Tag Archive for: Article of the Week

You are here: / Article of the Week

Posts

Article of the Week: TRT and rates of PCa or LUTS

/by

Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Testosterone treatment is not associated with increased risk of prostate cancer or worsening of lower urinary tract symptoms: prostate health outcomes in the Registry of Hypogonadism in Men

Frans M.J. Debruyne*, Hermann M. Behre†, Claus G. Roehrborn‡, Mario Maggi§, Frederick C.W. Wu, Fritz H. Schroder**, Thomas Hugh Jones††, Hartmut Porst‡‡, Geoffrey Hackett§§, Olivia A. Wheaton¶¶, Antonio Martin-Morales***, Eric J. Meuleman†††, Glenn R. Cunningham‡‡‡, Hozefa A. Divan¶¶ and Raymond C. Rosen ¶¶ for the RHYME Investigators

 

*Andros Men’s Health Institutes, Arnhem, The Netherlands, †Center for Reproductive Medicine and Andrology, Martin Luther University Halle-Wittenberg, Halle, Germany, ‡Southwestern Medical Center, University of Texas, Dallas, TX, USA, §Sexual Medicine and Andrology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy, ¶ University of Manchester, Manchester, UK, **Erasmus Medical Center, Rotterdam, The Netherlands, ††Barnsley Hospital NHS Foundation Trust, Barnsley, UK, ‡‡Private Practice of Urology/Andrology, Hamburg, Germany, §§Holly Cottage Clinic, Lichfield, Staffordshire, UK, ¶¶New England Research Institutes, Inc., Watertown, MA, USA, ***Carlos Haya University Hospital, Malaga, Spain, †††VU Medical Center, Amsterdam, The Netherlands, and ‡‡‡Baylor College of Medicine, St. Luke’s Episcopal Hospital, Houston, TX, USA

 

 
Read the full article

Abstract

Objectives

To evaluate the effects of testosterone-replacement therapy (TRT) on prostate health indicators in hypogonadal men, including rates of prostate cancer diagnoses, changes in prostate-specific antigen (PSA) levels and lower urinary tract symptoms (LUTS) over time.

Patients and Methods

The Registry of Hypogonadism in Men (RHYME) is a multi-national patient registry of treated and untreated, newly-diagnosed hypogonadal men (n = 999). Follow-up assessments were performed at 3–6, 12, 24, and 36 months. Baseline and follow-up data collection included medical history, physical examination, blood sampling, and patient questionnaires. Prostate biopsies underwent blinded independent adjudication for the presence and severity of prostate cancer; PSA and testosterone levels were measured via local and central laboratory assays; and LUTS severity was assessed via the International Prostate Symptom Score (IPSS). Incidence rates per 100 000 person-years were calculated. Longitudinal mixed models were used to assess effects of testosterone on PSA levels and IPSS.

feb-aotw-2-results

Results

Of the 999 men with clinically diagnosed hypogonadism (HG), 750 (75%) initiated TRT, contributing 23 900 person-months of exposure. The mean testosterone levels increased from 8.3 to 15.4 nmol/L in treated men, compared to only a slight increase from 9.4 to 11.3 nmol/L in untreated men. In all, 55 biopsies were performed for suspected prostate cancer, and 12 non-cancer related biopsies were performed for other reasons. Overall, the proportion of positive biopsies was nearly identical in men on TRT (37.5%) compared to those not on TRT (37.0%) over the course of the study. There were no differences in PSA levels, total IPSS, or the IPSS obstructive sub-scale score by TRT status. Lower IPSS irritative sub-scale scores were reported in treated compared to untreated men.

Conclusions

Results support prostate safety of TRT in newly diagnosed men with HG.

 

Read more articles of the week

Editorial: Mythology and Reality Should Never Be Confused (But Often Are)

/by

The debating halls of learned urological societies often attempt to define theories based on little substance. Unfortunately, although this type of scientific discourse should be encouraged, it can create both content for unrepeatable ‘late breaking’ abstracts and headlines for mass circulation newspapers. Once started, the momentum can make a perception become a ‘reality’ that is invariably difficult to dislodge. An area of particular current interest to both the scientific and lay press, and indeed the regulatory authorities in the USA and the European Union, is testosterone replacement. Within this context, an important potential myth-buster is described in the article by DeBruyne et al. [1]. The hypothesis (aka myth) that was being examined was that application of exogenous testosterone, irrespective of formulation, could exacerbate both benign and malignant prostatic disease. To understand the importance of this type of definitive study we must start at the beginning.

