Can we improve the definition of high‐risk,hormone naïve,non‐metastatic prostate cancer?

• To identify criteria beyond Tumour‐Node‐Metastasis (TMN)‐, prostate‐specific antigen (PSA)‐ and Gleason score‐based standard classifications to enhance the stratification of non‐metastatic high‐risk prostate cancer.
• A detailed search of the literature was performed using PubMed.
• The authors reviewed the literature and used a modified Delphi approach to identify relevant approaches to enhance standard classifications.
• Specific criteria for high‐risk prostate cancer vary across guidelines and clinical trials, reflecting the differing perspectives concerning the definition of ‘risk’ between different specialities within the urology/radiation oncology community.
• In addition to the present classifications, evidence exists that the measure of cancer volume can provide additional prognostic value.
• More accurate imaging, especially multiparametric magnetic resonance imaging can also provide information concerning staging and cancer volume, and thus may assist in the identification of patients with high‐risk prostate cancer.
• A refined definition of non‐metastatic high‐risk prostate cancer is proposed.
• Within this high‐risk cohort, patients with multiple high‐risk criteria are especially at risk of prostate cancer‐specific mortality.

     

Is posterior percutaneous screw-rod instrumentation a safe and effective alternative approach to TLSO rigid bracing for single-level pyogenic spondylodiscitis? Results of a retrospective cohort analysis

Background contextCurrently, treatment for patients diagnosed with noncomplicated (ie, known infectious agent, no neurologic compromise, and preserved spinal stability) pyogenic spondylodiscitis (PS) is based on intravenous antibiotics and rigid brace immobilization. Since January 2010, we started offering our patients percutaneous posterior screw-rod instrumentation as an alternative approach to rigid bracing. Supposed benefits of posterior percutaneous instrumentation over rigid bracing are earlier free mobilization, increased comfort, and faster recovery.PurposeTo evaluate safety and effectiveness of posterior percutaneous spinal instrumentation for single-level PS and compare clinical and quality-of-life outcomes with standard thoracolumbosacral orthosis (TLSO) rigid bracing.Study design/SettingRetrospective observational cohort study.Patient sampleTwenty-seven patients consecutively diagnosed with single-level noncomplicated lower thoracic or lumbar PS from January 2010 to December 2011.Outcome measuresHealing rate, healing time, and changes in segmental kyphosis Cobb angle were compared in the two treatment groups. Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and complete blood count at regular time points until complete healing were also obtained. Self-report measures included Visual Analog Scale (VAS), Short-Form 12 (SF-12), and EuroQol five-dimension (EQ-5D) questionnaires.MethodsAt enrollment, patients were offered to choose between 24/7 TLSO rigid bracing for 3 to 4 months and bridging posterior percutaneous screw-rod instrumentation followed by soft bracing for 4 weeks after surgery. All patients underwent antibiotic therapy accordingly to isolated infectious agents. Patients were seen in the clinic at 1, 3, 6, and 9 months, and ESR, CRP, complete blood count, VAS, SF-12, and EQ-5D questionnaires were obtained. Segmental kyphosis was measured at diagnosis and at 9 months follow-up. Two-way repeated-measures analysis of variance was used to assess group and time differences across time points.ResultsFifteen patients chose conservative treatment, whereas 12 patients chose surgical treatment. Complete infection healing was achieved in all patients with no significant differences in healing time (p<.366). C-reactive protein and ESR levels decreased in both groups accordingly with positive response to therapy with no significant differences. Surgically treated patients had significantly lower VAS scores at 1 month (2.76±0.80 vs. 5.20±1.21, p<.001) and 3 months (2.31±0.54 vs. 2.85±0.54, p<.016) post-diagnosis over TLSO patients. Moreover, surgery patients also showed steeper and statistically significant improvements in SF-12 scores over TLSO patients at 1, 3, and 6 months post-diagnosis (p<.012); no significant differences were detected at the other time points. EuroQol five-dimension index was significantly higher in surgery patients at 1 month (0.764±0.043 vs. 0.458±0.197, p<.001) and 3 months (0.890±0.116 vs. 0.688±0.142, p<.001); no significant changes were observed in segmental pre- and posttreatment kyphosis between the two groups. No instrumentation-related complications were observed in any patient.ConclusionsPosterior percutaneous spinal instrumentation is a safe, feasible, and effective procedure in relieving pain, preventing deformity, and neurologic compromise in patients affected by noncomplicated lower thoracic (T9–T12) or lumbar PS. Posterior instrumentation did not offer any advantage in healing time over TLSO rigid bracing because infection clearance is strongly dependent on proper antibiotic therapy. Nevertheless, surgical stabilization was associated with faster recovery, lower pain scores, and improved quality of life compared with TLSO conservative treatment at 1, 3, and 6 months after treatment.     

