Pelvic/retroperitoneal salvage lymph node dissection for patients treated with radical prostatectomy with biochemical recurrence and nodal recurrence detected by [11C]choline positron emission tomography/computed tomography

Background

The management of patients with clinical recurrence of prostate cancer after radical prostatectomy (RP) remains challenging.

Objective

To determine whether the removal of positive lymph nodes at [11C]choline positron emission tomography/computed tomography (PET/CT) scan may have an impact on the prognosis of patients with biochemical recurrence (BCR) and nodal recurrence after RP.

Design, setting, and participants

Prospective analysis of 72 patients affected by BCR after RP associated with a nodal pathologic [11C]choline PET/CT scan.

Intervention

Patients underwent salvage lymph node dissection (LND).

Measurements

Biochemical response (BR) to treatment was defined as prostate-specific antigen (PSA) <0.2 ng/ml at 40 d after salvage LND. Kaplan-Meier and Cox regression analyses addressed time to and predictors of clinical recurrence (CR) after salvage LND, respectively.

Results and limitations

Overall, 56.9% of patients achieved BR. Mean and median follow-up after LND were 39.4 and 39.8 mo, respectively. The 5-yr BCR-free survival rate was 19%. Preoperative PSA <4 ng/ml (hazard ratio [HR]: 0.12; p = 0.005), time to BCR <24 mo (HR: 7.52; p = 0.005), and negative lymph nodes at previous RP (HR: 0.19; p = 0.04) represented independent predictors of BR. Overall, 5-yr CR-free and cancer-specific survival were 34% and 75%, respectively. At multivariable analyses, only PSA >4 ng/ml (HR: 2.13; p = 0.03) and the presence of retroperitoneal uptake at PET/CT scan (HR = 2.92; p = 0.004) represented independent preoperative predictors of CR. Similarly, the presence of pathologic nodes in the retroperitoneum (HR: 2.78; p = 0.02), higher number of positive lymph nodes (HR: 1.04; p = 0.006), and complete BR to salvage LND (HR: 0.31; p = 0.002) represented postoperative independent predictors of CR. Main limitations consisted of the lack of a control group and the heterogeneity of patients included in the analyses.

Conclusions

Salvage LND is feasible in patients with BCR after RP and nodal pathologic uptake at [11C]choline PET/CT scan. Biochemical response after surgery can be achieved in a consistent proportion of patients. Although most patients invariably progressed to BCR after surgery at longer follow-up, 35% of patients showed the absence of CR at 5 yr.     

Prospective evaluation of 11C-choline positron emission tomography/computed tomography and diffusion-weighted magnetic resonance imaging for the nodal staging of prostate cancer with a high risk of lymph node metastases

Background

Contrast-enhanced computed tomography (CT) and magnetic resonance (MR) imaging for lymph node (LN) staging of prostate cancer (PCa) are largely inadequate.

Objective

Our aim was to assess prospectively the sensitivity, specificity, and positive and negative predictive values for the LN staging by ¹¹C-choline positron emission tomography (PET)-CT and MR diffusion-weighted imaging (DWI) of the pelvis before retropubic radical prostatectomy (RRP) with extended pelvic LN dissection (PLND).

Design, setting, and participants

From February 2008 to August 2009, 36 patients with histologically proven PCa and no pelvic LN involvement on contrast-enhanced CT with a risk ≥10% but ≤35% at LN metastasis according to the Partin tables were enrolled in this study.

Intervention

Patients preoperatively underwent ¹¹C-choline PET-CT and DWI. Subsequently all patients underwent a wide RRP and an extended PLND.

Measurements

Sensitivity, specificity, and positive and negative predictive values (PPV and NPV) for LN status of ¹¹C-choline PET-CT and DWI were calculated with the final histopathology of the LNs as comparator.

Results and limitations

Seventeen patients (47%) had a pN1 stage, and 38 positive LNs were identified. On a LN region-based analysis, sensitivity, specificity, PPV, NPV, and the number of correctly recognised cases at ¹¹C-choline PET-CT were 9.4%, 99.7%, 75.0%, 91.0%, and 7.9%, respectively, and at DWI these numbers were 18.8%, 97.6%, 46.2%, 91.7%, and 15.8%, respectively. Twelve LN regions containing macrometastases, of which 2 had capsular penetration, were not detected by ¹¹C-choline PET-CT; 11 LNs, of which 2 had capsular penetration, were not detected by DWI. This is a small study with 36 patients, but we intend to recruit more patients.

