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International Journal of Surgery Case... May 2024Benign prostate hyperplasia is common condition among elderly men, but giant intravesical prostatic protrusion is rare and may be confused with bladder carcinoma.
INTRODUCTION AND IMPORTANCE
Benign prostate hyperplasia is common condition among elderly men, but giant intravesical prostatic protrusion is rare and may be confused with bladder carcinoma.
CASE PRESENTATION
We report an unusual case of giant intravesical prostatic protrusion mimicking bladder carcinoma. A diagnosis of giant intravesical prostatic protrusion was confirmed with the assistance of cystoscopy and patient was managed by transvesical simple open prostatectomy where he had uneventfully recovery.
CLINICAL DISCUSSION
Both bladder carcinoma and benign prostate hyperplasia are more prevalent in elderly men and they all present with lower urinary tract symptoms. Ultrasound and computer tomography may all suggest bladder carcinoma. The two conditions are treated differently, and therefore having correct diagnosis is mandatory. Cystoscopy is an important investigation that can act as a tiebreaker in differentiating giant intravesical prostatic protrusion from bladder carcinoma. Transvesical simple open prostatectomy is the preferred surgical approach with good postoperative outcome.
CONCLUSION
This case report reminds urology surgeons on the possibility of having giant intravesical prostate mimicking bladder carcinoma and the importance of cystoscopy in differentiating the two. Transvesical simple open prostatectomy has promising result.
PubMed: 38581945
DOI: 10.1016/j.ijscr.2024.109590 -
World Journal of Gastrointestinal... Mar 2024Colorectal cancer is the third most common cancer and the second highest cause of cancer-related mortality worldwide. About 5%-10% of patients are diagnosed with locally...
BACKGROUND
Colorectal cancer is the third most common cancer and the second highest cause of cancer-related mortality worldwide. About 5%-10% of patients are diagnosed with locally advanced rectal cancer (LARC) on presentation. For LARC invading into other structures ( T4b), multivisceral resection (MVR) and/or pelvic exenteration (PE) remains the only potential curative surgical treatment. MVR and/or PE is a major and complex surgery with high post-operative morbidity. Minimally invasive surgery (MIS) has been shown to improve short-term post-operative outcomes in other gastrointestinal malignancies, but there is little evidence on its use in MVR, especially so for robotic MVR.
AIM
To assess the feasibility and safety of minimally invasive MVR (miMVR), and compare post-operative outcomes between robotic and laparoscopic MVR.
METHODS
This is a single-center retrospective cohort study from 1 January 2015 to 31 March 2023. Inclusion criteria were patients diagnosed with cT4b rectal cancer and underwent MVR, or stage 4 disease with resectable systemic metastases. Patients who underwent curative MVR for locally recurrent rectal cancer, or metachronous rectal cancer were also included. Exclusion criteria were patients with systemic metastases with non-resectable disease. All patients planned for elective surgery were enrolled into the standard enhanced recovery after surgery pathway with standard peri-operative management for colorectal surgery. Complex surgery was defined based on technical difficulty of surgery ( total PE, bladder-sparing prostatectomy, pelvic lymph node dissection or need for flap creation). Our primary outcomes were the margin status, and complication rates. Categorical values were described as percentages and analysed by the chi-square test. Continuous variables were expressed as median (range) and analysed by Mann-Whitney test. Cumulative overall survival (OS) and recurrence-free survival (RFS) were analysed using Kaplan-Meier estimates with life table analysis. Log-rank test was performed to determine statistical significance between cumulative estimates. Statistical significance was defined as < 0.05.
RESULTS
A total of 46 patients were included in this study [open MVR (oMVR): 12 (26.1%), miMVR: 36 (73.9%)]. Patients' American Society of Anesthesiologists score, body mass index and co-morbidities were comparable between oMVR and miMVR. There is an increasing trend towards robotic MVR from 2015 to 2023. MiMVR was associated with lower estimated blood loss (EBL) (median 450 1200 mL, = 0.008), major morbidity (14.7% 50.0%, = 0.014), post-operative intra-abdominal collections (11.8% 50.0%, = 0.006), post-operative ileus (32.4% 66.7%, = 0.04) and surgical site infection (11.8% 50.0%, = 0.006) compared with oMVR. Length of stay was also shorter for miMVR compared with oMVR (median 10 30 d, = 0.001). Oncological outcomes-R0 resection, recurrence, OS and RFS were comparable between miMVR and oMVR. There was no 30-d mortality. More patients underwent robotic compared with laparoscopic MVR for complex cases (robotic 57.1% laparoscopic 7.7%, = 0.004). The operating time was longer for robotic compared with laparoscopic MVR [robotic: 602 (400-900) min, laparoscopic: Median 455 (275-675) min, < 0.001]. Incidence of R0 resection was similar (laparoscopic: 84.6% robotic: 76.2%, = 0.555). Overall complication rates, major morbidity rates and 30-d readmission rates were similar between laparoscopic and robotic MVR. Interestingly, 3-year OS (robotic 83.1% 58.6%, = 0.008) and RFS (robotic 72.9% 34.3%, = 0.002) was superior for robotic compared with laparoscopic MVR.
