Pathogen elimination and prevention within a regulated,Designated Pathogen Free,closed pig herd for long‐term breeding and production of xenotransplantation materials

Background

We established a Source Animal (barrier) Facility (SAF ) for generating designated pathogen‐free (DPF ) pigs to serve as donors of viable organs, tissues, or cells for xenotransplantation into clinical patients. This facility was populated with caesarian derived, colostrum deprived (CDCD ) piglets, from sows of conventional‐specific (or specified) pathogen‐free (SPF ) health status in six cohorts over a 10‐month period. In all cases, CDCD piglets fulfilled DPF status including negativity for porcine circovirus (PCV ), a particularly environmentally robust and difficult to inactivate virus which at the time of SAF population was epidemic in the US commercial swine production industry. Two outbreaks of PCV infection were subsequently detected during sentinel testing. The first occurred several weeks after PCV ‐negative animals were moved under quarantine from the nursery into an animal holding room. The apparent origin of PCV was newly installed stainless steel penning, which was not sufficiently degreased thereby protecting viral particles from disinfection. The second outbreak was apparently transmitted via employee activities in the Caesarian‐section suite adjacent to the barrier facility. In both cases, PCV was contained in the animal holding room where it was diagnosed making a complete facility depopulation‐repopulation unnecessary.

Method

Infectious PCV was eliminated during both outbreaks by the following: euthanizing infected animals, disposing of all removable items from the affected animal holding room, extensive cleaning with detergents and degreasing agents, sterilization of equipment and rooms with chlorine dioxide, vaporized hydrogen peroxide, and potassium peroxymonosulfate, and for the second outbreak also glutaraldehyde/quaternary ammonium. Impact on other barrier animals throughout the process was monitored by frequent PCV diagnostic testing.

Result

After close monitoring for 6 months indicating PCV absence from all rooms and animals, herd animals were removed from quarantine status.

Conclusion

Ten years after PCV clearance following the second outbreak, due to strict adherence to biosecurity protocols and based on ongoing sentinel diagnostic monitoring (currently monthly), the herd remains DPF including PCV negative.

     

Accuracy of administrative coding data in colorectal cancer resections and short‐term outcomes

Background

Administrative data are routinely captured for each hospital admission and may serve as an alternative source for populating databases. This study aims to determine the accuracy of administrative data to provide tumour characteristics and short‐term post‐operative outcomes, after a colorectal cancer (CRC) resection, compared with clinical data.

Methods

A retrospective study of all CRC resections at a single hospital from 1 January 2008 to 31 December 2013 was conducted. Local administrative data were coded as per ICD‐10‐AM (International Classification of Diseases, Tenth Revision, Australian Modification) and Australian Classification of Health Interventions. Clinical data for all patients were extracted from the medical charts and compared with administrative data. Code combinations and algorithms were used to improve the accuracy of administrative data.

Results

A total of 436 patients were identified. The accuracy of algorithms combining tumour location and type of operation for right colon, left colon and rectum were 93, 89 and 88%, respectively. The accuracy of histological type was 89%, lymph node status 92% and metastasis status 88%. The accuracy of return to theatre and in‐hospital mortality was 100%.

Conclusion

Administrative data can provide reliable information on tumour details and short‐term post‐operative outcomes. The potential for administrative data to validate data captured in registries and be used independently for audit and research should be further explored.

     

Stereotactic electrical stimulation of the pontine micturition centre in the pig

OBJECTIVE

To apply stereotactic electrical stimulation of the pig brainstem and thus identify a pontine micturition centre.

MATERIALS AND METHODS

In 10 anaesthetized female Vietnamese minipigs a needle‐electrode was positioned in the pontine region. Pressure responses in the lower urinary tract identified the micturition centre functionally during electrical stimulation. Stereotactic coordinates were recorded, and the needle visualized by fluoroscopy, magnetic resonance imaging (MRI) or histologically.

RESULTS

The stimulation evoked responses similar to voiding, i.e. a urethral pressure decrease followed by a bladder pressure increase; or similar to a continence manoeuvre, i.e. urethral pressure increase and no change in bladder pressure. In a few cases a continence response was evoked by stimulating a site 1 mm away from the site where a voiding response was evoked. The electrode position was detected by the fluoroscopy‐based stereotactic procedure followed by subsequent MRI (one animal), and by histological analysis, verifying it to be in the dorsolateral pontine region.

CONCLUSIONS

These results show that a pontine micturition centre exists in pigs similar to that described in rats, cats, dogs and humans.

