Satisfaction and regret after open retropubic or robot-assisted laparoscopic radical prostatectomy

BACKGROUND: To counsel patients adequately, it is important to understand the variables influencing satisfaction and regret following prostatectomy. OBJECTIVE: To identify independent predictors for satisfaction and regret after radical prostatectomy. DESIGN, SETTING, AND PARTICIPANTS: Patients who had undergone retropubic radical prostatectomy (RRP) or robot-assisted laparoscopic radical prostatectomy (RALP) between 2000 and 2007 were mailed cross-sectional surveys composed of sociodemographic information, the Expanded Prostate Cancer Index Composite (EPIC), and questions regarding satisfaction and regret. MEASUREMENTS: Sociodemographic variables, perioperative complications, type of procedure, length of follow-up, and EPIC scores were evaluated as independent predictors of satisfaction and regret in multivariate logistic regression analysis. RESULTS AND LIMITATIONS: A total of 400 patients responded (response rate 61%) of whom 84% were satisfied and 19% regretted their treatment choice. In multivariate analysis, lower income (odds ratio [OR], 0.08; 95% confidence interval [CI], 0.03-0.23), shorter follow-up (OR, 0.63; 95% CI, 0.41-0.98), having undergone RRP versus RALP (OR, 4.45; 95% CI, 1.90-10.4)], urinary domain scores (OR, 2.70; 95% CI, 1.60-4.54), and hormonal domain scores (OR, 2.01; 95% CI, 1.30-3.12) were independently associated with satisfaction (p相似文献   

Contemporary outcomes after superficial femoral artery angioplasty and stenting: the influence of TASC classification and runoff score

OBJECTIVE: A recent randomized trial suggested nitinol self-expanding stents (SES) were associated with reduced restenosis rates compared with simple percutaneous transluminal angioplasty (PTA). We evaluated our results with superficial femoral artery (SFA) SES to determine whether TransAtlantic InterSociety Consensus (TASC) classification, indication for intervention, patient risk factors, or Society of Vascular Surgery (SVS) runoff score correlated with patency and clinical outcome, and to evaluate if bare nitinol stents or expanded polytetrafluoroethylene (ePTFE) covered stent placement adversely impacts the tibial artery runoff. METHODS: A total of 109 consecutive SFA stenting procedures (95 patients) at two university-affiliated hospitals from 2003 to 2006 were identified. Medical records, angiographic, and noninvasive studies were reviewed in detail. Patient demographics and risk factors were recorded. Procedural angiograms were classified according to TASC Criteria (I-2000 and II-2007 versions) and SVS runoff scores were determined in every patient; primary, primary-assisted, secondary patency, and limb salvage rates were calculated. Cox proportional hazard model was used to determine if indication, TASC classification, runoff score, and comorbidities affected outcome. RESULTS: Seventy-one patients (65%) underwent SES for claudication and 38 patients (35%) for critical limb ischemia (CLI). Average treatment length was 15.7 cm, average runoff score was 4.6. Overall 36-month primary, primary-assisted, and secondary rates were 52%, 64%, and 59%, respectively. Limb salvage was 75% in CLI patients. No limbs were lost following interventions in claudicants (mean follow-up 16 months). In 24 patients with stent occlusion, 15 underwent endovascular revision, only five (33%) ultimately remained patent (15.8 months after reintervention). In contrast, all nine reinterventions for in-stent stenosis remained patent (17.8 months). Of 24 patients who underwent 37 endovascular revisions for either occlusion or stenosis, eight (35%) had worsening of their runoff score (4.1 to 6.4). By Cox proportional hazards analysis, hypertension (hazard ratio [HR] 0.35), TASC D lesions (HR 5.5), and runoff score > 5 (HR 2.6) significantly affected primary patency. CONCLUSIONS: Self-expanding stents produce acceptable outcomes for treatment of SFA disease. Poorer patency rates are associated with TASC D lesions and poor initial runoff score; HTN was associated with improved patency rates. Stent occlusion and in-stent stenosis were not entirely benign; one-third of patients had deterioration of their tibial artery runoff. Future studies of SFA interventions need to stratify TASC classification and runoff score. Further evaluation of the long-term effects of SFA stenting on tibial runoff is needed.     

Vascular access calcification predicts mortality in hemodialysis patients

Vascular calcification is a recognized risk factor for cardiovascular mortality in patients with end-stage renal disease. The aim of this study was to identify risk factors for vascular access calcification and to determine if patients with this disorder are at increased risk of death. Vascular access calcification was found in 49 of 212 hemodialysis patients as measured by plain X-ray (arteriovenous fistula or synthetic graft) in two dimensions. Male gender, diabetes mellitus, and length of time on dialysis were independent predictors for access calcification determined by logistic regression multivariate analysis. Serum parameters were not independently related to access calcification. Kaplan-Meier analysis showed an increased mortality risk, and Cox regression analysis confirmed that vascular access calcification was an independent mortality predictor. Our study suggests that detection of vascular access calcification is a cost-effective method to identify patients at increased mortality risk.     

Physical Examination of Arteriovenous Fistulae by a Renal Fellow: Does It Compare Favorably to an Experienced Interventionalist?

