Evaluating post radical prostatectomy mechanisms of early continence

BACKGROUND

To identify the periprostatic structures associated with early return of urinary continence after radical prostatectomy (RP).

METHODS

We compared total continence results between four different techniques of robot-assisted radical prostatectomy (RARP). Specifically, we studied 1-week and 1-month zero-pad continence rates of anterior (n = 60), posterior (n = 59), a novel hybrid posterior-anterior (n = 12), and transvesical (n = 12) approaches of RARP. Each technique preserved a unique set of periprostatic anatomic structures, thereby, allowing evaluation of the individual impact of preservation of nerves, bladder neck, and space of Retzius with associated anterior support structures on early continence. Urethral length was preserved in all approaches. The space of Retzius was preserved in posterior and transvesical approaches, while the bladder neck was preserved in posterior and hybrid approaches. Nerve sparing was done per preoperative oncological risk. For all patients, 24-h pad usage rates and 24-h pad weights were noted at 1 week and 1 month after catheter removal. Multivariable logistic regression analysis was performed to identify predictors of early continence. Data were obtained from prospective studies conducted between 2015 and 2021.

RESULTS

At 1 week, 15%, 42%, 45%, and 8% of patients undergoing anterior, posterior, hybrid, and transvesical RARP approaches, respectively, were totally continent (p = 0.003). These rates at 1 month were 35%, 66%, 64%, and 25% (p = 0.002), respectively. The transvesical approach, which preserved the space of Retzius but not the bladder neck, was associated with the poorest continence rates, while the posterior and hybrid approaches in which the bladder neck was preserved with or without space of Retzius preservation were associated with quickest urinary continence recovery. Bladder neck preservation was the only significant predictor of 1-week and 1-month total continence recovery in adjusted analysis, Odds ratios 9.06 (p = 0.001) and 5.18 (p = 0.004), respectively.

CONCLUSIONS

The beneficial effect of the Retzius-sparing approach on early continence recovery maybe associated with bladder neck preservation rather than space of Retzius preservation.

Prostate Cancer Survival Estimates by the General Public Using Unrestricted Internet Searches and Online Nomograms

BACKGROUND

Patient understanding of cancer-associated risk influences treatment preferences and is vital for making informed treatment decisions. Although patients traditionally relied on physician visits for cancer information, most adults now use the Internet as a primary source of health information.

OBJECTIVE

To evaluate whether US adults can accurately estimate survival for hypothetical prostate cancer patients using unrestricted Internet searching and an online nomogram.

DESIGN, SETTING, AND PARTICIPANTS

Adults were recruited at the Minnesota State Fair. Participants were shown a pathology report for a prostatectomy cancer specimen and asked to estimate the patient's 15-yr survival using an unrestricted Internet search. Participants were then asked to re-estimate using a freely available, validated prostate cancer nomogram.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Participants' answers were compared to a "reference" estimate and a "ballpark" estimate of ±10 percentage points of the "reference" value.

RESULTS AND LIMITATIONS

A total of 129 participants met the inclusion criteria and generated complete responses. Only 12% (95% confidence interval [CI] 7.8-19.2%) were within the "ballpark" estimate when using unrestricted Internet searching for overall survival estimates. 23% (95% CI 16.8-31.3%) correctly used the nomogram and 51% (95% CI 42.6-59.6%) estimated within the "ballpark" when using the nomogram.

CONCLUSIONS

Use of an unrestricted Internet search often yields inaccurate estimations of life expectancy, while estimations significantly improve with nomogram use. Physicians should educate and guide patients towards credible online health resources, facilitate their effective use, and engage in discussion with patients regarding the utility of this information.

PATIENT SUMMARY

The general public finds it difficult to estimate prostate cancer survival using unrestricted Internet searches. Most patients would benefit from Internet guidance from their clinicians to better understand prostate cancer pathology reports.

Managing Urology Consultations During COVID-19 Pandemic: Application of a Structured Care Pathway

Objective

To describe and evaluate a risk-stratified triage pathway for inpatient urology consultations during the SARS-CoV-2 (COVID-19) pandemic. This pathway seeks to outline a urology patient care strategy that reduces the transmission risk to both healthcare providers and patients, reduces the healthcare burden, and maintains appropriate patient care.

Materials and Methods

Consultations to the urology service during a 3-week period (March 16 to April 2, 2020) were triaged and managed via one of 3 pathways: Standard, Telemedicine, or High-Risk. Standard consults were in-person consults with non COVID-19 patients, High-Risk consults were in-person consults with COVID-19 positive/suspected patients, and Telemedicine consults were telephonic consults for low-acuity urologic issues in either group of patients. Patient demographics, consultation parameters and consultation outcomes were compared to consultations from the month of March 2019. Categorical variables were compared using Chi-square test and continuous variables using Mann-Whitney U test. A P value <.05 was considered significant.

