A Systematic Review and Meta-analysis of Functional Outcomes and Complications Following Transurethral Procedures for Lower Urinary Tract Symptoms Resulting from Benign Prostatic Obstruction: An Update

CONTEXT

A number of transurethral ablative techniques based on the use of innovative medical devices have been introduced in the recent past for the surgical treatment of benign prostatic obstruction (BPO).

OBJECTIVE

To conduct a systematic review of the literature and a meta-analysis of available randomized controlled trials (RCTs), and to evaluate the efficacy and safety of transurethral ablative procedures for BPO.

EVIDENCE ACQUISITION

A systematic literature search was performed for all RCTs comparing any transurethral surgical technique for BPO to another between 1992 and 2013. Efficacy was evaluated after a minimum follow-up of 1 yr based on International Prostate Symptom Score, maximum flow rate, and postvoid residual volume. Efficacy at midterm follow-up, prostate volume, perioperative data, and short-term and long-term complications were also assessed. Data were analyzed using RevMan software.

EVIDENCE SYNTHESIS

A total of 69 RCTs (8517 enrolled patients) were included. No significant difference was found in terms of short-term efficacy between bipolar transurethral resection of the prostate (B-TURP) and monopolar transurethral resection of the prostate (M-TURP). However, B-TURP was associated with a lower rate of perioperative complications. Better short-term efficacy outcomes, fewer immediate complications, and a shorter hospital stay were found after holmium laser enucleation of the prostate (HoLEP) compared with M-TURP. Compared with M-TURP, GreenLight photoselective vaporization of the prostate (PVP) was associated with a shorter hospital stay and fewer complications but no different short-term efficacy outcomes.

CONCLUSIONS

This meta-analysis shows that HoLEP is associated with more favorable outcomes than M-TURP in published RCTs. B-TURP and PVP have resulted in better perioperative outcomes without significant differences regarding efficacy parameters after short-term follow-up compared with M-TURP. Further studies are needed to provide long-term comparative data and head-to head comparisons of emerging techniques.

PATIENT SUMMARY

Bipolar transurethral resection of the prostate, photovaporization of the prostate, and holmium laser enucleation of the prostate have shown efficacy outcomes comparable with conventional techniques yet reduce the complication rate. The respective role of these new options in the surgical armamentarium needs to be refined to propose tailored surgical treatment for benign prostatic obstruction relief.

International retrospective study of the pipeline embolization device: a multicenter aneurysm treatment study

BACKGROUND AND PURPOSE

Flow diverters are increasingly used in the endovascular treatment of intracranial aneurysms. Our aim was to determine neurologic complication rates following Pipeline Embolization Device placement for intracranial aneurysm treatment in a real-world setting.

MATERIALS AND METHODS

We retrospectively evaluated all patients with intracranial aneurysms treated with the Pipeline Embolization Device between July 2008 and February 2013 in 17 centers worldwide. We defined 4 subgroups: internal carotid artery aneurysms of ≥10 mm, ICA aneurysms of <10 mm, other anterior circulation aneurysms, and posterior circulation aneurysms. Neurologic complications included spontaneous rupture, intracranial hemorrhage, ischemic stroke, permanent cranial neuropathy, and mortality. Comparisons were made with t tests or ANOVAs for continuous variables and the Pearson χ(2) or Fisher exact test for categoric variables.

RESULTS

In total, 793 patients with 906 aneurysms were included. The neurologic morbidity and mortality rate was 8.4% (67/793), highest in the posterior circulation group (16.4%, 9/55) and lowest in the ICA <10-mm group (4.8%, 14/294) (P = .01). The spontaneous rupture rate was 0.6% (5/793). The intracranial hemorrhage rate was 2.4% (19/793). Ischemic stroke rates were 4.7% (37/793), highest in patients with posterior circulation aneurysms (7.3%, 4/55) and lowest in the ICA <10-mm group (2.7%, 8/294) (P = .16). Neurologic mortality was 3.8% (30/793), highest in the posterior circulation group (10.9%, 6/55) and lowest in the anterior circulation ICA <10-mm group (1.4%, 4/294) (P < .01).

CONCLUSIONS

Aneurysm treatment with the Pipeline Embolization Device is associated with the lowest complication rates when used to treat small ICA aneurysms. Procedure-related morbidity and mortality are higher in the treatment of posterior circulation and giant aneurysms.

Initial clinical experience with the ADAPT technique: a direct aspiration first pass technique for stroke thrombectomy

BACKGROUND

The development of new revascularization devices has improved recanalization rates and time but not clinical outcomes. We report our initial results with a new technique utilizing a direct aspiration first pass technique with a large bore aspiration catheter as the primary method for vessel recanalization.

