Frailty, geriatric assessment and prehabilitation in elderly patients undergoing urological surgery - is there a need for change of the daily clinical practice? Synthesis of the available literature

Introduction

The population of older people is heterogeneous and constantly growing. Over 50% of urological operations are performed in elderly patients. Some elderly patients present with frailty syndrome - a state of increased vulnerability to external stressors resulting in increased risk of hospitalizations, adverse treatment outcomes and death. Currently, there is no widely accepted system of qualification and preparation for surgical treatment developed specifically for elderly patients.

Material and methods

We searched Medline/Pubmed, Embase and Cochrane Libraries databases from 2000-2020 (week 5). The following medical subject headings (MeSH) terms were used to ensure the sensitivity of the searches: geriatric assessment, frailty, urology, and prehabilitation. Relevant articles were also identified through a manual search of the reference lists of potentially relevant articles.

Results

A total of 23 papers met the criteria and were included in the current study. Screening for frailty seems to be promising in predicting adverse outcomes, but frail patients should undergo detailed geriatric assessment (GA) which may indicate a need for preoperative intervention which can be unavailable during the hospitalization. The concept of prehabilitation is becoming increasingly discussed in thoracic and abdominal surgery, but only a few studies are available in the field of urology.

Conclusions

Geriatric assessment seems to be a valuable tool for urologists in daily clinical practice. A proper form of prehabilitation may provide enhanced recovery after surgery.

Geriatric assessment among elderly patients undergoing urological surgery: A systematic literature review

The elderly constitute the group of patients who most often undergo elective urological procedures, and they are at the highest risk of poor surgical outcomes because of comorbidity and frailty. The current model of qualification for surgery is often subjective and based on tools which do not address the characteristics of the elderly. The Comprehensive Geriatric Assessment (CGA) and screening tools can help in the evaluation of older, particularly frail patients. The aim of the study was to review the literature on the usefulness of preoperative geriatric evaluation in patients undergoing urological treatment. The review was based on MEDLINE/PubMed, Embase and Cochrane Library bibliographic databases from 2000-2017 for full-text, English-language publications meeting pre-defined criteria. Six prospective and 3 retrospective studies were selected for further analysis. The patient populations, methods of geriatric assessment, interventions, and outcome measures varied between the studies. None of the studies were randomized controlled trials. In 2 studies, the CGA was used; in other studies, rather basic screening tests were used. In only 2 studies, an intervention was performed after the CGA. In general, the variables of the CGA were both prospectively and retrospectively significant predictors of complications of urological surgery. Although the use of CGA is not a standard practice in everyday urological clinical practice, components of the CGA appear to be predictive of postoperative complications. Therefore, inclusion of geriatric assessment as part of routine preoperative care in geriatric urology patients should be considered. Because of the lack of randomized controlled trials on preoperative CGAs in urology patients, further studies are needed.

Can laparoscopic cystectomy become the method of choice in the treatment of invasive urothelial urinary bladder cancer?

BACKGROUND

Radical cystectomy with pelvic lymphadenectomy is the method of choice for muscle-invasive urothelial cell cancer (UCC) treatment and provides the best cancer-specific survival. It can be performed as an open radical cystectomy (ORC), laparoscopic radical cystectomy (LRC) or robot-assisted surgery (RARC).

OBJECTIVES

The aim of this study was to compare laparoscopic and open radical cystectomy in terms of perioperative and oncological results.

MATERIAL AND METHODS

This retrospective study included 260 patients who underwent surgery due to invasive bladder cancer. A laparoscopic radical cystectomy (LRC) was performed on 131 patients and an open radical cystectomy (ORC) on 129 patients. Group was stratified according to the urinary diversion. Oncologic results expressed as perioperative variables were analyzed, adjusted to the type of urinary diversion.

RESULTS

The LRC patients were in worse perioperative condition according to the American Society of Anesthesiologists (ASA) score than the ORC group (3.1 and 2.52, respectively; p = 0.001). The serum protein level was significantly lower in the ORC group, with no difference in body mass index (BMI) between the groups. The median operation time was significantly shorter in the LRC group with ileal conduit and uretero-cutaneostomy than in the same groups operated using open approach (252.5 min and 180 min vs 290 min and 225 min, respectively), as was the hospital discharge time (8.18 days and 11.63 days, respectively; p = 0.004). In both LRC groups, median blood loss was lower, compared with corresponding ORC groups (325 mL and 400 ml vs 800 mL and 1,100 mL, respectively; p < 0.001 in both cases). The level of complications was significantly lower in both LRC groups than in the ORC groups (p < 0.001 and p = 0.001, respectively). The lymph node yield was 12 in the LRC group and 10 in the ORC group. The LRC group had a lower positive surgical margins ratio.

