Functional and oncologic outcomes of prostate capsule-sparing radical cystectomy: A systematic review and meta-analysis

Radical cystectomy (RC) is the gold standard treatment for patients with organ-confined bladder cancer. However, despite the success of this treatment, many men who undergo orthotopic neobladder substitution develop significant erectile dysfunction and urinary symptoms, including daytime and nighttime urinary incontinence. Prostate-capsule-sparing radical cystectomy (PCS-RC) with orthotopic neobladder (ONB) has been described in the literature as a surgical technique to improve functional outcomes in appropriately selected patients. We performed a systematic review and meta-analysis of manuscripts on PCS-RC with ONB published after 2000. We included retrospective and prospective studies with more than 25 patients and compared PCS-RC with nerve-sparing or conventional RC. Studies in which the entire prostate was spared (including the transitional zone) were excluded. Comparative studies were analyzed to assess rates of daytime continence, nighttime continence, and satisfactory erectile function in patients undergoing PCS-RC compared with those undergoing conventional RC. Fourteen reports were included in the final review. Our data identify high rates of daytime (83%-97%) and nighttime continence (60%-80%) in patients undergoing PCS-RC with ONB. In comparative studies, meta-analysis results demonstrate no difference in daytime continence (RR:1.12; 95% CI: 0.72-1.73) in those undergoing PCS-RC compared to those undergoing conventional RC. Similarly, nighttime continence was similar between the 2 groups (RR:1.85; 95% CI: 0.57-6.00. Erectile function was improved in those undergoing PCS-RC (RR 5.35; 95% CI: 1.82-15.74) in the PCS-RC series. Bladder cancer margin positivity and recurrence rates were similar to those reported in the literature with conventional RC with an average weighted follow-up of 52.2 months. While several studies utilized different prostate cancer (CaP) screening techniques, the rates of CaP were low (incidence 0.02; 95% CI:0.01-0.04), and oncologic outcomes were similar to standard RC. PCS-RC is associated with improved nighttime continence and erectile function compared to conventional RC techniques. Further work is needed to standardize CaP screening before surgery, but the data suggest low rates of CaP with similar oncologic outcomes when compared to RC.

Long-term outcomes of pelvic-fascia sparing robotic-assisted radical prostatectomy versus standard technique: Superior urinary function and quality of life without compromising oncologic efficacy in a single-surgeon series

BACKGROUND

Prostatic fascia-sparing robotic-assisted radical prostatectomy (PFS-RARP) has improved short-term postoperative continence compared to standard prostatectomy (S-RARP) but long-term differences remain unclear.

MATERIALS AND METHODS

One hundred two S-RARP followed by 239 PFS-RARPs were performed by a single surgeon. Univariate analyses were performed with t-test, χ2, Wilcoxon rank sum, Fisher exact, and analysis of variance (ANOVA). Regression models analyzed associates of EPIC-CP scores and oncologic outcomes. Cox proportional hazards modeling assessed postoperative continence. Primary outcomes included patient-reported urinary incontinence (UI) via EPIC-CP and continence rates. Secondary outcomes included EPIC-CP scores, positive surgical margins (PSM), and biochemical recurrence (BCR). Perioperative outcomes and time to continence were measured.

RESULTS

Median follow-up for PFS-RARP vs. S-RARP was 26 vs. 65 months. PFS-RARP demonstrated improved EPIC-CP UI and total scores at 24 months. On multivariate analysis, PFS-RARP was associated with improved EPIC-CP UI and total scores through 18 months, but not with PSM or BCR. PFS-RARP had a 39% and 66% reduced risk of incontinence using 0 and 0 to 1 pad-use definitions (HR 0.61, 95% CI 0.39 - 0.95; HR:0.34, 95% CI 0.16 - 0.76). Continence returned faster with PFS-RARP (0 PPD: 91.0 days vs. 261 days, P < 0.001; 0-1 PPD: 32.7 days vs. 171 days, P < 0.001). There were no differences in PSM (35% vs. 25%, P = 0.064). There were more anterior PSM in PFS-RARP vs. S-RARP (47% vs. 26% P = 0.035), but no differences in BCR (16% vs. 22% P = 0.241).

CONCLUSIONS

PFS-RARP improves continence and patient-reported QOL up to 24 months postoperatively without compromising oncologic outcomes.

