Guideline for optimization of surgical and pathological quality performance for radical prostatectomy in prostate cancer management: evidentiary base

Background:

The objective is to provide surgical and pathological guidelines for radical prostatectomy (RP) with or without concurrent pelvic lymph node dissection (PLND) to achieve optimal benefit for patients, with minimal risk of harm.

Methods:

For surgical questions, a literature search of MEDLINE, EMBASE and the Cochrane database was performed. A literature search for the pathological questions was not conducted since the protocol for invasive carcinomas of the prostate gland developed by the College of American Pathologists (CAP) was endorsed. Urologists and pathologists were consulted for their assessment of the surgical and pathological recommendations.

Results:

Limited high-quality evidence from 95 primary studies was available and, therefore, the expert panel developed recommendations on the basis of a consensus of the expert opinion of the working group and through a consultation with urologists and pathologists. In addition to the CAP protocol, some technical recommendations related to the handling and processing of the specimen were made.

Conclusion:

Radical prostatectomy is recommended for the surgical treatment of prostate cancer, depending on a patient’s preoperative risk profile. The panel unanimously determined that the goals for RP are to attain a positive margin rate of <25% for pT2 disease, a mortality rate of <1%, rates of rectal injury of <1% and blood transfusion rates of <10% in non-anemic patients. Standard PLND should be mandatory in high-risk patients, should be recommended for intermediate-risk patients and should be optional for low-risk patients. The quality and effectiveness of this treatment and of subsequent patient care depend on good management, effective communication and reporting between surgeons and pathologists working together as part of a multidisciplinary team. The complete guideline document is posted on the Cancer Care Ontario website (www.cancercare.on.ca); search in their Toolbox, Quality Guidelines & Standards, Clinical Program category under “surgery.”     

Pruritus ani

INTRODUCTION

Pruritus ani is a common condition with many causes, predominately anorectal pathology. There are some new insights and therapies, but the most recommendations are based on low-level evidence.

PATIENTS AND METHODS

A literature search was carried out using Medline and the internet with the keywords ‘pruritus ani’ from 1950 to 2007.

RESULTS

A review of the evidence is presented and a management plan based on the elimination of irritants and scratching, general control measures and active treatment measures is offered.

CONCLUSIONS

Treatment of primary and secondary pruritus ani has a good prospect of regression of symptoms and skin changes.     

Prostate Specific Antigen: The Past,Present and Future

Aim

To review current data available on use of prostate specific antigen for screening healthy men for prostate cancer.

Methods

Literature was reviewed and the guidelines from, American cancer Society, American Urologic Association was reviewed.

Results

Current screening protocols lead to over diagnosis of prostate cancer. This often results in unnecessary biopsy procedures and treatments.

Conclusion

We must consider the benefit of screening and treatment with the harms of over diagnosis and over treatment. Newer imaging modalities like magnetic resonance imaging have to be evaluated further.Key Words: Prostate cancer, Prostate-specific antigen, Screening     

Catheter use and infection reduction in plastic surgery

BACKGROUND:

Catheter-associated urinary tract infections (CAUTI) are the most common hospital-associated infection and can result in increased health care costs, morbidity and even mortality. In 2009, The Scott & White Memorial Hospital/Texas A&M Health Science Center (Texas, USA) system’s CAUTI rate placed it in the upper quartile (ie, highest rate) for the country, necessitating a system-wide change.

OBJECTIVE:

To design and implement a guideline to reduce the incidence of CAUTI.

METHODS:

A multidisciplinary team was formed and completed both a root cause analysis and a review of the available literature. Consolidating the best evidence, the team formulated a best practice guideline detailing the proper indications for insertion of, improper use of and techniques to minimize infection with catheters. Included as part of this protocol was nursing and patient education, changes in identifying patients with a catheter and automatic termination orders. Three-, six- and 12-month reviews identifying additional opportunities for improvement at the end of 2010 were completed.

