Does diabetes mellitus increase the risk of high-grade prostate cancer in patients undergoing radical prostatectomy?

The objective was to test the hypothesis that in patients with prostate cancer undergoing radical prostatectomy (RP), diabetic patients are at a higher risk of harboring a high-grade tumor than non-diabetic patients. We examined 2060 consecutive men who underwent RP between 2001 and 2009. Of them, 7.1% had type 2 diabetes mellitus (DM). A high-grade tumor was defined as having a Gleason score ≥ 8. Univariable and multivariable logistic regression analyses were used to test the relationship between type 2 DM and high-grade tumor. Mean patient age was 64 years (range: 45-85). Mean total PSA level was 9 ng ml(-1) (range: 1-89.5). A significantly higher percentage of diabetic patients had high-grade tumor on biopsy (16.3 vs 7.6%; P = 0.001) and on RP specimen (21.1 vs 11.7%; P = 0.001) in comparison with non-diabetic patients. In multivariable analyses, DM was an independent predictor of high-grade tumor on biopsy (odds ratio = 2.31, P = 0.001) and on final pathological specimen (odds ratio = 2.22, P = 0.002). In patients undergoing RP, those with type 2 DM had a higher risk of harboring a poorly differentiated tumor on final pathological examination.     

Is seminal vesicle ablation mandatory for all patients undergoing radical prostatectomy? A multivariate analysis on 1283 patients

OBJECTIVE: With a shift in prostate cancer stage and a majority of patients operated nowadays with PSA levels <10 ng/ml, rates of seminal vesicle (SV) invasion found on radical prostatectomy specimens have decreased as compared to historical data. Since SV-sparing surgery may possibly have an influence on post-operative erectile dysfunction and urinary recovery, we tried to determine which patients could be safely spared SV excision during radical prostatectomy. MATERIAL AND METHODS: We used preoperative data from 1283 patients operated by radical retropubic prostatectomy--777 with serum PSA <10.0 ng/ml--to predict SV invasion on final pathological examination. Variables analyzed included age, digital rectal examination, serum PSA, biopsy Gleason score and percentage of biopsy cores invaded by prostate cancer. Statistical analysis included univariate, multivariate logistic regression analysis and receiver operating characteristic (ROC) curves. RESULTS: Out of 1283 patients, 137 (10.6%) had SV involvement, 41/777 (5.2%) with PSA <10.0 ng/ml, 16.1% in the 10-20 ng/ml range and 26.2% when PSA was >20 ng/ml. Percentage of biopsies affected by prostate cancer and biopsy Gleason score were significant predictors of SV invasion in multivariate analysis, both in the entire population and in the subset of patients with PSA <10.0 ng/ml (p < 0.0001). Probability graphs created for patients with PSA <10 ng/ml indicate a risk of seminal invasion <5% when Gleason score on biopsy is <7 or when the percentage of biopsies affected by cancer is <50%. CONCLUSIONS: Resection of SV might not be "oncologically" necessary in all patients undergoing RP when PSA levels are below 10 ng/ml except when biopsy Gleason score is > or =7 or when more than 50% of prostate biopsy cores show cancer involvement. SV-sparing surgery could be prospectively compared to standard retropubic prostatectomy in selected individuals analyzing potential benefits on erectile function and urinary continence.     

IV paracetamol effect on propofol–ketamine consumption in paediatric patients undergoing ESWL

Purpose

Electroshock wave lithotripsy (ESWL) is a painful procedure performed with sedoanalgesia in paediatric patients. The propofol?Cketamine combination may be the preferable anaesthesia for this procedure, and propofol?Cketamine consumption may be decreased with the administration of intravenous (IV) paracetamol. In this study we investigated the effect of IV paracetamol administration on propofol?Cketamine consumption, recovery time and frequency of adverse events in paediatric patients undergoing ESWL.

Methods

Sixty children, ranging in age from 1 to 10?years and with American Society of Anesthesiologists Physical Status 1?C2, were included in this prospective, randomized, double-blinded study. Thirty minutes prior to the procedure children randomly assigned to Group I received IV 15?mg/kg paracetamol, and those randomly assigned to Group II received 1.5?mL/kg IV saline infusion 30?min. The propofol?Cketamine combination was prepared by mixing 25?mg propofol and 25?mg ketamine in a total 10?mL solution in the same syringe. After the administration of 0.1?mg/kg midazolam and 10???g/kg atropine to both groups and during the procedure, the propofol?Cketamine combination was administered at 0.5?mg/kg doses to achieve a Wisconsin sedation score of 1 or 2. Oxygen saturation and heart rate were recorded at 5-min intervals. Propofol?Cketamine consumption, recovery times and adverse events were also recorded.