     

Operative and Functional Outcome After Pulmonary Endarterectomy for Advanced Thromboembolic Pulmonary Hypertension

Aim

To evaluate the midterm hemodynamic and functional outcome of pulmonary endarterectomy (PEA) for patients with advanced chronic thromboembolic pulmonary hypertension (CTEPH).

Methods

Thirty‐eight consecutive patients underwent PEA for CTEPH from May 2004 to March 2012. All patients were followed prospectively at six months postoperatively and annually thereafter. Each patient underwent serial cardiopulmonary exercise testing (CPET) and transthoracic echocardiography, and were followed for up to four years.

Results

Overall, 31.5% (12/38) of patients had Jamieson class II disease while 65.8% (25/38) had class III disease. There were three in‐hospital mortalities (7.9%), all of which had baseline pulmonary vasculature resistance (PVR) greater than 1400 dynes‐sec‐cm^?5. Preoperative PVR and mean pulmonary artery pressure were 1209 ± 723 dynes‐sec‐cm^?5 and 50 ± 14 mmHg, respectively, signifying a high‐risk operative group. Ninety‐seven percent of patients were in NYHA class III or IV preoperatively. At median follow‐up of 29 months 89.5% (17/19) of patients were in NYHA class I or II. CPET revealed a progressive increase in peak oxygen consumption from 16.5 ± 4.1 ml/kg/min at first follow‐up, to a plateau of 20.2 ± 5.6 ml/kg/min (p = 0.032) at two years.

Conclusions

CPET can be used to quantify progress in functional capacity post‐CTEPH, although improvements in peak oxygen consumption plateau at two years. doi: 10.1111/jocs.12646 (J Card Surg 2016;31:3–8)

     

Correlations of SELENOF and SELENOP genotypes with serum selenium levels and prostate cancer

Background

Selenium status is inversely associated with the incidence of prostate cancer. However, supplementation trials have not indicated a benefit of selenium supplementation in reducing cancer risk. Polymorphisms in the gene encoding selenoprotein 15 (SELENOF) are associated with cancer incidence/mortality and present disproportionately in African Americans. Relationships among the genotype of selenoproteins implicated in increased cancer risk, selenium status, and race with prostate cancer were investigated.

Methods

Tissue microarrays were used to assess SELENOF levels and cellular location in prostatic tissue. Sera and DNA from participants of the Chicago‐based Adiposity Study Cohort were used to quantify selenium levels and genotype frequencies of the genes for SELENOF and the selenium‐carrier protein selenoprotein P (SELENOP). Logistic regression models for dichotomous patient outcomes and regression models for continuous outcome were employed to identify both clinical, genetic, and biochemical characteristics that are associated with these outcomes.

Results

SELENOF is dramatically reduced in prostate cancer and lower in tumors derived from African American men as compared to tumors obtained from Caucasians. Differing frequency of SELENOF polymorphisms and lower selenium levels were observed in African Americans as compared to Caucasians. SELENOF genotypes were associated with higher histological tumor grade. A polymorphism in SELENOP was associated with recurrence and higher serum PSA.

Conclusions

These results indicate an interaction between selenium status and selenoprotein genotypes that may contribute to the disparity in prostate cancer incidence and outcome experienced by African Americans.

     

Open radical prostatectomy in the elderly: a case for concern?

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Adverse outcomes after radical prostatectomy are more often recorded in the elderly. In the USA, elderly patients undergoing radical prostatectomy are treated at institutions where suboptimal outcomes are recorded.

OBJECTIVE

• ? To assess the rate of adverse outcomes after open radical prostatectomy (ORP) in the elderly and to examine the effect of annual hospital caseload (AHC) and academic institutional status on adverse outcomes in these of patients.

PATIENTS AND METHODS

• ? Within the Health Care Utilization Project Nationwide Inpatient Sample, we focused on ORPs performed between 1998 and 2007. Subsequently, we restricted to patients aged ≥75 years.
• ? In both datasets, we examined transfusion rates, intra‐operative and postoperative complication rates, and in‐hospital mortality rates.
• ? Stratification was performed according to AHC tertiles and academic status.
• ? Multivariable logistic regression analyses were fitted.

