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Journal of Perianesthesia Nursing :... Jan 2024Pain after open urological procedures is often intense. The aim of the study was to compare the efficacy of intrathecal morphine with systemic analgesia approaches.
PURPOSE
Pain after open urological procedures is often intense. The aim of the study was to compare the efficacy of intrathecal morphine with systemic analgesia approaches.
DESIGN
Prospective, randomized, single-blind controlled study.
METHODS
Patients undergoing open prostatectomy or nephrectomy were randomly divided into the intervention group or the control group. Patients in the intervention group received morphine 250 mcg in 2.5 mL saline intrathecally. Anesthesia was identical in both groups. All patients were admitted to the intensive care unit (ICU) postoperative and received paracetamol 1 g intravenously every 6 hours and diclofenac 75 mg intramuscularly every 12 hours. If postoperative pain exceeded four on the numeric rating scale, morphine 10 mg was administered subcutaneously. Pain intensity, time to first dose of morphine, morphine doses, and side effects were recorded.
FINDINGS
In total, 41 patients were assigned to the intervention group and 57 to the control group. The time to administration of the first dose of morphine was significantly (P < .001) longer in the intervention group when compared to controls. This observation was also noted individually for patients undergoing nephrectomy (36.86 hours vs 4.06 hours) and prostatectomy (33.13 hours vs 4.5 hours). Many patients did not need opioids after surgery in the intervention group (nephrectomy 72% vs 3%, prostatectomy 75% vs 4.5%, P < .001). There was no significant difference in the incidence of side effects.
CONCLUSIONS
The results of our study confirmed that preoperative intrathecal morphine provides long-lasting analgesia and reduces the need for postoperative systemic administration of opioids. Adverse effects are minor and comparable between groups.
PubMed: 38300193
DOI: 10.1016/j.jopan.2023.10.019 -
European Urology Open Science Jan 2024Prostatic urethral lift, or UroLift, has gained popularity as a treatment for lower urinary tract symptoms associated with benign prostatic hyperplasia (BPH). Surgical...
Incidence of Surgical Reintervention for Benign Prostatic Hyperplasia Following Prostatic Urethral Lift, Transurethral Resection of the Prostate, and Photoselective Vaporization of the Prostate: A TriNetX Analysis.
BACKGROUND
Prostatic urethral lift, or UroLift, has gained popularity as a treatment for lower urinary tract symptoms associated with benign prostatic hyperplasia (BPH). Surgical reintervention rates are a reliable indicator for treatment durability.
OBJECTIVE
The objective of this study was to utilize TriNetX, a third-party database, to investigate the incidence of surgical reintervention following UroLift, transurethral resection of the prostate (TURP), and photoselective vaporization of the prostate (PVP) procedures for BPH from 2015 to 2018.
DESIGN SETTING AND PARTICIPANTS
Male patients aged 18-100 yr diagnosed with BPH were identified in the TriNetX Diamond Network database between January 2015 and December 2018. Cohorts of individuals undergoing their first UroLift procedure were built using Current Procedural Terminology and International Classification of Diseases 10th Revision codes. TURP and PVP cohorts were built as comparison groups. The cohorts were then queried for subsequent BPH-related procedures.
OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS
Reprocedure rates were assessed and descriptive statistics were used.
RESULTS AND LIMITATIONS
The mean age at first-time UroLift was 70.1 ± 9.4 yr ( = 14 343). Cumulative reprocedure rates collected after first-time UroLift included 1 yr after UroLift (5.1%, = 14 343) and 4 yr after UroLift (16.1%, = 710), with an average annual increase of +3.6% per year following 1 yr after the procedure. Comparatively, TURP ( = 22 071) and PVP ( = 14 110) had 4-yr reprocedure rates of 7.5% and 7.8%, respectively, during the same timeframe. Limitations include a lack of clinical data and loss of follow-up data outside the Diamond Network.
CONCLUSIONS
The reprocedure rate of UroLift at 4 yr is double the rate of TURP and PVP. In appropriately selected patients, UroLift might be a suitable option for those who desire symptomatic relief from BPH with minimal erectile and ejaculatory side effects. However, the risk of secondary surgical intervention should be considered when considering BPH treatments.
