The Comprehensive Complication Index. Proposed modification to improve estimates of perioperative morbidity after radical cystectomy. A pilot study.

INTRODUCTION: The aim of this article was to compare the 30-day morbidity after radical cystectomy comparing the prevalent Clavien-Dindo Classification (CDC) and the novel Comprehensive Complication Index (CCI). Additionally, we evaluated the correlation between particular clinical features and the severity of perioperative morbidity. MATERIAL AND METHODS: A total of 42 patients were included into the study (33 men and 9 women) who underwent open radical cystectomy (RC) with bilateral lymphadenectomy for bladder cancer. The selection of complications was based on groundbreaking research on morbidity after RC. The assessment of perioperative complications was performed using the CDC and then the CCI. RESULTS: The CCI was found to be a significant upgrade in capturing cumulative morbidity in comparison to the CDC when used as the only evaluational tool. CONCLUSIONS: Using only the CDC may underestimate the severity of perioperative complications. Unfavorable clinical features e.g. older age, chronic kidney disease (CKD), persistent nodal (pN+) disease, prior abdominal and pelvic surgeries as well as smoking are of significant importance for the increase of the severity of perioperative complications.

Is ERCC1 a prognostic biomarker for urothelial cancer following radical cystectomy? A long-term analysis.

INTRODUCTION: Excision repair cross-complementation 1 protein (ERCC1) plays a vital role in cancer cells enabling DNA repair via nucleotide excision repair. Thus, we hypothesized whether expression of this protein may be utilized as a prognostic marker in patients after radical cystectomy. MATERIAL AND METHODS: The final analysis involved 123 patients with urothelial bladder carcinoma who underwent radical cystectomy with bilateral lymphadenectomy. The median follow-up time was equal to 853 days. ERCC1 status was evaluated immunohistochemically with the application of tissue microarrays. RESULTS: Positive ERCC1 expression was noted in 46% of the studied cases. Among the analyzed clinical and pathological factors, we could not establish a statistically significant correlation with ERCC1. Similarly, survival curves were statistically indifferent in patients with tumors categorized according to both expression categories. We did not confirm a prognostic value of ERCC1 in the multivariate regression analysis. CONCLUSIONS: ERCC1 expression does not influence the overall survival of patients with urothelial bladder carcinoma after radical cystectomy.

Late-Onset Medullary Thyroid Cancer in a Patient with a Germline RET Codon C634R Mutation.

Background: Multiple endocrine neoplasia type 2A (MEN2A) is a rare, hereditary syndrome resulting from a germline mutation in the RET proto-oncogene and characterized primarily by medullary thyroid cancer (MTC), pheochromocytoma (PHEO), and hyperparathyroidism. Types of RET mutation have been associated with age at onset, clinical outcomes of MTC, and the penetrance of other components. Patients classified as 'high-risk' by the American Thyroid Association (ATA), based on the aggressiveness of MTC and the penetrance of other components, are recommended to undergo early prophylactic thyroidectomy at age ≤ 5 years and to be screened for PHEO at age ≥ 11 years. Patients with RET codon C634R mutations have been classified as high-risk. Case presentation: The present study describes a 71-year-old woman newly diagnosed with hereditary MTC related to a RET C634R germline mutation. Her basal serum calcitonin level was high, but there was no evidence of distant metastases. Surgery revealed bilateral MTC with two metastatic lymph nodes. Because microscopic resection was incomplete and extranodal extension was observed, the patient underwent adjuvant external beam radiotherapy. Response to therapy was excellent. Follow-up after 1.5 years showed no evidence of disease or other manifestations of MEN2A. Conclusion: Despite RET C634R carriers being classified as high-risk by the ATA, this patient did not present with either distant MTC or PHEO until her seventies. To our knowledge, only one other patient has shown a similar late identification of a RET C634R mutation, but MTC could not be diagnosed because the patient was lost to follow-up. Further research is required to develop optimal protocols that could allow patients requiring prophylactic thyroidectomy to be differentiated from those who can be monitored closely without early surgery.

Is Male Sex A Prognostic Factor in Papillary Thyroid Cancer?

