Analysis of satisfaction and surgical outcomes of a major ambulatory surgery program for penile implant

INTRODUCTION AND OBJECTIVE

Penile prosthesis (PP) surgery is performed in many institutions as an inpatient procedure. We have recently initiated a major ambulatory surgery (MAS) program, thus reducing the hospital stay. The objective of this study was to assess the feasibility, complications and satisfaction of the implantation of outpatient surgery PP program in our hospital.

MATERIAL AND METHODS

Retrospective observational study evaluating the results and satisfaction of PP implanted as an outpatient procedure in Bellvitge University Hospital during 2018.

RESULTS

During 2018 we implanted 49 PP: 27 (55%) inpatient surgeries vs. 22 (45%) outpatient surgeries. Of these 22, 2 (9%) were second implants. All patients underwent both general anesthesia and crural, proximal dorsal nerve and transversus abdominis plane block (TAP). Complication rates between inpatient and outpatient procedures were similar, 2 (7%) and 1 (5%), respectively, without reporting infections or requiring PP removal. Postoperatively, a satisfaction telephone survey was conducted in 19 (86%) patients: 16 (84%) considered the time of hospital stay as appropriate, 15 (79%) would have preferred to be operated again in an outpatient care setting and 15 (79%) would recommend it. The patients' main concerns were related to being at home with no medical assistance at home and about coming back the next day for drainage removal. All patients reported well-controlled pain without requiring opioid intake in any case.

CONCLUSIONS

In our series, PP implantation in an ambulatory care setting is feasible and safe. Although there are some aspects that should be improved, the program showed acceptable satisfaction rates and an adequate postoperative pain control, neither raising the administration of opioids, nor increasing complications and re-admission rates.

Health-related quality of life in men with prostate cancer undergoing active surveillance versus radical prostatectomy, external-beam radiotherapy, prostate brachytherapy and reference population: a cross-sectional study

Background

The purpose of this study is to describe Health-Related Quality of Life (HRQoL) of localized prostate cancer patients in an Active Surveillance (AS) program, and to compare them with those undergoing radical prostatectomy (RP), external-beam radiotherapy (XRT) and brachytherapy (BT).

Methods

Multi-institutional pooled cross-sectional analysis on patients in an AS protocol: < 75 years old; pathologically confirmed LPC (maximum of three positive cylinders); Gleason score < 3 + 4; clinical stage T1a-T2b; and PSA < 15 ng/ml. Exclusion criteria for this study were: less than 6 months in AS, termination of AS protocol, or incomplete data. Patients in AS were matched with those treated with RP, XRT or BT from the ‘Spanish Multicentric Study of Clinically Localized Prostate Cancer’ cohort according to risk group, time from treatment selection to HRQoL survey, and age. Prostate-specific (EPIC) and generic (SF-36) HRQoL instruments were completed. Analysis was stratified by HRQoL survey moment (>or < 2.5 years from treatment selection), and age (>or < 70 years old).

Results

Median of time from treatment selection to HRQoL survey in the total 396 patients (99 per treatment group) was 2.4 years (range 0.5–8.3). Patients in AS presented higher (better) urinary incontinence scores than RP ones in both stratus of time from treatment selection to HRQoL survey (92.6 vs 67.0 and 81.4 vs 64.4, p <  0.01). Patients in AS for < 2.5 years presented greater sexual scores than any active treatment (p <  0.01), but only statistically higher than RP for those in AS for longer than 2.5 years. The magnitude of the differences between AS and RP groups in both EPIC domains ranged from moderate (0.7 SD) to large (1.0 SD).

Regardless of treatment applied, patients presented similar and slightly increased SF-36 scores than US general population reference norms. Nonetheless, patients in AS for < 2.5 years reported worse outcomes than other treatment groups on physical health domains, especially in bodily pain (0.5–0.6 SD), and vitality (0.6–0.8 SD).

Conclusions

Considering patients’ well-being, AS can be a good therapeutic option due to the low impact caused on urinary continence and sexual function. However, longitudinal studies are required to take into account HRQoL evolution over time.

Electronic supplementary material

The online version of this article (10.1186/s12955-019-1082-4) contains supplementary material, which is available to authorized users.

Simultaneous bilateral percutaneous nephrolithotomy: Effectiveness and safety

OBJECTIVES

To evaluate the effectiveness and safety of simultaneous bilateral percutaneous nephrolithotomy performed in patients affected with bilateral renal calculi.

MATERIALS AND METHODS

This is a prospective study from September 2012 to November 2016. Patients diagnosed of bilateral kidney stones with abdominal CT scan were included. Surgical technique prone position, renal puncture guided by fluoroscopy and tract dilation up to 24Ch. We reviewed demographic and stone characteristics, stone free rate, clinical success, complications and follow-up.