RESULTS

• ? Of 115 554 ORP patients, 2109 (1.8%) were aged ≥75 years.
• ? In multivariable analyses performed in the entire cohort, elderly age increased homologous blood transfusion rates (P < 0.001), intra‐operative (P= 0.001) and postoperative (P < 0.001) complication rates, and the mortality rate (P= 0.007).
• ? Most elderly were treated at low or intermediate AHC (68.5%) and non‐academic centres (56.2%).
• ? Within the elderly cohort, intra‐operative (2.9%) and postoperative (22.2%) complications tended to be highest at low AHC institutions compared to institutions of intermediate (2.7% and 17.4%) and high AHC (1.7% and 14.5%). Similarly, intra‐operative (2.7% vs 2.1%) and postoperative complications (19.1% vs 13.9%) tended to be higher at non‐academic than academic centres.
• ? In multivariable analyses performed in the elderly subgroup, low AHC predicted higher intra‐operative complications and higher homologous transfusions, whereas non‐academic status predicted higher postoperative complications.

CONCLUSIONS

• ? Adverse outcomes are more often recorded in the elderly.
• ? Most elderly are treated at institutions where suboptimal outcomes are recorded.

     

Prognostic role of the preoperative serum albumin : globulin ratio after radical nephroureterectomy for upper tract urothelial carcinoma

Objectives

To elucidate the effects of the preoperative albumin : globulin ratio on the survival of patients with upper tract urothelial carcinoma after radical nephroureterectomy.

Methods

We retrospectively reviewed 124 consecutive patients with upper tract urothelial carcinoma who underwent radical nephroureterectomy at Chiba Cancer Center, Chiba, Japan between 2002 and 2015. The albumin : globulin ratio was defined: albumin / (total protein ? albumin). Associations between preoperative clinicopathological factors, including the albumin : globulin ratio, and recurrence‐free survival, cancer‐specific survival and overall survival were assessed. The log–rank test and Cox proportional hazards models were used for univariate and multivariable analyses, respectively. The study cohort was separated into two groups based on the optimal albumin : globulin ratio cut‐off value determined using receiver operating characteristic curve analysis.

Results

The median survival time was 55 months (interquartile range 28–76 months), and 31 patients died during follow up. A low preoperative albumin : globulin ratio <1.40 was associated with tumor grade and surgical margin status. Kaplan–Meier analyses showed that a low albumin : globulin ratio was more significantly correlated with worse recurrence‐free survival, cancer‐specific survival and overall survival. Multivariate analyses showed that a low albumin : globulin ratio was an independent predictive factor associated with poor recurrence‐free survival (hazard ratio 3.758; P = 0.0028), cancer‐specific survival (hazard ratio 5.687; P = 0.0044) and overall survival (hazard ratio 3.124; P = 0.0030).

Conclusions

A low albumin : globulin ratio is an independent predictive factor associated with poor prognosis in upper tract urothelial carcinoma patients treated with radical nephroureterectomy.

     

Systematic overview and critical appraisal of meta‐analyses of interventions in intensive care medicine

Rationale

Meta‐analysed intervention effect estimates are perceived to represent the highest level of evidence. However, such effects and the randomized clinical trials which are included in them need critical appraisal before the effects can be trusted.

Objective

Critical appraisal of a predefined set of all meta‐analyses on interventions in intensive care medicine to assess their quality and assessed the risks of bias in those meta‐analyses having the best quality.

Methods

We conducted a systematic search to select all meta‐analyses of randomized clinical trials on interventions used in intensive care medicine. Selected meta‐analyses were critically appraised for basic scientific criteria, (1) presence of an available protocol, (2) report of a full search strategy, and (3) use of any bias risk assessment of included trials. All meta‐analyses which qualified these criteria were scrutinized by full “Risk of Bias in Systematic Reviews” ROBIS evaluation of 4 domains of risks of bias, and a “Preferred Reporting Items for Systematic Reviews and Meta‐Analyses” PRISMA evaluation.

Results

We identified 467 meta‐analyses. A total of 56 meta‐analyses complied with these basic scientific criteria. We scrutinized the risks of bias in the 56 meta‐analyses by full ROBIS evaluation and a PRISMA evaluation. Only 4 meta‐analyses scored low risk of bias in all the 4 ROBIS domains and 41 meta‐analyses reported all 27 items of the PRISMA checklist.

Conclusion

In contrast with what might be perceived as the highest level of evidence only 0.9% of all meta‐analyses were judged to have overall low risk of bias.

     

Evaluation of stimulated raman scattering microscopy for identifying squamous cell carcinoma in human skin

Background and Significance

There is a need to develop non‐invasive diagnostic tools to achieve early and accurate detection of skin cancer in a non‐surgical manner. In this study, we evaluate the capability of stimulated Raman scattering (SRS) microscopy, a potentially non‐invasive optical imaging technique, for identifying the pathological features of s squamous cell carcinoma (SCC) tissue.