Results

Demographic data were similar between groups. Propofol?Cketamine consumption (Group I, 25.2?±?17.7?mg; Group II, 35.4?±?20.1?mg; p?=?0.04) and recovery times (Group I, 19.4?±?7.9?min; Group II, 29.6?±?11.4?min; p?Conclusion Our data suggest that the administration of IV paracetamol decreases propofol?Cketamine consumption for adequate sedation during ESWL procedures in paediatric patients and shortens recovery time.     

Does increasing the nodal yield improve outcomes in contemporary patients without nodal metastasis undergoing radical prostatectomy?

ObjectivesTo determine if the number of lymph nodes (LNs) removed is an independent predictor of biochemical recurrence (BCR) in patients without LN metastases undergoing radical prostatectomy (RP).Material and methodsRetrospective analysis of 7,310 patients treated at 7 centers with RP and pelvic LN dissection for clinically localized prostate cancer between 2000 and 2011. Patients with LN metastases (n = 398) and other reasons (stated later in the article) (n = 372) were excluded, which left 6,540 patients for the final analyses.ResultsOverall, median biopsy and RP Gleason score were both 7; median prostate specific antigen level was 6 ng/ml (interquartile range [IQR]: 5); and median number of LNs removed was 6 (IQR: 8). A total of 3,698 (57%), 2,064 (32%), and 508 (8%) patients had ≥6, ≥10, and ≥20 LNs removed, respectively. Patients with more LNs removed were older, had a higher prostate specific antigen level, had higher clinical and pathologic T stage, and had higher RP Gleason score (all P<0.002). Within a median follow-up of 21 (IQR: 16) months, more LNs removed was associated with an increased risk of BCR (continuous: P = 0.021; categorical: P = 0.014). In multivariable analyses that adjusted for the effects of standard clinicopathologic factors, none of the nodal stratifications predicted BCR.ConclusionsThe number of LNs did not have any prognostic significance in our contemporary cohort of patients with LN-negative prostate cancer. This suggests that the risk of missed clinically significant micrometastasis may be minimal in patients currently treated with RP and having a lower LN yield.     

Do blood groups have effect on prognosis of patients undergoing radical cystectomy?

Purpose

The purpose of the study was to investigate the effect of ABO blood groups and Rhesus (Rh) factor on prognosis of patients undergoing radical cystectomy.

Materials and methods

In this study, total number of 290 patients who underwent radical cystectomy between January 1990 and September 2012 were evaluated retrospectively. Patients were grouped as O and non-O according to ABO antigens; also positive and negative according to Rh factor. Parameters such as age, sex, stage, lymph node involvement and positive surgical margins were investigated. Disease-free and overall survival rates have been compared. Multivariate analysis were performed to determine independent prognostic factors.

Results

A total of 260 (89.7 %) male and 30 (10.3 %) female patients participated in the study. Mean follow-up was 37.7 ± 18.9 months. A total of 180 patients were non-O (62.1 %),while the 110 patients had the blood group O (37.9 %). The number of Rh positive and negative patients were 247 (85.2 %) and 43 (14.8 %), respectively. According to the univariate and multivariate analyses, ABO blood groups and Rh factor did not exhibit any significant impact on overall and disease-specific survival.

Conclusion

ABO blood group and Rh factor were not associated with the prognosis of bladder cancer patients who underwent radical cystectomy. However, prospective studies are needed in larger patient series for further evaluations.     

The effect of intra- and postoperative allogenic blood transfusion on patients’ survival undergoing radical cystectomy for urothelial carcinoma of the bladder

Purpose

Radical cystectomy (RC) can be associated with significant blood loss. Allogenic blood transfusion (ABT) may alter disease outcome because of a theoretical immunomodulatory effect. We evaluated the effects of ABT on overall survival (OS) and progression-free survival (PFS) of patients undergoing RC for urothelial carcinoma of the bladder (UCB).

Materials and methods

This is a retrospective single-center study of 350 consecutive patients of a university health center with a median follow-up of 70.1 month. All patients underwent RC and pelvic lymph node dissection. The effect of ABT on OS and PFS was analyzed using univariable and multivariable Cox proportional hazards models.

Results

The overall ABT rate was 63 % (n = 219), with intraoperative blood transfusion and postoperative blood transfusion being performed in 183 patients (52 %) and 99 patients (28 %), respectively. Preoperative anemia was detected in 156 patients (45 %) with median estimated blood loss of 800 ml (IQR: 500–1,200). ABT was associated with significant decrease of OS and PFS in multivariable analyses (p < 0.001), whereas patients’ prognosis worsened the more packed red blood cells (PRBC) were transfused (p < 0.001). The study is limited in part due to its retrospective design.