METHODS

A retrospective evaluation of a prospectively captured database of 37 patients at six institutions was performed on patients where the ADAPT technique was utilized. The data represent the initial experience with this technique.

RESULTS

The ADAPT technique alone was successful in 28 of 37 (75%) cases although six cases had large downstream emboli that required additional aspiration. Nine cases required the additional use of a stent retriever and one case required the addition of a Penumbra aspiration separator to achieve recanalization. The average time from groin puncture to at least Thrombolysis in Cerebral Ischemia (TICI) 2b recanalization was 28.1 min, and all cases were successfully revascularized. TICI 3 recanalization was achieved 65% of the time. On average, patients presented with an admitting National Institutes of Health Stroke Scale (NIHSS) score of 16.3 and improved to an NIHSS score of 4.2 by the time of hospital discharge. There was one procedural complication.

DISCUSSION

This initial experience highlights the fact that the importance of the technique with which new stroke thrombectomy devices are used may be as crucial as the device itself. The ADAPT technique is a simple and effective approach to acute ischemic stroke thrombectomy. Utilizing the latest generation of large bore aspiration catheters in this fashion has allowed us to achieve excellent clinical and angiographic outcomes.

US multicenter experience with the wingspan stent system for the treatment of intracranial atheromatous disease: periprocedural results

BACKGROUND AND PURPOSE

The current report details our initial periprocedural experience with Wingspan (Boston Scientific/Target), the first self-expanding stent system designed for the treatment of intracranial atheromatous disease.

METHODS

All patients undergoing angioplasty and stenting with the Gateway balloon-Wingspan stent system were prospectively tracked.

RESULTS

During a 9-month period, treatment with the stent system was attempted in 78 patients (average age, 63.6 years; 33 women) with 82 intracranial atheromatous lesions, of which 54 were > or =70% stenotic. Eighty-one of 82 lesions were successfully stented (98.8%) during the first treatment session. In 1 case, the stent could not be delivered across the lesion; the patient was treated solely with angioplasty and stented at a later date. Lesions treated involved the internal carotid (n=32; 8 petrous, 10 cavernous, 11 supraclinoid segment, 3 terminus), vertebral (n=14; V4 segment), basilar (n=14), and middle cerebral (n=22) arteries. Mean+/-SD pretreatment stenosis was 74.6+/-13.9%, improving to 43.5+/-18.1% after balloon angioplasty and to 27.2+/-16.7% after stent placement. Of the 82 lesions treated, there were 5 (6.1%) major periprocedural neurological complications, 4 of which ultimately led to patient death within 30 days of the procedure.

CONCLUSIONS

Angioplasty and stenting for symptomatic intracranial atheromatous disease can be performed with the Gateway balloon-Wingspan stent system with a high rate of technical success and acceptable periprocedural morbidity. Our initial experience indicates that this procedure represents a viable treatment option for this patient population.

Wingspan in-stent restenosis and thrombosis: incidence, clinical presentation, and management

OBJECTIVE

Wingspan (Boston Scientific, Fremont, CA) is a self-expanding stent designed specifically for the treatment of symptomatic intracranial atheromatous disease. The current series reports the observed incidence of in-stent restenosis (ISR) and thrombosis on angiographic follow-up.

METHODS

A prospective, intent-to-treat registry of patients in whom the Wingspan stent system was used to treat symptomatic intracranial atheromatous disease was maintained at five participating institutions. Clinical and angiographic follow-up results were recorded. ISR was defined as stenosis greater than 50% within or immediately adjacent (within 5 mm) to the implanted stents and absolute luminal loss greater than 20%.

RESULTS

To date, follow-up imaging (average duration, 5.9 mo; range, 1.5-15.5 mo) is available for 84 lesions treated with the Wingspan stent (78 patients). Follow-up examinations consisted of 65 conventional angiograms, 17 computed tomographic angiograms, and two magnetic resonance angiograms. Of these lesions with follow-up, ISR was documented in 25 and complete thrombosis in four. Two of the 4 patients with stent thrombosis had lengthy lesions requiring more than one stent to bridge the diseased segment. ISR was more frequent (odds ratio, 4.7; 95% confidence intervals, 1.4-15.5) within the anterior circulation (42%) than the posterior circulation (13%). Of the 29 patients with ISR or thrombosis, eight were symptomatic (four with stroke, four with transient ischemic attack) and 15 were retreated. Of the retreatments, four were complicated by clinically silent in-stent dissections, two of which required the placement of a second stent. One was complicated by a postprocedural reperfusion hemorrhage.