CONCLUSIONS

The laparoscopic approach should be a valid option for radical cystectomy, given the fewer complications, smaller blood loss, and shorter operating and hospitalization times experienced by patients who underwent a laparoscopic cystectomy.

Urinary bladder hypertrophy and overactive bladder determine urinary continence after radical prostatectomy

BACKGROUND

Several clinical and biological factors exacerbate urinary incontinence (UI) and reduce the patient's quality of life after radical prostatectomy (RP).

OBJECTIVES

The purpose of this study was to evaluate the effects of urinary bladder hypertrophy and overactive bladder (OAB) on UI in patients after RP.

MATERIAL AND METHODS

Seventy patients were enrolled in the study and were divided into 2 groups: patients with bladder outlet obstruction (BOO) but without OAB (group I; n = 20) and patients with BOO and OAB (group II; n = 50). Before the RP procedure, all patients were administered IPSS and OAB symptom questionnaires and ultrasonography and uroflowmetry were performed. The follow-up visits were scheduled for 1, 3, 6, 9, and 12 months after the operation to evaluate postoperative continence.

RESULTS

The results show that patients with BOO and concurrent OAB experienced urinary bladder hypertrophy. Patients with OAB presented a normal desire to void with less urinary bladder capacity. The coexistence of OAB before RP resulted in more extensive UI, as measured with the ICIQ-UI-SF scores and postoperative daily pad usage. A gradual improvement in urinary continence was observed. Urinary incontinence was significantly less severe in successive check-ups (3, 6, 9, and 12 months after RP). Urgency was responsible for 1-15% or 16-29% of episodes of urinary leakage in 20% and 16% of cases, respectively.

CONCLUSIONS

Patients with preoperative OAB are at a higher risk of developing more severe UI after RP, and the restoration of pre-surgery urinary continence is limited.

Correlation between malnutrition, body mass index and complications in patients with urinary bladder cancer who underwent radical cystectomy

BACKGROUND

Nutrition is the 3rd most important factor in surgery, following anesthesia and asepsis. Until now, it has been a poorly explored field of urology. The relationship between malnutrition and postoperative complications has been proven beyond doubt in general surgery, where 30% of patients are operated in a malnutrition state.

OBJECTIVES

The aim of our work was to assess the influence of malnutrition, defined by nutritional risk screening (NRS) scale and body mass index (BMI), on postoperative results in patients with bladder cancer after radical cystectomy.

MATERIAL AND METHODS

The research was carried out at 8 urological centers between 2012 and 2014, and included patients with bladder cancer at stage from T2 to T4, who underwent radical cystectomy. The degree of malnutrition was assessed with the aid of the NRS 2002 questionnaire. Other examined parameters were BMI, age, type of operation, and the number of complications, the latter of which were measured by applying the Clavien-Dindo scale.

RESULTS

A total of 125 patients were enrolled in our study, out of whom 64 (51.2%) were undernourished. According to the BMI, most of the patients were overweight - 50 (40%) or had normal body weight - 49 (39.2%); 24 (19.2%) were obese, and 2 (1.6%) were underweight.

CONCLUSIONS

There was no relationship between malnutrition, defined by the NRS scale, and postoperative complications, and we did not find a significant relationship between the other tested variables. We observed only 1 significant relationship between the nutrition state, measured by BMI scale, and the degree in Clavien-Dindo scale. Body mass index under 18.5 and over 30 increased postoperative complications. Nowadays, the recommended scale is NRS 2002, which is based mostly on loss of weight. In our patients, qualitative malnutrition is more probable than quantitative malnutrition.

The angiotensin II receptors type 1 blockage affects the urinary bladder activity in hyperosmolar-induced detrusor overactivity in rats: Preliminary results

BACKGROUND

Angiotensin II receptors play a role in the pathogenesis of urinary bladder dysfunction, especially in the case of bladder outlet obstruction. The function of these receptors in the detrusor overactivity (DO) still remains unclear.

