Perioperative outcomes in male patients undergoing cystectomy, radical colorectal procedure or total pelvic exenteration

Background

Total pelvic exenteration (TPE) in men is a surgical procedure to treat genitourinary and colorectal malignancies. Despite improvement in multimodal strategies and technology, mortality is still high and literature is limited about perioperative outcomes comparison to other radical procedures.

Methods

We analyzed National Surgical Quality Improvement Program (NSQIP) baseline database of all male patients undergoing cystectomy, low anterior resection/abdominoperineal resection (LAR/APR) or TPE from January 1, 2005 to December 31, 2016. Postoperative complications within 30 days after surgery were measured including: Wound infection, septic complications, deep vein thrombosis, cardiovascular events, and return to the operating room or mortality, etc. Differences between groups were analyzed using analysis of variance (ANOVA) tests.

Results

A total of 7,375 patients underwent radical cystectomy, 49,762 underwent LAR/APR and 792 underwent TPE. Cystectomy patients were on average older compared to TPE or LAR/APR patients (P<0.001). In univariable and multivariable analysis, patients undergoing TPE had greater infectious and septic complications compared to cystectomy (odds ratio =1.09; 95% confidence interval (CI): 1.06-1.12) and LAR/APR (odds ratio =1.08; 95% CI: 1.05-1.11). Moreover, TPE had a slightly higher mortality within the 30-day postoperatively than those who underwent LAR/APR (odds ratio =1.01; 95% CI: 1.00-1.02) and cystectomy (odds ratio =1.01; 95% CI: 1.00-1.01).

Conclusions

Men undergoing TPE had greater rates of infections and postoperative complications compared to those undergoing radical cystectomy and LAR/APR. From a clinical standpoint, TPE has high morbidity that could provide opportunity for quality improvement projects with the goal of mitigating high complication rates.

Application of the single-port robotic platform during radical nephroureterectomy for upper tract urothelial carcinoma: feasibility of the single-port robot in the multi-quadrant setting

Urothelial carcinoma of the upper tract (UTUC) is a malignancy that accounts for 5-10% of all urothelial carcinomas. Radical surgery is the primary treatment option due to the high rate of invasive stages at the time of diagnosis. Nephroureterectomy (NU) with bladder cuff excision is the current standard of care. While laparoscopic NU has been established since 1991, many centres still perform open surgery due to the complexity of laparoscopic instrumentation and the steep learning curve for excising the bladder cuff. With the increasing adoption of the multi-port (MP) robotic surgery, NU has increasingly been performed using this platform. The use of MP robotic systems for NU has been challenged by the need for patient repositioning and/or redocking of the robot, which can consume valuable operative time. The transition from the daVinci Si to the daVinci Xi system has seen a noticeable reduction in redocking and patient repositioning. However, owing to the multi-quadrant nature of the surgery in question, the use of multiple ports and external instrument clashing are still persistent problems. Moreover, there is a growing interest in utilizing a retroperitoneal approach for robot-assisted NU due to its potential benefits such as improved control of hilar structures, reduction of blood loss, shorter operative time and hospital stay, reduced complications and decreased postoperative discomfort. The application of the daVinci single-port (SP) robotic platform during radical NU for UTUC is feasible and has the potential to improve the current surgical approach. Indeed, the use of a SP platform may solve the problem of patient repositioning and redocking of the robot, improve superficial aesthetic outcome and minimize external instrument clashing. While maintaining an optimal oncological control, the retroperitoneal approach, which has been difficult to replicate and adopt using the MP approach, may become standard practice. However, more studies are needed to confirm the benefit of this approach and ultimately determine the impact of the daVinci SP on the management of UTUC.

The Impact of Smoking on Sexual Function

OBJECTIVES

Smoking is a well-established risk factor for sexual dysfunction. However, the impact of smoking cessation on sexual function is unclear. We hypothesize that there is an improvement in sexual function following smoking cessation. To evaluate this hypothesis, we analyzed the association between cigarette smoking and smoking cessation with sexual function among participants of the Reduction by Dutasteride in Prostate Cancer Events (REDUCE) study.

MATERIALS AND METHODS

We analyzed baseline data of 6,754 men, ages 50-75 years-old divided into: lifelong nonsmokers, former smokers and current smokers. We examined total testosterone (TT, normal range ≥10 nmol/L) and sexual function variables: self-reported sexual activity, low libido and erectile dysfunction. Differences between current vs nonsmokers and former vs current smokers were analyzed using chi-square test, linear and logistic regressions.