Lung ultrasound during hemodialysis: the role in the assessment of volume status

Objective

Fluid balance is important in patients undergoing hemodialysis. “Dry” weight is usually estimated clinically, and also, bioimpedance is considered reliable. Ultrasonography of inferior vena cava (IVC) estimates central venous pressure, and lung ultrasound evaluates extravascular (counting B-lines artifact) lung water. Our study was aimed to clarify their usefulness in the assessment of volume status during hemodialysis.

Methods

A total of 71 consecutive patients undergoing hemodialysis underwent lung and IVC ultrasound and bioimpedance spectroscopy immediately before and after dialysis.

Results

There was a significant reduction in the number of B-lines (3.13 vs 1.41) and in IVC diameters (end-expiratory diameter 1.71 vs 1.37; end-inspiratory diameter 1.19 vs 0.95) during dialysis. The reduction in B-lines correlated with weight reduction during dialysis (p 0.007); none of the parameters concerning the IVC correlated with fluid removal. At the end of the dialysis session, the total number of B-lines correlated with bioimpedance residual weight (p 0.002).

Discussion

The reduction in B-lines correlated with fluid loss due to hemodialysis, despite the small pre-dialysis number, confirming that lung ultrasound can identify even modest variations in extravascular lung water. IVC ultrasound, which reflects the intravascular filling grade, might not be sensitive enough to detect rapid volume decrease. Clinically estimated dry weight had a poor correlation with both bioimpedance and ultrasound techniques. Post-dialysis B-lines number correlates with residual weight assessed with bioimpedance, suggesting a role for ultrasound in managing hemodialysis patients.     

Robot-assisted Laparoscopic Adrenalectomy: Step-by-Step Technique and Comparative Outcomes

Background

Recent evidence supports the use of robotic surgery for the minimally invasive surgical management of adrenal masses.

Objective

To describe a contemporary step-by-step technique of robotic adrenalectomy (RA), to provide tips and tricks to help ensure a safe and effective implementation of the procedure, and to compare its outcomes with those of laparoscopic adrenalectomy (LA).

Design, setting, and participants

We retrospectively reviewed the medical charts of consecutive patients who underwent RA performed by a single surgeon between April 2010 and October 2013. LA cases performed by the same surgeon between January 2004 and May 2010 were considered the control group.

Surgical procedure

The main steps of our current surgical technique for RA are described in this video tutorial: patient positioning, port placement, and robot docking; exposure of the adrenal gland; identification and control of the adrenal vein; circumferential dissection of the adrenal gland; and specimen retrieval and closure.

Outcome measurements and statistical analysis

Demographic parameters and main surgical outcomes were assessed.

Results and limitations

A total of 76 cases (RA: 30; LA: 46) were included in the analysis. Median tumor size on computed tomography (CT) was significantly larger in the LA group (3 cm [interquartile range (IQR): 3] vs 4 cm [IQR: 3]; p = 0.002). A significantly lower median estimated blood loss was recorded for the robotic group (50 ml [IQR: 50] vs 100 ml [IQR: 288]; p = 0.02). The RA group presented five minor complications (16.7%) and one major (Clavien 3b) complication (3.3%), whereas four minor complications (8.7%) and one major (Clavien 3b) complication (2.3%) were observed in the LA group. No significant difference was noted between groups in terms of malignant histology (p = 0.66) and positive margin rate (p = 0.60). Distribution of pheochromocytomas in the LA group was significantly higher than in the RA group (43.5% vs 16.7%; p = 0.02).

Conclusions

The standardization of each surgical step optimizes the RA procedure. The robotic approach can be applied for a wide range of adrenal indications, recapitulating the safety and effectiveness of open surgery and potentially improving the outcomes of standard laparoscopy.

Patient summary

In this report we detail our surgical technique for robotic removal of adrenal masses. This procedure has been standardized and can be offered to patients, with excellent outcomes.     

Impact of COVID-19 on outpatient visits and intravitreal treatments in a referral retina unit: let’s be ready for a plausible “rebound effect”

Graefe's Archive for Clinical and Experimental Ophthalmology - To quantify the shrinking in outpatient and intravitreal injections’ volumes in a tertiary referral retina unit secondary to...