OBJECTIVES

The study aims to investigate some of the mechanisms through which hyperosmolarity induces urinary bladder overactivity. The effect of angiotensin II receptor type 1 - AT1 (telmisartan) on urinary bladder function in physiological state and in hyperosmolar-induced DO in rat model was explored.

MATERIAL AND METHODS

Experiments were performed on 32 female Wistar rats. DO was induced by hyperosmolar saline intravesical instillation. Surgical procedures and cystometry were performed under urethane anesthesia. The measurements represent the average of 5 bladder micturition cycles. We analyzed: basal pressure, threshold pressure, micturition voiding pressure, intercontraction interval, compliance, functional bladder capacity, motility index and detrusor overactivity index.

RESULTS

Intravesical hyperosmolar saline instillation induced DO. Telmisartan diminished the severity of hyperosmolar-induced DO. We observed a statistically significant increase of intercontraction interval (55%), functional bladder capacity (54%), compliance (140%). Also, a statistically significant decrease of detrusor overactivity index (18%) and motility index (9%) were observed. The difference of basal pressure, threshold pressure and micturition voiding pressure were not statistically significant. Moreover, telmisartan has no effect on urodynamic parameters in naïve rats.

CONCLUSIONS

Detrusor overactivity due to intravesical increased osmolarity seems to be at least partially mediated by AT1 receptors activity. On one hand, telmisartan diminished the severity of hyperosmolarinduced DO, and, on the other hand, has no effect on urodynamic parameters in naïve rats.

Chronic exposure to neonicotinoids reduces honey bee health near corn crops

Experiments linking neonicotinoids and declining bee health have been criticized for not simulating realistic exposure. Here we quantified the duration and magnitude of neonicotinoid exposure in Canada’s corn-growing regions and used these data to design realistic experiments to investigate the effect of such insecticides on honey bees. Colonies near corn were naturally exposed to neonicotinoids for up to 4 months—the majority of the honey bee’s active season. Realistic experiments showed that neonicotinoids increased worker mortality and were associated with declines in social immunity and increased queenlessness over time. We also discovered that the acute toxicity of neonicotinoids to honey bees doubles in the presence of a commonly encountered fungicide. Our work demonstrates that field-realistic exposure to neonicotinoids can reduce honey bee health in corn-growing regions.

The role of the peripheral cannabinoid system in the pathogenesis of detrusor overactivity evoked by increased intravesical osmolarity in rats

The cannabinoid receptors CB1 and CB2 are localized in the urinary bladder and play a role in the regulation of its function. We investigated the pathomechanisms through which hyperosmolarity induces detrusor overactivity (DO). We compared urinary bladder activity in response to blockade of CB1 and CB2 receptors using AM281 and AM630, respectively, in normal rats and after hyperosmolar stimulation. Experiments were performed on 44 rats. DO was induced by intravesical instillation of hyperosmolar saline. Surgical procedures and cystometry were performed under urethane anaesthesia. The measurements represent the average of 5 bladder micturition cycles. We analysed basal, threshold, and micturition voiding pressure; intercontraction interval; compliance; functional bladder capacity; motility index; and detrusor overactivity index. The blockage of CB1 and CB2 receptors diminished the severity of hyperosmolar-induced DO. In comparison with naïve animals the increased frequency of voiding with no significant effect on intravesical voiding pressure profile was observed as a result of the blockage of CB1 and CB2 receptors. These results demonstrate that hyperosmolar-induced DO is mediated by CB1 and CB2 receptors. Therefore, the cannabinoid pathway could potentially be a target for the treatment of urinary bladder dysfunction.

Cajal-like interstitial cells as a novel target in detrusor overactivity treatment: true or myth?

Introduction

The Cajal–like intestitial cells (ICCs) act as a pacemaker and are responsible for generating smooth muscle activity in the gastrointestinal tract (GI). Interstitial cells that resemble ICCs in the GI have been identified in the urinary bladder.

Materials and methods

This review is based on a systemic literature research. The medline/pubmed, scopus, embase, and Web of Science databases were browsed in order to identify original and review articles, as well as editorials relating to cajal–like cells, urinary bladder, detrusor overactivity, overactive bladder, glivec, etc. The controlled vocabulary of the Medical Subject Headings (MeSH) database was used to ensure the sensitivity of the searches. 40 papers met the criteria and were used for this review.