The foundation of the mythology, or in reality a Canadian-US urological tragedy, was ironically in the Nobel Prize winning work of Charles B Huggins. The ‘good news’ was that prostatic tumour regression could be affected by androgen deprivation, a finding certainly worthy of global recognition and acceptance; however, this became embellished to a certain extent, incorporating other aliquots of somewhat circumstantial evidence, leading to a suggestion that testosterone replacement could increase the probability and/or rate of prostate cancer progression. As a result, various societies perhaps understandably adopted their normal conservative approach of inserting a warning (with varying degrees of emphasis) in their guidelines [2]. Over the last decade, with the increasing use of testosterone replacement in the treatment of men with hypogonadism, the issue of benefit–risk has become more relevant, indeed is often transposed to risk–benefit, and is increasingly likely to feature in the popular press. Within the last couple of years, we have seen the spectre of testosterone and cardiovascular risk played out in full public view, but the issue of testosterone and exacerbation of prostatic disease has continued to smoulder in the background.

The RHYME study [1], although it is largely confirmatory as other studies have described similar conclusions, is of considerable ‘real-life’ value. The power of the study is that it should be considered to be representative of the potential hypogonadal population likely to present to the physician. Although not used for regulatory approval purposes, a registry study is considered to be the ‘gold standard’ for this type of analysis. So what are the conclusions of this and the majority of other studies? In essence, there is no evidence that restoration of testosterone to the normal range does increase the incidence or progression of either benign (BPH) or malignant prostatic disease. Any slight changes in PSA level were considered not to be clinically relevant and likely to be as a consequence of the direct pharmacology of increased testosterone levels [3]. This does not imply that exacerbations will never be seen or that appropriate monitoring should not be carried out; more that the conventional wisdom on testosterone and prostatic disease has gone (or should go) the way of antimuscarinic agents, invariably causing urinary retention in patients with BPH. It is to be hoped that studies such as the RHYME study will continue to be undertaken and help provide perspective for specialist and primary care physicians alike in areas of emergent clinical interest.

Read the full article
Michael Wyllie
Global Pharma Consulting Ltd, Stratton House, Shenington, Banbury, Oxfordshire

 

References

 

1 Debruyne FMJ, Behre HM, Roehrborn CG et al. Testosterone treatment is not associated with increased risk of prostate cancer or worsening of lower urinary tract symptoms: prostate health outcomes in the Registry of Hypogonadism in Men (RHYME). BJU 2017; 119: 216–24

 

2 Bhasin S, Cunningham GR, Hayes FJ et al. Testosterone therapy in men with androgen deficiency syndromes: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2010; 95: 2536–59

 

3 Boyle P, Koechlin A, Bota M, D’Onofrio A et al. Endogenous and exogenous testosterone and the risk of prostate cancer and increased prostate specific antigen (PSA) level: a meta-analysis. BJU Int 2016; 118: 731–41

 

Article of the Week: Comparison of cSCI vs tSCI

/1 Comment/by

Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Comparison of spinal cord contusion and transection: functional and histological changes in the rat urinary bladder

Benjamin N. Breyer*, Thomas M. Fandel*, Amjad Alwaal*, E. Charles Osterberg*, Alan W. Shindel†, Guiting Lin*, Emil A. Tanagho* and Tom F. Lue*

 

*Department of Urology, University of California, and †Department of Urology, University of California at Davis, San Francisco, CA, USA

 

Read the full article

Abstract

Objective

To compare the effect of complete transection (tSCI) and contusion spinal cord injury (cSCI) on bladder function and bladder wall structure in rats.

