Management of patients with localized prostate cancer and biochemical recurrence in Spain: A medical survey

INTRODUCTION

The management of patients with prostate cancer (PCa) is established in clinical practice guidelines, which are based on randomized studies according to the level of evidence. In Spain, the degree of compliance with these guidelines in clinical practice is unknown.

OBJECTIVES

To describe the profiles of PCa patients at the time of diagnosis and the management of patients with localized PCa and those with BCR in Spain.

MATERIALS & METHODS

A medical survey was conducted in specialized care (85 urologists [UROs], 64 radiation oncologists [ROs], and 21 medical oncologists [MOs]). Three questionnaires were developed for this study with 22 (UROs and ROs) or 21 questions (MOs).

RESULTS

The annual incidence of PCa was 24,057 in participating hospitals (N = 131). The extrapolated annual incidence in Spain is 40,531 cases. The estimated prevalence of PCa in Spain is 221,689. Of note, 79% and 80% of patients seen by UROs and ROs, respectively had localized PCa at diagnosis. Biopsy was the most used diagnostic test among the three specialties, followed by abdominopelvic computer tomography. More than 90% of patients with BCR underwent standard tests. Next generation imaging tests and PET-choline/PSMA are still used residually. Most patients with localized PCa are currently treated with either surgery or radiotherapy, while for BCR patients, UROs and ROs prefer radiotherapy and MOs androgen deprivation therapy alone or in combination.

CONCLUSION

This study describes patient profiles at the time of diagnosis and provides an overview of the current therapeutic management of localized PCa and BCR in clinical practice in Spain.

Progressive perioperative benefits of laparoscopy in combination with an ERAS (Enhanced Recovery After Surgery) protocol in radical cystectomy with ileal conduit

INTRODUCTION

Although in the recent years, laparoscopy and Enhanced Recovery After Surgery (ERAS) protocols have improved postoperative recovery in radical cystectomy (RC), the clinical efficacy of their association remains unclear. Our objective is to analyze the possible benefits obtained from laparoscopic RC (LRC) and its subsequent combination with an ERAS (ERAS-LRC) protocol compared to open RC (ORC).

MATERIAL AND METHODS

We analyzed 187 consecutive RCs with ileal conduit performed in our center, of which 139 met the inclusion criteria: 47 ORC, 39 LRC (both with conventional protocol) and 52 ERAS-LRCs.

RESULTS

No significant differences were found regarding age, sex, BMI and ASA score between groups. ERAS-LRC obtained a shorter length of stay than LRC and ORC (median 8 [7-10]) vs. 13 [10-17] vs. 15 [13-19.5] days, respectively; P<.001). ERAS-LRC had a shorter stay in the ICU and less days of nasogastric tube (P<.001). Postoperative complications and readmission rates were similar among groups. Multivariate logistic regression showed that absence of complications, younger age and ERAS behaved as independent factors for shorter hospital stay, while ERAS was the only independent factor of lower readmission rate at 90 days.

CONCLUSIONS

Although LRC presented perioperative benefits compared to ORC, the results were better after the implementation of an ERAS protocol. ERAS protocol had stronger impact on recovery than the surgical approach of the procedure.

Impact of anemia on the survival of patients undergoing radical cystectomy for bladder cancer

OBJECTIVE

To evaluate the prevalence of preoperative anemia and its effect on oncological outcomes in patients undergoing radical cystectomy (RC) due to bladder cancer.

MATERIAL AND METHODS

Retrospective single-center study with 176 RCs between May 2008 and July 2018. Anemia was defined according to the WHO classification (male<130mg/dL, female<120mg/dL). Kaplan-Meier test was used to estimate recurrence-free, cancer-specific and overall survival rates. Multivariate logistic regression was used to identify factors associated with overall mortality rates.

RESULTS

Overall, 89 (50.6%) patients had preoperative anemia, and 44 of them (49.4%) received neoadjuvant chemotherapy. Anemic patients resulted in higher rates of ASA (ASA>2: 54.6 vs. 27.5%; P=.003), ectasia rate previous to RC (41.6 vs. 19.5%; P=.002), treatment with neoadjuvant chemotherapy (49.4 vs. 19.5%; P<.001), blood transfusion rate (25.8 vs. 11.5%; P=.015) and pathological stage (pT>2: 49.4 vs. 33.3%; P=.03) compared to non-anemic patients. Median follow-up was 27.2 months (IQR 11.12-72.28). Median overall survival (105 vs. 34 months, log-rank; P=.001), cancer-specific survival (89 vs. 61 months; P=.004) and recurrence-free survival (85 vs. 57 months; P=.002) were significantly lower in anemic patients compared to the non-anemic group. In multivariable Cox analysis, preoperative anemia, pT>2 and N≥1 were independently associated with overall mortality.

CONCLUSION

Preoperative anemia was common in patients undergoing RC for bladder cancer, and it is related with a worse cancer prognosis. Anemia is a preoperative modifiable factor; we believe that the implementation of Patient Blood Management programs during prehabilitation may have a relevant role in improving the oncological outcomes in these patients.

Impact of the baseline study with penile doppler ultrasound in patients with prostate cancer before radical prostatectomy

INTRODUCTION

Given the high prevalence of erectile dysfunction in male population between 40-70 years old and the effect of radical prostatectomy on this domain, it is important to perform a baseline study.