RESULTS:

In 2009, the hospital’s CAUTI rate was 1.46 per 1000 catheter days. In 2011 – the first complete year of the finalized guideline – the hospital’s CAUTI rate was 0.52 per 1000 catheter days, ranking the institution in the bottom quartile (ie, lowest rate) for the country. The surgery and plastic surgery subgroup analyses also demonstrated statistically significant reduction in both catheter use and CAUTI.

CONCLUSION:

The incidence of CAUTI was successfully reduced at The Texas A&M Healthcare Center. The guideline, its development and how it applies to plastic surgery patients are discussed.     

Cancer Care Ontario Guidelines for radical prostatectomy: striving for continuous quality improvement in community practice

Objective:

Cancer Care Ontario has published an evidence-based guideline on their website “Guideline for Optimization of Surgical and Pathological Quality Performance for Radical Prostatectomy in Prostate Cancer Management: Surgical and Pathological Guidelines.” The evidentiary base for this guideline was recently published in CUAJ. The CCO guideline proposes the following: a positive surgical margin (PSM) rate of <25% for organ-confined disease (pT2), a perioperative mortality of <1%, a rate of rectal injury <1%, and a blood transfusion rate <10% in non-anemic patients. The objective of this study was to review the radical prostatectomy practice at the Grey Bruce Health Services, an Ontario community hospital, and to compare our performance in relation to the Cancer Care Ontario guideline and the literature.

Methods:

We conducted a retrospective review of all radical prostatectomies performed at the Grey Bruce Health Services from January 1, 2006 to December 31, 2007. The following data were obtained from clinical records and pathology reports: patient age, pre-biopsy prostate-specific antigen, biopsy Gleason score, resected prostate gland weight, radical prostatectomy Gleason score, surgical margin status, pathological tumour stage (pT), lymph node dissection status, perioperative incidence of transfusion of blood products and if the patient was anemic (hemoglobin <140 g/L) preoperatively, incidence of rectal injury, and perioperative mortality within 30 days following surgery.

Results:

Using the method proposed by D’Amico, most patients undergoing radical prostatectomy were intermediate risk (62%), with a minority of low-risk (24%) and high-risk (14%) patients. The overall PSM rate was 37%. The rate of PSMs in organ-confined disease (pT2) was 26%. There was a statistically significant trend between increasing D’Amico risk category and increasing rate of PSM (Cochran-Armitage trend test, p = 0.023). There was a strong correlation between the pathological tumour stage and the rate of PSM (Cochran-Armitage trend test, p = 0.0003). The rate of blood transfusion in non-anemic patients was 6%. There was 1 patient (0.8%) who experienced a rectal injury. There were no perioperative deaths in our study group.

Conclusion:

Our results show that a community hospital group can appropriately select patients to undergo radical prostatectomy, as well as achieve an acceptable rate of PSMs. We believe that ongoing critical appraisal and reflective practice are essential to improving surgical outcomes and providing quality care.     

Salvage radiotherapy after high-intensity focused ultrasound treatment for localized prostate cancer: feasibility, tolerance and efficacy

Background:

The objective of this study is to evaluate the feasibility, tolerance and efficacy of salvage external beam radiotherapy (EBRT) in persistent or recurrent prostate cancer after failed high intensity focused ultrasound (HIFU) therapy.

Methods:

We reviewed data on tolerance and oncologic outcomes for all patients with biopsy-proven locally recurrent or persistent prostate cancer who underwent salvage EBRT in our department between April 2004 and June 2008. Minimum follow-up for inclusion was 2 years. Failure with EBRT was defined as biochemical relapse (Phoenix definition) or introduction of androgen deprivation therapy (ADT). Gastrointestinal and urinary toxicity and urinary stress incontinence were scored at 12 and 24 months (Radiation Therapy Oncology Group and Ingelman Sundberg rating, respectively).