Materials and Methods

A total of 30 female Sprague–Dawley rats were randomly divided into three equal groups: an uninjured control, a cSCI and a tSCI group. The cSCI group underwent spinal cord contusion, while the tSCI group underwent complete spinal cord transection. At 6 weeks post-injury, 24-h metabolic cage measurement and conscious cystometry were performed.

aotw-feb-2-results

Results

Conscious cystometry analysis showed that the cSCI and tSCI groups had significantly larger bladder capacities than the control group. The cSCI group had significantly more non-voiding detrusor contractions than the tSCI group. Both injury groups had more non-voiding contractions compared with the control group. The mean threshold pressure was significantly higher in the tSCI group than in the control and cSCI groups. The number of voids in the tSCI group was lower compared with the control group. Metabolic cage analysis showed that the tSCI group had larger maximum voiding volume as compared with the control and cSCI groups. Vesicular acetylcholine transporter/smooth muscle immunoreactivity was higher in the control than in the cSCI or tSCI rats. The area of calcitonin gene-related peptide staining was smaller in the tSCI group than in the control or cSCI groups.

Conclusions

Spinal cord transection and contusion produce different bladder phenotypes in rat models of SCI. Functional data suggest that the tSCI group has an obstructive high-pressure voiding pattern, while the cSCI group has more uninhibited detrusor contractions.

Read more articles of the week

Editorial: Correlating SCI with NGB

/by

Breyer et al. [1] conclude from cystometry and antibody staining for vesicular acetylcholine transporter (VAChT) and calcitonin gene-related peptide (CGRP) in rats that both contusion spinal cord injury (cSCI) and transection spinal cord injury (tSCI), when compared with controls, increase bladder capacities and the number of non-voiding bladder contractions (with more non-voiding contractions in the cSCI than the tSCI group) and that the mean threshold (voiding) pressure was higher in the tSCI group than in the control or cSCI groups. These findings are consistent with detrusor sphincter dyssynergia. VAchT staining of the smooth muscle was lower in the cSCI and tSCI groups than in controls, and CGRP was also lower in the tSCI group compared with the cSCI and control groups.

An analysis of the spinal cord injury in these rats was not performed in the present study; therefore, although the tSCI group had a complete injury, the potential variability in cSCI was not determined, and so it is not possible to directly correlate the bladder findings with the SCI received. In addition, the bladder images do not show many of the neuronal elements in which VAChT and CRGP are found, and the immunohistochemistry staining is relatively sparse compared with other published images for the same neurotransmitters in the same region [2].

A similar study [3] including cSCI and tSCI models found that, while micturition pressure, non-voiding contractions, bladder capacity and post-void residual urine volumes differed from controls, there was no significant difference between the cSCI and tSCI groups. CGRP was significantly elevated in the dorsal horn in the SCI groups compared with the control group, but was not different between the SCI groups. These findings differ from those of Breyer et al., probably because of methodological differences in cSCI performance and the timing of studies in the experimental protocol.

Calcitonin gene-related peptide is primarily associated with afferent activity in the bladder [4], so it makes sense that afferent neurons would accumulate more CRGP in the bladder after tSCI, whereas the partial injury caused by contusion would allow some CRGP signal transmission, and thus not allow it to accumulate in the bladder. The efferent effects of CGRP in the urinary bladder are controversial; the effects in different preparations have led to conflicting results [4]. A similar argument may be made for VAChT in the bladder because VAChT is a good marker for cholinergic neurons [5], which are more likely to be involved in efferent pathways, although acetylcholine has also been shown to have a role in normal and spinal cord injury afferent pathways [6].

In humans, contusive injuries are much more common than transection injuries, the latter leading to varying degrees of incomplete recovery with time. There is a correlation between the length of cervical contusive injuries with changes in the American Spinal Injury Association scale reflecting outcomes. Long contusive injuries result in clinically complete spinal cord injuries, with shorter injuries resulting in more neurological improvement during the recovery period. Haematomas >4 mm have a worse prognosis in terms of recovery, as does cord ischaemia [7].

The variable nature of human spinal cord injuries is well known to urologists. Such injuries affect bladder function through detrusor sphincter dyssynergia and changes in bladder compliance and capacity, with variable degrees of hyperreflexia, and can lead to the complications of infection, incontinence, stone disease and the potential for renal insufficiency and renal failure. The identification of two phenotypes of bladder responses with regard to cSCI vs tSCI is a justifiable study conclusion, but a more complex pathophysiological model will likely emerge. The problem is that contusion injuries, although performed similarly each time, result in different neurological deficits, for a variety of reasons. Future studies must define both the neurological injury, anatomically and mechanistically, and the physiological changes occurring in the bladder. This would lead to a more comprehensive understanding of the pathophysiology behind both the short- and long-term spinal cord injury responses and how these correlate to the concurrent alterations and longer-term pathophysiological changes in the neurogenic bladder.