Study Design

We studied ex vivo SCC and healthy skin tissues using SRS microscopy, and compared the SRS contrast with the contrast obtained in reflectance confocal microscopy (RCM) and standard histology.

Results and Conclusion

SRS images obtained at the carbon‐hydrogen stretching vibration at 2945 cm^?1 exhibit contrast related protein density that clearly delineates the cell nucleus from the cell cytoplasm. The morphological features of SCC tumor seen in the SRS images show excellent correlation with the diagnostic features identified by histological examination. Additionally, SRS exhibits enhanced cellular contrast in comparison to that seen in confocal microscopy. In conclusion, SRS represents an attractive approach for generating protein density maps with contrast that closely resembles histopathological contrast of SCC in human skin. Lasers Surg. Med. 45:496–502, 2013. © 2013 Wiley Periodicals, Inc.

     

UK practice regarding reversal of vasectomy 2001-2010: relevance to best contemporary patient management

Study Type – Practice trends (survey) Level of Evidence 2c What's known on the subject? and What does the study add? Approximately 6% of men who have had a vasectomy subsequently decide to have it reversed. For such men there are various options available, including vasal reconstruction, surgical sperm retrieval with assisted reproductive techniques, use of donated sperm or adoption. The decision‐making process with regard to the most appropriate management is challenging and the urologist requires both an intimate knowledge of the advantages and disadvantages of each of the available options and the opportunity to counsel a couple appropriately. The study confirms that patient management after previous vasectomy is a complex process, demanding detailed knowledge about the availability and outcomes of alternatives to vasectomy reversal. It recommends that couples should not be seen by urologists with diverse interests but by those with appropriate knowledge of all of the factors influencing outcome and the available management options and their costs. Urologists should also have appropriate facilities to offer intra‐operative demonstration of and, potentially, storage of sperm.

OBJECTIVES

• ? To review the management of men presenting for reversal of vasectomy amongst consultant members of the British Association of Urological Surgeons (BAUS) between 2001 and 2010.
• ? To make recommendations for contemporary practice.

SUBJECTS AND METHODS

• ? Three consecutive questionnaire‐based surveys were undertaken by BAUS consultant members in 2001, 2005 and 2010.
• ? Standard questionnaires were sent on each occasion asking urologists about their counselling of couples regarding options in achieving a conception, expectation of outcome from reconstructive surgery and the techniques of vaso‐vasostomy used.
• ? In 2005 additional information was obtained about the availability of fertility treatments and sub‐specialization of the urologist and in 2010 about the eligibility criteria for in‐vitro fertilization (IVF) treatment and synchronous sperm retrieval.

RESULTS

• ? Overall there was a 47% response rate with >80% of respondents still performing vaso‐vasostomy.
• ? More than 75% of respondents were doing <15 procedures a year and <50% of respondents counselled couples about other management options.
• ? Only 41% gave their personalized outcomes from vaso‐vasostomy, whilst >80% were using some form of magnification intra‐operatively.
• ? Members of the BAUS section of andrology were more likely to discuss options for becoming a parent and criteria for IVF treatment, to present their individualized outcomes from vaso‐vasotomy and to carry out >15 procedures a year than urologists with no andrological affiliation.

CONCLUSIONS

• ? Patient management after previous vasectomy is a complex process necessitating detailed knowledge concerning the availability and outcomes of alternatives to vaso‐vasostomy.
• ? Couples should not be seen by urologists with diverse interests but by those with appropriate knowledge of all of the factors influencing outcome.
• ? Vaso‐vasostomy should no longer be seen as a procedure within the remit of any adequately trained urologist but as one option to be considered by a sub‐specialist with access to appropriate micro‐surgical training and assisted reproductive technologies.

     

Positive predictive value of prostate biopsy indicated by prostate‐specific‐antigen‐based prostate cancer screening: trends over time in a European randomized trial*

Study Type – Diagnosis (validating cohort) Level of Evidence 1b What's known on the subject? and What does the study add? The European Randomized study of Screening for Prostate Cancer (ERSPC) showed a reduction in prostate cancer mortality of 21% for PSA‐based screening at a median follow‐up of 11 years. In the ERSPC, men are screened at 4‐year intervals. A prostate biopsy is recommended for men with a PSA level ≥3.0 ng/mL. The study shows that the positive predictive value (PPV) of a prostate biopsy indicated by PSA‐based screening remains equal throughout consecutive screening rounds in men without a previous biopsy. In men who have previously had a benign biopsy, the PPV drops considerably, but 20% of the cancers detected still show aggressive characteristics.