Economic Outcomes of Hexaminolevulinate Blue-Light Cystoscopy in Non-Muscle Invasive Bladder Cancer: A 5-Year, Medicare-Based Model

BACKGROUND: Bladder cancer is the most expensive cancer to treat on a per-patient basis. Blue light cystoscopy with hexaminolevulinate (BLC) has demonstrated improved diagnostic accuracy compared with white light cystoscopy (WLC) in non-muscle invasive bladder cancer (NMIBC). With higher upfront costs, questions remain about long-term BLC cost outcomes. OBJECTIVE: This study seeks to investigate the 5-year cost comparison of BLC and WLC from the Medicare payer perspective. METHODS: A representative 5-year NMIBC management model was constructed and Medicare reimbursement values were overlaid. The primary outcome was mean year-over-year cumulative cost discounted to present value at a 3% annual percentage rate. The secondary outcome was the rate of clinical events. RESULTS: Patients in the BLC cohort experienced fewer recurrences. On a cumulative present value cost basis, BLC was more expensive per patient in years 1, 2, and 3 than WLC, however, in years 4 and 5, BLC was economically favorable. Year 5 BLC mean cumulative cost savings was $1,172 per patient. Overall, 31.6% of all patients in the BLC group generated cumulative cost savings compared to WLC at year 1 compared with 50.9% at the end of year 5. CONCLUSIONS: Despite a higher initial annual cost, a slight cumulative economic advantage of BLC is realized after surveillance year 3. Additionally, a greater proportion of patients who received BLC achieved cost savings at the end of year 5. As novel technology emerges, economic models can help health care systems predict associated costs and quality improvements.

Renal surgery in patients with a duplicated inferior vena cava: a case series and review of the literature

Abnormal inferior vena cava (IVC) anatomy may present unique challenges for urologists when performing retroperitoneal surgery. Duplication of the IVC is one such anomalous variation and can be found in up to 3% of the population. Misunderstanding of the implications of this aberrant anatomy may lead to intraoperative or postoperative complications. Here, we present two cases of patients undergoing renal surgeries with duplicate IVC. We then review the embryologic origin and anatomic findings in those with abnormal IVC anatomy as well as discuss the surgical implications and considerations for urologists.

Implementation of instructional videos improves nursing comfort with commonly encountered urinary catheter care scenarios

INTRODUCTION

Placement of coudé catheters, manual irrigation of urinary catheters, and management of continuous bladder irrigation (CBI) are routine interventions for which nurses often receive little or no formal education. In this study, our aim was to determine factors associated with higher comfort levels for these catheter-care techniques and to assess whether online instructional videos could be used to improve nursing comfort.

MATERIALS AND METHODS

Three 5-minute videos were created to demonstrate proper technique for coudé catheter placement, manual irrigation of a catheter, and management of CBI. An online module with pre- and post-video surveys was created and administered to all nursing staff at MedStar Georgetown University Hospital.

RESULTS

A total of 821 nurses participated in this study and completed the online module with both pre-- and post-video surveys. Using a 10-point Likert scale, pre-video median comfort levels for coudé catheter placement, manual irrigation of a catheter, and management of CBI were 5, 6, and 5, respectively. Post-video median comfort levels increased significantly to 9, 8, and 8, respectively (p < 0.001). In the linear regression models, prior formal training was significantly associated with higher baseline comfort levels for all three techniques (p < 0.001).

CONCLUSIONS

Prior formal training as well as baseline nursing comfort levels for common catheter related techniques tend to be low and the implementation of simple instructional videos via an online platform may be a useful strategy for improving nursing comfort. This study demonstrates a reproducible strategy for disseminating catheter education for nurses on a larger scale.

Complex space of Retzius lymphocele resulting in iliac compression and submassive pulmonary embolism after robotic Retzius sparing prostatectomy

Lymphoceles are common following prostatectomy with lymph node dissection, but the vast majority are asymptomatic. We present a unique case of a large complex lymphocele tracking into the anterior space of Retzius following Retzius sparing prostatectomy and bilateral pelvic lymphadenectomy. The patient initially presented with shortness of breath and subsequent diagnosis of a submassive pulmonary embolism. Further evaluation revealed compression of the iliac vessels by the fluid collection. Following multiple failed attempts of drainage percutaneously, the patient required return to the operating room for peritoneal marsupialization, drainage of fluid collection, and evacuation of large amounts of clot within the collection.

Promoting patient followup treatment with intra-detrusor onabotulinumtoxinA for overactive bladder

INTRODUCTION

We aimed to characterize patient-related factors that promote followup of repeat onabotulinumtoxinA treatments for overactive bladder via a mixed-methods approach.