Read the full article
John P. Lavelle

 

Urology Section, Department of Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA

 

References

 

1 Breyer BN, Fandel TM, Alwaal A et al. Comparison of spinal cord contusion and transection: functional and histological changes in the rat urinary bladder. BJU Int 2017; 119: 333–41

 

2 McNeill DL, Shew RL, Holzbeierlein JM, Papka RE. Effects of spinal cord transection and MK-801 on CGRP immunostaining in the rat urinary bladder. Exp Neurol 1992; 116: 339–44
 

3 Mitsui T, Tanaka H, Moriya K, Kitta T, Kanno Y, Nonomura K. Lower Urinary tract function in Spinal Cord Injury Rats: Contusion versus Transection of the Spinal Cord. In: Scientific Programme, 41st Annual  Meeting of the International Continence Society (ICS) 29 August – 2 September 2011, Glasgow, UK. Neurourology and Urodynamics. 2011: 30:787–1206

 

4 Andersson KE. Pharmacology of the lower urinary tract. In Corcos J, Ginsberg D, Karsenty G eds, Textbook of the Neurogenic Bladder, 3rd edn. Chapt 2. Boca Raton, FL, USA: CRC Press, 2016: 9–31

 

5 Arvidsson U, Riedl M, Elde R, Meister B. Vesicular acetylcholine transporter (VAChT) protein: a novel and unique marker for cholinergic neurons in the central and peripheral nervous systems. J Comp Neurol 1997; 378: 454–67

 

6 Fry CH, Vahabi B. The Role of the Mucosa in Normal and Abnormal Bladder Function. Basic Clin Pharmacol Toxicol 2016; 119: 57–62

 

7 LeE, Aarabi B, Hersh DS et al. Predictors of intramedullary lesion expansion rate on MR images of patients with subaxial spinal cord injury. J Neurosurg Spine 2015; 22: 611–21

 

Article of the Week: Accuracy of prostate biopsies for predicting Gleason score in radical prostatectomy specimens: nationwide trends 2000–2012

/by

Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Accuracy of prostate biopsies for predicting Gleason score in radical prostatectomy specimens: nationwide trends 2000–2012

Daniela Danneman*, Linda Drevin†, Brett Delahunt‡, Hemamali Samaratunga§¶, David Robinson**, Ola Bratt††‡‡, Stacy Loeb§§ Par Stattin¶¶*** and Lars Egevad*†††

 

*Department of Oncology-Pathology, Karolinska Institute, Stockholm, † Regional Cancer Centre, Uppsala University Hospital, Uppsala, Sweden, ‡Wellington School of Medicine and Health Sciences, University of Otago, Wellington, New Zealand, §Aquesta Pathology, The University of Queensland School of Medicine, Brisbane, Qld, Australia, **Department of Urology, Ryhov County Hospital, Jonkoping, Sweden, ††Department of Urology, Cambridge University Hospitals, Cambridge, UK, ‡‡Department of Translational Medicine, Lund University, Lund, Sweden, §§Department of Urology and Population Health, New York University and Manhattan Veterans Affairs Medical Centre, New York, NY, USA, ¶¶Department of Surgical and Perioperative Sciences, Urology and Andrology, Umea University, Umea, ***Department of Surgical Sciences, Uppsala University, Uppsala, Umea, and †††Department of Pathology, Karolinska University Hospital, Stockholm, Sweden

 

Read the full article

Abstract

Objectives

To investigate how well the Gleason score in diagnostic needle biopsies predicted the Gleason score in a subsequent radical prostatectomy (RP) specimen before and after the 2005 International Society of Urological Pathology (ISUP) revision of Gleason grading, and if the recently proposed ISUP grades 1–5 (corresponding to Gleason scores 6, 3 + 4, 4 + 3, 8 and 9–10) better predict the RP grade.