CONCLUSION

The ISR rate with the Wingspan stent is higher in our series than previously reported, occurring in 29.7% of patients. ISR was more frequent within the anterior circulation than the posterior circulation. Although typically asymptomatic (76% of patients in our series), ISR can cause neurological symptoms and may require target vessel revascularization.

Management of stage T1 tumors of the bladder: International Consensus Panel

The International Consensus Panel on T1 bladder tumors markers reviewed the subject from a clinical perspective. From diagnosis to treatment decisions, what are the important issues in the management of a new patient? The assessment of prognostic factors for progression requires optimal resection and documentation. The role of immediate adjuvant intravesical chemotherapy after resection remains controversial. How often should the upper tract be assessed for tumor recurrence? The decision on whether to attempt bladder conservation with intravesical therapy or to perform a cystectomy is the most difficult issue in the management of superficial bladder cancer today. Finally, what therapies exist if initial intravesical bacille Calmette-Guérin fails to eradicate the disease or prevent recurrence? The panel thoroughly explored all these subjects and has made recommendations with supporting evidence.

Aneurysm Study of Pipeline in an Observational Registry (ASPIRe)

BACKGROUND AND OBJECTIVE

Few prospective studies exist evaluating the safety and efficacy of the Pipeline Embolization Device (PED) in the treatment of intracranial aneurysms. The Aneurysm Study of Pipeline In an observational Registry (ASPIRe) study prospectively analyzed rates of complete aneurysm occlusion and neurologic adverse events following PED treatment of intracranial aneurysms.

MATERIALS AND METHODS

We performed a multicenter study prospectively evaluating patients with unruptured intracranial aneurysms treated with PED. Primary outcomes included (1) spontaneous rupture of the Pipeline-treated aneurysm; (2) spontaneous nonaneurysmal intracranial hemorrhage (ICH); (3) acute ischemic stroke; (4) parent artery stenosis, and (5) permanent cranial neuropathy. Secondary endpoints were (1) treatment success and (2) morbidity and mortality at the 6-month follow-up. Vascular imaging was evaluated at an independent core laboratory.

RESULTS

One hundred and ninety-one patients with 207 treated aneurysms were included in this registry. The mean aneurysm size was 14.5 ± 6.9 mm, and the median imaging follow-up was 7.8 months. Twenty-four aneurysms (11.6%) were small, 162 (78.3%) were large and 21 (10.1%) were giant. The median clinical follow-up time was 6.2 months. The neurological morbidity rate was 6.8% (13/191), and the neurological mortality rate was 1.6% (3/191). The combined neurological morbidity/mortality rate was 6.8% (13/191). The most common adverse events were ischemic stroke (4.7%, 9/191) and spontaneous ICH (3.7%, 7/191). The complete occlusion rate at the last follow-up was 74.8% (77/103).

CONCLUSIONS

Our prospective postmarket study confirms that PED treatment of aneurysms in a heterogeneous patient population is safe with low rates of neurological morbidity and mortality. Patients with angiographic follow-up had complete occlusion rates of 75% at 8 months.

Influence of patient age and stenosis location on wingspan in-stent restenosis

BACKGROUND AND PURPOSE

Wingspan is a self-expanding, microcatheter-delivered microstent specifically designed for the treatment of symptomatic intracranial atherosclerotic disease. Our aim was to discuss the effect of patient age and lesion location on in-stent restenosis (ISR) rates after percutaneous transluminal angioplasty and stenting (PTAS) with the Wingspan system.

MATERIALS AND METHODS

Clinical and angiographic follow-up results were recorded for all patients from 5 participating institutions. ISR was defined as >50% stenosis within or immediately adjacent (within 5 mm) to the implanted stent and >20% absolute luminal loss. For the present analysis, patients were stratified into younger (</=55 years) and older (>55 years) age groups.

RESULTS

ISR occurred at a rate of 45.2% (14/31) in the younger group and 24.2% (15/62) in the older group (odds ratio, 2.6; 95% confidence interval, 1.03-6.5). In the younger group, ISR occurred after treatment of 13/26 (50%) anterior circulation lesions versus only 1/5 (20%) posterior circulation lesions. In the older group, ISR occurred in 9/29 (31.0%) anterior circulation lesions and 6/33 (18.2%) posterior circulation lesions. In young patients, internal carotid artery lesions (10/17 treated, 58.8%), especially those involving the supraclinoid segment (8/9, 88.9%), were very prone to ISR. When patients of all ages were considered, supraclinoid segment lesions had much higher rates of both ISR (66.6% versus 24.4%) and symptomatic ISR (40% versus 3.9%) in comparison with all other locations.

