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Journal of Clinical Medicine Jun 2024The management of urothelial carcinoma has evolved with the introduction of minimally invasive techniques such as laparoscopic or robotic procedures, challenging the... (Review)
Review
The management of urothelial carcinoma has evolved with the introduction of minimally invasive techniques such as laparoscopic or robotic procedures, challenging the traditional approach of open surgery, and giving rise to atypical recurrences (ARs). ARs include port-site metastasis and peritoneal carcinomatosis, yet discrepancies persist among authors regarding their precise classification. Incidence rates of ARs vary widely across studies, ranging from less than 1% to over 10% in both muscle-invasive bladder cancer (MIBC) and upper tract urothelial tumor (UTUC). Peritoneal metastases predominate as the most common ARs in patients with MIBC, while retroperitoneal metastases are prevalent in those with UTUC due to differing surgical approaches. The timing of AR presentation and survival outcomes closely mirror those of conventional recurrences, with which they are frequently associated. Pneumoperitoneum has progressively been regarded less as the cause of ARs, while surgical-related risk factors have gained prominence. Current major surgical-related causes include tumor spillage and urinary tract violation during surgery, avoidance of endo bag use for specimen extraction, and low surgical experience. Factors such as tumor stage, histological variants, and lympho-vascular invasion correlate with the risk of ARs, suggesting a close association with tumor biology. Further studies are required to better understand the incidence, risk factors, characteristics, and outcomes of ARs.
PubMed: 38930066
DOI: 10.3390/jcm13123537 -
Journal of Clinical Medicine Jun 2024: The aim of the study was to find tools to assess patient characteristics that would help in choosing between orthotopic neobladder and ileal conduit in patients... (Review)
Review
Choosing between Orthotopic Neobladder and Ileal Conduit after Radical Cystectomy: Tools for Assessing Patient-Specific Characteristics and Enhancing the Decision-Making Process-A Review of Current Studies.
: The aim of the study was to find tools to assess patient characteristics that would help in choosing between orthotopic neobladder and ileal conduit in patients undergoing radical cystectomy. An additional goal was to search for aids that improve preoperative counseling to support patients in the decision-making process. : A systematic review of MEDLINE, Web of Science, and Scopus databases was conducted, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement, in April 2024. Inclusion criteria were specified in PICO format. Two reviewers independently screened titles/abstracts and full papers. Upon study selection, the results and conclusions from the studies were abstracted and quantitatively summarized in the results section of this article. : Seven articles, involving a total 834 patients, were included. One article described frailty, two reviewed cognitive status, one article described functional dexterity, one described personality, two articles reviewed patients' values and goals, and one article reviewed role of patient-physician dialogue in the context of choosing UD after RC. The reviewed articles identified tools and approaches that could be valuable in evaluating the suitability for continent urinary diversion (CUD) or incontinent urinary diversion (ICUD). : This is the first systematic review that summarizes the new available methods of patient assessment which improve preoperative counseling and choosing the most suitable UD after RC. Efficient tools for this purpose are still missing, and further studies that will aid in creating a simple aid for patient selection are necessary.
PubMed: 38930035
DOI: 10.3390/jcm13123506 -
Fukushima Journal of Medical Science Jun 2024We report four cases of isolated fallopian tube torsion (IFTT) successfully treated with laparoscopic surgery over the past 10 years. Two young women (each 19 years old)...
We report four cases of isolated fallopian tube torsion (IFTT) successfully treated with laparoscopic surgery over the past 10 years. Two young women (each 19 years old) were IFTT with paraovarian cyst (POC) and tubal preservation was possible with detorsion and cystectomy. The other two patients (a 41-year-old woman with hydrosalpinx and a 50-year-old woman with hematosalpinx) underwent salpingectomy and adnexectomy, respectively, because there was no desire for tubal preservation. One patient had emergency surgery due to severe abdominal pain, one had semi-emergency surgery due to mild abdominal pain, and the other two were diagnosed during scheduled surgery without symptoms.Although IFTT was considered a very rare disease, our case series and recent reports suggest that it may have been underestimated, as it accounts for approximately 10% of adnexal torsion cases. Preoperative diagnosis of IFTT may be more difficult than for adnexal torsion because of its infrequency and nonspecific, vague clinical symptoms. Since the prevalent age for this disease is young, as in our first 2 patients, early surgical intervention to preserve the fallopian tubes should be chosen when necessary, and it seems to be important for gynecologists to be aware of this disease for earlier diagnosis and appropriate surgical intervention.
