRR models revealed that age above the median was associated with higher NDSM (hazard ratio [HR]1.7, 95% confidence interval [CI] 1.1-2.7; p=0.019). Conversely, leiomyosarcoma (HR 1.9, 95% CI 1.4-2.6; p<0.0001), sarcoma not otherwise specified (HR 2.4, 95% CI 1.5-3.8; p<0.0001) and other RPS (HR 2, 95% CI 1.2-3.4; p=0.01) histologic subtypes, high grade (HR 3, 95% CI 2.3-4; p<0.0001), and tumor size above the median (HR 1.4, 95% CI 1.1-3.8; p=0.012) were associated with higher DSM. This is a retrospective study and misclassification bias may be present because of the reliability of the distinction between DSM and NDSM.

CONCLUSIONS

The impact of NDSM in surgically treated nmRPS is not trivial, particularly among patients with favorable characteristics such as liposarcoma histologic subtype and low-grade tumors.

PATIENT SUMMARY

Mortality from causes not related to the specific disease is important in patients with retroperitoneal sarcoma (RPS) treated surgically. In particular, patients with good tumor characteristics, namely liposarcoma histologic subtype and low grade, most often do not die from their cancer but succumb to causes other than RPS. Unfortunately, tumor characteristics and radiotherapy administration shed relatively little light on predicting mortality from causes other than cancer in patients with surgically treated RPS. Our report compares the risk of dying from RPS with that of dying from other causes according to the type of surgically treated sarcoma.

Treatment of leydig cell tumours of the testis: Can testis-sparing surgery replace radical orchidectomy? Results of a systematic review

INTRODUCTION

The gold standard for Leydig cell tumours (LCTs) is still considered radical orchidectomy, but testis sparing surgery (TSS) in conjunction with intraoperative frozen section (FSE) has been recently attempted with promising results.

ACQUISITION OF EVIDENCE

Studies were identified by searching electronic databases. A bibliographic search covering the period from January 1980 to December 2012 was conducted using PubMed/MEDLINE and EMBASE database. Studies were excluded if they were single case reports, meeting abstracts and conference proceedings.

SYNTHESIS OF EVIDENCE

The present analysis is based on a total of 13 studies that fulfilled the predefined inclusion criteria. A total of 247 participants were included in the 13 studies examined in this systematic review. 145 were treated with radical orchiectomy and 102 with TSS. In the radical surgery group, the follow-up varied from 6 to 249 months). In the TSS group, the follow-up varied from 6 to 192 months. Frozen section was performed in a total of 96 patients. Sensitivity was 87.5%. None of the patients treated with TSS presented a metastatic recurrence, while in patients treated with radical orchiectomy three patients presented with metastatic recurrence In selected cases radical surgery appears excessive and the potential for a shift to TSS as the standard management is gathering momentum.

CONCLUSIONS

The results confirm the favourable course of LCT treated with TSS. The results obtained are encouraging and the concept is attractive to become the standard therapy in all patients and not only in people affected by (sub)fertility or with solitary testis.

One day surgery in the treatment of benign prostatic enlargement with thulium laser: A single institution experience

PURPOSE

Various articles have previously addressed the introduction of new surgical laser therapies for an enlarged prostate gland causing obstructive symptoms. The objective of this study was to report the feasibility of performing the thulium laser vapo-enucleation of the prostate (ThuVEP) procedure for benign prostatic obstruction in a 1-day surgery.

MATERIALS AND METHODS

From September 2011 to September 2013, we conducted a prospective study on patients who underwent ThuVEP in a 1-day surgery. The primary outcomes measured perioperatively included operative time, resected tissue weight, hemoglobin decrease, transfusion rate, postoperative irrigation and catheterization time, and postoperative hospital stay. Also, the preoperative and postoperative International Prostate Symptom Score (IPSS) and results of uroflowmetry performed on the 7th and 30th postoperative days were recorded. All perioperative and postoperative complications were monitored.

RESULTS

A total of 53 patients underwent the surgical treatment in a 1-day surgery. Seven patients continued antiaggregant therapy with aspirin. Mean preoperative prostatic adenoma volume was 56.6 mL. Mean operative time was 71 minutes. The average catheter time was 14.8 hours. The peak urinary flow rate on day 7 improved from 9.3 to 17.42 mL/s (p<0.001) and the IPSS improved from 18 to 10.2 (p<0.01). Patients were routinely discharged on the day of catheter removal. No complications were recorded.

CONCLUSIONS

ThuVEP can be safely conducted as a 1-day surgical procedure. This strategy results in cost savings. ThuVEP shows good standardized outcomes with respect to improvement in flow parameters and length of bladder catheterization.

Is stone diameter a variable in the decision process of employing a ureteral stent in patients undergoing uncomplicated ureterorenoscopy and associated intracorporeal lithotripsy?

INTRODUCTION

A number of randomized trials and meta-analysis in patients who underwent ureteroscopic stone removal investigated the effects of placing a ureteral stent at the end of the procedure on complication rates. However, none of these investigates the stone diameter and its possible influence on complication rates and, as such, if it should be considered a possible variable in the decision process of placing or not a ureteral stent.