Conclusions

We found that ABT and the number of PRBC transfused are associated with poor prognosis for UCB patients undergoing RC, whereas preoperative anemia had no influence on survival. This emphasizes the importance of surgeon’s awareness for a strict indication for ABT. A prospective study will be necessary to evaluate the independent risks associated with ABT during surgical treatments.     

Benefits of antibiotic-impregnated inflatable penile prosthesis (InhibiZone®) in patients at high risk of infection in Taiwan

ObjectiveTo evaluate the benefits of antibiotic-impregnated inflatable penile prosthesis (IPP; InhibiZone^®) in patients at high risk of infection in Taiwan.Materials and methodsFrom 2004 to 2008, 39 patients diagnosed with uncorrectable erectile dysfunction received an IPP implantation at our hospitals. Based on the underlying diseases, the patients were divided into groups. The results of the two study groups were compared with a control group, which received a conventional IPP implantation. The control group was also divided into two groups based on underlying diseases, similar to that of the study groups. Single-tailed Student t test was performed to determine the difference between each group and to compare the data of our patients with our previously published results.ResultsSurgical outcome analysis showed that the postoperative infection rate is lower in the InhibiZone group (2.6% overall, 5.6% in the high-risk group, and 8.3% in revision surgeries) compared with the conventional (control) IPP group (9.6% overall, 25% in the high-risk group, and 33.3% in revision surgeries). The postoperative infection rate is obviously higher in the high-risk group, irrespective of whether the patient received InhibiZone prostheses or the conventional ones. Furthermore, for patients prone to a high risk of prosthesis infection, InhibiZone penile prosthesis was used instead of the conventional prosthesis, and this was found to reduce the infection rate (from 25% to 5.6%); furthermore, the overall infection rate (from 9.6% to 2.6%) was found to be reduced in the group that received InhibiZone prostheses and in patients with common etiologies (from 5% to 0%), both of which were prominent and statistically significant.ConclusionAn antibiotic-impregnated IPP (InhibiZone^®) definitely increases the success rate of reimplantation surgery, and can be indicated for patients at a high risk of postoperative infection.     

How does preoperative opioid use impact postoperative health-related quality of life scores for patients undergoing lumbar microdiscectomy?

Background ContextNarcotic use amongst patients suffering from lumbar radiculopathy is common, but the clinical benefit of narcotics for lumbar radiculopathy is likely minimal. It is unknown what the impact of preoperative use of narcotics has on outcomes related to lumbar microdiscectomy.PurposeDetermine the impact that preoperative opioid use has on postoperative outcomes after lumbar microdisectomy.Study DesignRetrospective analysis of a prospectively collected database.Patient SampleOne hundred and twenty-six patients undergoing a microdiscectomy for a lumbar disc herniation.Outcome MeasuresPatient-reported outcomes measurement information system mental health scores (PROMIS MHS), patient-reported outcomes measurement information system physical health scores (PROMIS PHS) and oswestry disability index (ODI).MethodsWe analyzed a prospectively collected database of patients undergoing a lumbar microdiscectomy for preoperative opioid use. We measured the severity of lumbar pathology on MRI based on degree of facet/disc degeneration and cross-sectional area of the dural tube at the disc herniation. We tracked PROMIS MHS, PROMIS PHS and ODI for patients both preoperatively and postoperatively. A Mann-Whitney test was used to compare HRQOL scores and time to MCID for the opioid using cohort (OC) and the nonopioid using cohort (non-OC). We performed a linear regression analysis to determine correlation between preoperative opioid use and postoperative HRQOLs.ResultsThere were 44 of 126 microdiscectomy patients in the OC (32.5%). There was no difference in the dural cross-sectional area (p=.91), degree of facet degeneration (p=.38), or disc degeneration (p=.5) between OC and non-OC. There were no differences in PROMIS PHS, PROMIS MHS or ODI between the OC and non-OC at the preoperative visit and all postoperative time points. There were no differences in time to reach MCID between the OC and non-OC for ODI (p=.9), PROMIS PHS (p=.64) or PROMIS MHS (p=.90). At three months out from surgery there was a statistically significant correlation between pre-op opioid use and ODI (p=.02), PROMIS MHS (p=.02) and PROMIS PHS (p=.049).ConclusionsOur results demonstrate that patients that use opioids prior to lumbar microdiscectomy have equivalent postoperative outcomes as those that do not use opioids. Use of higher doses of opioids is associated with worse short-term outcomes.     