PubMed: 38925957
DOI: 10.5387/fms.23-00021 -
BJU International Jun 2024To investigate the lymph node invasion (LNI) rate in patients exhibiting complete pathological response (CR) to neoadjuvant chemotherapy (NAC) and to test the...
OBJECTIVES
To investigate the lymph node invasion (LNI) rate in patients exhibiting complete pathological response (CR) to neoadjuvant chemotherapy (NAC) and to test the association of CR status with lower LNI and better survival outcomes.
MATERIALS AND METHODS
We included patients with bladder cancer (BCa; cT2-4a; cN0; cM0) treated with NAC and radical cystectomy (RC) + pelvic lymph node dissection (PLND) at our institution between 2012 and 2022 (N = 157). CR (ypT0) and LNI (ypN+) were defined at final pathology. Univariable and multivariable logistic regression analysis was performed to test the association between CR and LNI after adjusting for number of lymph nodes removed (NLR). Kaplan-Meier and Cox regression analyses were used to assess overall survival (OS), metastasis-free survival (MFS) and disease free-survival (DFS) according to CR status.
RESULTS
Overall CR and LNI rates were 40.1% and 19%, respectively. The median (interquartile range [IQR]) NLR was 26 (19-36). The LNI rate was lower in patients with CR vs those without CR (2 [3.2%] vs 61 [29.8%]; P < 0.001). After adjusting for NLR, CR reduced the LNI risk by 93% (odds ratio 0.07, 95% confidence interval [CI] 0.01-0.25; P < 0.001). Kaplan-Meier plots depicted better 5-year OS (69.7 vs 52.2%), MFS (68.3 vs 45.5%) and DFS (66.6 vs 43.5%) in patients with CR vs those without CR. After multivariable adjustments, CR independently reduced the risk of death (hazard ratio [HR] 0.44, 95% CI 0.24-0.81; P = 0.008), metastatic progression (HR 0.41, 95% CI 0.23-0.71; P = 0.002) and disease progression (HR 0.41, 95% CI 0.24-0.70; P = 0.001).
CONCLUSION
Based on these findings, we postulate that PLND could potentially be omitted in patients exhibiting CR after NAC, due to negligible risk of LNI. Prospective Phase II trials are needed to explore this challenging hypothesis.
PubMed: 38923233
DOI: 10.1111/bju.16440 -
Pathogens (Basel, Switzerland) Jun 2024Cystic echinococcosis (CE) cysts may persist for decades because of immune modulation mechanisms. Here, we characterize the cysts and the blood immune responses in...
BACKGROUND
Cystic echinococcosis (CE) cysts may persist for decades because of immune modulation mechanisms. Here, we characterize the cysts and the blood immune responses in patients with CE.
METHODS
We enrolled 61 patients with CE and 19 control subjects. We received tissue samples from seven patients with CE and a control subject requiring liver cystectomy. The immunohistochemistry evaluation of the immune cell subtypes and cytokines in the pericysts and surrounding liver and the antigen B (AgB)-specific response analysis of whole blood were performed.
RESULTS
In CE, the pericyst and the surrounding liver parenchyma showed aggregates of CD3 T lymphocytes, mainly CD4. B lymphocyte aggregates were present in the liver tissue. Monocytes/granulocytes were rarely observed. Th2 cytokine expression was scarce, whereas IFN-γ expression was present in the CE tissues. The control subject did not show an inflammatory infiltrate. The IL-4-specific response to AgB was increased in the patients with CE compared to the control, and this result was confirmed in a larger cohort ( = 0.003), whereas the IFN-γ-response was similar between the two groups ( = 0.5570).
CONCLUSION
In patients with CE, CD4 lymphocytes infiltrate the pericyst and the surrounding liver tissue with a low IL-4/IL-13 expression level and a moderate IFN-γ expression level; moreover, an IL-4 parasite-specific response is detected in the periphery. These results support adventitia involvement in CE immunopathogenesis.
PubMed: 38921775
DOI: 10.3390/pathogens13060477 -
Minerva Urology and Nephrology Jun 2024The relationship between venous thromboembolism (VTE) and solid malignancy has been established over the decades. With rising projected rates of bladder cancer (BCa)...
The impact of venous thromboembolism before open or minimally-invasive radical cystectomy in the USA: insurance claims data on perioperative outcomes and healthcare costs.
BACKGROUND
The relationship between venous thromboembolism (VTE) and solid malignancy has been established over the decades. With rising projected rates of bladder cancer (BCa) worldwide as well as increasing number of patients experiencing BCa and VTE, our aim is to assess the impact of a preoperative VTE diagnosis on perioperative outcomes and health-care costs in BCa cases undergoing radical cystectomy (RC).