PATIENT SUMMARY
We compared the reintervention rates of prostatic urethral lift (PUL), transurethral resection of the prostate (TURP), and photoselective vaporization of the prostate (PVP) using the TriNetX database, and have found that the highest reintervention rates were for PUL of 16% at 4 yr of follow-up, compared with about 8% for those who had TURP and PVP. Interestingly, the most common reintervention was the same operation at 1 yr. This has important implications when counseling patients about the durability of these various outlet procedures for BPH.
PubMed: 38298771
DOI: 10.1016/j.euros.2023.11.009 -
European Urology Open Science Jan 2024
PubMed: 38298763
DOI: 10.1016/j.euros.2023.11.001 -
BMJ Open Jan 2024Despite radical prostatectomy (RP) and radiotherapy (RT) being established treatments for localised prostate cancer, a significant number of patients experience...
HypoFocal SRT Trial: Ultra-hypofractionated focal salvage radiotherapy for isolated prostate bed recurrence after radical prostatectomy; single-arm phase II study; clinical trial protocol.
INTRODUCTION
Despite radical prostatectomy (RP) and radiotherapy (RT) being established treatments for localised prostate cancer, a significant number of patients experience recurrent disease. While conventionally fractionated RT is still being used as a standard treatment in the postoperative setting, ultra-hypofractionated RT has emerged as a viable option with encouraging results in patients with localised disease in the primary setting. In addition, recent technological advancements in RT delivery and precise definition of isolated macroscopic recurrence within the prostate bed using prostate-specific membrane antigen-positron emission tomography (PSMA-PET) and multiparametric MRI (mpMRI) allow the exploration of ultra-hypofractionated schedules in the salvage setting using five fractions.
METHODS AND ANALYSIS
In this single-arm prospective phase II multicentre trial, 36 patients with node-negative prostate adenocarcinoma treated with RP at least 6 months before trial registration, tumour stage pT2a-3b, R0-1, pN0 or cN0 according to the UICC TNM 2009 and evidence of measurable local recurrence within the prostate bed detected by PSMA PET/CT and mpMRI within the last 3 months, will be included. The patients will undergo focal ultra-hypofractionated salvage RT with 34 Gy in five fractions every other day to the site of local recurrence in combination with 6 months of androgen deprivation therapy. The primary outcome of this study is biochemical relapse-free survival at 2 years. Secondary outcomes include acute side effects (until 90 days after the end of RT) of grade 3 or higher based on Common Terminology Criteria for Adverse Events V.5, progression-free survival, metastasis-free survival, late side effects and the quality of life (based on European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-C30, QLQ-PR25).
ETHICS AND DISSEMINATION
The study has received ethical approval from the Ethics Commission of the Canton of Bern (KEK-BE 2022-01026). Academic dissemination will occur through publications and conference presentations.
TRIAL REGISTRATION NUMBER
NCT05746806.
Topics: Male; Humans; Prostate; Prostatic Neoplasms; Treatment Outcome; Androgen Antagonists; Positron Emission Tomography Computed Tomography; Prospective Studies; Quality of Life; Neoplasm Recurrence, Local; Prostatectomy; Salvage Therapy; Prostate-Specific Antigen; Multicenter Studies as Topic; Clinical Trials, Phase II as Topic
PubMed: 38296279
DOI: 10.1136/bmjopen-2023-075846 -
BMC Urology Jan 2024To summarize current evidence to report a comparative systematic review and meta-analysis of prostatic artery embolization (PAE) with transurethral resection of the... (Meta-Analysis)
Meta-Analysis
Comparing prostatic artery embolization to surgical and minimally invasive procedures for the treatment of benign prostatic hyperplasia: a systematic review and meta-analysis.
BACKGROUND
To summarize current evidence to report a comparative systematic review and meta-analysis of prostatic artery embolization (PAE) with transurethral resection of the prostate (TURP) and open simple prostatectomy (OSP) for the treatment of benign prostatic hyperplasia (BPH).