Do androgen-directed therapies improve outcomes in prostate cancer patients undergoing radical prostatectomy? A systematic review and meta-analysis

IntroductionApproximately 50% of patients with non-metastatic prostate cancer are treated with radical prostatectomy (RP). While some men will be cured with surgery alone, a substantial proportion will experience cancer recurrence. Androgen-directed therapy (ADT) is an effective adjuvant therapy for patients treated with prostate radiation. Comparatively, the efficacy of ADT in surgical patients has not been well-studied.MethodsA systematic search of MEDLINE, Embase, and the Cochrane Library from inception to July 2020 was performed. Randomized trials comparing ADT with RP vs. prostatectomy alone in patients with clinically localized prostate cancer were included. Neoadjuvant ADT and adjuvant ADT interventions were assessed separately. The primary outcomes were cancer recurrence-free survival (RFS) and overall survival (OS). Pathological outcomes following neoadjuvant ADT were also evaluated.ResultsFifteen randomized trials met eligibility criteria; 11 evaluated neoadjuvant ADT (n=2322) and four evaluated adjuvant ADT (n=5205). Neoadjuvant ADT (three months of treatment) did not improve RFS (hazard ratio [HR] 0.90, 95% confidence interval [CI] 0.74–1.11) or OS (HR 1.22, 95% CI 0.62–2.41). Neoadjuvant ADT significantly decreased the risk of positive surgical margins (relative risk [RR] 0.48, 95% CI 0.41–0.56) and extraprostatic tumor extension (RR 0.75, 95% CI 0.64–0.89). Adjuvant ADT improved RFS (HR 0.65, 95% CI 0.45–0.93) but did not improve OS (HR 1.02, 95% CI 0.84–1.24).ConclusionsNeoadjuvant ADT causes a pathological downstaging of prostate tumors but has not been found to delay cancer recurrence nor extend survival. Few studies have evaluated adjuvant ADT. Trials are needed to determine the benefits and harms of intermediate- or long-term adjuvant ADT for RP patients.     

Is HCl duloxetine effective in the management of urinary stress incontinence after radical prostatectomy?

INTRODUCTION: Up to 70% of patients who undergo radical prostatectomy complain about urine leakage, but persistent stress incontinence 1 year after surgery affects <5% of them. HCl duloxetine is a dual serotonin and norepinephrine reuptake inhibitor that relieves the symptoms of stress urinary incontinence. The purpose of this study was to evaluate the efficacy of HCl duloxetine in the management of urinary incontinence after radical prostatectomy and its impact in urodynamic parameters such as maximal urethral closure pressure (MUCP), abdominal leak point pressure (ALPP) and retrograde leak point pressure (RLPP). MATERIAL AND METHODS: The study included 18 men with stress urinary incontinence 12 months after radical prostatectomy. All underwent a pad test to quantify the degree of urine loss and a urodynamic evaluation before and after a three month treatment with HCl duloxetine. The intrinsic sphincter was evaluated by ALPP and RLPP and the striated sphincter by MUCP. RESULTS: At the pretreatment evaluation the mean ALPP was 52.1 cm H(2)O, the mean MUCP was 52.5 cm H(2)O and the mean RLPP was 43.1 cm H(2)O. After 3 months of HCl duloxetine treatment the mean ALPP was 59.1 cm H(2)O, the mean MUCP was 67.3 cm H(2)O and the mean RLPP was 45.1 cm H(2)O. There was a statistically significant correlation among RLPP, MUCP and ALPP before treatment. After HCl duloxetine treatment there was significant correlation between RLPP and ALPP. CONCLUSION: The use of HCl duloxetine results in mild increase of MUCP and in significant reduction of urine loss. Its action on the extrinsic sphincter does not provide a complete treatment option for postprostatectomy incontinence.     

Impact of positive surgical margins on prostate-specific antigen failure after radical prostatectomy in adjuvant treatment-naïve patients

Study Type – Therapy (case series)
Level of Evidence 4 What’s known on the subject? and What does the study add? Despite excellent surgical cancer control, up to 40% of patients will have biochemical recurrence following radical prostatectomy (RP) for localized prostate cancer. Positive surgical margins (PSM) have been clearly demonstrated to be one of the main predictive factors for biochemical failure, disease progression and cancer mortality. However, decision of further management (adjuvant or salvage therapy) in patients with PSM remains controversial, and many debatable questions arise concerning the incidence of clinical progression and the impact of systematic adjuvant treatment on the cancer specific and overall survival. Analysis of the pathological and disease recurrence outcomes of our large cohort of patients treated by RP provides evidence that PSMs are associated with a poor prognosis in terms of PSA failure and need for salvage therapy. However, such a distinction between negative or positive margin cancers seems to appear clinically less relevant in locally advanced disease with seminal vesicle or high Gleason score ≥ 8 due to the predominant significance of these two poor prognosis factors for prediction of PSA failure.