Conclusions

From this prospective histopathology-based evaluation of ¹¹C-choline PET-CT and DWI for LN staging in high-risk PCa patients, it is concluded that these techniques cannot be recommended at present to detect occult LN metastases before initial treatment.     

Utility of PET, CT, and EUS to identify pathologic responders in esophageal cancer

Background

This study evaluates the utility of positron emission tomography (PET), endoscopic ultrasonography (EUS), and computed tomographic (CT) scans to predict pathologic response and survival following preoperative chemoradiation (CRT) in esophageal cancer.

Methods

One hundred three sequential patients with locoregionally advanced esophageal cancer, who were treated with CRT and esophageal resection between May 2001 and November 2003 at the University of Texas M.D. Anderson Cancer Center, were retrospectively reviewed. PET, EUS, and CT were performed before (pre) or after (post) CRT and before surgical resection. PET standardized uptake value (SUV) was defined as maximal uptake in primary tumor.

Results

Most patients were male (91 [88%]) with adenocarcinoma (90 [87%]). Pretreatment clinical stages were: IIA (42 [41%]), IIB (5 [5%]), III (50 [49%]), and IVA (6 [6%]). At the time of surgery, 58 patients (56%) had a pathologic response to CRT (≤10% viable cells). Post-CRT measurements that correlated with pathologic response were: CT esophageal wall thickness (13.3 vs 15.3 mm, p = 0.04), EUS mass size (0.7 vs 1.7 cm, p = 0.01) and PET SUV (3.1 vs 5.8, p = 0.01). Post-CRT PET SUV equal to or greater than 4 had the highest accuracy for pathologic response (76%). Univariate and multivariate Cox regression analysis demonstrated that a post-CRT PET SUV equal to or greater than 4 was an independent predictor of survival (HR, 3.5, p = 0.04).

Conclusions

The FDG-PET SUV is the most accurate noninvasive test to predict long-term survival after preoperative CRT and before surgical resection. Post-CRT FDG-PET cannot, however, rule out residual microscopic disease so esophagectomy should remain a therapeutic option even if the post-CRT imaging modalities are normal.     

The predictive value of incidental PET/CT findings suspicious for breast cancer in women with non-breast malignancies

Background

On occasion, patients followed with positron emission tomographic (PET)/computed tomographic (CT) imaging for nonbreast malignancies will have incidental breast findings concerning for second primary breast cancers. The aim of this study was to determine the predictive value of PET/CT imaging to identify breast cancers in these patients.

Methods

Patients with primary nonbreast malignancies and findings concerning for second primary breast cancers were identified from a prospectively acquired nuclear medicine database from January 2005 to July 2008. Chart reviews were then performed.

Results

Nine hundred two women underwent PET/CT imaging to evaluate nonbreast malignancies. Nine women (1%) had concerning breast findings, and 5 (56%) had subsequent breast cancer diagnoses. The positive predictive value of PET/CT imaging in these patients was 63%. Evidence of compliance with current screening guidelines was present in only 22% of these patients.

Conclusions

The data suggest that findings concerning for an additional primary breast cancer should be evaluated and that age-appropriate screening tools should not be abandoned.     

Factors affecting postoperative course and survival after en bloc resection for esophageal carcinoma

Background

To identify factors affecting postoperative course and survival after esophagectomy for cancer and reasons for improved survival over time.

Methods

Complete esophageal resection was attempted for middle and lower third esophageal carcinomas in 386 consecutive patients between January 1982 and January 2002. Two study periods were analyzed: 1982 to 1993 and 1994 to 2002. Prognostic factors were identified by multivariate analysis and the two periods compared.