Results

Cajal cells lie in close proximity to the muscle cells, autonomic nerve endings, and urothelial cells. There is increasing evidence that ICCs play role in urinary tract dysfunction development (e.g. detrusor overactivity, primary obstructive megaureter, congenital ureteropelvic junction obstruction, etc.). ICCs may be responsible for generating electrical potentials and induction of detrusor muscle contractions. Novel pathomechanisms of detrusor overactivity development have been postulated, as follows: 1) the disturbance of spontaneous contractility caused by altered signal transduction of ICCs between nerves and detrusor muscle cells, and 2). the alteration in signal transduction between urothelium and afferent nerve endings via suburothelial ICCs. The c–kit receptor is not only a detection marker of these cells, but may also play a crucial role in the control of bladder function.

Conclusions

Cajal cells in urinary bladder suggest that the c–kit receptor may provide a novel target for treating detrusor overactivity. The review presents the current knowledge of ICCs, its role in urinary bladder function, and potential novel therapeutic strategy.

[Iatrogenic ureteral injury in adults--diagnosis and treatment]

Ureteral injuries are rare and a special group are iatrogenic ureteral injury. Such a situation may occur during open surgery, laparoscopic surgery and endoscopy. The mechanism typically includes cutting or ligation of the ureter or combination of both what may lead to urinary retention and tissue infiltration by urine. The priority is to prevent the incidence of injury. Even 75% of ureteral damage can be not identified during the surgery, when the injury occurred. The basis of treatment is to drain the urine, the urine leakage and ureter reconstruction.

[Bilateral ureterocele in adult--a case report and review of literature]

Lower urinary tract symptoms in men are associated usually with the presence of bladder outlet obstruction, especially with benign prostatic hyperplasia. We present a case of a patient whose cause of urinary frequency, difficulty in starting micturition and feeling of incomplete emptying of the bladder was ureterocele, causing symptoms of bladder outlet obstruction. Treatment consisted of endoscopic electroresection of the cyst. Following treatment the complete resolution of symptoms reported before treatment was achieved.

[The use of hemostatic agent Tachosil in surgical treatment of kidney cancer infiltrating liver--case report]

The right kidney cancer very rarely locally invades the liver as compared with blood metastasis which occur more frequent. In these cases, the only extensive surgical resection of part of the liver gives the opportunity to improve survival dependent on kidney cancer. In the intra-and postoperative bleeding and leakage of bile from the liver cut surface is a complication that it depends on the success of the treatment. A valuable complement to traditional ways of obtaining hemostasis is sealed section of liver collagen patches of horse, which are covered with tissue adhesive supplemented human fibrinogen and thrombin (Tachosil). The aim of this study is to present the case of 38-year-old woman with a tumor of the upper pole of the right kidney invasive by the continuity of the right lobe of liver, in which the classic methods of obtaining hemostasis supplemented using Tachosil postoperative course and a comparison with data from the literature.

RESULTS

We demonstrated the usefulness of the application Tachosil sealing vascular suture in the vein cava inferior and obtain hemostasis and tissue sealing the right liver lobe cross-section area of about 250 cm2. After treatment, a patient had drainage from the site of the kidney comparable with data from the literature. Patient was discharged home on postoperative day 7 in good condition.

CONCLUSIONS

Tachosil in major surgery because of locally advanced kidney cancer that invades the liver is a valuable complement to conventional surgical methods allowing for atraumatic stop bleeding and seal parenchymal liver tissue. Doing so helps to avoid early and late complications and reduce the cost of treating these complications.

[Selected markers of oxidative stress and carcinogenic trace elements concentrations in the renal cell carcinoma tissue]

In industrialized countries, increasing concentrations of harmful trace elements in the human environment increases their concentration in the organs, which in turn may be responsible for the growth of cancer including cancer of the kidney. Trace elements by increasing the concentration of active free radicals damage cell DNA, and in a consequence increase the risk of carcinogenesis. The aim of this study was to determine concentrations of biochemical markers providing an increase in the concentration of free radicals in the cell kidney cancer and renal cortical tissue, from which it originates and to attempt correlation of these markers with the concentration of carcinogenic trace elements identified in these same tissues using spectral analysis of PIXE (Proton induced X-Ray Emmision).

