Surgical checklist adherence across urology expertise levels impacts transurethral resection of bladder tumour quality indicators

Objectives

To address the association of perioperative surgical checklist across variable surgical expertise with transurethral resection of bladder tumour (TURBT) accuracy and oncological outcomes in non-muscle-invasive bladder cancer.

Patients and Methods

We relied on our prospective collaborative database of patients treated with TURBT between 2012 and 2017. Surgical experience was stratified into three groups: resident vs young vs expert consultants. The association of surgical experience with detrusor muscle (DM) presence and adherence to the standardised peri-procedural nine-items TURBT checklist was evaluated with logistic regression models. A Cox regression model was used to investigate the association of surgical experience with recurrence-free survival (RFS).

Results

A total of 503 patients were available for analysis. TURBT was performed by expert consultants in 265 (52.7%) patients, by young consultants in 149 (29.6%) and by residents in 89 (17.7%). Residents were more likely to have DM in the TURBT specimen than expert consultants (odds ratio [OR] 1.75, 95% confidence interval [CI] 1.03–2.99, P = 0.04). Conversely, no differences in DM presence were seen between young vs expert consultants (OR 1.09, 95% CI 0.71–1.70, P = 0.69). The median checklist completion rate was higher for both residents and young consultants when compared to experts' counterparts (56% and 56% vs 44%, P = 0.009). When focusing on patients receiving a second-look TURBT, the persistent disease was associated with resident status (OR 4.24, 95% CI 1.14–17.70, P = 0.037) at initial TURBT. Surgical experience was not associated with 5-years RFS.

Conclusion

Surgeon's experience in the case of adequate perioperative surgical checklist implementation was inversely associated with the presence of DM in the specimen but directly linked to higher probability of persistent disease at re-TURBT, although no 5-year RFS differences were noted.     

Oncological impact of cystoscopic findings in non-muscle-invasive bladder cancer: a meta-analysis

Objective

To assess the association between cystoscopic findings and oncological outcomes in patients with non-muscle-invasive bladder cancer (NMIBC) given that the oncological impact of quantity and quality assessment of tumours with cystoscopy has not been well verified.

Methods

Multiple databases were queried in May 2022 for studies investigating the association of oncological outcomes, such as recurrence-free (RFS), progression-free (PFS), and cancer-specific survival (CSS), with cystoscopic findings, including multiplicity, size, and gross appearance of tumours in patients with NMIBC.

Results

Overall, 73 studies comprising 28 139 patients were eligible for the meta-analysis. Tumour multiplicity was associated with worse RFS (pooled hazard ratio [HR] 1.61, 95% confidence interval [CI] 1.48–1.74) and PFS (pooled HR 1.44, 95% CI 1.18–1.76) in NMIBC patients (including both Ta and T1). Tumour size (≥3 cm) was associated with worse RFS (pooled HR 1.97, 95% CI 1.69–2.30) and PFS (pooled HR 1.81, 95% CI 1.52–2.15) in NMIBC patients. In patients with T1 bladder cancer (BCa), tumour multiplicity and size (≥3 cm) were also associated with worse RFS, PFS and CSS. By contrast, among patients treated with bacillus Calmette-Guérin (BCG), tumour multiplicity was not associated with worse RFS, and tumour size (≥3 cm) was not associated with worse PFS. Sessile tumours were associated with worse RFS (pooled HR 2.14, 95% CI 1.52–3.01) and PFS (pooled HR 2.17, 95% CI 1.42–3.32) compared to pedunculated tumours. Compared to papillary tumours, solid tumours were associated with worse RFS (pooled HR 1.84, 95% CI 1.25–2.72) and PFS (pooled HR 3.06, 95% CI 2.31–4.07) in NMIBC patients, and CSS in T1 BCa patients (pooled HR 2.32, 95% CI 1.63–3.30).

Conclusions

Cystoscopic findings, including tumour multiplicity, size, and gross appearance, strongly predict oncological outcomes in NMIBC patients. Cystoscopic visual features can help in the decision-making process regarding the timeliness and extent of tumour resection as well as future management such as intravesical therapy.     

经尿道前列腺电切术1370例手术体会

目的总结1370例经尿道前列腺电切术经验,提高手术疗效。方法回顾性分析1998年7月至2012年3月期间我院收治1370例BPH患者行TURP术的临床资料。年龄58～99岁,平均（67．4±5．5）岁。前列腺体积21～85ml,平均（53±4．4）ml。详细记录手术时间、术中出血量、术后留置尿管时间及手术并发症,统计并分析手术前后国际前列腺症状评分（IPSS）、生活质量评分（QOL）及残余尿量（Ruv）等指标。结果1370例患者中,成功施行TURP术1367例,中转开放手术3例。手术时间25～93min,平均（52．0±6．4）min。术中出血量30～800ml,平均（120．0±8．8）ml,输血12例。术后留置尿管2～9d,平均（4．5±1．1）d。术后随访3个月,IPSS、QOL及RUV与术前比较有统计学差异。术中水中毒1例,术后迟发性出血18例,暂时性尿失禁11例,尿道狭窄26例。结论TURP术具有创伤小、疗效好,安全有效,并发症少等的优点,充分的围手术期准备是手术顺利实施和减少并发症的重要保证,值得临床推广。     