RESULTS

During the study period, 732 percutaneous nephrolithotomies were performed. Eighteen patients were included (36 renal units, 2.5%), 13 men and 5 women, with a median age of 58 years and an interquartile range (IQR) of 40-66. Median stone burden was 228mm² (IQR 134-389); median operative time, 150minutes (IQR 97-180); and median hospital stay, 5 days (IQR 5-15). Stone free rate was 80%. Residual calculi were encountered in 8 renal units (22.2%) and required other complementary techniques for their complete tesolution 4 external shockwave lithotripsies, one open ureterolithotomy, 2 ureteroscopies and one second look. Major complications included 4 cases of severe hemorrhage managed with angiographic embolization. The median follow-up was 36 months (range 26-46).

CONCLUSIONS

Simultaneous bilateral percutaneous nephrolithotomy is an effective and safe procedure in patients affected with bilateral renal calculi. It is a surgical challenge that should be performed in selected patients and in centers with experience.

Our experience in the management of prostate cancer in renal transplant recipients

INTRODUCTION AND OBJECTIVES

The management of Prostate cancer (PCa) in renal transplant recipients (RTR) is challenging and remain controversial. Currently there is no consensus about this condition. The aim of the study was to analyse our experience in the diagnosis and management of PCa in RTR.

METHOD

Retrospective monocentric study of a prospective and consecutive database from 2003-2017. Inclusion of RTR diagnosed of PCa. Staging and treatment in agreement with the contemporary guidelines. The main outcome measures included clinical staging, type of treatment, oncological outcomes and follow-up.

RESULTS

1,330 renal transplants were performed (787 males), diagnosed of PCa in 33 RTR (4.2%), mean age 66years±6.3 (51-78). Median PSA was 8.8ng/ml and PSA ratio 0.19. Mean time between renal transplantation and PCa diagnosis 130months±90 (2-236).

TREATMENTS

Radical prostatectomy (RP) (n=22; 66.7%), Radiation therapy (RT) with Androgen deprivation therapy (ADT) (n=7; 21.2%), Active surveillance (n=3; 9.1%), ADT (n=1; 3%). No graft loss neither impaired renal function due to PCa treatment was reported. After RP two patients (9.1%) presented biochemical recurrence treated with RT. Remission of the 100%. Mean follow-up was 61months±37 (6-132).

CONCLUSIONS

PCa in renal transplant patients can be managed with the same therapeutic options as in the general population. Active surveillance should also be provided in RTR despite being under immunosuppressive therapy.

The Patient's Comorbidity Burden Correlates with the Erectile Dysfunction Severity

OBJECTIVE

To explore the potential relationship between erectile dysfunction (ED), low testosterone levels, and the Charlson Comorbidity Index (CCI).

MATERIAL AND METHODS

Cross-sectional study on patients referred to the andrology unit in 7 Spanish centers. The ED was diagnosed and graded using the International Index of Erectile Function (IIEF-5) score. Total testosterone, the prevalence of each comorbidity, and the CCI were compared between patients with different grades of ED. Besides, the correlation between total testosterone and the CCI score, the influence of each comorbidity, and the ED severity on the CCI was assessed in a multiple linear regression.

RESULTS

The study included 430 men with a mean age of 61 years. The mean CCI was 3.5, and mean total testosterone 15.2 nmol/L; 389 (91%) subjects had some grade of ED: 97 (23%) mild, 149 (35%) mild-to-moderate, 86 (20%) moderate, and 57 (13%) severe. The increase in ED severity was significantly associated with a decrease in total testosterone (P=.002), and an increase in the CCI score (P<.001). Testosterone levels were significantly lower in patients with obesity, diabetes, hypercholesterolemia, and hypertriglyceridemia (P<.05). However, only the prevalence of diabetes and hypertension was significantly associated with the severity of ED. The multivariate analysis including variables related to all assessed comorbidities, total testosterone levels, and the DE severity significantly predicted the CCI score (P<.001, R²=.426). The severity of ED significantly contributed to this model (P=.011), but total testosterone did not (P=.204).

CONCLUSIONS

The CCI is significantly associated with the ED severity, but it shows a weak correlation with the testosterone levels.

Treatment options and predictive factors for recurrence and cancer-specific mortality in bladder cancer after renal transplantation: A multi-institutional analysis

OBJECTIVES

Bladder cancer (BC) in the transplanted population can represent a challenge owing to the immunosuppressed state of patients and the higher rate of comorbidities. The objective was to analyze the treatment of BC after renal transplant (RT), focusing on the mode of presentation, diagnosis, treatment options and predictive factors for recurrence.

MATERIAL AND METHODS

We conducted an observational prospective study with a retrospective analysis of 88 patients with BC after RT at 10 European centers. Clinical and oncologic data were collected, and indications and results of adjuvant treatment reviewed. The Kaplan-Meier method and uni- and multivariate Cox regression analyses were performed.