METHODS

A retrospective chart review was conducted for patients who received intra-detrusor injection of onabotulinumtoxinA at our institution from 2011-2018, who were then surveyed to evaluate their experience, knowledge, and perceptions regarding onabotulinumtoxinA treatment and followup. Patients who received one onabotulinumtoxinA treatment and patients who underwent multiple treatments were compared to assess followup rates following initial treatment, group characteristics, patient comfort, and patient knowledge of needed retreatment.

RESULTS

A total of 29.3% of patients received a single treatment and 70.7% of patients received multiple treatments. There was no difference in clinical, demographic, or intake variables between groups. Patients receiving multiple treatments reported having their first procedure in the operating room and reported greater improvement in symptoms and procedure comfort. This group was also more likely to understand that repeat treatments are necessary than those undergoing one treatment.

CONCLUSIONS

No research to date has systematically explored patient-reported factors that promote retreatment of onabotulinumtoxinA for overactive bladder. This novel, mixed-methods approach indicates that patient comfort and patient knowledge were the strongest predictors of previous retreatment and anticipated retreatment, suggesting concrete avenues for improved periprocedural patient counselling and education.

Practice patterns for extended venous thromboembolism chemoprophylaxis among urologic oncologists after radical cystectomy

INTRODUCTION

Extended outpatient chemoprophylaxis (ECP) following radical cystectomy (RC) for bladder cancer is proven to reduce rates of venous thromboembolism (VTE). While ECP is commonly performed with enoxaparin, its cost-effectiveness and adherence rate has been called into question. Data from orthopedic literature suggest that ECP with direct oral anticoagulants (DOACs) may be as effective in VTE prevention as enoxaparin in patients undergoing joint surgery. Our goal is to determine how urologic oncologists employ ECP following RC.

METHODS

Members of the Society of Urologic Oncology were surveyed on practice patterns for the use of ECP after RC. Specific questions were asked regarding the use of inpatient and outpatient VTE prophylaxis, as well as perceived barriers to DOACs and enoxaparin.

RESULTS

There were 121 of 878 (13.8%) respondents and the majority were in academic practices (83%). Most respondents had at least 5 years of experience and performed greater than 10 cystectomies annually. Almost all participants utilized inpatient (97%) and extended (80%) chemoprophylaxis for VTE prevention. Of those who elected for ECP, almost all (96%) used enoxaparin. Only 3 respondents (3%) prescribed oral agents such as rivaroxaban (2) or warfarin (1). Among those using enoxaparin, financial-specific barriers to treatment such as lack of insurance coverage (38%), inability to afford the medication (51%), and need for additional insurance authorization (44%) were reported. Poor patient adherence and refusal to perform injections were reported by 20% and 18% of respondents, respectively. Among the 23 physicians who did not use ECP, cost (39%) and delivery method (26%) were cited as barriers to treatment.

CONCLUSIONS

The majority of surveyed urologic oncologists are prescribing subcutaneous enoxaparin ECP following RC. Poor patient adherence due to self-injections and financial barriers were frequently reported and represent a possible opportunity for the use of oral anticoagulants in the post-operative setting. These data will be used in the development of a proposed clinical trial of a DOAC in the post-RC setting.

Near-infrared excited state dynamics of melanins: the effects of iron content, photo-damage, chemical oxidation, and aggregate size

Ultrafast pump-probe measurements can discriminate the two forms of melanin found in biological tissue (eumelanin and pheomelanin), which may be useful for diagnosing and grading melanoma. However, recent work has shown that bound iron content changes eumelanin's pump-probe response, making it more similar to that of pheomelanin. Here we record the pump-probe response of these melanins at a wider range of wavelengths than previous work and show that with shorter pump wavelengths the response crosses over from being dominated by ground-state bleaching to being dominated by excited-state absorption. The crossover wavelength is different for each type of melanin. In our analysis, we found that the mechanism by which iron modifies eumelanin's pump-probe response cannot be attributed to Raman resonances or differences in melanin aggregation and is more likely caused by iron acting to broaden the unit spectra of individual chromophores in the heterogeneous melanin aggregate. We analyze the dependence on optical intensity, finding that iron-loaded eumelanin undergoes irreversible changes to the pump-probe response after intense laser exposure. Simultaneously acquired fluorescence data suggest that the previously reported "activation" of eumelanin fluorescence may be caused in part by the dissociation of metal ions or the selective degradation of iron-containing melanin.