CONCLUSION
MiMVR had lower post-operative complications compared to oMVR. Robotic MVR was also safe, with acceptable post-operative complication rates. Prospective studies should be conducted to compare short-term and long-term outcomes between robotic laparoscopic MVR.
PubMed: 38577068
DOI: 10.4240/wjgs.v16.i3.777 -
European Urology Open Science May 2024Registry-based studies for prostate cancer (PCa) document higher overall mortality (OM) after high-dose radiotherapy (RT) than after radical prostatectomy (RP). Our aim...
BACKGROUND AND OBJECTIVE
Registry-based studies for prostate cancer (PCa) document higher overall mortality (OM) after high-dose radiotherapy (RT) than after radical prostatectomy (RP). Our aim was to explore the association between pretreatment patient-reported health ("OverallHealth": OH) and curative treatment type, and the impact on early OM.
METHODS
New PCa patients registered between 2017 and 2019 in the Cancer Registry of Norway ( = 1949) completed the European Organisation for Research and Treatment of Cancer Quality-of-Life Core 30 (QLQ-C30) questionnaire before RP ( = 592) or RT ( = 610) or after allocation to active surveillance (AS; = 747). We dichotomised the QLQ-C30 summary score to classify patients with un-impaired versus impaired OH Standard univariable and multivariable analyses with treatment type or OM as the outcome were conducted. The mean observation time was 4.7 years (standard deviation 1.0). Statistical significance was set at < 0.05.
KEY FINDINGS AND LIMITATIONS
Impaired OH was more frequent in the RT group (38%) than in the RP (25%) or AS (28%) group ( < 0.001). Higher age, higher risk group, and impaired OH increased the probability of undergoinRT rather than RP ( < 0.001). Impaired OH was associated with a twofold higher early OM rate in the RT group (16% vs 8%; = 0.009) and fourfold higher OM rate in the AS group (13% vs 3%; < 0.001). These findings remained significant in Cox regression analyses controlled for age and risk group. After RP, only locally advanced high-risk tumours were significantly associated with OM. Unknown psychometrics for the OH variable is the main study limitation.
CONCLUSIONS AND CLINICAL IMPLICATIONS
Pretreatment patient-reported impaired OH, measured as the QLQ-C30 summary score, was positively associated with allocation to RT or AS and is a prognostic factor for early OM. Before allocation to RT or AS, elderly patients with PCa should be screened and treated for health problems that can be remedied. Future studies should determine the psychometrics of the QLQ-C30 summary score in comparison to established frailty screening instruments.
PATIENT SUMMARY
Patient-reported scores reflecting their overall health can help in choosing curative treatment for prostate cancer and are associated with survival during the first 5 years after treatment.
PubMed: 38558766
DOI: 10.1016/j.euros.2024.03.005 -
European Urology Open Science May 2024A combined approach of magnetic resonance imaging (MRI)-targeted biopsy (TBx) and bilateral systematic biopsy (SBx) is advised in patients who have an increased risk of...
The Impact of Omitting Contralateral Systematic Biopsy on the Surgical Planning of Patients with a Unilateral Suspicious Lesion on Magnetic Resonance Imaging Undergoing Robot-assisted Radical Prostatectomy for Prostate Cancer.
BACKGROUND AND OBJECTIVE
A combined approach of magnetic resonance imaging (MRI)-targeted biopsy (TBx) and bilateral systematic biopsy (SBx) is advised in patients who have an increased risk of prostate cancer (PCa). The diagnostic gain of SBx in detecting PCa for treatment planning of patients undergoing robot-assisted radical prostatectomy (RARP) is unknown. This study aims to determine the impact of omitting contralateral SBx on the surgical planning of patients undergoing RARP in terms of nerve-sparing surgery (NSS) and extended pelvic lymph node dissection (ePLND).