OBJECTIVE

? To study the impact of positive surgical margins (PSMs) as an independent predictor of prostate‐specific antigen (PSA) failure after radical prostatectomy in adjuvant treatment‐naïve patients.

PATIENTS AND METHODS

? From 2000 to 2008, 1943 men who underwent a radical prostatectomy at Henri Mondor Hospital and who did not receive neoadjuvant or adjuvant therapy were included. Follow‐up was recorded into a prospective database. Mean follow‐up was 68.8 months. ? The biochemical recurrence‐free survival (RFS), defined by a PSA > 0.2 ng/mL, and the need for salvage therapy in univariate and multivariate models, were evaluated.

RESULTS

? PSA failure was reported in 14.7% and PSMs were noted in 25.6%. In the overall cohort, PSM was significantly predictive for PSA failure (P < 0.001; hazard ratio, HR, 2.6), need for salvage therapy (P < 0.001; HR, 2.9) and specific deaths (P= 0.006; HR, 3.7). The 5‐year RFS was 84.4% in men with negative margins compared to 57.5% in the case of PSM. ? After stratification by pathological stage and Gleason score, margin status was significantly predictive for PSA failure in pT2 (P < 0.001), pT3a (P= 0.001) and/or Gleason score ≤7 cancers (P < 0.001), whereas the impact of PSM did not reach significance in pT3b (P= 0.196), pT4 (P= 0.061) and/or Gleason score ≥8 cancers (P= 0.115).

CONCLUSIONS

? PSMs are associated with a poor prognosis in terms of RFS and the need for salvage therapy. ? Such a distinction between negative or positive margin cancers appears to be clinically less relevant in locally advanced disease with seminal vesicle or high Gleason score (≥8).     

Is microvascular decompression surgery a high risk for postoperative nausea and vomiting in patients undergoing craniotomy?

Purpose

Patients undergoing microvascular decompression surgery often experience postoperative nausea and vomiting (PONV). However, there is little information about the incidence of PONV after microvascular decompression. We hypothesized that microvascular decompression is an especially high-risk procedure for PONV in patients undergoing neurosurgery, and investigated risk factors related to PONV after neurosurgery.

Methods

All patients who underwent craniotomy in our institution during a period of 2 years were investigated retrospectively. Medical charts were reviewed to identify PONV during the 24-h postoperative period and related risk factors. Multivariate logistic regression analysis was conducted to elucidate the impact of microvascular decompression on PONV after craniotomy.

Results

Among 556 craniotomy cases, 350 patients met the inclusion criteria. Multivariate logistic regression analysis showed that microvascular decompression was an independent risk factor for PONV after craniotomy (odds ratio 5.38, 3.02–9.60), in addition to female gender, non-smoker status, amount of intraoperative fentanyl administered, and cerebrovascular surgery.

Conclusion

In this retrospective study, microvascular decompression surgery was an especially high-risk factor for PONV in patients undergoing craniotomy. It may be necessary to adopt a combination of prophylactic methods to reduce the incidence of PONV after microvascular decompression.     

Can single dose preoperative intrathecal morphine sulfate provide cost-effective postoperative analgesia and patient satisfaction during radical prostatectomy in the current era of cost containment?

We retrospectively analyzed the analgesic efficacy and surgical outcomes of a single preoperative intrathecal long-acting morphine sulfate injection (0.25-0.5 mg) and postoperative intravenous (i.v.) ketorolac in 62 patients who underwent radical retropubic prostatectomy (RRP). Total postoperative analgesic requirement was documented along with assessment of length of hospital stay, pain control and time for resumption of normal activity. Postoperatively, 45% of patients required only nonsteroidal agents (ketorolac), whereas 55% needed a mean of 13.3 mg of supplemental i.v. morphine sulfate. Mean hospital stay was 2.3+/-0.3 days. Eighty-two per cent of patients felt the length of hospital stay adequate. Ninety-seven per cent of patients were satisfied with anesthesia selected and 95% of patients considered pain control on postoperative days 1 and 2 as effective. All patients resumed to full physical activity by 5.3+/-0.4 weeks after surgery. We conclude that a single preoperative injection of intrathecal morphine sulfate combined with i.v. ketorolac postoperatively results in effective analgesia, diminished supplemental narcotic requirement and high patient satisfaction during radical retropubic prostatectomy.