Results

Hospital mortality rate decreased from 5.4% to 2.9% (p = 0.245). Both anastomotic leakage and pulmonary complications rates decreased from 9.8% to 2.2% (p = 0.001) and 24.1% to 19.3% (p = 0.295), respectively. An increased proportion of patients had R0 resection in the latter period, 78.5% versus 67.0%, (p = 0.028). Five-year survival rate after R0 resection increased from 29% to 46% (p = 0.001), with a decreased recurrence rate from 65.8% to 44.3% (p = 0.002). Three favorable prognostic factors were identified: low pT stage, pN0 stage, and operation during the 1994 to 2002 study period.

Conclusions

Short-term outcome and survival of patients with resected esophageal cancer have improved over time. Advances in perioperative technique, staging methods, and surgical management combined with higher patient selection and use of neoadjuvant chemoradiation may be responsible for this progress.     

Perioperative F-fluorodeoxyglucose-guided imaging using the becquerel as a quantitative measure for optimizing surgical resection in patients with advanced malignancy

Background

¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography/computed tomography (PET/CT) scanning is a widely accepted preoperative tumor imaging modality. Herein, we evaluate the becquerel (Bq) as a potential novel quantitative PET measure for application of surgical specimen imaging.

Methods

Retrospectively, PET-avid lesions that could be followed from preoperative imaging, confidently identified in the operating room, imaged ex vivo, and correlated with histopathology were included in this study. Bq counts from both in vivo (preoperative) and ex vivo (surgical specimen) PET/CT images were measured and correlated with histopathology.

Results

Fifty-five PET-avid lesions in 37 patients were included. Forty-six of 55 PET-avid lesions identified were found to contain malignancy on histopathology. Mean Bq counts for the PET-avid lesions were significantly higher that the adjacent PET-nonavid areas (background) within both in vivo and ex vivo imaging (P < .001 and P < .001, respectively). When analyzing all 55 lesions, we found significant increases in Bq levels. PET-avid lesions from in vivo to ex vivo images (P < .001) without significant increases in Bq levels in PET-nonavid lesions from in vivo to ex vivo images (P = .06). When comparing Bq levels between the 2 groups (malignant and benign), we found significantly higher Bq counts in the malignant group on in vivo imaging (P = .02) as well as significantly lower Bq counts in FDG-nonavid areas on ex vivo imaging (P = .04) within the malignant group. Significant differences in PET-avid to PET-nonavid Becquerels ratios within both in vivo and ex vivo images (P = .004, P = .002 respectively) were found, with ex vivo ratio being significantly higher (P < .001).

Conclusions

¹⁸F-FDG PET/CT imaging using Bqs is the potential to discern malignant lesions from benign tissues within both in vivo and ex vivo scans.     

Training residents in mitral valve surgery

Background

The safety of training residents in complex procedures has not been elucidated. In particular, the impact of resident-performed mitral valve surgery on patient outcomes is unknown.

Methods

All mitral valve procedures performed by residents between 1998 and 2003 were compared with those performed by staff surgeons. Operative mortality and a composite morbidity (reoperation for bleeding, myocardial infarction, infection, stroke, or ventilation > 24 hours) were compared using multivariate analysis. Individual outcomes were compared with the use of propensity scores.

Results

There were 1020 cardiac surgeries performed by residents, including 165 mitral valve procedures (86 replacements, 79 repairs). In the same period, the staff surgeons performed 261 mitral procedures. Crude operative mortality for isolated mitral procedures was 5.4% and 4.7% (resident and staff, respectively, p = 1.00). Mitral valve repair including combined procedures had an operative mortality of 3.8% and 4.3% (resident and staff, respectively, p = 1.00). The composite morbidity outcome was 29.7% and 35.3% for resident and staff-performed cases, respectively (p = 0.24). In multivariate analysis, resident was not associated with the adverse outcomes examined (OR 0.80, 95% CI, 0.47, 1.37). The incidence of major adverse outcomes for propensity score-matched mitral valve cases, including combined procedures, were similar between residents and staff, respectively: mortality, 7.4% versus 8.7% (p = 0.67), stroke, 4.0% versus 6.7% (p = 0.30), and reoperation for bleeding, 4.7% versus 9.4% (p = 0.11).

Conclusions

There were no significant differences in morbidity and mortality in patients undergoing mitral valve surgery between resident and staff surgeons. It is possible to train residents to perform complex cardiac cases without adversely affecting outcomes.     