Patients and Methods

All prostate cancers diagnosed in Sweden are reported to the National Prostate Cancer Register (NPCR). We analysed the Gleason scores and ISUP grades from the diagnostic biopsies and the RP specimens in 15 598 men in the NPCR who: were diagnosed between 2000 and 2012 with clinical stage T1–2 M0/X prostate cancer on needle biopsy; were aged ≤70 years; had serum PSA concentration of <20 ng/mL; and underwent a RP <6 months after diagnosis as their primary treatment.

aotw-jan-4-2017-results

Results

Prediction of RP Gleason score increased from 55 to 68% between 2000 and 2012. Most of the increase occurred before 2005 (nine percentage points; P < 0.001); however, when adjusting for Gleason score and year of diagnosis in a multivariable analysis, the prediction of RP Gleason score decreased over time (odds ratio [OR] 0.98; P < 0.002). A change in the ISUP grades would have led to a decreasing agreement between biopsy and RP grades over time, from 68% in 2000 to 57% in 2012, with an OR of 0.95 in multivariable analysis (P < 0.001).

Conclusion

Agreement between biopsy and RP Gleason score improved from 2000 to 2012, with most of the improvement occurring before the 2005 ISUP grading revision. Had ISUP grades been used instead of Gleason score, the agreement between biopsy and RP grade would have decreased, probably because of its separation of Gleason score 7 into ISUP grades 2 and 3 (Gleason score 3 + 4 vs 4 + 3).

Read more articles of the week

Article of the Week: International Consultation on Urological Diseases and EAU International Consultation on Minimally Invasive Surgery in Urology: laparoscopic and robotic adrenalectomy

/by

Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video discussing the paper.

If you only have time to read one article this week, it should be this one.

International Consultation on Urological Diseases and European Association of Urology International Consultation on Minimally Invasive Surgery in Urology: laparoscopic and robotic adrenalectomy

 

Mark W. Ball*, Ashok K. Hemal† and Mohamad E. Allaf*

 

*James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, and †Department of Urology, Wake Forest School of Medicine, Winston-Salem, NC, USA

 

Read the full article

Abstract

The aim of this study was to provide an evidence-based systematic review of the use of laparoscopic and robotic adrenalectomy in the treatment of adrenal disease as part of the International Consultation on Urological Diseases and European Association of Urology consultation on Minimally Invasive Surgery in Urology. A systematic literature search (January 2004 to January 2014) was conducted to identify comparative studies assessing the safety and efficacy of minimally invasive adrenal surgery. Subtopics including the role of minimally invasive surgery for pheochromocytoma, adrenocortical carcinoma (ACC) and large adrenal tumours were examined. Additionally, the role of transperitoneal and retroperitoneal approaches, as well as laparoendoscopic single-site (LESS) and robotic adrenalectomy were reviewed. The major findings are presented in an evidence-based fashion. Large retrospective and prospective data were analysed and a set of recommendations provided by the committee was produced. Laparoscopic surgery should be considered the first-line therapy for benign adrenal masses requiring surgical resection and for patients with pheochromocytoma. While a laparoscopic approach may be feasible for selected cases of ACC without adjacent organ involvement, an open surgical approach remains the ‘gold standard’. Large adrenal tumours without preoperative or intra-operative suspicion of ACC may be safely resected via a laparoscopic approach. Both transperitoneal and retroperitoneal approaches to laparoscopic adrenalectomy are safe. The approach should be chosen based on surgeon training and experience. LESS and robotic adrenalectomy should be considered as alternatives to laparoscopic adrenalectomy but require further study.

 

aotwjan3-reults

 

Read more articles of the week

 

Editorial: Laparoscopic adrenalectomy – the ‘gold standard’ when performed appropriately

/1 Comment/by

Since its development 25 years ago, laparoscopic adrenalectomy (LA) has played a major role in the management of adrenal diseases. The guideline by the International Consultation on Urological Diseases-European Association of Urology (ICUD-EAU) International Consultation on Minimally Invasive Surgery in Urology, published in this month’s issue of BJUI [1], will further expand the appropriate use of LA to a majority of patients.

After the development of laparoscopic nephrectomy in 1990, the idea of LA was conceived by several urologists and endocrine surgeons. The first LA was performed by Go et al. [2] in January of 1992 in Japan, and the first results were published by Higashihara et al. [3] in July 1992, followed by results from Gagner et al. [4] in October 1992 [4].

Nowadays, almost all clinical guidelines strongly recommend laparoscopic surgery as the ‘gold standard’ approach to non-invasive small benign adrenal tumours. Even though there are no prospective randomized studies comparing laparoscopic and open adrenalectomies, there is a consensus that LA is associated with less postoperative pain, earlier recovery and similar long-term outcomes compared with open surgery. The conclusion in the present guideline is very acceptable.