Identifying risk factors is crucial for predicting papillary thyroid cancer (PTC) with severe course, which causes a clinical problem. The purpose of this study was to assess whether male sex can be such a predictive factor and to verify whether including it as a predictive factor of high initial risk of recurrence/persistence would help to enhance the value of the American Thyroid Association initial risk stratification system (ATA). We retrospectively analyzed 1547 PTC patients (1358 females and 189 males), treated from 1986 to 2018. The relationship between sex and clinicopathological features, response to therapy, and disease status was assessed. Men with PTC showed some adverse clinicopathological features more often than women, including angioinvasion, lymph node metastases, and tumor size > 40 mm. There were sex-related disparities with respect to response to initial therapy and final follow-up. Male sex is associated with some unfavorable clinicopathological features of PTC, which may affect response to initial therapy or final disease status. In our study, modification of the ATA system by including male sex as a risk factor does not enhance its value. Thus, further studies are needed to assess whether males require treatment modalities or oncological follow-up protocols that are different from those of females.

Incidence of the CHEK2 Germline Mutation and Its Impact on Clinicopathological Features, Treatment Responses, and Disease Course in Patients with Papillary Thyroid Carcinoma.

The CHEK2 gene is involved in the repair of damaged DNA. CHEK2 germline mutations impair this repair mechanism, causing genomic instability and increasing the risk of various cancers, including papillary thyroid carcinoma (PTC). Here, we asked whether CHEK2 germline mutations predict a worse clinical course for PTC. The study included 1547 unselected PTC patients (1358 women and 189 men) treated at a single center. The relationship between mutation status and clinicopathological characteristics, treatment responses, and disease outcome was assessed. CHEK2 mutations were found in 240 (15.5%) of patients. A CHEK2 I157T missense mutation was found in 12.3%, and CHEK2 truncating mutations (IVS2 + 1G > A, del5395, 1100delC) were found in 2.8%. The truncating mutations were more common in women (p = 0.038), and were associated with vascular invasion (OR, 6.91; p < 0.0001) and intermediate or high initial risk (OR, 1.92; p = 0.0481) in multivariate analysis. No significant differences in these parameters were observed in patients with the I157T missense mutation. In conclusion, the CHEK2 truncating mutations were associated with vascular invasion and with intermediate and high initial risk of recurrence/persistence. Neither the truncating nor the missense mutations were associated with worse primary treatment response and outcome of the disease.

Modified technique for laparoscopic running vesicourethral anastomosis.

INTRODUCTION: A vesicourethral anastomosis is the most challenging and time-consuming step of radical prostatectomy. In 2003, van Velthoven introduced his own technique of connecting the bladder neck with the membranous urethra, which has remained the most popular method since. Despite being effective, this method is time consuming and is not free from the risk of complications. AIM: Here we describe our technique for laparoscopic vesicourethral anastomosis using a running suture as an alternative to the traditional approach. MATERIAL AND METHODS: The vesicourethral anastomosis is created using a running stitch placed first at the 5 o'clock position on the posterolateral aspect of the bladder outside-in and then through the urethra at the same location inside-out. Proceeding anticlockwise, the running suture is placed 5 times more through both the bladder neck and the urethra in a similar fashion until it meets the free end at the 5 o'clock position. A single knot is then tied outside the bladder. RESULTS: The anastomotic technique has been used in 28 patients with clinically organ confined prostate cancer. The mean anastomosis time was 9.53 min, the mean operative time was 155.20 min, the mean drain permanence was 2.71 days, and the mean catheterisation time was 17.28 days. Continence rate 3 months after surgery was 92.85%, and 100% at 6- and 12-month follow-up visits. CONCLUSIONS: We describe a safe, feasible and efficient technique for vesicourethral anastomosis. Further studies on a larger group of patients are needed to confirm our encouraging preliminary results.

Laparoscopic radical prostatectomy with bladder neck preservation: positive surgical margin and urinary continence status.

INTRODUCTION: Preservation of the bladder neck (BN) has been controversial, as limited excision of the bladder neck may result in incomplete resection of the disease. Moreover, the urinary continence rate may not be improved. AIM: To evaluate the effect of bladder neck sparing on urinary continence, and surgical margins status in prostate cancer (PCa) patients treated with laparoscopic radical extraperitoneal prostatectomy. MATERIAL AND METHODS: A retrospective analysis of 295 consecutive patients who had undergone laparoscopic radical extraperitoneal prostatectomy for clinically localised prostate cancer in a single institution was performed. Positive surgical margin (SM(+)) and urinary continence status at 3, 6, and 12 months were evaluated. RESULTS: The distribution of SM(+) for pT2, pT3, and pT4a was 15.3% (27/176), 49.1% (58/118), and 100% (1/1), respectively. Overall, there were 55.61%, 80.61%, and 84.69% of men continent at 3, 6, and 12 months, respectively. However, when limiting the analysis to those who did not receive adjuvant radiotherapy within 12 months following surgery, urinary continence rates were 59.23%, 85.86%, and 90.21% at 3, 6, and 12 months, respectively. Preoperative prostate-specific antigen (PSA) and pathological T stage were identified as significant predictors of positive surgical margins. CONCLUSIONS: Laparoscopic radical extraperitoneal prostatectomy with bladder neck preservation has been a safe procedure which has resulted in good functional outcome. We observed a relatively high incidence of positive surgical margins which could be attributed to a large number of extracapsular disease cases.