Allogenic blood transfusion does not predispose to infection after cardiac surgery

Background

Many retrospective studies report increased postoperative infection after allogenic blood transfusion. To investigate this phenomenon, we prospectively studied 232 patients undergoing cardiac surgery.

Methods

Patients were screened daily for evidence of culture positive infections. Wounds were examined daily and defined on the ASEPSIS score. Chest radiographs and white cell counts and differentials were recorded on days 1, 2, and 4. The use of blood products was monitored blindly and independently. Patients were grouped according to transfusion status and compared using χ² or Fisher's test. Logistic regression analyses were performed to identify predictors of transfusion and infection.

Results

Of 232 patients, 116 (50%) received blood product transfusion. Patients receiving blood had lower preoperative hemoglobin, were older, with a greater proportion of urgent/emergency or revision surgery, and were higher risk. Despite this, there were no differences in the frequency of chest infection (20% versus 15%, p = 0.38), urinary infection (3.5% versus 5.3%, p = 0 0.75), wound infection (3.5% versus 8.0%, p = 0.16), or overall infection (28% versus 30%, p = 0.89) comparing the transfused versus untransfused groups. There was no evidence to suggest that administration of blood products was associated with infection (odds ratio 0.92, p = 0.77).

Conclusions

The administration of blood per se did not lead to increased postoperative infection. Clinicians should reconsider withholding blood transfusion in patients solely owing to concerns of predisposition to infection.     

Intraaortic balloon pumping improves hemodynamics and right ventricular efficiency in acute ischemic right ventricular failure

Background

Left ventricular unloading has a potentially deleterious effect in right ventricular failure as a result of altered septal interplay. However, a positive effect of an intraaortic balloon pump during right ventricular failure has been suggested. We investigated the impact of intraaortic balloon pumping on hemodynamics and both left and right ventricular function in an experimental model of isolated right ventricular failure.

Methods

Sixteen anesthetized pigs (25 to 34 kg) were used in an in vivo model. Pressure-conductance catheters assessed right and left ventricular pressure-volume relationships. Acute right ventricular failure was induced by right coronary microembolization, and led to severely impaired right ventricular function, reduced cardiac output and arterial pressure, and an increased pulmonary vascular resistance and pulmonary arterial elastance. Animals were then randomized to balloon pump or control groups and evaluated with respect to hemodynamics and ventricular function after 1 hour.

Results

Intraaortic balloon pumping did not alter right or left ventricular contractility. However, balloon pump-treated animals had significantly improved cardiac output (+18% ± 18% versus −6% ± 7%; p = 0.003) and mean arterial pressure (+36% ± 30% versus −7% ± 14%; p = 0.004) compared with controls. Animals in the balloon pump group had lower pulmonary vascular resistance (795 ± 63 versus 912 ± 259 dynes · sec · cm⁻⁵; p < 0.01) and pulmonary arterial elastance (1.14 ± 0.20 versus 1.69 ± 0.65 mm Hg/mL; p < 0.01), and increased stroke volume (22.3 ± 4.7 versus 17.9 ± 4.7 mL; p = 0.016). Right ventricular efficiency was also improved in the balloon pump group (stroke work per pressure-volume area = 0.60 ± 0.14 versus 0.41 ± 0.12; p < 0.01).

Conclusions

Intraaortic balloon pump support does not alter right or left ventricular function in acute right ventricular failure. However, arterial pressure, cardiac output, and right ventricular efficiency are improved, possibly because of a balloon pump-induced reduction in pulmonary arterial resistance.     

Cancer-specific and other-cause mortality after radical prostatectomy versus observation in patients with prostate cancer: competing-risks analysis of a large North American population-based cohort

Background

Initial treatment options for low-risk clinically localized prostate cancer (PCa) include radical prostatectomy (RP) or observation.

Objective

To examine cancer-specific mortality (CSM) after accounting for other-cause mortality (OCM) in PCa patients treated with either RP or observation.

Design, setting, and participants

Using the Surveillance Epidemiology and End Results Medicare-linked database, a total of 44 694 patients ≥65 yr with localized (T1/2) PCa were identified (1992-2005).

Intervention

RP and observation.