CONCLUSION

Post-Wingspan ISR is more common in younger patients. This increased risk can be accounted for by a high prevalence of anterior circulation lesions in this population, specifically those affecting the supraclinoid segment, which are much more prone to ISR and symptomatic ISR than all other lesions.

Neuroform in-stent stenosis: incidence, natural history, and treatment strategies

OBJECTIVE

Delayed in-stent stenosis is an important and well-characterized complication of angioplasty and stenting for the treatment of intra- and extracranial atheromatous disease. The current series describes the incidence and natural history of in-stent stenosis after the deployment of the Neuroform stent within the cerebrovasculature for the treatment of aneurysms.

METHODS

The collaborative Cleveland Clinic Foundation-Barrow Neurological Institute endovascular database was reviewed to identify cases of delayed moderate or severe in-stent stenosis observed during the follow-up of cerebral aneurysms treated with the Neuroform stent. The hospital charts, clinic records, and operative reports for these patients were reviewed.

RESULTS

Of a total of 156 patients with follow-up, nine (5.8%) cases of moderate or severe delayed (>2 mo) in-stent stenosis were identified, including two parent vessel occlusions. In two cases, patients presented 3 months after stent-supported aneurysm embolization with focal neurological symptoms. Both of these patients were treated with angioplasty. One eventually required surgical bypass. Of the seven asymptomatic patients, four demonstrated some degree of spontaneous resolution at follow-up, one progressed to complete occlusion, one is awaiting further follow-up, and one patient died of unrelated causes. Of the nine patients in the series, five were treated with "bioactive" coils (Matrix, Hydrocoil, Cerecyte), three were treated with bare platinum coils, and one was treated with stenting alone. The earliest time interval to diagnosis was 2.5 months and 3 months for asymptomatic and symptomatic patients, respectively. The earliest interval documented for spontaneous resolution was 9 months.

CONCLUSION

Delayed Neuroform in-stent stenosis, occurring in 5.8% of cases, is not a rare phenomenon. The stenosis can be symptomatic and may require endovascular treatment or surgical bypass. In asymptomatic patients, a strategy of "watchful waiting" may be effective because many patients demonstrate partial or complete resolution at follow-up. The spontaneous resolution of delayed in-stent stenosis has not been previously described. This may be a phenomenon unique to the application of low radial force, self-expanding stents within the nonatheromatous cerebrovasculature.

Quantum magnetic excitations from stripes in copper oxide superconductors

In the copper oxide parent compounds of the high-transition-temperature superconductors the valence electrons are localized--one per copper site--by strong intra-atomic Coulomb repulsion. A symptom of this localization is antiferromagnetism, where the spins of localized electrons alternate between up and down. Superconductivity appears when mobile 'holes' are doped into this insulating state, and it coexists with antiferromagnetic fluctuations. In one approach to describing the coexistence, the holes are believed to self-organize into 'stripes' that alternate with antiferromagnetic (insulating) regions within copper oxide planes, which would necessitate an unconventional mechanism of superconductivity. There is an apparent problem with this picture, however: measurements of magnetic excitations in superconducting YBa2Cu3O6+x near optimum doping are incompatible with the naive expectations for a material with stripes. Here we report neutron scattering measurements on stripe-ordered La1.875Ba0.125CuO4. We show that the measured excitations are, surprisingly, quite similar to those in YBa2Cu3O6+x (refs 9, 10) (that is, the predicted spectrum of magnetic excitations is wrong). We find instead that the observed spectrum can be understood within a stripe model by taking account of quantum excitations. Our results support the concept that stripe correlations are essential to high-transition-temperature superconductivity.

A 7-YEAR EXPERIENCE WITH BALLOON-MOUNTED CORONARY STENTS FOR THE TREATMENT OF SYMPTOMATIC VERTEBROBASILAR INTRACRANIAL ATHEROMATOUS DISEASE

OBJECTIVE

Balloon-mounted coronary stents (BMCS) have been adapted for use in the intracranial circulation for the treatment of symptomatic intracranial atheromatous disease (ICAD). We performed a retrospective analysis of our 7-year experience with these devices in an attempt to quantify the periprocedural risks and long-term outcomes in patients with symptomatic ICAD of the vertebrobasilar (VB) system treated with BMCS.