METHODS
A systematic literature search was performed to identify studies published from inception until August 2021. The search terms used were (prostate embolization OR prostatic embolization) AND (prostatic hyperplasia OR prostatic obstruction) as well as the abbreviations of PAE and BPH. Risk of bias was assessed using the Cochrane Risk of Bias tool for randomized controlled trials (RCTs) and the Risk of Bias in Non-randomized Studies-of Interventions (ROBINS-I) tool for observational studies. Random-effects meta-analysis was performed using Revman 5.4.
RESULTS
Seven studies were included with 810 patients: five RCTs and one observational study compared PAE with TURP, and one observational study compared PAE with OSP. The included studies had considerable risk of bias concerns. TURP and OSP were associated with more statistically significant improvements in urodynamic measures and BPH symptoms compared to PAE. However, PAE seems to significantly improve erectile dysfunction compared to OSP and improve other outcome measures compared to TURP, although not significantly. PAE appeared to reduce adverse events and report more minor complications compared with TURP and OSP, but it is unclear whether PAE is more effective in the long-term.
CONCLUSION
PAE is an emerging treatment option for patients with symptomatic BPH who cannot undergo surgery or have undergone failed medical therapy. Overall, PAE groups reported fewer adverse events. Future ongoing and longer-term studies are needed to provide better insight into the benefit of PAE compared to other treatment options.
Topics: Male; Humans; Prostate; Prostatic Hyperplasia; Treatment Outcome; Transurethral Resection of Prostate; Embolization, Therapeutic; Arteries; Minimally Invasive Surgical Procedures; Lower Urinary Tract Symptoms; Observational Studies as Topic
PubMed: 38281906
DOI: 10.1186/s12894-023-01397-1 -
Central European Journal of Urology 2023A positive surgical margin (PSM) in the radical prostatectomy (RP) specimen is associated with biochemical recurrence (BCR) and the need for adjuvant radiation therapy,...
INTRODUCTION
A positive surgical margin (PSM) in the radical prostatectomy (RP) specimen is associated with biochemical recurrence (BCR) and the need for adjuvant radiation therapy, and is an analysis of surgical procedure quality. We present data describing the identification, anatomy, and management of PSM after RP performed via an open operation and laparoscopically. The aim of the study was to compare assessment of RP (open vs. laparoscopic) in terms of analysis of PSM in postoperative histopathological tissue.
MATERIAL AND METHODS
Patients with pT1 to pT3b prostate cancer with detailed surgical margin parameters and BCR status were analysed. The patients were divided into groups depending on the stage of neoplastic disease and the choice of operative procedure.
RESULTS
In total, we obtained data from 140 PC patients. Positive surgical margins were confirmed in 11 cases treated with open surgery and in 7 cases treated with laparoscopic procedure. There was no statistically significant (p >0.05) relationship between the frequency of positive margins and the type of procedure. There was no statistically significant (p >0.05) relationship between the frequency of positive margins and the type of procedure in subgroups according to the Gleason score. There was a statistically significant (p <0.05) relationship between the clinical stage of the tumor and the type of margin. This particularly refers to tumours with stage T3b (more numerous in the group of open surgeries) and T2c (more numerous in the laparoscopic group).
CONCLUSIONS
There was no statistically significant correlation between the type of surgery and the incidence of a positive surgical margin.
PubMed: 38230315
DOI: 10.5173/ceju.2023.77 -
Urology Journal May 2024To analyze the perioperative factors that influence the risk of biochemical recurrence (BCR) in patients with localized PCa undergoing radical prostatectomy Materials...
PURPOSE
To analyze the perioperative factors that influence the risk of biochemical recurrence (BCR) in patients with localized PCa undergoing radical prostatectomy Materials and Methods: A total of 457 patients, operated by 2 surgeons in our high-volume oncological center were included in the initial database. Patients who underwent RP for clinically localized PCa in our clinic from 2016 to 2021 were included in the study. Perioperative data were retrospectively reviewed for this study. Follow-up data including post-operative PSA and adjuvant treatment was prospectively gathered by contacting the patients or from the follow-up consultation. Final database was composed of 366 patients who underwent open or 3D laparoscopic RP. Statistical analysis was performed to emphasize the most powerful parameters that influence the BCR. Results: Accounting for multivariable analysis, 4 parameters were statistically significant: initial PSA (iPSA), Gleason score, vascular involvement and positive surgical margins. For the group of patients with no positive margins, 3 parameters were statistically significant: iPSA above 10,98 ng/mL (AUC=0,71); lymph node involvement and Gleason score. Multivariable Cox regression showed that positive margins and iPSA had a significant impact on the time to BCR. Patients that received adjuvant therapy were excluded from the study. Out of the whole cohort, 27,3% of patients presented BCR.