Measurements

Propensity-score matching was used to adjust for potential selection biases associated with treatment type. The matched cohort was randomly divided into the development and validation sets. Competing-risks regression models were fitted and a competing-risks nomogram was developed and externally validated.

Results and limitations

Overall, 22 244 (49.8%) patients were treated with RP versus 22450 (50.2%) with observation. Propensity score-matched analyses derived 11 669 matched pairs. In the development cohort, the 10-yr CSM rate was 2.8% (2.3-3.5%) for RP versus 5.8% (5.0-6.6%) for observation (absolute risk reduction: 3.0%; relative risk reduction: 0.5%; p < 0.001). In multivariable analyses, the CSM hazard ratio for RP was 0.48 (0.38-0.59) relative to observation (p < 0.001). The competing-risks nomogram discrimination was 73% and 69% for prediction of CSM and OCM, respectively, in external validation. The nature of observational data may have introduced a selection bias.

Conclusions

On average RP reduces the risk of CSM by half in patients aged ≥65 yr, relative to observation. The individualized protective effect of RP relative to observation may be quantified with our nomogram.     

Fenoldopam prophylaxis of postoperative acute renal failure in high-risk cardiac surgery patients

Background

Acute renal failure requiring replacement therapy occurs in 1% to 2% of patients who have undergone cardiac surgery with cardiopulmonary bypass and is associated with a very high mortality rate. The aim of this study was to determine if prophylactic treatment with fenoldopam mesylate of patients at high risk of postoperative acute renal failure reduced the incidence of this event.

Methods

This was a multicenter, prospective, cohort study in which 108 patients at high risk of postoperative acute renal failure and undergoing cardiac surgery with cardiopulmonary bypass were treated with fenoldopam mesylate (0.08 μg · kg⁻¹ · min⁻¹) starting at the induction of anesthesia and throughout at least the next 24 hours. A homogeneous control group of 108 patients was created using a propensity-score analysis.

Results

Fenoldopam prophylaxis was significantly associated with a reduction in acute renal failure incidence (from 22% to 11%, p = 0.028), a less pronounced creatinine clearance decrease (p = 0.05), and a lower mortality rate (6.5% versus 15.7%, p = 0.03) by the univariate analysis, but these results were not confirmed by a multivariable analysis. Within the subgroup of patients who suffered a postoperative low output syndrome, fenoldopam prophylaxis was an independent protective factor for postoperative renal failure (odds ratio, 0.14; 95% confidence interval, 0.03 to 0.7; p = 0.017).

Conclusions

Given the limitations of a nonrandomized prospective trial, our results support the hypothesis that fenoldopam may reduce the risk of acute renal failure in patients in whom endogenous and exogenous cathecolamines action may induce a renal vascular constrictive condition.     

Value of 18-FDG-positron emission tomography/computed tomography before and after transarterial chemoembolization in patients with hepatocellular carcinoma undergoing liver transplantation: initial results

Introduction

Liver transplantation is the treatment of choice for various types of end-stage liver disease and the most appropriate alternative for the treatment of hepatocellular carcinoma (HCC)-associated liver cirrhosis. The aim of this study was to describe our initial experience with the use of 18-FDG positron emission tomography (PET)/computed tomography CT before and after transarterial chemoembolization (TACE) in HCC patients undergoing liver transplantation, seeking to predict the percentage of tumor necrosis achieved by TACE procedures.

Patients and Methods

From January 2007 through December 2009, 39 patients with HCC and liver cirrhosis were included in our liver transplantation program. We selected the 6 subjects who underwent 18-fluorodeoxyglucose PET/CT (18-FDG PET/CT) pre- and post-TACE.

Results

The median SUV (standarized uptake value) in the lesions studied were 4 (range, 2.79-6.95) before TACE with a median post-TACE SUV of 0 (range, 0-4). Among patients whose post-TACE SUV decreased to <3, the percentage of necrosis after studying the hepatectomy was >80%.

Conclusion

Performance of an 18-FDG PET/CT before and after TACE and comparison of SUV in patients with HCC awaiting liver transplantation provided valuable information regarding the effectiveness of TACE.     