OBJECTIVE

• ? To assess the positive predictive value (PPV) of prostate biopsy, indicated by a prostate‐specific antigen (PSA) threshold of ≥3.0 ng/mL, over time, in the Rotterdam section of the European Randomized study of Screening for Prostate Cancer (ERSPC).

PATIENTS AND METHODS

• ? In the Rotterdam section of the ERSPC, a total of 42 376 participants, aged 55–74 years, identified from population registries were randomly assigned to a screening or control arm.
• ? For the ERSPC men undergo PSA screening at 4‐year intervals. A total of three screening rounds were evaluated; therefore, only men aged 55–69 years at the first screening were eligible for the present study.

RESULTS

• ? PPVs for men without previous biopsy remained equal throughout the three subsequent screenings (25.5, 22.3 and 24.8% respectively).
• ? Conversely, PPVs for men with a previous negative biopsy dropped significantly (12.0 and 15.2% at the second and third screening, respectively).
• ? Additionally, in men with and without previous biopsy, the percentage of aggressive prostate cancers (clinical stage >T2b, Gleason score ≥7) decreased after the first round of screening from 44.4 to 23.8% in the second (P < 0.001) and 18.6% in the third round (P < 0.001).
• ? Repeat biopsies accounted for 24.6% of all biopsies, but yielded only 8.6% of all aggressive cancers.

CONCLUSIONS

• ? In consecutive screening rounds the PPV of PSA‐based screening remains equal in previously unbiopsied men.
• ? In men with a previous negative biopsy the PPV drops considerably, but 20% of cancers detected still show aggressive characteristics.
• ? Individualized screening algorithms should incorporate previous biopsy status in the decision to perform a repeat biopsy with the aim of further reducing unnecessary biopsies.

     

Train hard and well but train intelligently: a comment on 'Operative experience of urological trainees in the UK'

Study Type – Prognosis (cohort) Level of Evidence 2a What's known on the subject? and What does the study add? Married individuals have lower morbidity and mortality rates for all major causes of death. Cancer‐specific survival is better in married patients with testis cancer, prostate cancer, breast cancer, cervical cancer, as well as head and neck cancers. We have found the effect of marital status on outcomes after radical cystectomy to be variable, depending on gender and the outcome addressed. Being married is predictive of lower all‐cause mortality for both men and women relative to their separated, divorced or widowed (SDW) or never‐married counterparts. It is also predictive of lower bladder‐cancer‐specific mortality relative to SDW individuals. Marriage also exerts a protective effect on men regarding non‐organ‐confined disease, with those never having married having significantly higher rates.

OBJECTIVES

• ? To examine the effect of marital status (MS) on the rate of non‐organ‐confined disease (NOCD) at radical cystectomy (RC)
• ? To assess the effect of MS on the rate of bladder‐cancer‐specific mortality (BCSM) and all‐cause mortality (ACM) after RC for urothelial carcinoma of the urinary bladder (UCUB).

MATERIALS AND METHODS

• ? A total of 14 859 patients, who underwent RC for UCUB, were captured within the Surveillance, Epidemiology, and End Results database, between 1988 and 2006.
• ? Logistic regression analysis was used to assess the rate of NOCD (T_3‐4/N_I‐3/M₀) at RC and Cox regression analyses were used to assess BCSM and ACM.
• ? Analyses were stratified according to gender; covariates included socio‐economic status, tumour stage, age, race, tumour grade and year of surgery.

RESULTS

• ? Never‐married males had a higher rate of NOCD at RC (odds ratio = 1.22, P= 0.004), an effect not found in never‐married females.
• ? Separated, divorced or widowed (SDW) males (hazard ratio [HR]= 1.18, P= 0.005) and females (HR = 1.16, P= 0.002) had higher rates of BCSM than their married counterparts.
• ? SDW and never‐married males had higher rates of ACM than their married counterparts (HR = 1.22, P < 0.001 and HR = 1.26, P < 0.001, respectively).
• ? SDW and never‐married females also had higher rates of ACM than married females (HR = 1.24, P < 0.001 and HR = 1.22, P= 0.01, respectively).

CONCLUSIONS

• ? For both men and women, being SDW conveyed an increased risk of BCSM after RC.
• ? SDW and never marrying had a deleterious effect on ACM.
• ? Unfavourable stage at RC was also seen more commonly in never‐married males.