METHODS
Case files from 80 men with biopsy-proven PCa were studied. All men had a unilateral suspicious lesion on MRI, and underwent TBx and bilateral SBx. Case files were presented to five urologists for the surgical planning of RARP. Each case file was presented randomly using two different sets of information: (1) results of TBx + bilateral SBx, and (2) results of TBx + ipsilateral SBx. The urologists assessed whether they would perform NSS and/or ePLND.
KEY FINDINGS AND LIMITATIONS
A change in the surgical plan concerning NSS on the contralateral side was observed in 9.0% (95% confidence interval [CI] 6.4-12.2) of cases. Additionally, the indication for ePLND changed in 5.3% (95% CI 3.3-7.9) of cases. Interobserver agreement based on Fleiss' kappa changed from 0.44 to 0.15 for the indication of NSS and from 0.84 to 0.83 for the indication of ePLND.
CONCLUSIONS AND CLINICAL IMPLICATIONS
In our series, the diagnostic information obtained from contralateral SBx has limited impact on the surgical planning of patients with a unilateral suspicious lesion on MRI scheduled to undergo RARP.
PATIENT SUMMARY
In patients with one-sided prostate cancer on magnetic resonance imaging, omitting biopsies on the other side rarely changed the surgical plan with respect to nerve-sparing surgery and the indication to perform extended lymph node dissection.
PubMed: 38558763
DOI: 10.1016/j.euros.2024.03.006 -
Urology Case Reports May 2024Post-operative pyoderma gangrenosum is a rare neutrophilic dermatosis which forms within skin wounds following surgery. This condition is not well recognised, can be...
Post-operative pyoderma gangrenosum is a rare neutrophilic dermatosis which forms within skin wounds following surgery. This condition is not well recognised, can be difficult to diagnose and often mimics necrotising fasciitis. While wound exploration and debridement remains the standard of care in post-operative wound infection, this can paradoxically exacerbate pyoderma gangrenosum resulting in further morbidity and mortality. As such, surgeons that encounter post-operative pyoderma gangrenosum face a diagnostic dilemma. Here we present a 65 year old gentleman who developed pyoderma gangrenosum following open radical prostatectomy. We reflect on his management and discuss the pertinent points learned from this case.
PubMed: 38545250
DOI: 10.1016/j.eucr.2024.102709 -
European Urology Open Science Apr 2024Surgical education lacks a standardized, proficiency-based approach to evaluation and feedback.
BACKGROUND
Surgical education lacks a standardized, proficiency-based approach to evaluation and feedback.
OBJECTIVE
To assess the implementation and reception (ie, feasibility) of an automated, standardized, longitudinal surgical skill assessment and feedback system, and identify baseline trainee (resident and fellow) characteristics associated with achieving proficiency in robotic surgery while learning robotic-assisted laparoscopic prostatectomy.
DESIGN SETTING AND PARTICIPANTS
A quality improvement study assessing a pilot of a surgical experience tracking program was conducted over 1 yr. Participants were six fellows, eight residents, and nine attending surgeons at a tertiary cancer center.
INTERVENTION
Trainees underwent baseline self-assessment. After each surgery, an evaluation was completed independently by the trainee and attending surgeons. Performance was rated on a five-point anchored Likert scale (trainees were considered "proficient" when attending surgeons' rating was ≥4). Technical skills were assessed using the Global Evaluative Assessment of Robotic Skills (GEARS) and Prostatectomy Assessment and Competency Evaluation (PACE).
OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS
Program success and utility were assessed by evaluating completion rates, evaluation completion times, and concordance rates between attending and trainee surgeons, and exit surveys. Baseline characteristics were assessed to determine associations with achieving proficiency.
RESULTS AND LIMITATIONS
Completion rates for trainees and attending surgeons were 72% and 77%, respectively. Fellows performed more steps/cases than residents (median [interquartile range]: 5 [3-7] and 3 [2-4], respectively; p < 0.01). Prior completion of robotics or laparoscopic skill courses and surgical experience measures were associated with achieving proficiency in multiple surgical steps and GEARS domains. Interclass correlation coefficients on individual components were 0.27-0.47 on GEARS domains.
CONCLUSIONS
An automated surgical experience tracker with structured, longitudinal evaluation and feedback can be implemented with good participation and minimal participant time commitment, and can guide curricular development in a proficiency-based education program by identifying modifiable factors associated with proficiency, individualizing education, and identifying improvement areas within the education program.
PATIENT SUMMARY
An automated, standardized, longitudinal surgical skill assessment and feedback system can be implemented successfully in surgical education settings and used to inform education plans and predict trainee proficiency.
