前列腺癌根治术患者采用围术期康复干预对尿失禁的预防效果

目的分析前列腺癌根治术患者采用围术期康复干预对尿失禁的预防效果。方法 42例行前列腺癌根治术的患者,随机分为研究组与对照组,每组21例。对照组患者给予常规干预,研究组患者采取围术期康复干预。对比两组患者的尿失禁发生率,下尿路症状改善情况,生活质量。结果研究组患者的尿失禁发病率14.29%明显低于对照组的47.62%,差异具有统计学意义(P<0.05)。干预后,两组患者的下尿路症状评估量表(LUTS)评分均低于本组干预前,且研究组患者的LUTS评分(10.25±2.02)分明显低于对照组的(15.63±2.59)分,差异具有统计学意义(P<0.05)。研究组患者的生理功能、情感职能、社会功能、总体健康评分分别为(75.14±4.28)、(76.67±4.31)、(74.98±4.25)、(75.87±4.26)分,均高于对照组的67.21±4.35)、(68.22±4.39)、(66.58±4.37)、(68.01±4.36)分,差异具有统计学意义(P<0.05)。结论前列腺癌根治术患者采用围术期康复干预可以有效降低术后并发症发生率,改善患者临床症状,提高患者生活质量,效果显著,值得在临床上进一步推广应用。     

Metastatic stage vs complications at radical nephrectomy with inferior vena cava thrombectomy

BackgroundTo investigate perioperative complication rates at radical nephrectomy (RN) according to inferior vena cava thrombectomy (IVC-T) status and stage (metastatic vs non-metastatic) within kidney cancer patients.Materials and methodsWe ascertained perioperative complication rates within the National Inpatient Sample database (2016–2019). First, log-link linear Generalized Estimating Equation function (GEE) regression models (adjusted for hospital clustering and weighted for discharge disposition) tested complication rates in IVC-T patients, according to metastatic stage. Subsequently, a subgroup analysis relied on RN patients with or without IVC-T. Here, multivariable logistic regression models tested complication rates in RN patients according to IVC-T status, after propensity score matching including metastatic stage.ResultsOf 26,299 RN patients, 461 (2%) patients underwent IVC-T. Of those, 252 (55%) were non-metastatic vs 209 (45%) were metastatic. Rates of acute kidney injury (AKI), transfusion, cardiac, thromboembolic and other medical complications in non-metastatic vs metastatic patients were 40 vs 40%, 25 vs 22%, 21 vs 23%, 19 vs 14% and 38 vs 40%, respectively (all p ≥ 0.2). Metastatic stage in IVC-T patients did not predict differences in complications in log-link linear GEE regression models (all p > 0.1). However, in logistic regression models with propensity score matching, relying on the overall cohort of RN patients, IVC-T status was associated with higher complication rates (all p < 0.001): AKI (Odds ratio [OR]:2.60; 95%-CI [95%-Confidence interval: 1.97–3.44), transfusions (OR:2.40; 95%-CI: 1.72–3.36), cardiac (OR:2.27; 95%-CI: 1.49–3.47), thromboembolic (OR:9.07; 95%-CI: 5.21–16.58) and other medical complications (OR:2.01; 95%-CI: 1.52–2.66).ConclusionsThe current analyses indicate that presence of concomitant IVC-T is associated with higher complication rate at RN. Conversely, metastatic stage has no effect on recorded complication rates.     

EAU-EANM-ESTRO-ESUR-SIOG Guidelines on Prostate Cancer—2020 Update. Part 1: Screening,Diagnosis, and Local Treatment with Curative Intent