CONCLUSION
Perioperative factors need to be carefully analyzed and a detailed follow-up needs to be conducted in order to assess the risk of biochemical recurrence, resulting in the optimal time for adjuvant treatment implementation.
Topics: Humans; Prostatectomy; Male; Prostatic Neoplasms; Neoplasm Recurrence, Local; Middle Aged; Retrospective Studies; Prostate-Specific Antigen; Aged; Risk Assessment; Risk Factors; Perioperative Period
PubMed: 38219017
DOI: 10.22037/uj.v20i.7835 -
World Journal of Urology Jan 2024Versius CMR is a novel robotic system characterized by an open surgical console and independent bedside units. The system has potentials of flexibility and versatility,...
INTRODUCTION
Versius CMR is a novel robotic system characterized by an open surgical console and independent bedside units. The system has potentials of flexibility and versatility, and has been used in urological, gynecological, and general surgical procedure. The aim is to depict a comprehensive analysis of the Versius system for pelvic surgery.
METHODS
This is a study involving two Institutions, ASST Santi Paolo and Carlo, Milan, and Apuane Hospital, Massa, Italy. All interventions performed in the pelvic area with the Versius were included. Data about indications, intra-, and post-operative course were prospectively collected and analyzed.
RESULTS
A total of 171 interventions were performed with the Versius. Forty-two of them involved pelvic procedures. Twenty-two had an oncological indication (localized prostate cancer), the remaining had a non-oncological or functional purpose. The mostly performed pelvic procedure was radical prostatectomy (22) followed by annexectomy (9). No intra-operative complication nor conversion to other approaches occurred. A Clavien II complication and one Clavien IIIb were reported. Malfunctioning/alarms requiring a power cycle of the system occurred in 2 different cases. An adjustment in trocar placement according to patients' height was required in 2 patients undergoing prostatectomy, in which the trocar was moved caudally. In two cases, a pelvic prolapse was repaired concomitant with other gynecological procedures.
CONCLUSIONS
Pelvic surgery with the Versius is feasible without major complications; either dissection and reconstructive steps could be accomplished, provided a proper OR setup and trocar placement are pursued. Versius can be easily adopted by surgeons of different disciplines and backgrounds; a further multi-specialty implementation is presumed and long-term oncological and functional outcomes are awaited.
Topics: Male; Humans; Prostatectomy; Plastic Surgery Procedures; Prostatic Neoplasms; Robotic Surgical Procedures; Preoperative Care
PubMed: 38217724
DOI: 10.1007/s00345-023-04730-3 -
BJS Open Nov 2023It is not clear whether the routine placement of a pelvic drain after robot-assisted radical prostatectomy is a necessity. The aim of this study was to investigate this... (Meta-Analysis)
Meta-Analysis
BACKGROUND
It is not clear whether the routine placement of a pelvic drain after robot-assisted radical prostatectomy is a necessity. The aim of this study was to investigate this through a meta-analysis of RCTs and non-randomized studies.
METHODS
A search was performed in PubMed/MEDLINE, Embase, the Cochrane Library, and the Web of Science, up to 9 March 2023, for clinical trials comparing no drain with pelvic drain placement for patients with prostate cancer after robot-assisted radical prostatectomy. Two researchers independently conducted literature screening, data extraction, and quality assessment. A random-effect model was assumed for all analyses. The Cochrane Collaboration's risk-of-bias tool was used to evaluate the methodological quality of RCTs and, for non-randomized studies, the ROBINS-I tool was used (where ROBINS-I stands for Risk Of Bias In Non-randomized Studies - of Interventions). This meta-analysis was prospectively registered in PROSPERO, the international prospective register of systematic reviews (CRD42023406429).