RESULTS

A total of 10,000 RTs were performed. Diagnosis of BC occurred at a median of 73 months after RT. Median follow-up was 126 months. Seventy-one patients (81.6%) had non-muscle invasive bladder cancer, of whom 29 (40.8%) received adjuvant treatment; of these, six (20.6%) received bacillus Calmette-Guérin and 20 (68.9%) mitomycin C. At univariate analysis, patients who received bacillus Calmette-Guérin had a significantly lower recurrence rate (P=.043). At multivariate analysis, a switch from immunosuppression to mTOR inhibitors significantly reduced the risk of recurrence (HR 0.24, 95% CI: 0.053-0.997, P=.049) while presence of multiple tumors increased it (HR 6.31, 95% CI: 1.78-22.3, P=.004). Globally, 26 patients (29.88%) underwent cystectomy. No major complications were recorded. Overall mortality (OM) was 32.2% (28 patients); the cancer-specific mortality was 13.8%.

CONCLUSIONS

Adjuvant bacillus Calmette-Guérin significantly reduces the risk of recurrence, as does switch to mTOR inhibitors. Multiple tumors increase the risk.

Embolization of non-tolerated non-functioning kidney graft: alternative to surgical removal

The results of treatment by percutaneous transcatheter embolization in eight cases of non-tolerated non-functioning kidney graft are presented. The symptoms resulting from non-tolerance of the renal graft were fever, pain and haematuria. Embolization was well tolerated in all eight cases and the only adverse effect was post-embolization self-limited fever in five cases. The symptoms of non-tolerance of the graft disappeared immediately in all cases, with minimal morbidity and no mortality. In only one patient was it necessary to perform second embolization procedure to achieve permanent control of symptoms. We conclude that percutaneous embolization of non-tolerated non-functioning kidney graft is an effective procedure with significantly less morbidity than with surgical graft nephrectomy.

Prognostic value of the expression of E-cadherin and beta-catenin in bladder cancer

The purpose of this study was to assess the prognostic effect of the expression of E-cadherin, beta-catenin and CD44 adhesion molecules in bladder carcinoma. 22 superficial and 18 invasive bladder tumour samples were studied by immunohistochemistry. The median follow-up was 24 months (range: 1-50 months). Loss of E-cadherin and beta-catenin immunoreactivity was found in 14 (35%) and 17 (43%) tumours, respectively, and was significantly associated with invasiveness, high grade and p53 overexpression. There was no correlation between CD44 variant expression and clinicopathological findings. Loss of E-cadherin expression was an independent predictor of poor survival in a multivariate analysis, when assessed with age, grade, stage and p53 status (hazards ratio adjusted (HRa)=4.45 [95% confidence interval (CI), 1.06-18.63]). This effect was particularly augmented in patients with invasive bladder cancer. When expression of E-cadherin and beta-catenin were evaluated simultaneously, loss of immunoreactivity of both proteins was a strong predictor of poor survival (HRa=13.06 [95% CI, 0.95-178.55]). The same pattern was found when progression-free survival in relation to these variables was assessed. In conclusion, assessment of E-cadherin and beta-catenin immunoreactivity may be a useful prognostic marker in bladder cancer complementary to established prognostic factors.

Evaluation of renographic and metabolic parameters in human kidney transplantation

BACKGROUND

The aim of this work is to demonstrate that the value of the mean transit time (MTT) obtained from the 99mTc-MAG3 renogram deconvolution is related to the levels of adenine nucleotides determined in cortical biopsies from transplanted kidneys.

METHODS

The functional state was estimated by means of the MTT and the initial height (H0) of the renal retention function obtained from the 99mTc-MAG3 renogram deconvolution and by the measure of adenine nucleotides obtained from biopsies. We studied 30 kidney graft recipients, 25 normal functioning grafts (NFG) and 5 with acute tubular necrosis (ATN).

RESULTS

The MTT is significantly longer for ATN (p < 0.001). The initial uptake values (H0) are significantly lower for ATN (p < 0.001). The sum of adenine nucleotides (SAN) is significantly greater for NFG than for ATN (p < 0.001). The values of the MTT seem to reflect the energy state of the cells in transplanted kidney.

CONCLUSION

The analysis of MTT may be indicative of the functional metabolic recovery and thus it may be predictive of the renal graft function at least in the same extent than the biochemical analysis of a cortical renal biopsy immediately after blood reperfusion of the tissue.