Comparison of bilateral thoracic artery grafting with percutaneous coronary interventions in diabetic patients

Background

This study compares the outcome of percutaneous coronary interventions (PCI) with bilateral internal thoracic grafting (BITA) in diabetic patients.

Methods

From May 1996 to December 1999, 802 consecutive diabetic patients underwent myocardial revascularization: 363 by PCI and 439 by BITA. The two groups were similar; however, left main disease (28% versus 3.3%), ejection fraction less than 0.35 (14.5% versus 5.5%), and chronic obstructive lung disease (8.4% versus 3%) were more prevalent in the BITA group, and prior percutaneous transluminal coronary angioplasty, in the PCI group (16.8% versus 10.5%).

Results

The number of coronary vessels treated per patient was higher in the BITA group (3.4 versus 1.2; p < 0.001). Thirty-day mortality was similar: 3.4% in the BITA group and 2.8% in the PCI group. Late follow-up (3 to 6.5 years) showed decreased return of angina (11% versus 64%; p < 0.001), fewer reinterventions (2.7% versus 55%; p < 0.001), and increased cardiovascular event-free survival (80% versus 30%; p < 0.001) in the BITA group. Six-year survival of BITA and PCI patients was 85.5% and 81.2%, respectively (not significant). However, survival of the subgroups of patients with left main or three-vessel coronary artery disease was significantly better with BITA (86% versus 76%; p = 0.003).

Conclusions

Despite higher risk profile of diabetic patients treated surgically by BITA, their late outcome is better than that of patients treated by PCI. The results of this study support referring diabetics with single-vessel or double-vessel disease to PCI and those with three-vessel and left main coronary artery disease to surgery.     

Revascularization in severe ventricular dysfunction (15% ≤ LVEF ≤ 30%): a comparison of bypass grafting and percutaneous intervention

Background

We sought to determine the optimal approach to revascularization of patients with severe left ventricular (LV) dysfunction.

Methods

We conducted a single-center observational study of 117 consecutive patients who had severe LV dysfunction (15% ≤ LV ejection fraction ≤ 30%) and underwent either coronary artery bypass grafting (CABG, n = 69) or percutaneous revascularization (n = 48) between 1992 and 1997.

Results

The CABG group was younger (62 versus 67 years, p = 0.026), and fewer previous bypasses (7% versus 40%, p < 0.0001) and fewer prior percutaneous revascularizations (16% versus 42%, p = 0.0019) were noted. More vessels were revascularized (3 ± 0.8 versus 1.5 ± 0.7, p < 0.0001), and revascularization was more complete by CABG (84% versus 48%, p < 0.0001). Morbidity and mortality at 30 days were similar, and there was no significant difference in 3-year survival (73% versus 67%), although 3-year cardiac event-free survival (52% versus 25%, p = 0.0011) and 3-year target vessel revascularization-free survival (71% versus 41%, p < 0.0001) were significantly better in the CABG group, and LV ejection fraction was significantly improved after CABG. In the subgroup of patients 65 years of age or older and those without proximal left anterior descending coronary artery lesions, significant benefit of CABG in cardiac event-free and target vessel revascularization-free survival disappeared.

Conclusions

We found that in clinically selected patients with severe ventricular dysfunction, CABG compared with percutaneous revascularization achieves more complete revascularization, improved LV function, fewer cardiac events, and fewer target vessel revascularizations, but does not affect mid-term survival. A prospective controlled trial with defined criteria for treatment assignment is warranted to confirm our results regarding the two revascularization strategies in patients with severe LV dysfunction.     

Tolerance Profile of the Proliferation Signal Inhibitors Everolimus and Sirolimus in Heart Transplantation

Introduction

The side effects of proliferation signal inhibitors (PSIs) have been characterized as a class. However, it would be convenient to assess them according to the molecule.

Objective

To assess prospectively the tolerance of PSIs among heart transplant (HT) patients.

Patients and Methods

We studied 56 HT patients who sequentially received PSIs to either withdraw (77%) or reduce the dosage of a calcineurin inhibitor; 42 received everolimus (EVE) and 14 sirolimus (SRL). We analyzed the demographic variables, side effects, and need to withdraw the drug during a median follow-up period of 365 days.