     

Prognostic indicators for upper tract urothelial carcinoma after radical nephroureterectomy: the impact of lymphovascular invasion

Study Type – Prognosis (case series) Level of Evidence 4 What's known on the subject? and What does the study add? In an array of urological and non‐urological malignancies, lymphovascular invasion (LVI) is a pathological feature known to be associated with adverse outcomes for recurrence and survival. For some cancers, LVI has therefore been incorporated into American Joint Committee on Cancer TNM staging algorithms. This study presents an analysis of the impact of LVI in upper urinary tract urothelial carcinoma (UTUC) treated at our institution over a 20‐year period. In addition to known associations with features of aggressive disease and overall survival, we were able to show that LVI‐positive status upsets the TNM staging for UTUC. Namely, patients with superficial stage and LVI‐positive disease have overall survival outcomes similar to those of patients with muscle‐invasive LVI‐negative carcinoma. Such evidence may support the addition of LVI to future TNM staging algorithms for UTUC.

OBJECTIVE

• ? To assess the impact of lymphovascular invasion (LVI) on the prognosis of patients with upper urinary tract urothelial cell carcinoma (UTUC) treated with radical nephroureterectomy (RNU).

PATIENTS AND METHODS

• ? The Columbia University Medical Center Urologic Oncology database was queried and 211 patients undergoing RNU for UTUC between 1990 and 2010 were identified.
• ? These cases were retrospectively reviewed, and the prognostic significance of relevant clinical and pathological variables was analysed using log‐rank tests and Cox proportional hazards regression models.
• ? Actuarial survival curves were calculated using the Kaplan–Meier method.

RESULTS

• ? LVI was observed in 68 patients (32.2%).
• ? The proportion of LVI increased with advancing stage, high grade, positive margin status, concomitant carcinoma in situ, and lymph node metastases. The 5‐ and 10‐year overall survival rates were 74.7% and 53.1% in the absence of LVI, and 35.7% and 28.6% in the presence of LVI, respectively.
• ? In multivariate analysis, age, race and LVI were independent predictors of overall survival.

CONCLUSIONS

• ? The presence of LVI on pathological review of RNU specimens was associated with worse overall survival in patients with UTUC.
• ? LVI status should be included in the pathological report for RNU specimens to help guide postoperative therapeutic options.
• ? With confirmation from large international studies, inclusion of LVI in the tumour‐node‐metastasis staging system for UTUC should be considered.

     

The efficacy and safety of cold‐induced lipolysis in the treatment of pseudogynecomastia

Background

The treatment options for pseudogynecomastia have been limited. Cold‐induced lipolysis provides a noninvasive, localized subcutaneous adipocyte destruction by inducing adipocyte apoptosis.

Objective

This study has been designed to evaluate the efficacy of cold‐induced lipolysis as a treatment modality for pseudogynecomastia.

Methods

In this 28‐week prospective trial, a total of 12 male pseudogynecomastia patients (Korean) were treated twice with cold‐induced lipolysis. Efficacy was determined by chest circumference, ultrasonographic measurement of fat thickness, Simon's Gynecomastia class (SGC), photographic assessment, and the patient's satisfaction (baseline, weeks 4, 8, 16, and 28). Using a questionnaire, safety was evaluated at each visit.

Results

For 10 subjects that completed the trial, chest circumference and fat thickness significantly improved by week 8. This same improvement was gradually noticed through week 28. The patients SGC scores continuously decreased after two sessions. Photographic assessment showed an improvement until week 28. The result of the patient's satisfaction score was also meaningful. While there were no adverse events observed, transient pain and bruising at the treatment site were noticed.

Limitations

We recruited a limited number of participants. Also, we could not exclude there might be other individual factors in association with the patients pseudogynecomastia.

Conclusion

Cold‐induced lipolysis is a safe, effective therapeutic option in the treatment of pseudogynecomastia. Lasers Surg. Med. 48:584–589, 2016. © 2016 The Authors. Lasers in Surgery and Medicine Published by Wiley Periodicals Inc.

     

Predictors of early mortality after radical nephrectomy with renal vein or inferior vena cava thrombectomy – a population‐based study

Study Type – Prognosis (cohort) Level of Evidence 2a What's known on the subject? and What does the study add? Surgical volume has been well established as a predictor of outcomes for several complex surgical procedures, yet few studies have evaluated this relationship with regards to radical nephrectomy with either renal vein or inferior vena cava thrombectomy. In addition, most published literature consists of single‐institution series from centres of excellence. We performed a population‐level analysis and identified surgeon volume as a significant predictor of short‐term mortality for this procedure. Such findings have potential implications regarding future policy and regionalization of care.