MATERIALS AND METHODS

Of the 12 kidneys removed because of renal cell carcinoma clippings taken from the parenchyma of the kidney and kidney tumor, and then the concentration of markers of oxidative stress such as malonic dialdehyd (MDA), reduced form and oxidized glutathione and 1-ascorbic acid of the tissue. The concentration of elements was made by means of physical methods of analysis of multielemental PIXE (Proton Induced X-Ray Emission) in tumor tissue and kidney tissue of renal cortical tumor unchanged.

RESULTS

Malonic dialdehyd concentrations (MDA), reduced and oxidized forms of glutathione and 1-ascorbic acid were successively 2.11, 1.23, 0.84 and 2.25 microg/g for tissue kidney tumor and subsequently one, 58, 0.99, 0.58 and 2.3 microg/g in the kidney cortex from which the tumor originates. Demonstrated significant differences in MDA concentrations (p < 0.01) and the oxidized form of glutathione (p < 0.05). In the analysis of correlation between the concentrations of markers of the concentrations of elements are carcinogenic by IARC (International Agency for Research on Cancer) showed significant increase in the concentration of 1-ascorbic acid with increasing concentrations of lead in kidney tumor tissue. In the renal cortex increased concentrations of MDA and oxidized forms of glutathione was significantly correlated with increased levels of selenium.

CONCLUSIONS

By markers of oxidative stress has been shown indirectly to increased metabolism of oxygen free radicals in kidney tumor tissue compared to kidney cortex tissue from which it derives. At the same time was selected markers concentration dependence of the concentration of the elements considered by the IARC human carcinogens. Confirmation of these results on a larger group of patients may become a contribution to the study of substances that protect the kidney against carcinogens storage elements or substances that reduce oxidative stress in the kidney.

[Prostate cancer dependance upon cholesterol, statins and diet]

The aim of the work is to analyze the influence of higher cholesterol and LDL level on risk of prostate cancer. The work is based on the available literature in that field. The metabolism of cholesterol is mainly regulated by the statins, which may thus inhibit prostate cancer growth. Keeping the appropriate body mass and level of cholesterol by proper diet and physical exercises may be the prophylaxis of prostate cancer.

[Oxidative stress and its significance in prostate diseases]

The disturbed balance between production of reactive oxygen and nitrogen species (RONS) and efficiency of antioxydative systems leads to oxidative stress. This may be the cause of permanent biomolecules' damage. The results of many researches show dependence between disturbance in oxidative balance. And oxidative damage in prostate cells. However no clear evidence have been found that oxidative stress may lead to development of prostate cancer.

[Evaluation of 99mTc-DTPA scyntygraphy of the relative degree of renal dysfunction after surgical removal of kidney tumor]

In nephron sparing surgery (NSS) procedures the most important is oncological outcome and also the preservation of maximum renal function. Renal scyntygraphy using 99mTc-DTPA allows for assessment of renal function and its changes after surgery because of tumor.

THE AIM OF THIS STUDY

To assess the loss of kidney function operated using 99mTc-DTPA scyntygraphy, depending on the location of the tumor, type of growth, and time of warm ischemia of the operated kidney.

MATERIALS AND METHODS

Renal scyntygraphy was performed in 30 patients who underwent NSS procedures for renal cortical tumors of its diameter of about 3.2 cm (range: 2.5-4.1 cm) before surgery and after surgery at an average of 3.8 months (range: 2.3-5.4 months). All patients were stratified according to time of warm ischemia (up to and above 10 mines), type of tumor growth (endo- and egzophytic) and tumor location (upper, middle and lower pole).

RESULTS

The relative loss of kidney function operated depending on the type of kidney tumor growth when egzophytic and endophytic was amounted to 16% (range: 12-22%) and 29% (range: 24-46%) respectively (p < 0.01), in contrast depending on the location in the upper, middle and lower pole of the kidney 24% (range: 12-36%), 31% (range: 26-46%) and 25% (range: 15-38%), respectively (p < 0.05) Depending on the time of warm ischemia for up to and above 10 mines a relative loss of kidney function of surgery was set at 21% (range: 12-24%) and 31% (range: 29-46%), respectively (p < 0.1).

CONCLUSIONS

The results of this study suggest that the loss of kidney function after NSS procedures for renal cortical tumor is the largest in the middle field of tumor endophytic growth where, during the operation the time of warm ischemia is the longest. Tumors of this type should be operating in the centers performing these procedures on a routine basis.