METHODS
Patients ≥18 years of age with BCa diagnosis and undergoing open or minimally invasive (MIS) RC were identified in the Merative™ Marketscan Research Databases between 2007 and 2021. The association of previous VTE history with 90-day complication rates, postoperative VTE events, rehospitalization, and total hospital costs (2021 USA dollars) was determined by multivariable logistic regression modeling adjusted for patient and perioperative confounders. Sensitivity analysis on VTE degree of severity (i.e., pulmonary embolism [PE] and/or peripheral deep venous thrombosis [DVT]) was also examined.
RESULTS
Out of 8759 RC procedures, 743 (8.48%) had a previous positive history for any VTE including 245 (32.97%) PE, 339 (45.63%) DVT and 159 (21.40%) superficial VTE. Overall, history of VTE before RC was strongly associated with almost any worse postoperative outcomes including higher risk for any and apparatus-specific 90-days postoperative complications (odds ratio [OR]: 1.21, 95% CI, 1.02-1.44). Subsequent incidence of new VTE events (OR: 7.02, 95% CI: 5.93-8.31), rehospitalization (OR: 1.25, 95% CI: 1.06-1.48), other than home/self-care discharge status (OR: 1.53, 95% CI: 1.28-1.82), and higher health-care costs related to the RC procedure (OR: 1.43, 95% CI: 1.22-1.68) were significantly associated with a history of VTE.
CONCLUSIONS
Preoperative VTE in patients undergoing RC significantly increases morbidity, post-procedure VTE events, hospital length of stay, rehospitalizations, and increased hospital costs. These findings may help during the BCa counseling on risks of surgery and hopefully improve our ability to mitigate such risks.
Topics: Humans; Cystectomy; Venous Thromboembolism; Male; Female; United States; Aged; Middle Aged; Postoperative Complications; Urinary Bladder Neoplasms; Health Care Costs; Minimally Invasive Surgical Procedures; Patient Readmission; Retrospective Studies; Preoperative Period
PubMed: 38920012
DOI: 10.23736/S2724-6051.24.05699-4 -
Cureus May 2024Splenic cysts are extremely rare entities that typically result from prior abdominal trauma, infections, and degenerative diseases. They are divided into two categories:...
Splenic cysts are extremely rare entities that typically result from prior abdominal trauma, infections, and degenerative diseases. They are divided into two categories: true cysts with epithelial lining, and false pseudocysts without epithelial lining, which is more common than true cysts. We describe here a case of a non-traumatic splenic pseudocyst in a healthy 29-year-old male patient, who presented with left upper quadrant abdominal pain. Physical examination revealed scaphoid abdomen and left hypochondrium fullness. The spleen was uniformly enlarged, smooth, and firm, with mild tenderness. Laboratory testing was normal. An abdominal CT scan showed a huge unilocular non-enhancing cyst occupying the upper part of the spleen, measuring around 16 × 18.5 × 20 cm. The patient was managed with cyst aspiration and partial cystectomy. The histopathological examination findings are consistent with splenic pseudocyst. A one-year follow-up period revealed no complications or recurrence. Spleen cysts are rare in clinical practice, posing challenges in diagnosis and treatment. Surgical options include partial or total splenectomy, cyst aspiration, percutaneous drainage, partial cystectomy, and marsupialization. The choice depends on the cyst's size, splenic coverage, and relation to the hilum. Recently, spleen-preserving approaches have been favored to avoid life-threatening sepsis. Non-traumatic splenic pseudocysts present significant diagnostic dilemmas, requiring histopathological examination for definitive diagnosis. Spleen-preserving management is highly recommended to reduce the risk of life-threatening sepsis.
PubMed: 38919238
DOI: 10.7759/cureus.61110 -
International Urology and Nephrology Jun 2024This study evaluates the effectiveness of the Estimation of Physiologic Ability and Surgical Stress (E-PASS) scoring system in predicting postoperative complications...
INTRODUCTION
This study evaluates the effectiveness of the Estimation of Physiologic Ability and Surgical Stress (E-PASS) scoring system in predicting postoperative complications following radical cystectomy (RC).