Many comparative studies also support LA for pheochrmocytoma; however, a great concern is capsular injury during the operation. The incidence of malignancy in pheochromocytoma is >10%, and tumour spillage during laparoscopic surgery has been reported in the literature [5]. Avoiding capsular injury during adrenal surgery is very important, not only for pheochromocytoma, but also for all adrenal tumours. Even if the preoperative diagnosis is adrenocortical adenoma, some tumours could be adrenocortical cancer, especially when the tumour is >4 cm in diameter. Because the incidence of malignancy in paragangliomas is much higher, it is recommended that paragangliomas be resected by open surgery [6]. For small, non-invasive paragangliomas in surgically favourable locations, laparoscopic surgery could be an option based on the surgeon’s experience.

Indications for LA for malignant tumours is a matter of debate. It depends purely on the surgeon’s experience. The European Society for Medical Oncology Clinical Practice Guidelines for adrenal cancer in 2012 recommend LA as a safe and effective procedure for a select group of patients with small adrenocortical cancers without preoperative evidence of invasiveness. Small non-invasive metastatic adrenal tumours are also candidates for laparoscopic surgery. Most importantly, standard principles of oncological surgical treatment should be strictly respected, and open conversion is warranted when difficult dissection is encountered such as in cases of tumour adhesion or invasion or enlarged lymph nodes.

With regard to the laparoscopic approach to the adrenal tumour, the transperitoneal approach makes it easier to understand the surgical anatomy and may be suitable for less experienced surgeons when compared with retroperitoneal approaches; however, in cases when the transperitoneal approach is not suitable because of previous abdominal surgery, retroperitoneal approaches should be selected. As described in this guideline for the retroperitoneal approaches, the posterior approach has been reported frequently in the literature, with similar peri-operative outcomes to those of the transperitoneal approach. The posterior approach is unique, however, because of the prone position of the patient, and surgeons are required to have an understanding of anatomy in the prone position. The majority of urologists are more familiar with the lateral retroperitoneal approach, which is widely used for laparoscopic nephrectomy.

In conclusion, minimally invasive surgery, including laparoendoscopic single-site surgery and robot-assisted surgery, is desired by patients with adrenal diseases. In the USA, 60% of adrenalectomies are performed by urologists, while the rest are performed by endocrine surgeons [7]. Appropriate indications for and skilled performance of LA or robot-assisted adrenalectomy are critical if urologists are to be selected by endocrinologists and patients.

Read the full article
Tadashi Matsuda, President of the Endourological Society
Department of Urology and Andrology, Kansai Medical University, Hirakata, Japan

 

References

 

1 Ball MW, Hemal AK, Allaf ME. International Consultation on Urological Diseases and European Association of Urology International Consultation on Minimally Invasive Surgery in Urology: laparoscopic and robotic adrenalectomy. BJU Int 2017; 119: 13–21

 

2 GoH, Takeda M, Takahashi H et al. Laparoscopic adrenalectomy for primary aldosteronism: a new operative method. J Laparoendosc Surg 1993; 3: 455–9

 

3 Higashihara E, Tanaka Y, Horie S et al. A case report of laparoscopic adrenalectomy. Nihon Hinyokika Gakkai Zasshi 1992; 83: 1130–3

 

4 Gagner M, Lacroix A, BolteE. Laparoscopic adrenalectomy in Cushing’s syndrome and pheochromocytoma. N Engl J Med 1992; 327: 1033

 

5 LiML, Fitzgerald PA, Price DC, Norton JA. Iatrogenic pheochromocytomatosis: a previously unreported result of laparoscopic adrenalectomy. Surgery 2001; 130: 1072–7

 

6 Lenders JWM, Duh Q-Y, Eisenhofer G et al. Pheochromocytoma and paraganglioma: an endocrine society clinical practice guideline. J Clin Endocrinol Metab 2014; 99: 1915–42

 

7 Monn MF, Calaway AC, Mellon MJ et al. Changing USA national trends for adrenalectomy: the influence of surgeon and technique. BJU Int 2015; 115: 288–94

 

Video: International Consultation on Urological Diseases and European Association of Urology International Consultation on Minimally Invasive Surgery in Urology: laparoscopic and robotic adrenalectomy