ObjectiveTo present a summary of the 2020 version of the European Association of Urology (EAU)-European Association of Nuclear Medicine (EANM)-European Society for Radiotherapy and Oncology (ESTRO)-European Society of Urogenital Radiology (ESUR)-International Society of Geriatric Oncology (SIOG) guidelines on screening, diagnosis, and local treatment of clinically localised prostate cancer (PCa).Evidence acquisitionThe panel performed a literature review of new data, covering the time frame between 2016 and 2020. The guidelines were updated and a strength rating for each recommendation was added based on a systematic review of the evidence.Evidence synthesisA risk-adapted strategy for identifying men who may develop PCa is advised, generally commencing at 50 yr of age and based on individualised life expectancy. Risk-adapted screening should be offered to men at increased risk from the age of 45 yr and to breast cancer susceptibility gene (BRCA) mutation carriers, who have been confirmed to be at risk of early and aggressive disease (mainly BRAC2), from around 40 yr of age. The use of multiparametric magnetic resonance imaging in order to avoid unnecessary biopsies is recommended. When a biopsy is performed, a combination of targeted and systematic biopsies must be offered. There is currently no place for the routine use of tissue-based biomarkers. Whilst prostate-specific membrane antigen positron emission tomography computed tomography is the most sensitive staging procedure, the lack of outcome benefit remains a major limitation. Active surveillance (AS) should always be discussed with low-risk patients, as well as with selected intermediate-risk patients with favourable International Society of Urological Pathology (ISUP) 2 lesions. Local therapies are addressed, as well as the AS journey and the management of persistent prostate-specific antigen after surgery. A strong recommendation to consider moderate hypofractionation in intermediate-risk patients is provided. Patients with cN1 PCa should be offered a local treatment combined with long-term hormonal treatment.ConclusionsThe evidence in the field of diagnosis, staging, and treatment of localised PCa is evolving rapidly. The 2020 EAU-EANM-ESTRO-ESUR-SIOG guidelines on PCa summarise the most recent findings and advice for their use in clinical practice. These PCa guidelines reflect the multidisciplinary nature of PCa management.Patient summaryUpdated prostate cancer guidelines are presented, addressing screening, diagnosis, and local treatment with curative intent. These guidelines rely on the available scientific evidence, and new insights will need to be considered and included on a regular basis. In some cases, the supporting evidence for new treatment options is not yet strong enough to provide a recommendation, which is why continuous updating is important. Patients must be fully informed of all relevant options and, together with their treating physicians, decide on the most optimal management for them.     

Locally advanced cervical carcinoma patients treated with chemoradiation followed by radical surgery: clinical response and oncological outcomes according to histotype after propensity score analysis

IntroductionThe aims of this study were to analyze the pathological response, and survival outcomes of adenocarcinoma/adenosquamous (AC/ASC) versus squamous cell carcinoma (SCC) in patients with locally advanced cervical cancer (LACC) managed by chemoradiotherapy followed by radical surgery.MethodsRetrospective, multicenter, observational study, including patients with SCC and AC/ACS LACC patients treated with preoperative CT/RT followed by tailored radical surgery (RS) between 06/2002 and 05/2017. Clinical-pathological characteristics were compared between patients with SCC versus AC/ASC. A 1:3 ratio propensity score (PS) matching was applied to remove the variables imbalance between the two groups.ResultsAfter PS, 320 patients were included, of which 240 (75.0%) in the SCC group, and 80 (25.0%) in the AC/ASC group. Clinico-pathological and surgical baseline characteristics were balanced between the two study groups. Percentage of pathologic complete response was 47.5% in SCC patients versus 22.4% of AC/ASC ones (p < 0.001). With a median follow-up of 51 months (range:1–199), there were 54/240 (22.5%) recurrences in SCC versus 28/80 (35.0%) in AC/ASC patients (p = 0.027). AC/ASC patients experienced worse disease free (DFS), and overall survival (OS) compared to SCC patients (p = 0.019, and p = 0.048, respectively). In multivariate analysis, AC/ACS histotype, and FIGO stage were associated with worse DFS and OS.ConclusionIn LACC patients treated with CT/RT followed by RS, AC/ASC histology was associated with lower pathological complete response to CT/RT, and higher risk of recurrence and death compared with SCC patients. This highlights the need for specific therapeutic strategies based on molecular characterization to identify targets and develop novel treatments.     

中耳胆脂瘤手术ICD-9-CM-3编码分析

手术治疗特别是中耳病变切除联合鼓室成形术是目前根治中耳胆脂瘤最主要的方法,依据2012年版的中耳炎手术分型指南内容,按照手术对外耳道后壁和鼓窦上鼓室侧壁处理方式不同,中耳病变切除具体类型和对应ICD-9-CM-3编码为:完壁式乳突根治术20.4900x009、开放式乳突根治术20.4900x008、完桥式乳突根治术20.49和上鼓室鼓窦切开术20.4900x007等,为避免上述手术编码的混淆,编码员应掌握每种术式的具体内涵。同时对于重要的其它手术操作如鼓室成形术19.4~19.5、耳甲腔成形术18.79、外耳道后壁重建术18.6和乳突缩窄术20.92等也不能漏编和多编。编码员应加强中耳结构和手术知识的学习,当不能确定手术具体类型时,应与耳鼻喉医师沟通,确定正确手术类型和内容时方可编码。     