MATERIALS AND METHODS
In this single-center retrospective study, we analyzed data from patients who underwent open RC for muscle-invasive bladder cancer by a single surgeon between 2008 and 2023. Cases involving cystectomy for non-urothelial carcinoma or urinary diversion other than ileal conduit were excluded. We recorded patient demographics, body mass index (BMI), history of abdominal/retroperitoneal surgery, ASA score, performance status (PS), and pre-existing conditions, such as hypertension (HT), coronary artery disease (CAD), diabetes mellitus (DM), and chronic kidney disease (CKD). Intraoperative data included surgery duration, blood loss, and need for blood transfusion. Post-operative complications were classified using the Clavien-Dindo system. E-PASS score was calculated using the Preoperative Risk Score (PRS), Surgical Stress Score (SSS), and Comprehensive Risk Score (CRS).
RESULTS
The study included 252 patients. Patients who experienced postoperative complications had higher age, BMI, prior surgical history, ASA score, PS, and rates of CAD, HT, DM, and CKD compared to those who did not. Surgery duration, blood loss, blood transfusion requirement, and E-PASS scores (PRS, SSS, CRS) were also higher in this group. The ROC curve for CRS revealed a predictive cutoff of 0.4911 (AUC = 0.905, p < 0.001). Independent risk factors for postoperative complications included high BMI (p = 0.031), longer surgery duration (p < 0.001), HT (p = 0.042), CKD (p = 0.017), and CRS > 0.4911 (p < 0.001).
CONCLUSION
E-PASS system effectively predicts postoperative complications in RC patients.
PubMed: 38918284
DOI: 10.1007/s11255-024-04134-1 -
Surgical Oncology May 2024Bladder cancer (BCa) represents the second most common malignancy of the genitourinary tract. The major risk factors include age, gender, smoking attitude, and... (Review)
Review
Bladder cancer (BCa) represents the second most common malignancy of the genitourinary tract. The major risk factors include age, gender, smoking attitude, and occupational exposure, while the exact etiopathogenesis is still uncertain. Patients diagnosed with a BCa showing invasion of the muscle layer below the submucosa must undergo radical cystectomy (RC) with urinary diversion (UD). Many different surgical approaches to UD have been developed. Packaging an orthotopic neobladder (ON) with a bowel tract represents the gold standard when certain patient selection criteria are satisfied. Using PRISMA guidelines, we performed a systematic review assessing early (within 90 days) and late (beyond 90 days) post-procedural complications of different ON surgical approaches. A comprehensive systematic search was conducted in PubMed, Scopus, and Google Scholar databases to identify papers starting from 2012 using dedicated keywords ("neobladder", "orthotopic neobladder", "complications'' and "outcomes"). A total of 27 articles were found to satisfy the inclusion criteria and selected. Although the ON is a safe procedure that guarantees the patient the best quality of life (QoL), it is not free from risks. Many complications could occur during and after the surgical time which imposes the necessity of strict follow-up and careful checks over time, which should be properly discussed with patients before.
PubMed: 38917777
DOI: 10.1016/j.suronc.2024.102090 -
Radiology Jun 2024A 30-year-old female patient with a history of infertility and no pregnancy presented to the gynecologic endometriosis clinic for follow-up 1 month after oocyte...
A 30-year-old female patient with a history of infertility and no pregnancy presented to the gynecologic endometriosis clinic for follow-up 1 month after oocyte retrieval, to be evaluated for pelvic optimization before potential embryo transfer, with worsening dysmenorrhea, dyspareunia, and overall pelvic pain. Eleven years prior, the patient had undergone left ovarian cystectomy for treatment of endometrioma, as well as excision of deep infiltrative endometriosis. The oocyte retrieval procedure, where more than 30 eggs were retrieved, was complicated by ovarian hyperstimulation syndrome and intraperitoneal bleeding, which necessitated admission to the intensive care unit (ICU) for 3 days. Following discharge from the ICU, the patient experienced occasional on-and-off pressure of the urinary bladder and persistent aching pelvic pain. At the 1-month follow-up appointment, the patient's vital signs were assessed (blood pressure, 142/94 mm Hg; pulse rate, 95 per minute; temperature, 96.8 °F [36 °C]). Routine blood investigations, including white blood cell count, were within normal limits. Physical examination showed the abdomen was soft but there was mild pelvic tenderness. The serum β-human chorionic gonadotropin test result was negative for pregnancy, and urinalysis testing showed no leukocyte esterase or nitrites. MRI of the pelvis (Figs 1-3) was performed to evaluate the worsening pain.
Topics: Humans; Female; Adult; Magnetic Resonance Imaging; Endometriosis; Diagnosis, Differential; Pelvic Pain
PubMed: 38916503
DOI: 10.1148/radiol.231863