RESULTS

A total of 3,069 (45.4%) men were nonsmokers, 2,673 (39.6%) former smokers, and 1,012 (15%) current smokers. Current smokers were significantly younger than former and nonsmokers (mean age 61.6, 63.2, 62.7 years), leaner (mean body-mass index 27.0, 27.7, 27.2 kg/m² ), and had less hypertension (32.4%, 41.6%, 36.8%, respectively, all P < 0.01). In uni- and multivariable analysis, current smokers had higher mean TT compared to nonsmokers (485.4, 451.2 nmol/L, P < 0.001), higher prevalence of low libido (25.6%, 21.0%, P=0.002) and erectile dysfunction (31.6%, 26.0%, respectively, P < 0.001) with comparable sexual activity (81.7%, 82.8%, respectively, P=0.420). In multivariable analysis, former smoker had statistically significant less prevalence of low libido (OR: 0.8, P=0.013) and erectile dysfunction (OR: 0.8, P=0.006) compared to current smokers.

CONCLUSION

Cigarette smoking was associated with worse sexual health compared to nonsmoker, while former smokers had better erectile function and libido than current smokers. Smoking cessation may improve male sexual health and counselling on smoking cessation may be considered at the time of sexual health evaluations.

Vasectomy: a guidelines-based approach to male surgical contraception

Except for condom use, vasectomy is the only approved form of male contraception. The American Urological Association published guidelines on vasectomy in 2012, which clearly outlined patient counseling, vasectomy techniques to maximize successful occlusion, and postvasectomy care. However, there are certainly areas of further improvement to be addressed. Vasectomy is severely underutilized compared with tubal ligation for sterilization, likely due to lack of patient awareness. Although the majority of vasectomies are performed in the office with local anesthesia, some patients are still routinely prescribed narcotics for postprocedural pain, despite the well-described opioid pandemic. Finally, although patients are counseled on the necessity of a postvasectomy semen analysis to confirm sterility prior to the discontinuation of alternative contraceptives, more than 50% of men do not complete this test. Therefore, alternative strategies must be pursued to improve patient compliance.

Diagnostic Properties of Total and Free Prostate-Specific Antigen to Predict Overall and Clinically Significant Prostate Cancer Among Men With Low Testosterone and Prior Negative Biopsy

OBJECTIVE

To evaluate whether total serum PSA, free-PSA ratio and PSA density have similar diagnostic properties for detecting prostate cancer (PCa) and clinically-significant (cs) PCa in men with normal testosterone compared to men with low testosterone with a prior negative biopsy.

METHODS

We conducted a retrospective analysis of 3295 men undergoing a 2-year prostate biopsy following a negative prestudy biopsy in the placebo arm of the Reduction by Dutasteride of PCa Events (REDUCE) study. Men were divided in 2 groups based on testosterone level < or ≥300 ng/dL. Diagnostic properties of total serum PSA, free-PSA ratio, and PSA density to predict PCa and csPCa, defined as Gleason score ≥7, were determined for several thresholds and plotted as receiver operator characteristic curves.

RESULTS

A total of 603 men (18.3%) had low testosterone. The prevalence of PCa and csPCa was 92 (15.3%) and 27 (4.5%), respectively, for low testosterone men compared to 458 (17.0%) and 138 (5.1%), correspondingly, for normal testosterone men. Total PSA, free-PSA ratio and PSA density showed similar sensitivity, specificity, and accuracy to predict PCa and csPCa among low testosterone men compared to normal testosterone men.

CONCLUSION

Among subjects in a clinical trial with a prior negative biopsy, total PSA, free-PSA ratio and PSA density have comparable diagnostic characteristics for PCa screening in low and normal testosterone men.

Environmental Toxins and Male Fertility

PURPOSE OF REVIEW

Global industrialization has increased population exposure to environmental toxins. A global decline in sperm quality over the last few decades raises questions about the adverse impact of environmental toxins on male reproductive health.

RECENT FINDINGS

Multiple animal- and human-based studies on exposure to environmental toxins suggest a negative impact on semen quality, in terms of sperm concentration, motility, and/or morphology. These toxins may exert estrogenic and/or anti-androgenic effects, which in turn alter the hypothalamic-pituitary-gonadal axis (HPGA), induce sperm DNA damage, or cause sperm epigenetic changes. This chapter will discuss the most recent literature about the most common environmental toxins and their impact on spermatogenesis and its consequences on male fertility. Understanding the presence and underlying mechanism of these toxins will help us preserve the integrity of the male reproduction system and formulate better regulations against their indiscriminate use.