Results:

The mean age of the patients was 68.8 years (range: 60–79). Mean prostate-specific antigen (PSA) before EBRT was 5.57 ng/mL (range: 2.5–14.8). Median follow-up was 36.5 ± 10.9 months (range: 24–54). No patient received adjunctive ADT. The EBRT course was well-tolerated and completed by all patients. The mean PSA nadir was 0.62 ng/mL (range: 0.03–2.4) and occurred after a median of 22 months (range: 12–36). One patient experienced biochemical failure and was prescribed ADT 30 months after EBRT. The disease-free survival rate was 83.3% at 36.5 months. There was no major EBRT-related toxicity at 12 or 24 months.

Conclusions:

Our early clinical results confirm the feasibility and good tolerance of salvage radiotherapy after HIFU failure. Oncological outcomes were promising. A prospective study with longer follow-up is needed to identify factors predictive of success for salvage EBRT therapy after HIFU failure.     

Co-constructing sexual recovery after prostate cancer: a qualitative study with couples

Background

Men are likely to experience deterioration in sexual functioning as a consequence of treatment for prostate cancer. Indeed, sexual difficulties are common across all treatment modalities.

Objective

To determine the impact of treatment for prostate cancer on intimacy and sexual expression/relationships from the perspective of couples.

Methods

An observational study was conducted including in-depth interviews with 18 people affected by prostate cancer; comprising eight couples and two individual men.

Results

Four categories were identified that illustrated the impact of prostate cancer on intimacy and sexual recovery. These related to social influences and language used to describe the loss or recovery of sexual activities; difficulties in discussing sexual activity with clinicians; the clash of individual impact of prostate cancer recovery versus the impact on the couple, and the re-integration of sexual activities into the relationship.

Conclusions

Though only one person in a partnership experiences cancer, these data indicated the extent to which prostate cancer treatment also impacts on partners. The study indicates that adjustment to erectile dysfunction (ED) takes time, but is a highly significant event in couples’ lives and its importance should not be under-estimated. Consequently, we suggest that relational models of care should be considered, whereby side-effects are recognised as impacting on both members of the partnership (for example ED, or lack or ejaculate). Supportive care in this context, therefore, may best be based on a relational approach using language and interventions that are appropriate to the patient and their situation.     

Laparoscopic Colorectal Surgery: Summary of the Current Evidence

INTRODUCTION

Laparoscopic colectomy has not been accepted as quickly as laparoscopic cholecystectomy. This is because of its steep learning curve, concerns with oncological outcomes, lack of randomised controlled trials (RCTs) and initial reports on port-site recurrence after curative resection. The aim of this review is to summarise current evidence on laparoscopic colorectal surgery.

PATIENTS AND METHODS

Review of literature following Medline search using key words ‘laparoscopic’, ‘colorectal’ and ‘surgery’.

CONCLUSIONS

Laparoscopic colorectal surgery proved to be safe, cost-effective and with improved short-term outcomes. However, further studies are needed to assess the role of laparoscopic rectal cancer surgery and the value of enhanced recovery protocols in patients undergoing laparoscopic colorectal resections.     

Pre-treatment risk stratification of prostate cancer patients: A critical review

Introduction:

The use of accepted prostate cancer risk stratification groups based on prostate-specific antigen, T stage and Gleason score assists in therapeutic treatment decision-making, clinical trial design and outcome reporting. The utility of integrating novel prognostic factors into an updated risk stratification schema is an area of current debate. The purpose of this work is to critically review the available literature on novel pre-treatment prognostic factors and alternative prostate cancer risk stratification schema to assess the feasibility and need for changes to existing risk stratification systems.

Methods:

A systematic literature search was conducted to identify original research publications and review articles on prognostic factors and risk stratification in prostate cancer. Search terms included risk stratification, risk assessment, prostate cancer or neoplasms, and prognostic factors. Abstracted information was assessed to draw conclusions regarding the potential utility of changes to existing risk stratification schema.

Results:

The critical review identified three specific clinically relevant potential changes to the most commonly used three-group risk stratification system: (1) the creation of a very-low risk category; (2) the splitting of intermediate-risk into a low- and high-intermediate risk groups; and (3) the clarification of the interface between intermediate- and high-risk disease. Novel pathological factors regarding high-grade cancer, subtypes of Gleason score 7 and percentage biopsy cores positive were also identified as potentially important risk-stratification factors.