Endoscopic simple prostatectomy.

INTRODUCTION: Many options exist for the surgical treatment of lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH), including transurethral resection of the prostate (TURP), laser surgery, and open adenomectomy. Recently, endoscopic techniques have been used in the treatment of BPH. MATERIAL AND METHODS: We reviewed clinical studies in PubMed describing minimally invasive endoscopic procedures for the treatment of BPH. RESULTS: Laparoscopic adenomectomy (LA) and robotic-assisted simple prostatectomy (RASP) were introduced in the early 2000s. These operative techniques have been standardized and reproducible, with some individual modifications. Studies analyzing the outcomes of LA and RASP have reported significant improvements in urinary flow and decreases in patient International Prostate Symptom Score (IPSS). These minimally invasive approaches have resulted in a lower rate of complications, shorter hospital stays, smaller scars, faster recoveries, and an earlier return to work. CONCLUSIONS: Minimally invasive techniques such as LA and RASP for the treatment BPH are safe, efficacious, and allow faster recovery. These procedures have a short learning curve and offer new options for the surgeon treating BPH.

[Serum levels of 25(OH)D3 in patients with prostate cancer compared to healthy men]. / Ocena steienia 25(OH)D3 w grupie chorych z rakiem prostaty w porównaniu do grupy zdrowych mezczyzn.

UNLABELLED: Prostate cancer (CaP) is one of the most common cancers in men. On the basis of international and Polish epidemiological data it is estimated that is the second leading cause of death from cancer. These data tend to look for underlying causes such a high incidence. Detected in 1990, the relationship between UV radiation and the reduction of mortality rate due to CaP gave rise to the search for effects of vitamin D, in CaP. The aim of this study was to evalu ate the concentration of 25(OH)D3 in patients treated for prostate cancer (CaP) compared to the control group of healthy men, and attempt to assess the relationship 25(OH)D3 shortage of CaP incidence and degree of its clinical advancement. MATERIAL AND METHODS: The study included 42 men, aged from 42 to 86 years (average age 66.14+/-8.92 years) treated between 2005-2013 in sCO due to prostate cancer. The control group consisted of 40 healthy men aged from 42 to 78 years (average age 63.17+/-9.02) in whom CaP and other cancer disease were excluded. Patients treated for CaP were divid ed into two groups depending on the severity of the cancer being evaluated by the TNM scale. Group 1 consisted of 11 patients with low severity of CaP-T1, group 2 -31 patients with higher tumor stage (T2+T3+T4). In all patients, serum 25(OH)D3 was marked in venous blood collected in the morning. RESULTS: The concentration of 25(OH)D3 in the group of patients with CaP occured in 80.94. There was no statistically significant difference between patients 25(OH)D3 concentra tions of CaP and control group (p = 0.3756). In both subgroups of patients with CaP showed no statistically significant difference 25(OH)D3 concentra tions (p = 0.5672), depending on the tumor advancement stage (according to TNM). CONCLUSIONS: The majority of tested patients with prostate cancer were low concentrations of vitamin D3. There were no significant differences in concentrations of vitamin D3 in the group of patients with CaP and in the control group. Based on the analysis no relationship between the 25(OH)D3 concentration and the stage of CaP was showed, too.

[Does neuroendocrine differentiation have prognostic value in prostate core needle biopsies?]. / Czy róznicowanie neuroendokrynne w materiale uzyskanym metoda rdzeniowej biopsji stercza moze miec znaczenie prognostyczne?