RESULTS
A total of six studies with 1480 patients were included in the meta-analysis. Both the meta-analysis of RCTs and the meta-analysis of non-randomized studies showed that patients without drains had a similar estimated blood loss (mean difference 40.49 ml, 95% c.i. -59.75 to 140.74 ml, P = 0.430, and mean difference -14.20 ml, 95% c.i. -32.26 to 3.87 ml, P = 0.120 respectively), overall complication rate (OR 0.60, 95% c.i. 0.35 to 1.04, P = 0.070, and OR 0.90, 95% c.i. 0.59 to 1.39, P = 0.640 respectively), Clavien-Dindo grade I-II complication rate (OR 0.62, 95% c.i. 0.34 to 1.13, P = 0.120, and OR 0.83, 95% c.i. 0.28 to 2.51, P = 0.750 respectively), Clavien-Dindo grade III-V complication rate (OR 0.60, 95% c.i. 0.10 to 3.69, P = 0.590, and OR 0.92, 95% c.i. 0.25 to 3.39, P = 0.900 respectively), and duration of hospital stay (mean difference -0.08 days, 95% c.i. -0.45 to 0.29 days, P = 0.670, and mean difference -0.64 days, 95% c.i. -2.67 to 1.39 days, P = 0.540 respectively) compared with routinely drained patients. Meta-analysis of non-randomized studies revealed that the duration of operation for patients without drains was shorter than that for patients with drains (mean difference -34.88 min, 95% c.i. -43.58 to -26.18 min, P < 0.001), but the meta-analysis of RCTs indicated that there was no significant difference between the two groups (mean difference -7.64 min, 95% c.i. -15.61 to 0.32 min, P = 0.060).
CONCLUSION
The intraoperative and postoperative outcomes of patients without drains were not inferior to those of patients with drains. In selected patients, pelvic drains can be omitted after robot-assisted radical prostatectomy.
Topics: Humans; Male; Postoperative Complications; Prostatectomy; Robotic Surgical Procedures; Drainage
PubMed: 38155395
DOI: 10.1093/bjsopen/zrad143 -
European Urology Open Science Dec 2023On the basis of previous analyses of the incidence of urinary incontinence (UI) after radical prostatectomy (RP), the hospital RP volume threshold in the Netherlands was...
BACKGROUND
On the basis of previous analyses of the incidence of urinary incontinence (UI) after radical prostatectomy (RP), the hospital RP volume threshold in the Netherlands was gradually increased from 20 per year in 2017, to 50 in 2018 and 100 from 2019 onwards.
OBJECTIVE
To evaluate the impact of hospital RP volumes on the incidence and risk of UI after RP (RP-UI).
DESIGN SETTING AND PARTICIPANTS
Patients who underwent RP during 2016-2020 were identified in the claims database of the largest health insurance company in the Netherlands. Incontinence was defined as an insurance claim for ≥1 pads/d.
OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS
The relationship between hospital RP volume (HV) and RP-UI was assessed via multivariable analysis adjusted for age, comorbidity, postoperative radiotherapy, and lymph node dissection.
RESULTS AND LIMITATIONS
RP-UI incidence nationwide and by RP volume category did not decrease significantly during the study period, and 5-yr RP-UI rates varied greatly among hospitals (19-85%). However, low-volume hospitals (≤120 RPs/yr) had a higher percentage of patients with RP-UI and higher variation in comparison to high-volume hospitals (>120 RPs/yr). In comparison to hospitals with low RP volumes throughout the study period, the risk of RP-UI was 29% lower in hospitals shifting from the low-volume to the high-volume category (>120 RPs/yr) and 52% lower in hospitals with a high RP volume throughout the study period (>120 RPs/yr for 5 yr).
CONCLUSIONS
A focus on increasing hospital RP volumes alone does not seem to be sufficient to reduce the incidence of RP-UI, at least in the short term. Measurement of outcomes, preferably per surgeon, and the introduction of quality assurance programs are recommended.
PATIENT SUMMARY
In the Netherlands, centralization of surgery to remove the prostate (RP) because of cancer has not yet improved the occurrence of urinary incontinence (UI) after surgery. Hospitals performing more than 120 RP operations per year had better UI outcomes. However, there was a big difference in UI outcomes between hospitals.
PubMed: 38152486
DOI: 10.1016/j.euros.2023.09.014