Conclusions:

Multiple studies of prognostic factors have been performed to create currently utilized prostate cancer risk stratification systems. We propose potential changes to existing systems.     

The Epidemiology and Risk Factors for Renal Cancer

Background

Renal cancer is a frequently occurring malignancy with over 270,000 new cases diagnosed and it being responsible for 110,000 deaths annually on a global basis. Incidence rates have gradually increased whilst mortality rates are starting to plateau.

Objective

To review epidemiology and risk factors for renal cancer.

Methods

The current data is based on a thorough review of available original and review articles on epidemiology and risk factors for renal cancer with a systemic literature search utilising Medline.

Results

The prevalence of associated risk factors such as genetic susceptibility, smoking, hypertension and obesity are changing and could account for the changes in incidence whilst the role of diet and occupational exposure to carcinogens requires further investigation.

Conclusion

Despite the evidence of various associated risk factors, further work is required from well designed studies to gain a greater understanding of the etiology of renal cancer.Key Words: Epidemiology, Renal cancer, Risk factors     

Preoperative pregnancy testing

BACKGROUND:

In up to 2% of all pregnancies, the need for general anesthesia in a nonobstetrical surgery arises. Surgery on a pregnant woman may have significant implications for the fetus, patient, physician and hospital. On review of the plastic surgery literature, the authors were unable to find current guidelines or recommendations for preoperative pregnancy testing in the plastic surgery patient population.

METHODS:

Literature regarding maternal and fetal risk during anesthesia and surgery, as well as preoperative pregnancy testing was identified by performing a PubMed, OVID and MEDLINE key word search. The current literature was subsequently reviewed and summarized.

RESULTS:

A report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation allows physicians and hospitals to implement their own policies and practices with regard to preoperative pregnancy testing. The overall frequency of an incidentally found positive preoperative pregnancy test ranges from 0.34% to 2.4%.

DISCUSSION:

Various studies have reported increased rates of spontaneous abortions, congenital anomalies, such as neural tube defects, and low and very low birth weight infants born to mothers exposed to anesthesia and surgery during pregnancy. Because the accepted practice is to postpone elective surgery during pregnancy, identifying these patients before surgery is critical.

CONCLUSIONS:

Based on the current evidence, the authors’ best practice recommendation for preoperative pregnancy testing is provided.     

Use of an oncology sperm bank: a Canadian experience

Background:

We performed a retrospective chart review in 2006 to review oncology patients’ use of banked semen samples in fertility treatments at a tertiary care centre.

Methods:

From 2002 to 2005, 367 oncology patients banked semen. During the same period, 31 patients used banked samples in 48 treatment cycles. Samples were used for intrauterine insemination (IUI) in 28 cycles and for in vitro fertilization (IVF) with or without intracytoplasmic sperm injection (ICSI) in 20 cycles.

Results:

Pregnancy rates per cycle were 21% for IUI and 50% for IVF with or without ICSI. Overall, 16 of the 31 couples achieved a pregnancy with assisted reproductive technologies (52%).

Conclusion:

This data indicates high pregnancy success rates with the use of banked semen samples from men with cancer.     

pT0 Prostate Cancer: Predictive Clinicopathologic Features in an American Population

Introduction

The pT0 stage of prostate cancer describes the radical prostatectomy (RP) specimen where no cancer can be identified. Given known racial and geographic differences in prostate cancer incidence and survival, we reviewed our experience with pT0 disease to determine applicability of these predictive features in an American population.

Materials and Methods

A retrospective chart review was conducted for all RPs at one state tertiary care institution during a 20-year period (1991-2011). Clinicopathologic features of pT0 patients were collected and their relevant pathologic material re-reviewed.