OBJECTIVE

• ? To study the short‐term mortality associated with radical nephrectomy with renal vein or inferior vena cava thrombectomy and the variables associated with this adverse outcome.

METHODS

• ? Using the Ontario Cancer Registry, we identified 433 patients in the province of Ontario, Canada undergoing radical nephrectomy with venous thrombectomy between 1995 and 2004.
• ? We determined mortality rates at postoperative days 30 and 90.
• ? Other variables analysed include pathological tumour characteristics, surgeon graduation year, hospital/surgeon academic status, surgery year and hospital/surgeon volume.
• ? We used multivariable logistic regression to assess outcomes.

RESULTS

• ? Overall mortality was 2.8% (30‐day) and 5.8% (90‐day).
• ? Surgeons performing a single nephrectomy with venous thrombectomy performed 14% of the cases and had the highest 30‐day (6.7%) and 90‐day (10%) mortality. The mortality rate for surgeons performing more than one surgery was 2.1% (30‐day) and 5.1% (90‐day).
• ? In recent years, this procedure was performed more commonly by the highest volume surgeons – 67% of cases in 2004 vs 40% in 1995.
• ? Significant predictors of 30‐day mortality included procedure year and low surgeon volume.
• ? Significant predictors of 90‐day mortality included procedure year, low surgeon volume, left‐sided tumour and increasing hospital volume.

CONCLUSIONS

• ? For radical nephrectomy with venous thrombectomy, surgeon volume predicts short‐term mortality, emphasizing the importance of experience in patient outcome.
• ? Despite a shift towards high‐volume surgeons, 13.8% of cases continued to be performed by low‐volume providers.
• ? If these results are confirmed in other jurisdictions, radical nephrectomy with venous thrombectomy should be regionalized and performed by surgeons who manage these cases regularly.

     

Ureteroscopic endoureterotomy

OBJECTIVE

To highlight the current status of ureteroscopic endoureterotomy (UE) by reporting extensive experience with the endoscopic management of ureteric strictures, with special emphasis on factors determining success, and by reviewing publications on the minimally invasive management of ureteric strictures.

PATIENTS AND METHODS

The study comprised 50 patients (mean age 53 years, range 18–85, equal sex distribution) with ureteric strictures of varying causes; all had their stricture treated endoscopically. The follow‐up was 0.5–9 years; 10 patients with recurrent strictures had two ipsilateral stents placed to try to improve the outcome, and eight patients with completely obliterating strictures were treated by ureteroscopic re‐canalization.

RESULTS

The site of stricture had no bearing on the eventual outcome. Patients with uretero‐enteric and malignant strictures did not fare so well. The most important predictor of failure was the length of the stricture, with failure in all seven patients with strictures of > 2 cm. In the 10 patients treated with two ipsilateral stents, eight were successful, which was very promising considering that these patients had recalcitrant strictures and placing one stent had previously failed. The overall success rate was 74%.

CONCLUSION

UE has become the procedure of choice for the initial management of ureteric strictures. Simple balloon dilatation is also effective in certain situations. The characteristics of the stricture often govern the eventual outcome. In properly selected cases success rates of ≈ 75% can be expected.

     

Prospective study of robotic partial nephrectomy for renal cancer in Japan: Comparison with a historical control undergoing laparoscopic partial nephrectomy

Objectives

To evaluate the outcomes of robotic partial nephrectomy compared with those of laparoscopic partial nephrectomy for T1 renal tumors in Japanese centers.

Methods

Patients with a T1 renal tumor who underwent robotic partial nephrectomy were eligible for inclusion in the present study. The primary end‐point consisted of three components: a negative surgical margin, no conversion to open or laparoscopic surgery and a warm ischemia time ≤25 min. We compared data from these patients with the data from a retrospective study of laparoscopic partial nephrectomy carried out in Japan.

Results

A total of 108 patients were registered in the present study; 105 underwent robotic partial nephrectomy. The proportion of patients who met the primary end‐point was 91.3% (95% confidence interval 84.1–95.9%), which was significantly higher than 23.3% in the historical data. Major complications were seen in 19 patients (18.1%). The mean change in the estimated glomerular filtration rate in the operated kidney, 180 days postoperatively, was ?10.8 mL/min/1.73 m² (95% confidence interval ?12.3–9.4%).