MATERIAL AND METHODS

Prior radical prostatectomy, erectile function has been assessed prospectively in 112 prostate cancer patients using the erectile function (EF) domain of the International Index of Erectile Function (EF-IIEF), Erectile Hardness Score (EHS) and a penile doppler ultrasound (PDUS). Comorbidities and Charlson index were collected. The EORTC QLQ C-30 and PR-25 tests were administered.

RESULTS

According to EF-IIEF questionnaire, 50.9% of patients showed normal EF and EHS grade 3-4 erection was achieved in the 75.9%. PDUS was normal only in 28.6% of patients and 51.8% showed arterial insufficiency. We found a significant association (P<.0001) between categorized EF-IIEF (normal, mild/moderate/severe) and the EHS value. Between PDUS (normal vs. pathologic) and EHS (3-4 vs. 1-2) statistically significant association (P=.005) was found. Just 35.3% of patients with EHS 3-4 showed normal PDUS. Correlation between the PDUS and the EF-IIEF (≥26 vs.<26) was statistically significant (P=.043). Moreover, only 38.6% of patients with EF-IIEF≥26 had a normal PDUS.

CONCLUSIONS

In order to predict EF recovery after surgery, global assessment is required. Solely self-administered tests are not enough. In this baseline study, PDUS can play an important role.

Laparoscopic partial nephrectomy: Comparative study of the transperitoneal pathway and the retroperitoneal pathway

INTRODUCTION

Laparoscopic partial nephrectomy is the recommended treatment for tumours smaller than 4cm in cases where it is feasible. Depending on the location of the tumour, the transabdominal or direct retroperitoneal pathway may be considered.

OBJECTIVE

To compare the transperitoneal (TPPN) and direct retroperitoneal (RPPN) partial nephrectomies performed between 2007 and 2016.

MATERIAL AND METHODS

A retrospective study was conducted on 71 patients who underwent TPPN (42) or direct RPPN (29) partial nephrectomy. We evaluated the characteristics of the patients and tumours, including tumour complexity (PADUA, RENAL, C-index). We compared perioperational variables, including the complications between the 2 pathways.

RESULTS

We found no differences in terms of age, sex, Charlson's score and BMI. A larger proportion of patients in the direct RPPN group had prior major abdominal surgery (7.1 vs. 24.1%; P=.043). There were no differences in tumour size, laterality, polarity or complexity in any of the assessed scores. There were significant differences in tumour location (anterior/middle/posterior) between the TPPN and RPPN groups (54.8/31/14.3 vs. 3.4/13.8/82.8%; P<.001). There were no differences in the surgical time or length of stay. The TPPN group had a smaller urinary tract opening (4.8 vs. 27.6%; P=.007) and a higher percentage of haemostatic renorrhaphy (47.6 vs. 17.2%; P=.008). There were no differences in the need for warm ischaemia, in the changes in haemoglobin levels or in the glomerular filtration rate. The complication rates were similar for the two series.

CONCLUSION

The two pathways show similar results in terms of renal function preservation, complications and oncological results. However, we recommend understanding both techniques and adapting the access type to the clinical case.

Retroperitoneal and transperitoneal laparoscopic cryotherapy for small renal masses

OBJECTIVE

Cryotherapy is a minimally invasive ablative technique that is considered an alternative to conventional surgery for preserving renal function in small renal tumors and in selected cases. We present our results from laparoscopic renal cryotherapy.

MATERIAL AND METHOD

We retrospectively analyzed 17 renal tumors diagnosed in 16 patients treated with cryotherapy. The patients' mean age was 66 years (43-80). The mean tumor size was 1.8cm (0.7-3.7cm). Cryotherapy with double-freeze cycle was performed laparoscopically in all cases (10 by transperitoneal approach and 7 by retroperitoneal approach).

RESULTS

Perioperative biopsies were performed on all patients and were positive for malignancy in 10 cases (59%). The mean stay was 2.8 days. The mean operative time was 162 minutes. Only 1 case reverted to open surgery due to bleeding. One patient required a blood transfusion in the immediate postoperative period. The majority of complications were Clavien-Dindo grades I and II. Some 76.5% of the patients had no complications. After a mean follow-up of 31 months (6-102), 1 patient died from nontumor-related causes, and 12 patients (75%) still show no evidence of local recurrence or progression. One patient had tumor persistence and therefore underwent partial nephrectomy at 6 months. One patient had a metachronous recurrence in the same kidney at 36 months, and another patient had a recurrence at 23 months.

CONCLUSIONS

Laparoscopic renal cryotherapy is a safe and feasible technique and is a good alternative to surgery for selected renal tumors.

[Ischemic hepatitis in patients with heart failure]

Ischemic hepatitis is characterized by a marked and reversible elevation in either the serum alanine or aspartate aminotransferase level in a appropriate clinical setting that could lead to a reduction in hepatic blood flow, mainly in patients with heart failure. To establish the diagnosis other causes of hepatitis, such as virus and drugs, must be previously excluded. Centrilobular necrosis is the main histologic feature. In the present study we describe the three cases of ischemic hepatitis seen in our medical service during a period of one year. Its prevalence was 2.7% among all patients with heart failure admitted in our centre during the same period.