METHODS

A retrospective review of a prospectively maintained database was performed to determine the neurological and non-neurological periprocedural risks of BMCS treatment of ICAD. Patients were followed with serial transcranial Doppler (TCD) and, in some cases, angiographic imaging. The clinical status was determined based on clinic visits and by telephone interviews when possible.

RESULTS

Over the 6-year period from March 1999 to May 2005, 44 patients (35 men, 9 women; average age, 64.8 yr) with 47 symptomatic atheromatous lesions of the VB system were treated with BMCS. In two patients, the BMSC could not be delivered across the target lesion. Treatment of the remaining 45 lesions was technically successful (95.7%). The periprocedural neurological morbidity and mortality was 26.1% (10 clinically evident strokes, 2 deaths). One additional patient experienced a periprocedural transient ischemic attack (TIA). Two patients died of non-neurological causes within 6 months (4.3%, myocardial infarction and cholecystitis). The average stenosis measured 82.5%, declining to 10.0% stenosis after BMCS. TCD examinations showed a preprocedural velocity of 127.7 cm/second (n = 43; standard deviation, 63.7 cm/s), which declined to 54.0 cm/s immediately after the procedure (n = 42; standard deviation, 22.7 cm/s). In patients with serial TCD evaluations, velocities were typically constant over years of follow-up (six patients with &gt;5 yr of follow-up; average velocity, 52.2 cm/s). Angiographic follow-up was available for 11 patients. Three patients had stent occlusion (all symptomatic with TIAs), one patient had greater than 50% in-stent restenosis (ISR) (symptomatic with TIA) and seven had no significant (&lt;50%) stenosis. The overall ISR/occlusion rate was 12.5% (4 out of 32 lesions with angiographic and/or TCD follow-up &gt; 6 mo). Of the 42 patients who successfully underwent BMCS, clinical follow-up was available for 33 (78.6%, average follow-up period, 43.5 mo), three patients died before any follow-up could be performed, and seven were lost to follow-up. Of the patients with follow-up, five had recurrent vertebrobasilar ischemic symptoms (15%; four TIA, one stroke). Four out of five patients with recurrent symptoms had ISR or occlusion verified on conventional angiography. At the time of the last follow-up examination, seven patients of 44 patients who underwent attempted treatment were dead (modified Rankin Scale [mRS] score, 6); four had an mRS score of 3 to 5, 16 had an mRS score of 1 or 2, and 10 had an mRS score of 0.

CONCLUSION

Percutaneous transluminal angioplasty and stenting using BMCS for the treatment of symptomatic VB ICAD can be carried out with high rates of technical success and excellent immediate angiographic results. However, the procedure carries with it a very high rate of periprocedural morbidity and mortality. Greater than 50% ISR or stent occlusion occurred in 12.5% of the patients and was associated with recurrent TIAs. In the absence of ISR/occlusion, patients who tolerated the initial procedure did well neurologically and did not typically experience recurrent ischemic symptoms.

Laparoscopic Radical Prostatectomy for Localized Prostate Cancer: A Systematic Review of Comparative Studies

PURPOSE

We compared the safety and efficacy of laparoscopic and open radical prostatectomy through a systematic assessment of the literature.

MATERIALS AND METHODS

Literature databases were searched from 1996 to December 2004 inclusive. Studies comparing transperitoneal laparoscopic radical prostatectomy, extraperitoneal endoscopic radical prostatectomy or robot assisted radical prostatectomy with open radical retropubic prostatectomy or radical perineal prostatectomy for localized prostate cancer were included. Comparisons between different laparoscopic approaches were also included.

RESULTS

We identified 30 comparative studies, of which none were randomized controlled trials. There were 21 studies comparing laparoscopic with open prostatectomy with a total of 2,301 and 1,757 patients, respectively, and 9 comparing different laparoscopic approaches with a total of 1,148 patients. In terms of safety there did not appear to be any important differences in the complication rate between laparoscopic and open approaches. However, blood loss and transfusions were lower for laparoscopic approaches. In terms of efficacy operative time was longer for laparoscopic than for open prostatectomy but length of stay and duration of catheterization were shorter. Positive margin rates and recurrence-free survival were similar. Continence and potency were not well reported but they appeared similar for the 2 approaches. There were no important differences between laparoscopic approaches.

CONCLUSIONS

Laparoscopic radical prostatectomy is emerging as an alternative to open radical prostatectomy but randomized, controlled trials considering patient relevant outcomes, such as survival, continence and potency, with sufficient followup are required to determine relative safety and efficacy.