快速康复护理在腹腔镜下全子宫切除中的应用

目的探讨在腹腔镜下全子宫切除术中应用快速康复护理措施对患者围手术期指标和患者并发症的影响。方法将在本院行腹腔镜下全子宫切除术的70例患者随机分为两组,各35例,对照组35例给予常规护理,观察组35例给予快速康复护理,对比两组围手术期相关指标、手术前后VAS评分、并发症发生情况以及患者护理满意度。结果观察组胃肠蠕动时间[(9.32±1.67)h]、肛门排气时间[(4.67±1.37)h]、下床活动时间[(6.69±1.24)h]、术后进食时间[(6.21±0.55)h]和住院时间[(4.25±1.20)d]均显著短于对照组的[(12.87±2.08)h]、[(7.28±1.13)h]、[(9.75±3.29)h][(9.33±0.61)h]、[(7.25±1.38)d],P<0.05;观察组术后1 d和术后3 d的VAS评分分别为(4.01±1.28)分、(1.23±0.35)分,显著低于对照组的(6.80±1.32)分、(2.62±0.41)分,P<0.05;观察组和对照组术后并发症发生率(2.86%vs 17.14%)和患者护理满意度(97.14%vs.80.00%)比较,观察组均显著优于对照组P<0.05。结论对于行腹腔镜下全子宫切除术的患者,给予快速康复护理模式可促进患者早期康复,减少术后疼痛程度,降低术后并发症发生率。     

Patient frailty predicts worse perioperative outcomes and higher cost after radical cystectomy

Background: Relatively few studies investigated the importance of frailty in radical cystectomy (RC) patients. We tested the ability of frailty, using the Johns Hopkins Adjusted Clinical Groups indicator, to predict early perioperative outcomes after RC.Methods: RC patients were identified within the National Inpatient Sample database (2000–2015). The effect of frailty, age and Charlson Comorbidity Index were tested in five separate multivariable models predicting: (1) complications, (2) failure to rescue (FTR), (3) in-hospital mortality, (4) length of stay (LOS) and (5) total hospital charges (THCs). All models were weighted and adjusted for clustering, as well as all available patient and hospital characteristics.Results: Of 23,967 RC patients, 5833 (24.3%) were frail, 7721 (32.2%) were aged ≥75 years and 2832 (11.8%) had CCI ≥2. Frailty, age ≥75 years and CCI ≥2 were non-overlapping in 86.3% of the cohort. Any two or three of these features were recorded in 12.4 and 1.3%, respectively. Frailty was an independent predictor of all five examined endpoints and the magnitude of its association was stronger or at least equal than that of age ≥75 years and CCI ≥2.Conclusion: Frailty, advanced age and comorbidities represent non-overlapping patients’ characteristics. Of those, frailty represents the most consistent and strongest predictor of early adverse outcomes after RC. Ideally, all three indicators should be considered in retrospective, as well as prospective analyses. Pre-surgical recognition of frail patients should be ideally incorporate in clinical practice in order to address these patients to multimodal pre-habilitation programs that may potentially improve the perioperative prognosis.     

竖脊肌平面阻滞超前镇痛对老年胸腔镜肺癌根治术患者心肌的保护作用

目的探讨竖脊肌平面阻滞（ESPB）超前镇痛对老年胸腔镜肺癌根治术患者心肌的保护作用。 方法选择在惠州市中心人民医院择期行胸腔镜肺癌根治术的老年患者40例，按照患者意愿分组，其中19例采用ESPB联合全身麻醉（观察组），21例采用单纯全身麻醉（对照组）。在两组诱导前（T0）、手术开始1 h（T1）、手术结束时（T2）及术后4 h（T3）检测患者的肌钙蛋白Ⅰ（cTnⅠ）、心型脂肪酸结合蛋白（H-FABP）、肌酸激酶同工酶（CK-MB），并记录各时间点的平均动脉压（MAP）和心率。计量资料的组间比较采用t检验，重复测量资料采用重复测量方差分析。 结果两组患者MAP、心率、cTnⅠ、H-FABP、CK-MB的差异均呈现组间效应、时间效应和交互效应（MAP：F=24.021、33.512、9.184，心率：F=10.340、46.992、3.494，cTnⅠ：F=5.354、691.994、64.177，H-FABP：F=7.906、14.067、11.560，CK-MB：F=15.926、84.106、4.116，P<0.05或0.01）。与T0时间点比较，两组患者T1、T2、T3时间点MAP、心率、H-FABP、CK-MB均出现明显变化（P<0.05），T2、T3时间点cTnⅠ出现明显变化（P<0.05）。 结论老年胸腔镜肺癌根治术中应用ESPB超前镇痛，可明显降低心肌损伤相关因子水平，起到心肌保护作用。     

机器人辅助在前列腺癌外科治疗的研究进展

前列腺癌发病率和死亡率逐年升高,开放性根治性前列腺切除术仍是局部晚期前列腺癌的治疗金标准。近年来,腹腔镜和机器人辅助前列腺切除术等微创技术已广泛应用,与传统开放性手术比较,其在肿瘤切缘控制、尿控能力和性功能等方面取得巨大进步。另外机器人辅助前列腺切除术在改善患者功能学方面更具优势。本综述就根治性前列腺切除术的发展、不同手术入路的选择、围手术期并发症、肿瘤学、功能学及学习曲线等方面阐述机器人运用在前列腺癌根治术中的进展。