Particle therapy using carbon ions or protons as a definitive therapy for patients with primary sacral chordoma

OBJECTIVE

This study retrospectively evaluated the efficacy and toxicity of particle therapy using carbon ions or protons for primary sacral chordomas.

METHODS

We evaluated 23 patients with primary sacral chordoma treated with carbon ion therapy (CIT) or proton therapy (PT) between July 2005 and June 2011 at the Hyogo Ion Beam Medical Center, Hyogo, Japan. The median patient age was 72 years. 14 patients were treated with 70.4 Gy equivalents (GyE) in 16 fractions and 9 were treated with 70.4 GyE in 32 fractions. CIT was used for 16 patients, and PT was used for 7 patients.

RESULTS

The median follow-up period was 38 months. At 3 years, local control (LC), overall survival (OS) and progression-free survival (PFS) for all patients were 94%, 83% and 68%, respectively. The log-rank test revealed that male sex was significantly related to better PFS (p=0.029). No other factors, including dose fractionation and ion type, were significant for LC, OS or PFS. In nine patients, ≥ Grade 3 acute dermatitis was observed, and ≥ Grade 3 late toxicities were observed in nine patients. The 32-fraction protocol reduced severe toxicities in both the acute and late phases compared with the 16-fraction protocol.

CONCLUSION

Particle therapy for patients with sacral chordoma showed favourable LC and OS. Severe toxicities were successfully reduced by modifying the dose fractionation and treatment planning in the later treatment era. Thus, this therapeutic modality should be considered useful and safe.

ADVANCES IN KNOWLEDGE

This is the first study including both CIT and PT for sacral chordomas.

[Influence of age on cardiac pump function during laparoscopic cholecystectomy--measurements by ear densitography]

Using ear densitography, consisting of photoelectric plethysomography and Holter electrocardiography, we measured systolic time intervals (STI) in 21 patients, ASA class 1 and 2, undergoing laparoscopic cholecystectomy using CO2 insufflation under general anesthesia (neuroleptanesthesia with isoflurane in air, FIO2 0.5). The patients were divided into two groups: Y-group (10 patients under 59 years of age) and O-group (11 patients over 60 years of age). We investigated the influence of age on cardiac pump function during pneumoperitoneum non-invasively. Y-group showed improvement of cardiac pump function (reduction of PEP/LVET) from 30 minutes after the beginning of insufflation and quick recovery of cardiac function immediately after deflation. O-group showed a tendency of increasing PaCO2 and arterial diastolic pressure, and delayed recovery of cardiac function (elongation of PEP at 60 minutes, and increase of PEP/LVET at 60 and 90 minutes, respectively, after insufflation). Hypertension and tachycardia were apparent immediately after pneumoperitoneum in the O-group. We conclude that special care and monitoring are mandatory for the aged patients with impaired cardiac or respiratory function during laparoscopic surgery.

[Effects of morphine, buprenorphine and butorphanol on airway dynamics of the rabbit]

An investigation was made on the effects of morphine, buprenorphine, and butorphanol on airway dynamics with special reference to the airway smooth muscle in rabbits. After tracheostomy under anesthesia, the animals were ventilated with a Servo 900B ventilator, and airway resistance (R) and total compliance (C) were measured according to the method of Norlander, and the effect of each drug was examined. Intravenous injection of morphine 0.2 mg.kg-1 increased R significantly at 10 and 20 minutes after its administration in nontreated animals and changed R insignificantly in animals pretreated with intravenous administration of chlorpheniramine 2.5 mg, an antihistaminic. It is considered that the increase in R after the administration of morphine in the nontreated animals is due to histamine release. Buprenorphine 0.8 micrograms.kg-1 and butorphanol 0.1 mg.kg-1 brought no significant changes in R in both nontreated and the chlorpheniramine pretreated animals. C decreased in all the groups including the control group which received mechanical ventilation alone without any drug administration.

Effects of verapamil on histamine-induced changes in lung mechanics

The effects of verapamil on airway resistance and total thoracic compliance were studied in 15 rabbits with histamine-induced changes in lung mechanics. The animals, after being tracheotomized under anaesthesia, were subjected to mechanical ventilation in a time-cycled, volume-limited mode. Airway pressure and gas flow signals measured by a pneumotachograph and integrated for volume, were registered on a recorder. Each animal was given histamine hydrochloride in an isotonic solution of sodium chloride at a rate of 0.05 micrograms.kg-1.min-1 through a peripheral venous line. Verapamil was infused intravenously in an isotonic solution of sodium chloride at a rate of 20 micrograms.kg-1.min-1 after the initiation of histamine. Verapamil reduced the histamine-induced increase in airway resistance by 20% at 20 min after the start of administration.