/by

International Consultation on Urological Diseases and European Association of Urology International Consultation on Minimally Invasive Surgery in Urology: laparoscopic and robotic adrenalectomy

Mark W. Ball*, Ashok K. Hemal† and Mohamad E. Allaf*

 

*James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, and †Department of Urology, Wake Forest School of Medicine, Winston-Salem, NC, USA

 

Read the full article

Abstract

The aim of this study was to provide an evidence-based systematic review of the use of laparoscopic and robotic adrenalectomy in the treatment of adrenal disease as part of the International Consultation on Urological Diseases and European Association of Urology consultation on Minimally Invasive Surgery in Urology. A systematic literature search (January 2004 to January 2014) was conducted to identify comparative studies assessing the safety and efficacy of minimally invasive adrenal surgery. Subtopics including the role of minimally invasive surgery for pheochromocytoma, adrenocortical carcinoma (ACC) and large adrenal tumours were examined. Additionally, the role of transperitoneal and retroperitoneal approaches, as well as laparoendoscopic single-site (LESS) and robotic adrenalectomy were reviewed. The major findings are presented in an evidence-based fashion. Large retrospective and prospective data were analysed and a set of recommendations provided by the committee was produced. Laparoscopic surgery should be considered the first-line therapy for benign adrenal masses requiring surgical resection and for patients with pheochromocytoma. While a laparoscopic approach may be feasible for selected cases of ACC without adjacent organ involvement, an open surgical approach remains the ‘gold standard’. Large adrenal tumours without preoperative or intra-operative suspicion of ACC may be safely resected via a laparoscopic approach. Both transperitoneal and retroperitoneal approaches to laparoscopic adrenalectomy are safe. The approach should be chosen based on surgeon training and experience. LESS and robotic adrenalectomy should be considered as alternatives to laparoscopic adrenalectomy but require further study.

 

aotwjan3-reults
Read more articles of the week

 

Article of the Week: Quality Improvement in Cystectomy Care with Enhanced Recovery (QUICCER) study

/by

Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Quality Improvement in Cystectomy Care with Enhanced Recovery (QUICCER) study

Janet E. Baack Kukreja*, Maureen Kiernan*, Bethany Schempp†, Aisha Siebert, Adriana Hontar*, Benjamin Nelson*, James Dolan§, Katia Noyes, Ann Dozier, Ahmed Ghazi*, Hani H. Rashid*, Guan Wu* and Edward M. Messing*

 

*Department of Urology, Strong Memorial Hospital University of Rochester Medical Center, †School of Nursing, ‡School of Medicine and Dentistry, University of Rochester Medical Center, §Department of Public Health Sciences, and Department of Surgery, Strong Memorial Hospital University of Rochester Medical Center, Rochester, NY, USA

 

Read the full article

Objectives

To determine if patients managed with a cystectomy enhanced recovery pathway (CERP) have improved quality of care after radical cystectomy (RC), as defined by a decrease in length of hospital stay (LOS) without an increase in complications or readmissions compared with those not managed with CERP.

Subjects and Methods

The Quality Improvement in Cystectomy Care with Enhanced Recovery (QUICCER) study was a non-randomized quasi-experimental study. Data were collected between June 2011 and April 2015. The CERP was implemented in July 2013. The primary endpoint was LOS. Secondary endpoints were quality scores, complications and readmissions. Multivariable regression was performed. Propensity score matching was carried out to further simulate randomized clinical trial conditions. A CERP quality composite score was created and evaluated with regard to adherence to CERP elements.

aotwjanwfe

Results

The study included 79 patients managed with CERP and 121 who were not managed with CERP. After matching, there were 75 patients in the non-CERP group. The LOS was significantly different between the groups: the median LOS was 5 and 8 days for the CERP and non-CERP group, respectively (P < 0.001). Multivariable linear regression showed that any complication was the most significant predictor of total LOS at 90 days after RC. The higher the quality composite score the shorter the LOS (P < 0.001). There was no association between CERP and a greater number of complications or readmissions.

Conclusions

Audited quality measures in the CERP are associated with a reduction in LOS with no increase in readmissions or complications. The CERP is important for the future improvement of peri-operative care for RC and provides an opportunity to improve the quality of care provided.