AIM: The biological behaviour of prostate cancer (PCa) varies significantly and cannot be, therefore, predicted. Better understanding of the mechanisms underpinning PCa oncogenesis and progression with its yet-to-be discovered poor prognostic factors is essential in order to optimise and tailor treatment to an individual patient. The aim of this paper was to investigate the association between the rate of focal PCa neuroendocrine activity, tumour cell proliferation index score, and the rate of PCa positive core needle biopsy results. MATERIAL AND METHODS: 92 men, with histologically confirmed PCa, which was clinically confined to the prostate and was graded with Gleason score > or =7, had their core needle biopsies under transrectal ultrasonography guidance performed. The PCa neuroendocrine activity was immunohistochemically confirmed using antibodies against Chromogranin-A and neuron specific enolase. RESULTS: The neuroendocrine activity was detected in 14 (13%) out of 92 PCa patients participating in the study. The proliferative index was not increased in non-cancerous prostate cells. There was no relationship between PCa neuroendocrine activity, the number and percentage of PCa positive biopsies, prostate volume, serum PSA concentration, and Gleason score found. CONCLUSIONS: No association between selected PCa prognostic factors and neuroendocrine activity could be found in patients with organ confined prostate cancer.

[Prospective evaluation of pain associated with indwelling JJ stents following ureterorenoscopic lithotripsy]. / Prospektywna ocena dolegliwosci bólowych zwiazanych z pozostawieniem cewników JJ po ureterorenoskopii z litotrypsja.

AIM: Routine placement of JJ ure teric stents, following uncomplicated endoscopic removal of a ureteral stone, still remains debatable. Indwelling JJ stents are not without any risks. They often can cause marked discomfort, or even pain. The aim of this study was to prospectively evaluate patient's perceived pain due to renal colic and indwelling JJ stent left following ure terorenoscopic lithotripsy (URSL). MATERIAL AND METHODS: 54 patients with colicky pain due to distal ureteric stone, and who underwent uncompli cated ureterorenoscopic lithotripsy, were included in the study. Follow ing URSL, patients were randomly selected to have either JJ stent left in situ (Group I), or remain without a stent (Group II). Among all study par ticipants levels of pain prior, as well as 14 days after the procedure were evalu ated with the use of a visual analogue pain scale. RESULTS: Pain perception at the time of colic did not vary between men and women (6.30 +/- 1.33 and 6.38 +/- 1.11, respectively, p=0.293). Similarly, no differences in perceived pain were noted 14 days following URSL. Mean pain score in patients with indwelling JJ stent was 2.12 +/- 1.23 as compared to 2.15 +/- 0.67 in those without it (p=0.148). CONCLUSIONS: No increase in pain levels due to indwelling JJ stent could be observed. Further research to allow for better assessment of discomfort and pain caused by an indwelling JJ stent on a larger cohort, and which could also discriminate patients' psy chosomatic symptoms, is needed.

[Laparoscopic radical cystectomy with extracorporeal ileal neobladder reconstruction]. / Technika wytworzenia pecherza jelitowego u chorych poddanych laparoskopowej cystektomii radykalnej.

Open radical cystectomy with orthotopic neobladder reconstruction is a complex procedure not only carrying a significant risk of peri- and postoperative complications but also a high, 3% risk of mortality to the patient. The advantages of performing cystectomy with various urinary diversion methods by the use of minimal invasive techniques include minimal surgical trauma, lower requirement for blood transfusion, swift recovery and shorter hospital stay. The aim of this paper is to describe an operative technique for neobladder urinary diversion formation via minilaparotomy, and classic laparoscopic technique with our own modification in patients who underwent laparoscopic radical cystectomy.

Bladder neck preservation during classic laparoscopic radical prostatectomy - point of technique and preliminary results.