Results

Between March 16 and April 2, 2020, 53 inpatient consultations were performed. By following our triage pathway, a total of 19/53 consultations (35.8%) were performed via Telemedicine with no in-person exposure, 10/53 consultations (18.9%) were High-Risk, in which we strictly controlled the urology team member in-person contact, and the remainder, 24/53 consultations (45.2%), were performed as Standard in-person encounters. COVID-19 associated consultations represented 18/53 (34.0%) of all consultations during this period, and of these, 8/18 (44.4%) were managed successfully via Telemedicine alone. No team member developed COVID-19 infection.

Conclusion

During the COVID-19 pandemic, most urology consultations can be managed in a patient and physician safety-conscious manner, by implementing a novel triage pathway.

Spontaneous passage of ureteral stones in patients with indwelling ureteral stents

INTRODUCTION

To determine rates of spontaneous ureteral stone passage in patients with indwelling ureteral stents, and to identify factors associated with the spontaneous passage of stones while a ureteral stent is in place.

MATERIALS AND METHODS

From our institutional database, we identified patients who underwent ureteroscopic procedures for stone disease between January 1, 2013 and March 1, 2015. We compared the rates of spontaneous stone passage between patients who had previously undergone ureteral stent placement and those who had not. In patients with indwelling stents, multivariate logistic regression was performed to identify factors associated with spontaneous stone passage.

RESULTS

A total of 194 patients met inclusion criteria. Spontaneous stone passage rates were similar in the stented (17/119, 14%) and non-stented (15/75, 20%) groups (p = 0.30). In bivariate analysis of stented patients, smaller stone size (p < 0.001) and distal stone location (p = 0.01) were significantly associated with spontaneous stone passage. Multivariate logistic regression analysis of stented patients showed that only small stone size was significantly associated with the likelihood of stone passage (p = 0.01), whereas stent duration, stone location, and stone laterality were not.

CONCLUSIONS

A small, but clinically significant percentage of ureteral stones pass spontaneously with a ureteral stent in place. Small stone size is associated with an increased likelihood of spontaneous passage in patients with indwelling stents. These findings may help to identify patients who can potentially avoid additional surgical procedures for definitive stone removal after ureteral stent placement.

[Occurrence of scrapie in Switzerland: an anonymous cross-sectional study]

Scrapie is a transmissible spongiform encephalopathy of sheep and goats, which leads to neurological signs and ends with the death of the infected animal. In Switzerland only a few cases were reported since 1982. In 1999, a questionnaire survey was conducted to increase information about neurological diseases in sheep and goat breeding farms. The aim was to estimate the frequency of neurological disorders including Scrapie and to increase the disease awareness of sheep and goat breeders. The main goal of the study was to increase the reporting of suspect cases of Scrapie and its differential diagnoses. Out of a database of all registered farms with at least five breeding sheep or breeding goats a random sample of 4711 was drawn to which anonymous questionnaires were sent. The return rate was 36%. In a parallel study, 150 voluntarily participants were interviewed using the same questionnaire. The results of both parts of the survey coincided. For the years 1997 and 1998, on average 1.0% of the breeding sheep and breeding goats showed neurological signs. 7.7% of the breeders indicated to have observed animals with neurological symptoms in their flock. At the population level, a total of 1954-2336 animals with neurological signs are observed in 691-929 flocks. The minority is reported to the veterinary authorities.

Coupling of ventilation and CO2 production during exercise in children

The purpose of this study was to determine how ventilation (VE) and CO2 production (VCO2) in response to exercise change during the growth process in children and teenagers. Dynamic gas exchange responses were measured in two types of studies: 128 healthy children ranging in age from 6 to 18 yr performed progressive exercise tests ("ramp" type protocol) for measurement of the slope of the relationship between VE and VCO2--delta VE/delta VCO2; and the response characteristics of VE and VCO2 in the transition between rest and exercise were measured in 11 teenagers and 11 younger children. Gas exchange was measured breath by breath. We found a small but significant decrease in delta VE/delta VCO2 with increasing body weight (r = -0.46, p less than 0.05), height, or age (mean slope of 27 in the youngest in 21 in the oldest subjects). The response characteristics of VE and VCO2 (measured as the time constant of the best-fit exponential response) were longer than for VO2 in both younger children and teenagers; but the time constants for VE and VCO2 were each approximately 30% faster in younger children compared to teenagers. In addition, end-tidal PCO2 during exercise was significantly lower in the younger subjects (mean value of 39.6 torr) compared to the teenagers (mean value of 43.5 torr). The results suggest that the process of respiratory control in exercise matures to a small degree during childhood in that PCO2 may be regulated at lower levels in younger children and there may be growth-related differences in the relative amounts of CO2 that can be stored in tissues.