Effect of different preservation solutions on adenine nucleotide content and metabolism in human kidney transplantation

Differences in purine metabolism produced by three preservation solutions were studied by determining the adenine nucleotide (ATP, ADP, AMP, and IMP) and nucleoside (adenosine, inosine, and hypoxanthine) levels in human kidney cortical biopsies. Forty kidney allografts were studied using University of Wisconsin (UW) solution (n = 20), Euro-Collins (EC) solution (n = 12), and modified EC solution with mannitol (M; n = 8). No significant differences were found between the three solutions studied with regard to ATP, ADP, or AMP changes. The mean ATP level (nmol/mg prot +/- SEM) at the end of preservation in the UW group was 2.7 +/- 0.3 nmol/mg, in the EC group 3.8 +/- 0.7 nmol/mg, and in the M group 2.3 +/- 0.4 nmol/mg. ATP 30 min after reperfusion in the UW, EC, and M groups was 5.7 +/- 0.8 nmol/mg, 6.4 +/- 1.0 nmol/mg, and 4.6 +/- 0.5 nmol/mg, respectively. However, an important difference appeared in the catabolic products determined. Kidneys perfused with UW solution had a significantly higher level of adenosine (2.6 +/- 0.6 nmol/mg), inosine (11.8 +/- 2.2 nmol/mg), and hypoxanthine (18.1 +/- 2.1 nmol/mg) at the end of cold storage than those perfused with EC (0.4 +/- 0.1 nmol/mg, 2.0 +/- 0.8 nmol/mg, and 7.1 +/- 1.4 nmol/mg) and M solutions (0.2 +/- 0.05 nmol/mg, 0.5 +/- 0.1 nmol/mg, and 5.2 +/- 0.6 nmol/mg; P < 0.05). These levels returned to initial values 30 min postreperfusion and there were no differences with the EC or M solution groups at that time.(ABSTRACT TRUNCATED AT 250 WORDS)

Assessment of purine metabolism in human renal transplantation

Cortical levels of nucleotides and their degradation products from 42 transplanted human kidneys have been studied. Biopsies were performed during renal harvesting just before cooling, at the end of cold storage, and following reinstallment of renal blood circulation. ATP levels fell, and AMP and degradation products (inosine monophosphate [IMP], inosine, adenosine, and hypoxanthine) increased during cold storage and returned to near-normal values 30 min after recirculation. The major degradation product found was hypoxanthine, indicating very poor xanthine oxidase activity in human kidneys. The sum of adenine nucleotides (ATP+ADP+AMP) did not significantly decrease after cold storage, but adenylate energy charge (ATP+1/2ADP/ATP+ADP+AMP) was reduced to half, being recovered in implanted kidneys. The sum of adenine nucleotides was significantly reduced after implantation. The rate of acute tubular necrosis was higher in kidneys preserved for more than 30 hr. Kidneys with acute tubular necrosis had significantly lower levels of the total pool of adenine nucleotides at reperfusion, but there was no correlation between incidence of acute tubular necrosis and ATP or other metabolite levels in the kidneys before or during cold preservation. The success of human kidney transplantation does not seem to depend only on the pool of residual nucleotides at the end of cold storage but on other factors that determine the ability of the cell to recover a normal energy state after reperfusion.

[Hormonal treatment of cancer of the prostate]

We set forth the results obtained after application of a hormonal protocol in prostate carcinoma (P.C.) on 257 patients controlled between June 1976 and June 1987, of whom we have selected 160 who fulfilled the following requirements: under 80 years old, confirmed anatomopathological diagnosis, state equal to or above the T1 of the Union International contre le Cancer (U.I.C.C.) classification, tolerance of treatment applied, clinical, analytical and complete, systematic iconographic follow up and minimum survival of more than one year. We treated those patients with localised P.C. (they have no demonstrable metastases), who in our series numbered 78 (78/160), with Diethylethylbestrol (D.E.S.) at an orally administered dose of 1 mgr. a day. In these the plasma testosterone dropped below 100 nanograms/l. in 57 cases (57/79). In this case metastases appeared in 22 cases (22/78). We treated those patients with metastatized P.C., who in our series numbered 59 (59/160), with orally administered Estramustine Phosphate (Estracyt) at a dose of 560 mgr. every 24 h. in two goes. In these the plasma testosterone dropped below 100 nanograms/l. in 50 cases (50/59). In this group the metastases disappeared in 7 patients, became stabilized in 30 and worsened in the other 22 patients. We carried out surgical orchiectomy on 49 patients (49/160): in 17 cases due to associate vascular pathology, in 13 cases for sociocultural reasons, in 5 cases because of advanced age and in 14 cases it was conducted on patients with a poor response to D.E.S.

[Spontaneous subcapsular hematoma. Report of 4 new cases]

The Spontaneous Subcapsular Hematoma is an uncommon entity. In most cases it develops on a pathological kidney or in patients with coagulopathy. In the pathology reviewed we found a high index of tumoural pathology. We present 4 cases of Spontaneous Subcapsular Hematoma received in our service. As opposed to other series, in none of our patients could tumoural pathology be attributed as the primary cause of the hematoma.