Results

Of a total of 1,635 RPs performed, 4 (0.2%) not receiving neoadjuvant therapy or other prior prostate surgeries were stage pT0. Biopsies from 3 of 4 patients were re-evaluated and confirmed a small focus, <1% of tissue, of Gleason score 3+3 adenocarcinoma; a fourth was not available for re-review. Our re-review of the RP slides identified small foci of cancer in two of the four, thus yielding a final true pT0 incidence of 0.1%. Preoperative prostate specific antigen ranged from 4.4 to 7.4 ng/ml, clinical stages were all T1c, and there was no evidence of recurrence at 3 months to 10 years of follow-up.

Conclusions

Stage pT0 prostate cancer is very uncommon, occurring with an incidence of 0.1%, and in our experience occurs only in clinical T1c patients with pre-biopsy prostate specific antigen < 7.5 ng/ml, with Gleason score 3 + 3 adenocarcinoma comprising < 1%, 1 mm of a single core biopsy, a stricter threshold than that seen in non-American populations.Key Words: Prostate cancer, Biopsy, Cancer staging     

Pelvic fasciae in urology

INTRODUCTION

Despite the vast literature on pelvic fascia, there is confusion over the periprostatic structures and their nomenclature, including their orientation, the neurovascular bundles and the existence of the prostatic ‘capsule’. In this review, we seek to clarify some of these issues.

MATERIALS AND METHODS

Review of published medical literature relating to the anatomy of the pelvic fascia including a Pubmed search using the terms – pelvic fascia, Denonvilliers'' fascia, prostate capsule, neurovascular bundle of Walsh, pubo-prostatic ligament and the detrusor apron.

CONCLUSIONS

The findings of the study were as follows:

1. The ‘capsule’ of the prostate does not exist. Rather, the fibromuscular band surrounding the prostate forms an integral part of the gland.
2. The prostate is surrounded by fascial structures – anteriorly/anterolaterally by the prostatic fascia and posteriorly by the Denonvilliers'' fascia. Laterally, the prostatic fascia merges with the endopelvic fascia.
3. The posterior longitudinal fascia of the detrusor comprises a ‘posterior layer’ of the detrusor apron, extending from the bladder neck to the prostate base.
4. The neurovascular structures tend to be located posterolaterally, but may not always form a bundle. A significant proportion of fibres may lie away from the main nerve structures, along the lateral/posterior aspects of the prostate.

     

The pattern of prostate cancer local recurrence after radiation and salvage cryoablation

Objective:

We assessed the pattern of local recurrence after salvage cryoablation of the prostate, and the impact of local recurrence on intermediate-term outcome.

Methods:

One hundred twenty-two patients who underwent salvage cryoablation were studied after a mean follow-up of 56 months. Serial prostate biopsy was carried out after cryoablation. The histopathology of prostate biopsies before and after cryoablation were compared. The prognostic value of post-cryoablation biopsy was assessed with the Cox regression method.

Results:

23.1% of patients had a positive biopsy for prostate cancer following salvage cryoablation. Most cancer recurrences occurred in the apex (51.5%), base (21.2%) and seminal vesicles (18.2%). The presence of cancer at the base of the prostate was found to be a prognostic factor for eventual biochemical failure. Overall 5-year biochemical disease-free survival (bDFS) was 28%, however patients with cancer at the base of the prostate had a 5-year bDFS of 0%.

Conclusion:

Cancer recurrences occurred in areas where aggressive freezing was avoided as it might result in serious problems (e.g., urethro-rectal fistula and incontinence). Post-cryoablation biopsies and the location of persistent disease are of prognostic value.     

Development and validation of a virtual reality transrectal ultrasound guided prostatic biopsy simulator

Objective

We present the design, reliability, face, content and construct validity testing of a virtual reality simulator for transrectal ultrasound (TRUS), which allows doctors-in-training to perform multiple different biopsy schemes.

Methods

This biopsy system design uses a regular “end-firing” TRUS probe. Movements of the probe are tracked with a micro-magnetic sensor to dynamically slice through a phantom patient’s 3D prostate volume to provide real-time continuous TRUS views. 3D TRUS scans during prostate biopsy clinics were recorded. Intrinsic reliability was assessed by comparing the left side of the prostate to the right side of the prostate for each biopsy. A content and face validity questionnaire was administered to 26 doctors to assess the simulator. Construct validity was assessed by comparing notes from experts and novices with regards to the time taken and the accuracy of each biopsy.