PubMed: 38468865
DOI: 10.1016/j.euros.2024.02.014 -
Urology Research & Practice Jan 2024In this study, we assess the impact of frailty on the success rate and risk of complications of robot-assisted urological procedures and introduce effective preoperative...
In this study, we assess the impact of frailty on the success rate and risk of complications of robot-assisted urological procedures and introduce effective preoperative screening tools to evaluate frail patients' fitness to tolerate robot-assisted urological surgery. We performed a search of electronic databases for available studies, published up to August 2023, investigating the outcomes of robot-assisted urological oncology procedures and their safety in frail patients. Sixteen studies were ultimately selected, investigating the implications of frailty in robot-assisted radical cystectomy, robotassisted partial nephrectomy, and robot-assisted radical prostatectomy. All the studies used the Clavien-Dindo classification of complications with serious complications considered as Clavien-Dindo 3. Frail patients significantly benefit from robot-assisted urological procedures in comparison to open surgery, with lower rates of blood transfusion and a shorter length of stay. However, they also have a higher risk of postoperative complications than non-frail patients, as well as increased rates of conversion to open, total hospital costs, and in-hospital mortality after robot-assisted procedures. Robot-assisted urological procedures can improve the postoperative recovery of frail patients in comparison to open surgery. Reliable frailty indexes such as the Johns Hopkins indicator and simplified frailty index, as well as the Geriatric 8 screening tool, should be routinely used in the preoperative assessment of frail patients to optimize surgical decision-making.
PubMed: 38451128
DOI: 10.5152/tud.2024.23198 -
Urology Research & Practice Jan 2024Prostate cancer is the second- leading cause of cancer death among men. We aimed to evaluate high-intensity focused ultrasound (HIFU), open radical prostatectomy (ORP),...
OBJECTIVE
Prostate cancer is the second- leading cause of cancer death among men. We aimed to evaluate high-intensity focused ultrasound (HIFU), open radical prostatectomy (ORP), robot-assisted radical prostatectomy (RARP), and external beam radiation therapy (RT) in the treatment of localized low- and intermediate-risk prostate cancer.
METHODS
We searched bibliographic databases for case-control, cohort, and randomized controlled studies. We used MeSH subject headings and free text terms for prostate cancer, HIFU, ORP, RARP, RT, failure-free survival (FFS), biochemical disease-free survival (BDFS), urinary incontinence (UI), and erectile dysfunction (ED).
RESULTS
Fourteen studies were included in the review, for a total of 34 927 participants. Among the 8 studies of HIFU as the primary treatment of localized low- and intermediate- risk prostate cancer, 4 studies reported 5-year FFS rates ranging from 67.8% to 97.8%, 3 studies reported 5-year BDFS ranging from 58% to 85.4%, 5 studies reported 1-year UI rates ranging from 0% to 6%, and 4 studies reported 1-year ED rates ranging from 11.4% to 38.7%. Furthermore, our search revealed a 5-year FFS benefit favoring ORP compared to RT, a 1-year UI rate favoring ORP compared to RARP, and a 1-year ED rate favoring ORP compared to RARP.
CONCLUSION
Our systematic review and meta-analysis revealed lack of studies with active comparators comparing HIFU to standard of care (ORP, RARP, or RT) in primary treatment of localized low- and intermediate-risk prostate cancer. Open radical prostatectomy has favorable efficacy outcomes compared to RT, while RARP has beneficial functional outcomes compared to ORP, respectively.
PubMed: 38451125
DOI: 10.5152/tud.2024.23123 -
Journal of the West African College of... 2023Urological surgeries are a significant part of surgical services. The need for these services varies regionally and globally. Knowledge of the local need is important...
INTRODUCTION
Urological surgeries are a significant part of surgical services. The need for these services varies regionally and globally. Knowledge of the local need is important for prioritisation of resources.
OBJECTIVES
To describe the urological procedures done in our hospital for effective utilisation of the already scarce resource in this region.
PATIENTS AND METHODS
This was a retrospective one-year study of the urosurgical cases done in a Nigerian Teaching Hospital. The main theatre register was used to collate data. Data collected included age, sex, operation done and anaesthesia employed.