Physical examination (PE) has been highlighted to detect vascular access stenosis with high degree of accuracy when performed by an interventional nephrologist (IN) with expertise in physical examination. This study examines the accuracy of PE compared with angiography when performed by a nephrology fellow (NF). It also compares NF results to that of IN. Didactic and hands-on PE training was provided to a renal fellow for 1 month during an interventional nephrology rotation. Forty-five and 142 consecutive cases of arteriovenous fistula dysfunction were examined by the NF and IN, respectively. Preprocedure PE was performed by the NF and IN and the finding secured in a sealed envelope. Angiography from the feeding artery to the right atrium was then performed. The images were reviewed by an independent interventionalist with expertise in endovascular dialysis access procedures and the diagnosis was rendered. The reviewer was blinded to the physical examination. Cohen's Kappa was used as a measurement of the level of agreement beyond chance between the diagnosis made by physical examination and angiography. Outflow stenosis: NF [strong agreement (81%), Kappa value = 0.63]; IN [strong agreement (89%), Kappa score = 0.78]. Inflow stenosis: NF [strong agreement (80%), Kappa value = 0.56]; IN [strong agreement (83%), Kappa score = 0.55]. These differences between NF and IN were not significant. NF performed significantly better than the IN regarding central vein stenosis. NF [strong agreement (79%), Kappa value = 0.44]; IN [weak agreement (11%), Kappa value = 0.17]. An NF can be trained in physical examination and accurately detect and localize stenoses in a great majority of arteriovenous fistulae when compared with an IN. We suggest that nephrology training programs should place more emphasis on this aspect of vascular access education.     

Metabolic drug interactions with newer antipsychotics: a comparative review

Newer antipsychotics introduced in clinical practice in recent years include clozapine, risperidone, olanzapine, quetiapine, sertindole, ziprasidone, aripiprazole and amisulpride. These agents are subject to drug-drug interactions with other psychotropic agents or with medications used in the treatment of concomitant physical illnesses. Most pharmacokinetic interactions with newer antipsychotics occur at the metabolic level and usually involve changes in the activity of the major drug-metabolizing enzymes involved in their biotransformation, i.e. the cytochrome P450 (CYP) monooxygenases and/or uridine diphosphate-glucuronosyltransferases (UGT). Clozapine is metabolized primarily by CYP1A2, with additional contribution by other CYP isoforms. Risperidone is metabolized primarily by CYP2D6 and, to a lesser extent, CYP3A4. Olanzapine undergoes both direct conjugation and CYP1A2-mediated oxidation. Quetiapine is metabolized by CYP3A4, while sertindole and aripiprazole are metabolized by CYP2D6 and CYP3A4. Ziprasidone pathways include aldehyde oxidase-mediated reduction and CYP3A4-mediated oxidation. Amisulpride is primarily excreted in the urine and undergoes relatively little metabolism. While novel antipsychotics are unlikely to interfere with the elimination of other drugs, co-administration of inhibitors or inducers of the major enzymes responsible for their metabolism may modify their plasma concentrations, leading to potentially significant effects. Most documented metabolic interactions involve antidepressant and anti-epileptic drugs. Of a particular clinical significance is the interaction between fluvoxamine, a potent CYP1A2 inhibitor, and clozapine. Differences in the interaction potential among the novel antipsychotics currently available may be predicted based on their metabolic pathways. The clinical relevance of these interactions should be interpreted in relation to the relative width of their therapeutic index. Avoidance of unnecessary polypharmacy, knowledge of the interaction profiles of individual agents, and careful individualization of dosage based on close evaluation of clinical response and, possibly, plasma drug concentrations are essential to prevent and minimize potentially adverse drug interactions in patients receiving newer antipsychotics.     

Prostate cancer laterality as a rationale of focal ablative therapy for the treatment of clinically localized prostate cancer

BACKGROUND: Early detection of small-volume prostate cancer (PCa) has led to the concept of focal therapy to treat PCa as an organ-sparing, minimally invasive procedure. The authors sought to determine the frequency of unilateral cancers in the contemporary prostate-specific antigen (PSA) era to determine the percentage of patients who would be candidates for hemiablation of the prostate by using focal therapy while preserving the contralateral lobe. METHODS: Paraffin-embedded radical prostatectomy specimens (1184 specimens) from consecutive patients between 2002 and 2006 with pathologic organ confined PCa were analyzed. Pathologic assessment focused on tumor laterality and percentage of tumor involvement (PTI) along with other routine parameters such as pathological T-classification (pT), pathological Gleason Score (pGS), extracapsular extension (ECE), and surgical margins (SM). Clinical and pathologic parameters were analyzed by univariate and multivariate methods. RESULTS: Completely unilateral cancers were identified in 227 (19.2%) of 1184 patients. Of these patients, 164 (72.2%) had PTI of < or =5%, 40 (17.6%) had a PTI of 5.01%-10%, 9 (4.0%) had a PTI of 10.01%-15%, and 14 (6.2%) had a PTI of > 15%, respectively (P < .0005). African-American men had bilateral cancers more commonly that non-African-American men, eg, 90.8% versus 79.2%, respectively (P < .0005). Race, PTI, pGS, and SM were independent predictors by multivariate logistic regression (P < or = .05). CONCLUSIONS: This study suggests that 1 in 5 men diagnosed with PCa have small volume, completely unilateral cancers that may be amenable to hemiablation of the prostate. Further study is needed to develop predictive models to select candidates for focal therapy.