MATERIALS AND METHODS

A bibliographic search covering the period from January 1990 to March 2012 was conducted in PubMed, MEDLINE and EMBASE. This analysis is based on the fifteen remaining studies which fulfilled the predefined inclusion criteria. All statistical evaluations were performed using SAS version 9.2. and by RevMan 5.0.

RESULTS

A total of 1,416 patients were included. All the studies were published after 2000. Mean stone diameter ranged between 5.3 and 13.3 mm in the non-stented group and between 6.26 and 13.28 mm in the stented group. Meta-analysis showed that stone diameter was not statistically different for stented or non-stented subgroups, whereas surgical operative time was shorter for the non-stented subgroup. The effect of stone diameter, irrespectively if patients were operated with or without stents were grouped or considered separately, did not influence complications of fever, haematuria, unplanned medical visits after surgery and urinary tract infections.

CONCLUSIONS

Stone diameter is not a variable in the pre- or intraoperative decision process of placing or not placing a ureteral stent in patients undergoing uncomplicated ureterorenoscopy with intracorporeal lithotripsy.

Urgent shock wave lithotripsy as first-line treatment for ureteral stones: a meta-analysis of 570 patients

The rationale for the use of immediate shock wave lithotripsy (SWL) after a renal colic episode is to obtain maximum stone clearance in the shortest possible time with associated early detection of lithotripsy failures which can be treated with auxiliary procedures. The aim of this meta-analysis is to understand the role of this treatment option in the emergency setting as first-line treatment and to compare such an immediate procedure to a delayed one in terms of stone-free and complication rates. A bibliographic search covering the period from January 1995 to September 2010 was conducted in PubMed, MEDLINE and EMBASE. Database searches yielded 48 references. This analysis is based on the seven studies that fulfilled the predefined inclusion criteria. A total of 570 participants were included. The number of participants in each survey ranged from 16 to 200 (mean 81.42). Six studies were published after 2000 and one in the 1990s. All studies reported participants' age with mean of 40.9 years, and range between 11 and 88 years. All patients presented with unilateral lithiasis, as such the number of total stones treated was 570. Mean stone diameter ranged between 6.38 and 8.45 mm. According to the logistic regression applied stone-free rates were 79 % (61-95) for the proximal ureter, 78 % (69-88) for the mid ureter, 79 % (74-84) for the distal ureter and 78 % (75-82) for overall. Stone-free rates do not evidence a statistically significant difference compared to those described in the AUA and EAU guidelines for elective management. SWL management of ureteral stones in an emergency setting is completely lacking in the international guidelines and they results disperse in the literature in few works. According to our meta-analysis, immediate SWL for a stone-induced acute renal colic seems to be a safe treatment with high success rate. This evidence will be validated by further randomized studies, with a larger series of patients.

Inverted papilloma of the bladder: a review and an analysis of the recent literature of 365 patients

OBJECTIVES

Until the 1970s, inverted urothelial papilloma (IUP) of the bladder was generally regarded as a benign neoplasm. However, in the 1980s, several reported cases suggested the malignant potential of these papillomas, including cases with features indicative of malignancy, recurrent cases, and cases of IUP synchronous or metachronous with transitional cell carcinoma. The aim of this systematic review and analysis of the literature since 1990 to date is to contribute to unresolved issues regarding the biological behavior and prognosis of these neoplasms to establish some key points in the clinical and surgical management of IUP.

MATERIALS AND METHODS

Database searches yielded 109 references. Exclusion of irrelevant references left 10 references describing studies that fulfilled the predefined inclusion criteria.

RESULTS

One problem regarding these neoplasms is the difficulty of obtaining a correct histopathologic diagnosis. The main differential diagnosis is endophytic urothelial neoplasia, including papillary urothelial neoplasia of low malignant potential or urothelial carcinoma of low or high grade, while other considerably rare differential diagnoses include nephrogenic adenoma, paraganglioma, carcinoid tumor, cystitis cystica, cystitis glandularis, and Brunn's cell nests. The size of the lesions ranged from 1 to 50 mm (mean 12.8 mm). Most cases occurred in the fifth and sixth decade of life. The mean age of affected patients was 59.3 years (range 20-88 years). Analysis of the literature revealed a strong male predominance with a male/female ratio of 5.8:1. The most commonly reported sites of IUP were the bladder neck region and trigone. Of 285 cases included in 8 studies, 12 cases (4.2%) were multiple. Out of the total of 348 patients, 6 patients (1.72%) had a previous history of transitional cell carcinoma of the urinary bladder, 5 patients (1.43%) had synchronous transitional cell carcinoma of the urinary bladder, and 4 patients (1.15%) had subsequent transitional cell carcinoma of the urinary tract. The time before recurrence was <45 months (range 5-45 months, mean 27.7 months) after surgery.

CONCLUSIONS

Inverted papilloma could be considered a risk factor for transitional cell carcinoma, and it is clinically prudent to exclude transitional cell cancer when it is diagnosed. Follow-up is needed if the histologic diagnosis is definitive or doubtful. We recommend 4-monthly flexible cystoscopy for the first year and then every 6 months for the subsequent 3 years. Routine surveillance of the upper urinary tract in cases of inverted papilloma of the lower part of the urinary tract is not deemed necessary.