Results

No differences between groups were observed upon analysis of the clinical and demographic variables when the treatment was changed owing to renal dysfunction (67%) or tumor (32%). No difference between groups was observed over the follow-up period (P = .28). Infection was the most common side effect, 28.6%: EVE, 14.3% versus SRL, 71.4% (P < .0001). Edema occurred in 26.8% of patients: EVE, 14.3% versus SRL, 64.3% (P = .001); diarrhea in 5.4% of patients: EVE, 2.4% versus SRL, 14.3% (P = .15). Treatment was withdrawn in 23.2% of the patients due to intolerance: EVE, 11.9% versus SRL, 57.1% (P < .0001). EVE showed significantly better survival without edema or infections or used for drug withdrawal upon Kaplan-Meier analysis, (P = .01; P = .0005; P = .0097). Only SRL use was shown to be an independent predictor of side effects.

Conclusion

Edema and infections are the main problems caused by PSIs. EVE may display a better tolerance profile than SRL.     

A pig model of chronic heart failure by intracoronary embolization with gelatin sponge

Background

We produced a large-animal model of left ventricular (LV) failure induced by transcatheter embolization of the left coronary artery using a gelatin sponge.

Methods

Fourteen male pigs underwent transcatheter embolization of the left anterior descending artery (LAD) using gelatin sponge to produce anteroapical myocardial infarction. Coronary angiography was performed 1 week after the coronary embolization. The animals were followed up with echocardiography and LV pressure-volume study for the subsequent 8 weeks, and the data were compared with those of the control group (n = 13).

Results

The procedure mortality was 2 of 14 (14%). Coronary angiography revealed the occluded LAD was recanalized with poor run-off. The LV end-diastolic dimension progressively increased (control versus myocardial infarction: 39 ± 2 mm versus 49 ± 4 mm, p < 0.001 at week 4; and 40 ± 2 mm versus 57 ± 6 mm, p < 0.001 at week 8). Fractional area change decreased over 8 weeks (77% ± 10% versus 43% ± 6%, p < 0.001 at week 4; and 77% ± 10% versus 40% ± 8%, p < 0.001 at week 8). End-systolic elastance progressively decreased over 8 weeks (3.04 ± 0.73 mm Hg/mL versus 1.54 ± 0.51 mm Hg/mL, p < 0.0001 at week 4; and 2.88 ± 0.44 mm Hg/mL versus 1.05 ± 0.21 mm Hg/mL, p < 0.001 at week 8). The plasma levels of brain natriuretic peptide were significantly higher in the study group (543 ± 131 pg/mL versus 1,321 ± 364 pg/mL, p < 0.001 at week 4; and 610 ± 152 pg/mL versus 1,523 ± 232 pg/mL, p < 0.001 at week 8).

Conclusions

This pig model of chronic heart failure is reliable, reproducible, and amenable to investigate other surgical procedures.     

Difference of regeneration potential between healthy and diseased liver

Background

We sought to evaluate total and segmental liver regeneration by comparing preoperative computed tomographic (CT) volumetry and CT volumetry on postoperative day (POD) 7 after a right hepatectomy, in patients with various status and surgical indications.

Method

We included 36 patients who underwent right lobectomy for living donor liver transplantation (healthy group), and 29 for hepatocellular carcinoma treatment (disease group). All of the disease group patients were Child-Turcotte-Pugh (CTP) class A. The regeneration of lateral, medial segment and total remnant liver volumes were assessed on POD 7 using a CT-based program. Total volumes and segmental volumes were measured for total liver, future liver remnant (FLR), and liver remnant. We calculated total and segmental early regeneration indexes, defined as [(VLR−VFLR)/VFLR] × 100, where VLR is volume of the liver remnant and VFLR is volume of the FLR.

Result

The VLR at POD 7 showed a 72.9% increase in volume among the healthy versus 55% in the disease group, (P = .012) In the disease group, segmental volume and regeneration indexes were also significantly lower than among the healthy group: 59.0% versus 46.9% in the medial and 86.8% versus 57.7% in the lateral segment (P = .023 and P < .001) respectively.

Conclusion

The volume regeneration potential in diseased livers is significantly lower than that of a normal, healthy liver. So, we must consider a patient's liver status and volume profile before an extensive liver.     