Results

Imaging data from 50 patients were integrated into the simulator. The completed VR TRUS simulator uses real patient images, and is able to provide simulation for 50 cases, with a haptic interface that uses a standard TRUS probe and biopsy needle. Intrinsic reliability was successfully demonstrated by comparing results from the left and right sides of the prostate. Face and content validity respondents noted the realism of the simulator, and its appropriateness as a teaching model. The simulator was able to distinguish between experts and novices during construct validity testing.

Conclusions

A virtual reality TRUS simulator has successfully been created. It has promising face, content and construct validity results.     

The diagnostic accuracy of the Kemp’s test: a systematic review

Background:

The objective of this review was to evaluate the existing literature regarding the accuracy of the Kemp’s test in the diagnosis of facet joint pain compared to a reference standard.

Methods:

Several databases were searched. All diagnostic accuracy studies comparing the Kemp’s test with an acceptable reference standard were included. Included studies were scored for quality and internal validity.

Results:

Five articles met the inclusion criteria of this review. Two studies had a low risk of bias, and three had a low concern regarding applicability. Pooling of data from studies using similar methods revealed that the test’s negative predictive value was the only diagnostic accuracy measure above 50% (56.8%, 59.9%).

Conclusions:

Currently, the literature supporting the use of the Kemp’s test is limited and indicates that it has poor diagnostic accuracy. It is debatable whether clinicians should continue to use this test to diagnose facet joint pain.     

The role of diagnostic block in the management of Morton’s neuroma

Objective

To determine the outcome of surgical excision of Morton’s neuroma after a local anesthetic diagnostic block into the neuroma has relieved symptoms.

Design

A cohort study.

Setting

A university affiliated hospital.

Patients

A sequential series of 37 patients who underwent 41 excisions with at least 2 years’ follow-up. Seven patients had undergone repeat excision of a neuroma, and 34 primary excisions were performed. Surgery was performed by a specialist in orthopedic surgery of the foot and ankle.

Intervention

Excision of the Morton’s neuroma after a positive diagnostic block.

Main outcome measures

Grade of symptoms at follow-up done by independent review on a 4-point scale.

Results

Of 41 procedures, 11 had an unfavourable outcome: 4 procedures were graded 3, and 7 procedures were graded 4. Eight (24%) of the 34 primary procedures were reported as failures, and 3 (43%) of the 7 revision procedures were reported as failures. Most patients reported poor results owing to persistent pain.

Conclusions

Diagnostic blocks do not improve the results of surgery for excision of Morton’s neuroma and are not recommended. Because failure rates are greater than 20%, surgery for Morton’s neuroma should only be offered after a full course of nonoperative management.     

VEGF is associated with the poor survival of patients with prostate cancer: a meta-analysis

Background

Vascular endothelial growth factor (VEGF) is considered as a prime mediator of angiogenesis, and has been implicated in carcinogenesis and metastasis. Various studies examined the relationship between VEGF overexpression with the clinical outcome in patients with prostate cancer, but yielded conflicting results.

Methods

Electronic databases updated to July 2013 were searched to find relevant studies. A meta-analysis was conducted with eligible studies which quantitatively evaluated the relationship between VEGF status and survival of patients with prostate cancer. Survival data were aggregated and quantitatively analyzed.

Results

We performed a meta-analysis of 9 studies that evaluated the correlation between VEGF overexpression and survival in patients with prostate cancer. Combined hazard ratios suggested VEGF overexpression had an unfavorable impact on overall survival (OS) [hazard ratio (HR) =1.54, 95% CI (confidence interval): 1.25-1.83], but not disease free survival (DFS) (HR=1.23, 95% CI: 0.99-1.47) in patients with prostate cancer. No significant heterogeneity was observed among all studies.

Conclusions

VEGF overexpression indicates a poor prognosis for patients with prostate cancer.