Natural history of brainstem cavernous malformations

OBJECTIVE

To review the natural history and determine the rates of intra- and extralesional hemorrhaging of brainstem cavernous malformations (cavernomas) monitored by one neuro-ophthalmology service.

METHODS

A record review of all patients with brainstem cavernomas who were evaluated by a neuroophthalmology service between 1987 and 1999 was performed. We recorded the clinical symptoms and Rankin disability grade at presentation, during the worst clinical episode, and at the last follow-up examination. Magnetic resonance imaging scans were reviewed for evidence of intralesional hemorrhage (a bleeding episode), edema, or venous anomalies, and the cavernoma size was assessed.

RESULTS

Thirty-seven patients (age range, 6-73 yr; mean age at presentation, 37.5 yr) underwent a mean of 4.9 years of follow-up monitoring. At presentation, there were 27 bleeding events and 8 nonhemorrhagic events; 2 patients did not exhibit symptoms. Patients who were at least 35 years of age exhibited a lower risk of bleeding episodes (odds ratio, 0.15; 95% confidence interval, 0.1-0.4). Cavernomas of at least 10 mm were associated with a higher risk of bleeding episodes (odds ratio, 3.48; 95% confidence interval, 1.3-9.4). Thirty-nine bleeding episodes occurred in 31 patients, yielding a bleeding rate of 2.46%/yr. There were eight rebleeding episodes, yielding a rebleeding rate of 5.1%/yr. Three patients experienced extralesional bleeding episodes; all of these patients experienced rebleeding. Of the 39 follow-up magnetic resonance imaging scans, the cavernoma size was unchanged in 66.7%, smaller in 18%, and larger in 15%. At the last follow-up examination, the mean Rankin grade was 1.0 for all patients, 0.6 for the 25 nonsurgically treated patients, and 1.4 for the 12 surgically treated patients.

CONCLUSION

Rebleeding is not more common among patients who first present with bleeding, and it often has little effect on the neurological status of patients. Significant morbidity attributable to a brainstem cavernoma occurred in 8% of patients during follow-up monitoring of medium duration.

Effects of hand massage on anxiety in cataract surgery using local anesthesia

PURPOSE

To evaluate the effects of hand massage on patient anxiety during cataract surgery.

SETTING

Kangnam St. Mary's Hospital, Seoul, Korea.

METHODS

This study comprised 59 patients having cataract surgery from December 11, 1996, to February 12, 1997. The patients were divided into those having a hand massage 5 minutes before surgery (experimental group, n = 29) and those not receiving a hand massage (control group, n = 30). Patients' anxiety levels were measured using the Visual Analog Scale and by assessing the systolic blood pressure, diastolic blood pressure, and pulse rate before and after the hand massage and 5 minutes before the end of surgery. Epinephrine, norepinephrine, cortisol, blood sugar levels, neutrophil, and lymphocyte percentages in white blood cells were also measured.

RESULTS

After the hand massage, the psychological anxiety levels, systolic and diastolic blood pressures, and pulse rate were significantly lower than before the massage. The hand massage significantly decreased epinephrine and norepinephrine levels in the experimental group. Epinephrine, norepinephrine, and cortisol levels increased in the control group. The differences between groups were significant. There were no significant between-group differences in blood sugar levels or neutrophil and lymphocyte percentages in white blood cells.

CONCLUSION

The findings indicate that hand massage decreases the psychological and physiological anxiety levels in patients having cataract surgery under local anesthesia.

Twitter in urology and other surgical specialties at global conferences

BACKGROUND

Over recent years, Twitter has demonstrated an expanding role in scientific discussion, surgical news and conferences. This study evaluates the role of Twitter in urological conferences, with comparison to other surgical specialties.

METHODS

A retrospective analysis of Twitter metrics during the two largest recent English-speaking conferences for each surgical specialty was performed. Using www.symplur.com, all 'tweets' under the official conference hashtag from 0000 hour the first day to 24.00 hour the final day were assessed. The number of impressions, 'tweeters' and rates of 'tweeting' were analysed.

RESULTS

Nine of 18 conferences examined had official hashtags registered with Symplur Healthcare Hashtags. Plastic and urological surgery had both major conferences registered. Only one of two conferences for each cardiothoracic, general, orthopaedic, otolaryngology and paediatric was registered. Both major neurosurgical and vascular conferences were unregistered. Urological conferences were associated with significantly more Twitter activity than non-urological surgical conferences in all parameters, with greater than triple the number of impressions, tweets and 'tweeters'. Urological surgical conferences were associated with 337% more tweets and 164% more impressions per conference day, than non-urological surgical conferences.

