Opioid Use after Nephrectomy for Kidney Cancer in Ontario: A Population-Based Study

OBJECTIVE

To compare the odds of early and prolonged post-operative opioid use in patients undergoing minimally invasive surgery (MIS) versus open surgery for nephrectomy.

METHODS

For opioid-naïve patients in Ontario who underwent nephrectomy for kidney cancer (1994-2017, n=7900), post-discharge opioid use was determined by prescriptions in the Ontario Drug Benefit database (age ≥65 years) and the Narcotics Monitoring System (all patients from 2012). Early opioid use was defined as ≥ 1 prescription 1-90 days after surgery. Two separate definitions of prolonged opioid use were examined: (1) prescription(s) for ≥ 60 days during post-operative days 90-365; (2) ≥ 1 prescriptions between both of: 1-90 days AND 91-180 days after surgery. Predictors of opioid use were assessed using multivariable generalized estimating equation logistic regression, accounting for surgeon clustering.

RESULTS

Overall, 67.4% of patients received early opioid prescriptions; however, prolonged use was low, ranging from 1.6 to 4.4% of patients depending on the definition. In multivariable analysis, open nephrectomy was associated with higher odds of early opioid use compared to MIS nephrectomy (Odds Ratio [OR] 1.36, 95% Confidence Interval [CI] 1.19-1.55). Surgery type was not significantly associated with prolonged opioid use for either definition (OR 1.22, CI 0.79 1.89 and OR 1.06, CI 0.83, 1.35).

CONCLUSIONS

In this population-level study of patients undergoing nephrectomy for kidney cancer, patients who received open surgery were at increased odds of receiving early post-operative opioids compared to MIS. Prolonged opioid use was low overall and was not significantly with associated with type of surgery.

Clinical Characteristics and Outcomes of Late Relapse in Stage I Testicular Seminoma

AIMS

To identify the characteristics and outcomes associated with late relapse in stage I seminoma.

MATERIALS AND METHODS

A retrospective review was carried out of all patients with stage I seminoma managed at our institution between 1981 and 2011. Data were obtained from a prospectively maintained database. Late relapse was defined as tumour recurrence > 2 years after orchiectomy.

RESULTS

Overall, 1060 stage I seminoma patients were managed with active surveillance (n=766) or adjuvant radiotherapy (n=294). At a median follow-up of 10.6 years (range 1.2-30), 142 patients relapsed at a median (range) of 14 (3-129) months; 128 on active surveillance and 14 after adjuvant radiotherapy. The late relapse rate for the active surveillance and adjuvant radiotherapy groups was 4% and 1%, respectively. There was no specific clinicopathological factor associated with late relapse. Isolated para-aortic node(s) was the most common relapse site in active surveillance patients either in late (88%) or early relapse (82%). Among the active surveillance group, no patients with late relapse subsequently developed a second relapse after either salvage radiotherapy (n=25) or chemotherapy (n=6), whereas in early relapse patients a second relapse was reported in seven (10%) of 72 patients treated with salvage radiotherapy and one (4%) of 23 patients who received chemotherapy; all second relapses were subsequently salvaged with chemotherapy. No patient in the adjuvant radiotherapy group developed a second relapse after salvage chemotherapy (n=10) or inguinal radiotherapy/surgery (n=4). Of seven deaths, only one was related to seminoma. Among active surveillance patients, the 10 year overall survival for late and early relapse groups were 100% and 96% (P = 0.2), whereas the 10 year cancer-specific survival rates were 100% and 99% (P = 0.3), respectively.

CONCLUSIONS

In stage I seminoma, the extent and pattern of late relapse is similar to that for early relapse. For active surveillance patients, selective use of salvage radiotherapy/chemotherapy for relapse results in excellent outcomes regardless of the timing of relapse, whereas salvage radiotherapy for late relapse seems to be associated with a minimal risk of second relapse.

Safety and efficacy of photoselective vaporization of prostate in patients receiving anticoagulants

AIM

Objective of the present study was to evaluate the safety and efficacy of photoselective vaporization of the prostate (PVP) using a 80W potassium titanyl phosphate (KTP) laser, in benign prostatic enlargement (BPE) patients who were on ongoing anticoagulant therapy during the perioperative period.

METHODS

Prospectively collected laser prostatectomy patient database of our hospital for the period between July 2009-Jan 2012 was retrospectively reviewed. Data on perioperative safety, functional outcome and complications up to follow-up at 6 months of 45 eligible patients who underwent PVP-KTP and were on perioperative anticoagulant therapy (study group) was compared with 47 eligible patients who underwent PVP-KTP and were not on perioperative anticoagulant therapy (control group). P<0.05 was considered statistically significant.

RESULTS

The baseline characteristics of the two groups were similar except for ASA score which was significantly higher in the study group.(2.64±0.60 vs. 1.53±0.50). Though the need (15.55% vs. 4.25% patients) and duration of postoperative irrigation (243.33±49.66 vs. 52.5±10.60 min) was significantly higher in the study group, the postoperative hemoglobin drop 24 hours postoperatively did not differ significantly between the two groups (8.54% vs. 6.48%). No patient required a blood transfusion. The overall complication rate was similar in the two groups. In both groups, significant improvement was recorded in the IPSS, QOL, Q max, PVRU and prostate volume data upto 6 months follow up with no significant differences noted.

CONCLUSION

KTP-PVP can be performed safely and effectively in BPE patients on ongoing anticoagulation, without increasing the risk of perioperative bleeding or the need for blood transfusion.