[Analgesic effects of epidural morphine, fentanyl and lidocaine]

The analgesic effects of epidurally administered morphine 5 mg (group M, n = 15), fentanyl 100 micrograms (group F, n = 15), 2% lidocaine 60 mg (group L, n = 15) and normal saline (group S, n = 10) were investigated in 55 patients scheduled for abdominal surgery. Each drug was prepared in 3 ml solution and was injected though an epidural catheter introduced 3 cm cephalad into the epidural space at T10-11. Analgesic effects were assessed by changes in the dull pain sensation induced by electrical stimulation at 3 Hz through a pair of stainless needles which were placed subcutaneously at T7 and T10 dermatomes. In group M, analgesic effects at T10 were demonstrated in 12 of 15 subjects and the onset of analgesia was more rapid at T10 than at T7. The mean onset time of analgesia was 7.8 +/- 3.6 (mean +/- SD) min. There were 5 subjects in group F and 6 in group L who showed more rapid onset of analgesic effects at T10 than at T7, respectively. There were 2 subjects in group F and 5 in group L, with more rapid onset of analgesia at T7 than at T10. There were several subjects in group F and L with simultaneous onset of analgesia at T7 and T10. In group L, the mean distribution of analgesic area, confirmed with pinprick, was 5.2 +/- 1.9 (mean +/- SD) dermatomal segments. Hypercapnea, associated with somnolence, was frequently seen in group F. None of the subjects in group M, L or S showed such incidents. These results suggest that the main site of action of epidural morphine is located in the spinal cord while that of epidural fentanyl in the brain.

[Deterioration of oxygenation with mechanical ventilation, the lung time constant and cardiac output]

The influence of the lung time constant (tc) and preset volume on a ventilator-cardiac output ratio (Vv/Q) on the decrease in the oxygenation of blood (PaO2/FiO2) due possibly to mechanical controlled ventilation, was examined with special reference to the time of passive expiration in 18 patients. The degree of deterioration of oxygenation appeared to depend mainly on the time following FRC, during which the blood continued to perfuse the lungs until the next active insufflation by the ventilator. The characteristics of the negative exponential function indicated that the lungs theoretically were passively evacuated by 98% at tc x 4 (= TC) sec. The value for the expiratory time-TC/TC was 3. 7 +/- 1.3 before reduction of this expiratory time. Following reduction, 11 subjects showed improved oxygenation while no change was noted in the other 7. In the former Vv/Q was 1.19 +/- 0.21 and in the latter 0.94 +/- 0.03 before reduction, showing significantly smaller values in the latter (p less than 0.01). Within each of the four [(expiratory time-TC)/TC]/Vv/Q zones between 1.0 and 5.0 (1.0-2.0, 2.0-3.0, 3.0-4.0, 4.0-5.0), Vv/Q of those who showed no change in oxygenation was always less than Vv/Q of those who showed improved oxygenation (p less than 0.01). Thus, it is possible that a relatively prolonged exhalation time compared to the lung time constant, under the conditions of cardiac output dominance in Vv/Q, could be one of the causes of deterioration of oxygenation which occurs frequently during mechanically controlled ventilation.

[Relationship between molecular structure of halogenated methane compounds and their hypotensive effect in rats]

In this study gases of twelve halogenated methane compounds were administered by inspiration to Wistar rats in order to elucidate the relationship between molecular structure of the compounds and their hypotensive effect, and to develop new inhalational circulatory control agents. The correlation between the hypotensive effect of the compounds evaluated from the experimental data and computed van der Waals volume as well as surface area following molecular mechanics calculations of structure and energy, was investigated. The results showed that the compounds with van der Waals volume and surface area more than 73 A3 and 100 A2, respectively, had the hypotensive effect. In conclusion, our data suggest that the hypotensive effect of inhalational agents requires greater molecular sizes than regular ones.

Treatment of pigmentation of the lips and oral mucosa in Peutz-Jeghers' syndrome using ruby and argon lasers

Three patients with punctate pigmented spots on the lips and oral mucosa, accompanying the P-J Syndrome, were successfully treated with ruby and argon lasers. The basic principles of laser treatment, the characteristics of the different laser systems and the skin reaction to ruby and argon lasers are discussed.