RESULTS
One hundred and twenty-two male and three female patients were included with a male-to-female ratio of 41:1. The mean age of the patients was 56.6 ± 19.89 years. Elective cases accounted for 102 (81.6%) of surgeries. Regional anaesthesia was the most common form of anaesthesia accounting for 105 (84%) followed by local anaesthesia in 16 (12.8%). Day cases accounted for 77 (61.6%) of procedures. More than 80% of the study population was 50 years and older. Overall, the three most common performed surgeries were digital-guided prostate biopsy 47 (37.6%), suprapubic cystostomy 16 (12.8%) and open prostatectomy 9 (7.2%). In male patients, the three most common procedures were prostate biopsy 47 (38.5%), suprapubic cystostomy 16 (13.1 %), open prostatectomy 9 (7.4%) whereas nephrectomy, pyeloplasty and stent removal each accounted for 33.3% each of procedures in female patients. Endourological procedures accounted for 5 (4%) of cases.
CONCLUSION
Open surgeries accounted for the majority of these cases done with prostate-related procedures being the most common procedures. Few endourological procedures were performed.
PubMed: 38449550
DOI: 10.4103/jwas.jwas_61_23 -
International Braz J Urol : Official... 2024The superiority of the functional results of robot-assisted radical prostatectomyis still controversial. Despite this, it is known that minimally invasive surgery...
INTRODUCTION
The superiority of the functional results of robot-assisted radical prostatectomyis still controversial. Despite this, it is known that minimally invasive surgery obtains better results when analyzing blood loss, blood transfusion and length of stay, for example. Several studies have analyzed the impact of the resident physician's involvement on the results of urological surgeries. The simple learning curve for robot-assisted radical prostate surgery is estimated to be around 10 to 12 cases. Learning curve data for robotic surgeons is heterogeneous, making it difficult to analyze. Rare studies compare the results of a radical prostatectomy of an inexperienced surgeon starting his training in open surgery, with the results of the same surgeon, a few years later, starting training in robotic surgery.
OBJECTIVE
to analyze the results of open radical prostatectomy surgeries (ORP) performed by urology residents, comparing them to the results of robot-assisted radical prostatectomy (RARP), performed by these same surgeons, after completing their training in urology.
MATERIALS AND METHODS
a retrospective analysis of the cases of only 3 surgeons was performed. 50 patients underwent ORP (group A). The surgeons who operated on the ORP patients were in the 3rd and final year of the urology residency program and beginners in ORP surgery, but with at least 4 years of experience in open surgery. The same surgeons, already trained urologists, began their training in robotic surgery and performed 56 RARP surgeries (group B). For the comparative analysis, data were collected on age, number of lymph nodes removed, surgery time, hospitalization time, drain volume, drain permanence time, indwelling bladdercateter (IBC) permanence time, positive surgical margin, biochemical recurrence, risk classification (ISUP), intra and postoperative complications, urinary incontinence (UI) and erectile dysfunction (ED). The console used was the Da Vinci Si, from Intuitive®. For statistical analysis, the Shapiro-Wilk test verified that the data did not follow normality, the Levene test guaranteed homogeneity, and the Mann-Whitney test performed the comparative analysis of the quantitative data. For the analysis of qualitative data, the Chi-square test was used for nominal variables and the Mann-Whitney U test for ordinal variables. Additionally, the Friedman test analyzed whether there was an improvement in the perception of UI or ED over the months, for each group individually (without comparing them), and the post-hoc Durbin-Conover test, for the results with statistically significant difference. We used a p-value < 0.05, and the Jamovi® program (Version 2.0).
RESULTS
there was no statistically significant difference between the groups for age, number of lymph nodes removed, positive surgical margin, biochemical recurrence, risk classification and urinary incontinence. Additionally, we observed that the surgical time was longer in group B. On the other hand, the length of stay, drain volume, drain time, IBC time, complication rate and levels of erectile dysfunction in the third and sixth months were higher in group A, when compared to group B. We also observed that there was no evolutionary improvement in ED over the months in both groups, and that there was a perception of improvement in UI from the 1st to the 3rd month in group A, and from the 1st to the 6th month, and from the 3rd to the 12th month, in group B.
CONCLUSION
the learning curve of RARP is equivalent to the curve of ORP. In general, the results for the robotic group were better, however, the functional results were similar between the groups, with a slight tendency of advantage for the robotic arm.
Topics: Male; Humans; Robotic Surgical Procedures; Prostate; Robotics; Urology; Retrospective Studies; Erectile Dysfunction; Learning Curve; Margins of Excision; Prostatic Neoplasms; Treatment Outcome; Prostatectomy; Urinary Incontinence; Blood Transfusion
PubMed: 38446904
DOI: 10.1590/S1677-5538.IBJU.2024.9909