CONCLUSION

Twitter has been used to supplement surgical conferences. In this regard, the urological community leads the way compared to the remainder of surgical specialty communities.

Fifteen year quality of life outcomes in men with localised prostate cancer: population based Australian prospective study

OBJECTIVE

To assess treatment related changes in quality of life up to 15 years after diagnosis of localised prostate cancer.

DESIGN

Population based, prospective cohort study with follow-up over 15 years.

SETTING

New South Wales, Australia.

PARTICIPANTS

1642 men with localised prostate cancer, aged less than 70, and 786 controls randomly recruited from the New South Wales electoral roll into the New South Wales Prostate Cancer Care and Outcomes Study (PCOS).

MAIN OUTCOME MEASURES

General health and disease specific quality of life were self-reported at seven time points over a 15 year period, using the 12-item Short Form Health Survey scale, University of California, Los Angeles prostate cancer index, and expanded prostate cancer index composite short form (EPIC-26). Adjusted mean differences were calculated with controls as the comparison group. Clinical significance of adjusted mean differences was assessed by the minimally important difference, defined as one third of the standard deviation (SD) from the baseline score.

RESULTS

At 15 years, all treatment groups reported high levels of erectile dysfunction, depending on treatment (62.3% (active surveillance/watchful waiting, n=33/53) to 83.0% (non-nerve sparing radical prostatectomy, n=117/141)) compared with controls (42.7% (n=44/103)). Men who had external beam radiation therapy or high dose rate brachytherapy or androgen deprivation therapy as primary treatment reported more bowel problems. Self-reported urinary incontinence was particularly prevalent and persistent for men who underwent surgery, and an increase in urinary bother was reported in the group receiving androgen deprivation therapy from 10 to 15 years (year 10: adjusted mean difference -5.3, 95% confidence interval -10.8 to 0.2; year 15: -15.9; -25.1 to -6.7).

CONCLUSIONS

Patients receiving initial active treatment for localised prostate cancer had generally worse long term self-reported quality of life than men without a diagnosis of prostate cancer. Men treated with radical prostatectomy faired especially badly, particularly in relation to long term sexual outcomes. Clinicians and patients should consider these long term quality of life outcomes when making treatment decisions.

Training Standards in Neuroendovascular Surgery: Program Accreditation and Practitioner Certification

BACKGROUND AND PURPOSE

Neuroendovascular surgery is a medical subspecialty that uses minimally invasive catheter-based technology and radiological imaging to diagnose and treat diseases of the central nervous system, head, neck, spine, and their vasculature. To perform these procedures, the practitioner needs an extensive knowledge of the anatomy of the nervous system, vasculature, and pathological conditions that affect their physiology. A working knowledge of radiation biology and safety is essential. Similarly, a sufficient volume of clinical and interventional experience, first as a trainee and then as a practitioner, is required so that these treatments can be delivered safely and effectively.

METHODS

This document has been prepared under the aegis of the Society of Neurological Surgeons and its Committee for Advanced Subspecialty Training in conjunction with the Joint Section of Cerebrovascular Surgery for the American Association of Neurological Surgeons and Congress of Neurological Surgeons, the Society of NeuroInterventional Surgery, and the Society of Vascular and Interventional Neurology.

RESULTS

The material herein outlines the requirements for institutional accreditation of training programs in neuroendovascular surgery, as well as those needed to obtain individual subspecialty certification, as agreed on by Committee for Advanced Subspecialty Training, the Society of Neurological Surgeons, and the aforementioned Societies. This document also clarifies the pathway to certification through an advanced practice track mechanism for those current practitioners of this subspecialty who trained before Committee for Advanced Subspecialty Training standards were formulated.

CONCLUSIONS

Representing neuroendovascular surgery physicians from neurosurgery, neuroradiology, and neurology, the above mentioned societies seek to standardize neuroendovascular surgery training to ensure the highest quality delivery of this subspecialty within the United States.

Safety and efficacy of transurethral needle ablation of the prostate for symptomatic outlet obstruction

OBJECTIVES

To examine, in an observational study, the safety and efficacy of transurethral needle ablation (TUNA) of the prostate as a treatment for symptomatic benign prostatic enlargement.