Conclusions

Robotic partial nephrectomy for patients with a T1 renal tumor is a safe, feasible and more effective operative method compared with laparoscopic partial nephrectomy. It can be anticipated that robotic partial nephrectomy will become more widely used in Japan in the future.

     

Long-term results of sacral neuromodulation for women with urinary retention

OBJECTIVE

To review the long‐term results of sacral nerve stimulation in the treatment of women with Fowler's syndrome, over a 6‐year period at one tertiary referral centre.

PATIENTS AND METHODS

Between 1996 and 2002, 26 women with urinary retention were treated by implanting a sacral nerve stimulator. Their case records were reviewed for follow‐up, complications and revision procedures, and the most recent uroflowmetry results.

RESULTS

There were 20 patients (77%) still voiding spontaneously at the time of review (with two having deactivated their stimulator because of pregnancy). Fourteen patients (54%) required revision surgery, and the most common complications included loss of efficacy, implant‐related discomfort and leg pain. The mean postvoid residual volume was 75 mL and mean maximum flow rate 20.8 mL/s.

CONCLUSION

In young women with retention, for whom there is still no alternative to lifelong self‐catheterization, sacral neuromodulation is effective for up to 5 years after implantation. However, there was a significant complication rate, in line with other reports, which may be improved by new technical developments.

     

A five‐CpG DNA methylation score to predict metastatic‐lethal outcomes in men treated with radical prostatectomy for localized prostate cancer

Background

Prognostic biomarkers for localized prostate cancer (PCa) could improve personalized medicine. Our group previously identified a panel of differentially methylated CpGs in primary tumor tissue that predict disease aggressiveness, and here we further validate these biomarkers.

Methods

Pyrosequencing was used to assess CpG methylation of eight biomarkers previously identified using the HumanMethylation450 array; CpGs with strongly correlated (r >0.70) results were considered technically validated. Logistic regression incorporating the validated CpGs and Gleason sum was used to define and lock a final model to stratify men with metastatic‐lethal versus non‐recurrent PCa in a training dataset. Coefficients from the final model were then used to construct a DNA methylation score, which was evaluated by logistic regression and Receiver Operating Characteristic (ROC) curve analyses in an independent testing dataset.

Results

Five CpGs were technically validated and all were retained (P < 0.05) in the final model. The 5‐CpG and Gleason sum coefficients were used to calculate a methylation score, which was higher in men with metastatic‐lethal progression (P = 6.8 × 10^?6) in the testing dataset. For each unit increase in the score there was a four‐fold increase in risk of metastatic‐lethal events (odds ratio, OR = 4.0, 95%CI = 1.8–14.3). At 95% specificity, sensitivity was 74% for the score compared to 53% for Gleason sum alone. The score demonstrated better prediction performance (AUC = 0.91; pAUC = 0.037) compared to Gleason sum alone (AUC = 0.87; pAUC = 0.025).

Conclusions

The DNA methylation score improved upon Gleason sum for predicting metastatic‐lethal progression and holds promise for risk stratification of men with aggressive tumors. This prognostic score warrants further evaluation as a tool for improving patient outcomes.

     

Perineal anastomotic urethroplasty for managing post-traumatic urethral strictures in children: the long-term outcome

OBJECTIVE

To evaluate the long‐term results of one‐stage perineal anastomotic urethroplasty for post‐traumatic paediatric urethral strictures.

PATIENTS AND METHODS

Thirty‐five boys who had a perineal anastomotic urethroplasty for post‐traumatic bulbous or posterior urethral strictures between 1991 and 2003 were analysed retrospectively. Patients were followed up for a mean (range) of 46 (6–132) months by a history, urinary flow rate estimate, retrograde urethrography and voiding cysto‐urethrography.

RESULTS

The mean (range) age of the patients was 11.9 (6–18) years. The estimated radiographic stricture length before surgery was 2.6 (1–5) cm. The perineal anastomotic repair was successful in 31 of 35 (89%) patients. All treatment failures were at the anastomosis and were within the first year. Failed repairs were successfully managed endoscopically in two patients and by repeat perineal anastomotic repair in the remaining two, giving a final success rate of 100%. All boys are continent except two who had early stress incontinence, and that resolved with time. There was no chordee, penile shortening or urethral diverticula during the follow‐up.

CONCLUSIONS

The overall success of a one‐stage perineal anastomotic repair of post‐traumatic urethral strictures in boys is excellent, with minimal morbidity. Substitution urethroplasty or abdomino‐perineal repair should be reserved for the occasional patients with concomitant anterior urethral stricture disease or a complex posterior urethral stricture, respectively.