Smoking status is a risk factor for recurrence after transurethral resection of non-muscle-invasive bladder cancer

Background

Cigarette smoking is the most well-established risk factor for developing bladder cancer.

Objective

To investigate the role of smoking status on the clinical outcome of patients with non-muscle-invasive bladder cancer.

Design, setting, and participants

Data obtained during a prospective phase 3 study with three schedules of epirubicin were used for statistical analysis. Smoking status (obtained when entering the study), other prognostic variables, and clinical outcome measures of 718 patients were analyzed. Mean follow-up was 2.5 yr.

Measurements

The primary outcome measure was recurrence-free survival (RFS).

Results and limitations

Demographics were similar for nonsmokers versus ex-smokers and current smokers, except for gender (p < 0.001) and grade (p = 0.022). In univariate analyses, RFS was significantly shorter in male patients (p = 0.020), in patients with a history of recurrences (p < 0.003), in patients with multiple tumors (p < 0.004), in patients with a history of intravesical therapy (p = 0.037), and in ex-smokers and current smokers (p = 0.005). In multivariate analyses, a history of recurrences, multiplicity, and smoking status remained significant factors for predicting RFS. Gender and initial therapy were no longer a significant influence on RFS.Because progression was uncommon (n = 25) and follow-up was short and focused only on recurrences, no conclusion can be drawn on progression-free survival. A limitation of the study were the questionnaires. They were only used when entering the study, and there were no questions about passive smoking and other causal factors.

Conclusions

In this prospective study, the significance of known factors (history of recurrences and number of tumors) in predicting RFS was confirmed. Another significant factor that appears to predict RFS is smoking status: ex-smokers and current smokers had a significantly shorter RFS compared with nonsmokers.     

Stepwise approach for nerve sparing without countertraction during robot-assisted radical prostatectomy: technique and outcomes

Background

Although subtle technical variation affects potency preservation during robot-assisted laparoscopic radical prostatectomy (RARP), most prostatectomy studies focus on achieving the optimal anatomic nerve-sparing dissection plane. However, the impact of active assistant/surgeon neurovascular bundle (NVB) countertraction on sexual function outcomes has not been studied or quantified.

Objective

To illustrate technique and compare sexual function outcomes for nerve sparing without (NS-0C) versus with (NS-C) assistant and/or surgeon NVB countertraction.

Design, setting, and participants

This is a retrospective study of 342 NS-0C versus 268 NS-C RARP procedures performed between August 2008 and February 2011.

Surgical procedure

RARP.

Measurements

We used the Expanded Prostate Cancer Index Composite (EPIC) sexual function and potency scores, estimated blood loss (EBL), operative time, and positive surgical margin (PSM).

Results and limitations

In unadjusted analysis, men undergoing NS-0C versus NS-C were older, had worse baseline sexual function, higher biopsy and pathologic Gleason grade, and higher preoperative prostate-specific antigen (PSA) levels (all p ≤ 0.023). However, NS-0C versus NS-C was associated with higher 5-mo sexual function scores (20 vs 10; p < 0.001), and this difference was accentuated for bilateral intrafascial nerve sparing in preoperatively potent men (35.8 vs 16.6; p < 0.001). Similarly, 5-mo potency for preoperatively potent men was better with bilateral intrafascial NS-0C versus NS-C (45.0% vs 28.4%; p = 0.039). However, no difference in sexual function or potency was observed at 12 mo. In adjusted analyses, NS-0C versus NS-C was associated with improved 5-mo sexual function (parameter estimate: 10.90; standard error: 2.16; p < 0.001) and potency (odds ratio: 1.69; 95% confidence interval, 1.01-2.83; p = 0.046). NS-0C versus NS-WC was associated with shorter operative times (p = 0.001) and higher EBL (p = 0.001); however, there were no significant differences in PSM. Limitations include the retrospective, single-surgeon study design and smaller numbers for 12-mo comparison.

Conclusions

Reliance on countertraction to facilitate dissecting NVB away from the prostate leads to neuropraxia and delayed recovery of sexual function and potency. Subtle technical modification to dissect the prostate away from the NVB without countertraction enables earlier return of sexual function and potency.