In vivo dynamics of the 103N mutation following the withdrawal of non-nucleoside reverse transcriptase inhibitors in HIV-infected patients: preliminary results

Due to the preferential selection of the fittest HIV mutants, drug-resistant variants are often overgrown by wild-type virus after treatment interruption. Our objective was to investigate the dynamics of the 103N mutation (which usually does not reduce HIV fitness) following the withdrawal of non-nucleoside reverse transcriptase inhibitors (NNRTIs). Patients who were found to have the 103N mutation at or after failure of a NNRTI were selected from an observational database. Two groups of patients were identified: one which continued antiretroviral treatment without NNRTIs (group A) and one which discontinued all anti-retrovirals after failure of an NNRTI (group B). Genotype was obtained by direct sequencing of the replicating plasma virus. Sixty-two subjects tested between July 1998 and December 2002 were included in the analysis, 39 in group A and 23 in group B. At the time of the first resistance test, median (IQR) CD4+ T-lymphocytes and HIV-RNA were 269 (150-449) cells/microL and 25,000 (9,600-83,300) copies/mL. In 31 (50%), 30 (48%), and one case (2%), the 103N mutation was selected by nevirapine, efavirenz, and by delavirdine, respectively. A total of 149 tests were analyzed, with a median (IQR) of 2 (2-3) tests/patient. The median (IQR) interval between failure of NNRTIs and the last resistance test was 11 (5-22) months. Overall, a reversion to wild-type at position 103 was observed in 23/62 (37%) subjects, 14/39 (36%) in group A and 9/23 (39%) in group B. In group A, 14/23 (61%) patients tested within 12 months, 10/16 (63%) of those tested between 12 and 24 months, and 12/14 (86%) of those tested beyond 24 months from NNRTI discontinuation had the 103N mutation. In group B, 14/20 (70%) patients tested within 12 months, 3/4 (75%) of those tested between 12 and 24 months, and none out of two tested beyond 24 months from NNRTI discontinuation had the 103N mutation. In conclusion, following NNRTI discontinuation, in the majority of patients HIV variants carrying the 103N mutation are not overgrown for long by wild-type quasispecies at this position. This suggests that the 103N mutation per se influences minimally the viral fitness in vivo.

Gadobenate dimeglumine 0.5 M solution for injection (MultiHance) pharmaceutical formulation and physicochemical properties of a new magnetic resonance imaging contrast medium

OBJECTIVE

To characterize the proton-magnetic relaxation properties and complexation equilibria of gadobenate dimeglumine and to develop a pharmaceutical formulation for injection.

METHODS

Proton-magnetic relaxivities were determined at 20 MHz and 39 degrees C. Metal complexation was studied potentiometrically. Degradation pathways were identified through prolonged exposure to elevated temperature.

RESULTS

Because of its size and very weak interaction with serum albumin, gadobenate dimeglumine has proton-magnetic relaxivities that are larger than those of gadopentetate dimeglumine in both water and biological fluids. With regard to metal complexation, the two products are indistinguishable. The metal complexation behavior and thermal stability of the product allowed a pharmaceutical formulation for injection containing 0.5 M gadobenate dimeglumine without excipients. The physicochemical properties of the formulated product were determined.

CONCLUSION

Gadobenate dimeglumine has an elevated T1-relaxivity, especially in blood plasma. The high stability of the complex guarantees a negligible release of gadolinium ion. Gadobenate dimeglumine 0.5 M solution for injection has a shelf life of three years.

Stereoselective pharmacokinetics of moguisteine metabolites in healthy subjects

We studied the pharmacokinetics of moguisteine, a racemic non-narcotic peripheral antitussive drug, in 12 healthy male subjects after a single oral administration of 200 mg. The unchanged drug was absent in plasma and urine of all subjects. Moguisteine was immediately and completely hydrolyzed to its main active metabolite, the free carboxylic acid M1. Therefore, we evaluated the kinetic profiles of M1, of its enantiomers R(+)-M1 and S(-)-M1, and of M1 sulfoxide optical isomers M2/I and M2/II by conventional and stereospecific HPLC. Maximum plasma concentrations for M1 (2.83 mg/l), M2/I (0.26 mg/l) and M2/II (0.40 mg/l), were respectively reached at 1.3, 1.6 and 1.5 h after moguisteine administration. Plasma concentrations declined after the peak with mean apparent terminal half-lives of 0.65 h (M1), 0.88 h (M2/I) and 0.84 h (M2/II). Most of the administered dose was recovered in urine within 6 h from moguisteine treatment. The systemic and renal clearance values indicated high renal extraction ratio for all moguisteine metabolites, and particularly for M1 sulfoxide optical isomers. Plasma concentration-time profiles and urinary excretion patterns for M1 enantiomers R(+)-M1 and S(-)-M1 were quite similar. Thus, for later moguisteine pharmacokinetic evaluations the investigation of the plasma concentration-time curve and the urinary excretion of the sole racemic M1 through non-stereospecific analytical methods may suffice in most cases.