Read more articles of the week

Editorial: Quality improvement in cystectomy care with enhanced recovery (QUICCER) study

/by

Enhanced recovery after surgery (ERAS) is a multidisciplinary, multi-element care pathway approach that aims to standardise and improve perioperative management. Since the first publication on ERAS for radical cystectomy in the BJUI in 2008, the literature on this important factor in postoperative management of patients undergoing major surgery in the field of urology is rather scarce and mainly in form of reviews [1]. This clearly reflects the very slow adoption of this approach, the reasons for which remain unclear.

Baack Kukreja et al. [2] in this issue of BJUI performed an analysis of sequential patients, before and after introduction of an ERAS protocol in their institution, using a propensity matched approach. The length of stay (LOS) could be reduced significantly from 8 to 5 days without increasing the rate of complications or increasing the number of readmissions or emergency department visits. The rate of readmissions is comparable to other published reported series. The difference in LOS of 3 days with an ERAS approach is impressive. However, the parameter of LOS has to be interpreted in the context of the medical system of each country in itself, as many factors may influence this parameter. The data presented indicates that there was no biased drive to discharge patients earlier in the study context.

The ERAS programme presented here included preoperative counselling and intra- and postoperative precautions and interventions. Preoperative counselling focused on information on surgery and the handling of the stoma if needed. Patients were assessed for medical and socioeconomic factors that might have an influence on anaesthesia/surgery outcome, recovery, and management after discharge. As foreseen by ERAS, patients received probiotics and preoperative carbohydrate loading [3, 4].

Apart from the LOS, one of the major findings of this study [2] was a distinct decrease in gastrointestinal complications, such as ileus, which is not surprising as this is one of the declared goals of ERAS, which was first introduced in colorectal surgery.

The reported decrease of myocardial infarction is another interesting finding. There is no difference in American Society of Anesthesiologists score between the two groups. However, there is a tendency to more blood transfusions in the cystectomy enhanced-recovery pathway group in the study. The current debate on whether blood transfusions may have a negative effect on oncological outcomes might have an influence on this eventually. Astonishingly, fluid management was not different between the two groups despite the declared goal to avoid salt and water overload. The use of pulse pressure variation or an oesophageal Doppler probe to guide fluid management might be complemented by restrictive deferred hydration combined with preemptive noradrenaline infusion [5, 6].

After discharge patients did not require home i.v. fluid administration and were able to drink at least 1 L. They did not require more support at home than the control group.

The authors are to be complemented for implementing an ERAS protocol and evaluating the effect in a scientific manner. Some of the findings are confirmatory of other studies, some are novel and worthy of further analysis, while others suggest a potential for further improvement. The results of this study [2] clearly indicate the usefulness and validity of an ERAS protocol and the need to implement and further develop such an ERAS approach in everyday urological practice.

Read the full article
George N. Thalmann
Department of Urology, University Hospital, Inselspital, Bern, Switzerland

 

References

 

1 Arumainayagam N, McGrath J, Jefferson KP, Gillatt DA. Introduction of an enhanced recovery protocol for radical cystectomy. BJU Int 2008; 101: 698–701

 

2 Baack Kukreja JE, Kiernan M, Schempp B et al. Quality Improvement in Cystectomy Care with Enhanced Recovery (QUICCER) study. BJU Int 2017; 119: 38–49

 

3 Wind J, Polle SW, Fung Kon Jin PH et al. Systematic review of enhanced recovery programmes in colonic surgery. Br J Surg 2006; 93: 800–9

 

4 Fearon KC, Ljungqvist O, Von Meyenfeldt M et al. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr 2005; 24: 466–77

 

5 Wuethrich PY, Studer UE, Thalmann GN, Burkhard FC. Intraoperative continuous norepinephrine infusion combined with restrictive deferred hydration significantly reduces the need for blood transfusion in patients undergoing open radical cystectomy: results of a prospective randomised trial. Eur Urol 2014; 66: 352–60

 

6 WuethrichPY, Burkhard FC, Thalmann GN, Stueber F, Studer UE. Restrictive deferred hydration comb ined with preemptive norepinephrine infusio n during radical cystectomy reduces postoperative complications and hospitalization time: a randomized clinical trial. Anesthesiology 2014; 120: 365–77

 

© 2024 BJU International. All Rights Reserved.