Differences in stress response between patients undergoing transurethral resection versus endoscopic laser ablation of the prostate for benign prostatic hyperplasia

The objective of the study was to determine the differences in systemic stress response in patients undergoing transurethral resection of the prostate (TURP) versus endoscopic laser ablation of the prostate (ELAP) for benign prostatic hyperplasia (BPH). The study included 48 patients with BPH (24 treated by TURP and 24 by ELAP). Blood samples were taken from each patient before and immediately after the procedure and on postoperative days 1, 6, and 20, respectively. TURP caused more intense acute-phase response during 24 h after the procedure considering the serum c-reactive protein (CRP) level (p < 0,001) and absolute leukocyte (p = 0.001) and neutrophil number (p = 0.003) in peripheral blood. ELAP caused more decrease in the number of natural killer cells immediately after the procedure (p = 0.048). There were no statistically significant differences between TURP and ELAP procedures in protein and creatine kinase (CK) levels, adrenocorticotropic hormone, and cortisol as well as other immunological parameters. TURP causes more intense acute-phase response than ELAP.     

经尿道前列腺电切术后急性肾上腺皮质功能低下12例临床分析

目的 提高经尿道前列腺电切术后急性肾上腺皮质功能低下的诊治水平。方法 回顾性分析12例患者行经尿道前列腺电切术后的临床表现及诊治经过。结果 根据临床表现并检测血皮质醇浓度，12例患者均确诊为肾上腺皮质功能低下，经静注地塞米松20mg／d或静滴琥珀酸氢化可的松200mg／d均治愈，疗程20d。随访4也0个月，平均13个月，均未复发。结论 对于老年男性患者行经尿道前列腺电切术后，应警惕发生急性肾上腺皮质功能低下的可能，早期应用地塞米松或琥珀酸氢化可的松有利于及早诊治。     

经尿道前列腺电切术后尿道狭窄的原因分析

目的 分析并探讨经尿道前列腺电切术(TURP)术后尿道狭窄的原因,避免其发生.方法 回顾性分析我院1999年1月至2010年1月收治的23例前列腺电切术后尿道狭窄患者,年龄57~78岁,平均67.8岁;狭窄段尿道长度为1.6~3.5cm(平均2.3cm);最大尿流率为4～14ml/s,平均75ml/s;术后出现狭窄的时间为1个月~17年,平均25个月.其中前尿道狭窄6例,后尿道狭窄15例,膀胱颈口处狭窄2例.对于明确的尿道狭窄患者,针对不同情况分别给予尿道扩张、尿道内冷刀切开、残留前列腺组织切除或瘢痕切除处理.结果 随访3个月~6个月,23例患者中6例前尿道狭窄经定期尿道扩张后症状消失,疗效满意.后尿道狭窄的15例患者,2例采用定期尿道扩张的方法治愈,3例行残留腺体切除后症状逐渐缓解,另外1例因后尿道瘢痕较多,于尿道内行冷刀切开后复发,其余后尿道狭窄患者疗效满意.膀胱颈口处狭窄的2例患者,行膀胱颈口冷刀切开及瘢痕切除后治愈.术后23例患者最大尿流率19~29 ml/s,平均24.4 ml/s.结论 尿道狭窄是TULIP术后常见的并发症,其发生与尿路感染、操作损伤、术后留置尿管过粗、置管时间过长、腺体残留等因素密切相关.     

经尿道前列腺电切术围术期血液流变学的变化

目的 从血液流变学角度探讨经尿道前列腺电切术(TURP)患者围术期的管理。方法 择期行TURP手术32例，于术前、术中、术毕和术后4h，抽取静脉血检测血液流变学各项指标。结果 低切粘度、血浆粘度、低切还原粘度、中切还原粘度在术毕和术后4h时比术前显著升高；术中、术毕、术后4h与术前比较，红细胞刚性指数增高，变形指数下降。结论 TURP围术期应注意降低血液粘度、保护红细胞。     

经尿道前列腺电切术后尿频原因分析

目的分析经尿道前列腺电切术（transurethral resection of the prostate,TURP）后尿频的原因,为临床诊治疗提供参考。方法84例以尿频为主要症状就诊的前列腺增生症（BPH）行TURP术后1个月的患者,采用尿常规、尿道膀胱镜、尿流动力学等检查手段,查找其术后尿频的原因,并根据具体原因采取治疗,随访至尿频症状消失。结果手术可有效解除BPH患者膀胱出口梗阻,部分患者因术后相关并发症使尿频改善不理想,其中单纯泌尿系感染22例（26．2％）,尿道外口狭窄9例（10．7％）,尿道狭窄12例（14．3％）,逼尿肌不稳定29例（34．5％）,膀胱颈纤维化3例（3．6％）,不明原因尿频9例（10．7％）。根据病因采取相应的治疗措施,能获得较为理想的效果。结论TURP术后尿频的原因是多方面的,术前需向患者交代清楚;诊治过程中应该加以全面考虑,对因治疗是关键。