PATIENTS AND METHODS

This prospective study included 71 symptomatic men with unequivocal obstruction on pressure-flow urodynamics. The variables measured at baseline and up to 12 months after treatment included the American Urological Association (AUA)-7 symptom index and an added quality-of-life question, the AUA BPH-Impact Index, a sexual function score, transrectal ultrasonography of the prostate, a frequency-volume chart, free-flow uroflowmetry, post-void residual urine volume (PVR) and pressure-flow urodynamics. Transurethral resection of the prostate (TURP) was offered if the symptoms failed to resolve at any time during the follow-up period. TUNA was performed under local anaesthetic and sedation in 63 (89%) men and as a day-case procedure in 10 (14%). Five patients were on warfarin which was not discontinued.

RESULTS

There were no serious treatment-related adverse events. Eight of the initial nine patients who were not routinely catheterized after treatment with TUNA developed acute urinary retention. Although some haematuria occurred in all patients, only one (1.4%) developed catheter blockage by clot. There were no problems with bleeding in those patients on warfarin at the time of treatment. The mean (95% confidence interval, CI) AUA-7 index fell from 23 (1.7) to 10.6 (1.8) (P < 0.001, Mann-Whitney U-test) at 12 months, 29 men (41%) had an AUA-7 index of < or = 7. The maximum (95% CI) urinary flow rate increased from 9.0 (0.8) to 11.3 (1.1) mL/s (P < 0.001) and this was accompanied by a small but significant reduction in PVR of 70 (14) mL to 35 (8) mL (P < 0.001 Mann-Whitney U-test). There was a significant reduction in both maximal voiding pressure and detrusor pressure at peak flow at 3 months (Mann-Whitney U-test, both P < 0.001) and at 12 months (P < 0.001, Wilcoxon matched-pairs signed-ranks test). However, 78% of the 45 men undergoing repeat pressure-flow studies at 12 months were unequivocally obstructed according to the Abrams-Griffiths nomogram. The mean (95% CI) prostatic volume fell from 49.0 (4.8) mL at baseline to 40.8 (4.9) mL at 3 months, but this change was not statistically significant (P = 0.011, Mann-Whitney U-test). Two men reported erectile dysfunction, one experienced ejaculatory problems and seven reported an improvement in erectile function after TUNA. During the study, 22 men (31%) underwent TURP.

CONCLUSIONS

TUNA is a safe treatment which can be performed as an out-patient procedure under local anaesthesia and sedation in the vast majority of patients. There was no evidence of serious adverse events and no significant adverse effect on sexual function. The symptomatic improvement was sustained at 12 months in most (54%) patients, with modest improvements in peak flow rate, PVR and voiding pressures, indicating that TUNA may result in prolonged symptomatic improvement in a proportion of patients suffering from bladder outlet obstruction. A randomized controlled study against established therapies is now essential to clearly delineate its place in the management of such patients.

Mainstream consent programs for genetic counseling in cancer patients: A systematic review

As demand for germline genetic testing for cancer patients increases, novel methods of genetic counseling are required. One such method is the mainstream consent pathway, whereby a member of the oncology team (rather than a genetic specialist) is responsible for counseling, consenting, and arranging genetic testing for cancer patients. We systematically reviewed the literature for evidence evaluating mainstream pathways for patients with breast, ovarian, colorectal, and prostate cancer. Medline, EMBASE, and Cochrane Library were searched for studies that met inclusion and exclusion criteria. Article references were checked for additional studies. Trial databases were searched for ongoing studies. Of the 13 papers that met inclusion criteria, 11 individual study groups were identified (two study groups had two publications each). Ten of the 11 studies evaluated the acceptability, feasibility, and impact of BRCA testing for patients and/or clinicians in different clinical settings in breast and ovarian cancer, while the final study explored the attitudes of colorectal specialists toward genetic testing for colorectal cancer. None involved prostate cancer. Overall, mainstream pathways were acceptable and feasible. Medical oncologist- and nurse-driven pathways were particularly successful, with both patients and clinicians satisfied with this process. Although the content of pretest counseling was less consistent compared with counseling via the traditional model, patients were largely satisfied with the education they received. Further research is required to evaluate the mainstream pathway for men with prostate cancer.

Transurethral needle ablation (TUNA). A critical review of radiofrequency thermal therapy in the management of benign prostatic hyperplasia

Radiofrequency thermal therapy of the prostate is a new minimally invasive treatment for symptomatic benign prostatic hyperplasia (BPH). The procedure is called transurethral needle ablation (TUNA). With TUNA, the inner region of the prostate is selectively ablated with temperatures approaching 90-100 degrees C while the prostatic urothelium is preserved. The objective of this article is to discuss the basics of radiofrequency energy, instrumentation, surgical techniques, and to present an update of the clinical results as it applies to the treatment of BPH.