INTRODUCTION: Stress urinary incontinence after radical prostatectomy for prostate cancer organ-confined patients can significantly affect quality of life. The article presents a technique of bladder neck preservation, because it is believed that this point is one of many crucial points responsible for fast recovery of continence after laparoscopic radical prostatectomy (LRP). MATERIAL AND METHODS: Laparoscopic radical prostatectomy with the intention of bladder neck preservation was performed in 194 patients of clinically organ-confined prostate cancer (cT2 ≤ N0M0). The working space was done by tissues-fingers dissections and insufflation of the cavity under full visual control, without the Gaur-balloon device. We insert two 10 mm trocars, three trocars of 5 mm and both 0° and 30° laparoscopes. The most important points of technique include: identification of landmarks of bladder neck and prostate base; dissection of muscle fibres of the very superficial bladder wall; mobilization of the posterior part of the urethra and simultaneous seminal vesicles release; neuro-vascular bundles preservation. This procedure resulted in a long bladder neck which can be easily anastomosed with the urethra. Tension-free and end-to-end (bladder neck-urethra) anastomosis are the results. RESULTS: In all cases radical prostatectomy was performed laparoscopically in the extraperitoneal space. There were no complications of bladder neck preservation during laparoscopic radical prostatectomy (LRP) apart from 22 cases with a large medium lobe. The mean time of operation was 150 min (110-210 min). The mean blood loss during LRP was 150 ml (110-350 ml). Blood transfusion was not necessary. There were no postoperative complications. Mean hospitalization time was 5 days. Pathological result of the postoperative specimens was pT2a in 30%, pT2b in 60%, pT3a in 6%, and pT3b in 4% of patients. In 7% of patients a positive surgical margin was affirmed, but the bladder neck was not affected in any case. Full continence after 3, 6, and 12 months was observed in 75%, 85%, and 92% of analysed patients, respectively. CONCLUSIONS: Bladder neck preservation during LRP is an effective, safe procedure that offers good functional results based on fast recovery of continence. Bladder neck preservation offers full tight anastomosis, especially in cases with no large median lobe of prostatic adenoma. Continence of patients who underwent bladder neck preservation was improved during short-term follow-up. Long-term results are still not conclusive. We think that this technique applied to laparoscopy will finally result in real progress of continence preservation after radical prostatectomy, but larger groups of patients have to be compared.

Extraperitoneal laparoscopic Millin prostatectomy using finger enucleation.

PURPOSE: We evaluated the feasibilty, safety and results of extraperitoneal laparoscopic Millin prostatectomy using finger enucleation through an additional 1 cm suprapubic incision. MATERIALS AND METHODS: A total of 66 consecutive laparoscopic simple prostatectomies were performed with this technique in men with symptomatic bladder outflow obstruction and a prostate gland larger than 70 cc on transrectal ultrasound. Data such as operating time, intraoperative blood loss, transfusion rate, complications, catheterization period, hospitalization time and surgical specimen weight were prospectively collected and evaluated. Preoperative and 3-month postoperative International Prostate Symptom Score and urinary flow rates were used to assess the surgical outcome. RESULTS: Average operating time was 55 minutes with a mean estimated blood loss of 200 ml. No blood transfusion was necessary, and no conversion, complications or mortality was present. The mean postoperative catheterization period was 7.3 days with a mean hospital stay of 5.2 days. Mean enucleated tissue weight was 85.5 gm. At 3 months postoperatively the International Prostate Symptom Score improved to a mean of 5.8 (from a mean preoperative score of 29.5) while maximum urine flow improved to a mean of 18.5 ml per second (from a mean preoperative rate of 5.8 ml per second). CONCLUSIONS: This procedure is safe and fast with excellent functional outcomes. However, prolonged catheterization and hospitalization are still required.

Lymph node dissection during laparoscopic (LRC) and open (ORC) radical cystectomy due to muscle invasive bladder urothelial cancer (pT2-3, TCC).

AIM: The aim of the study was to compare the number of nodes dissected during laparoscopic and open radical cystoprostatectomy in men or anterior exenteration in women due to muscle invasive bladder urothelial cancer (IBC). MATERIAL AND METHODS: Fifty-one patients treated with laparoscopic radical cystectomy (LRC) and 63 with open radical cystectomy (ORC) were compared. The LRC group consisted of 47 pT2 tumours and 4 pT3, while the ORC group was composed of 27 pT2 tumours and 36 pT3. During ORC external, internal, common iliac and obturator lymph nodes were removed separately, but were added and analysed together for each side. Nodes dissected from one side during ORC were compared to en bloc dissected nodes in the LRC group. RESULTS: There were no complications associated with extended pelvic lymph node dissection during LRC or ORC. There were significant differences in the mean number of resected lymph nodes between LRC and ORC for pT2 tumours. The laparoscopic approach allowed about 8-9 more lymph nodes to be removed than open surgery in the pT2 group. In 15% of patients with pT2 disease treated with open radical cystectomy node metastases were observed. Active disease was detected in 18% of nodes resected laparoscopically due to pT2 disease. Fourty-seven percentage of patients with pT3 disease treated with open surgery were diagnosed as harbouring metastatic lymph nodes. The laparoscopic group with pT3 disease was too small to analyse. CONCLUSIONS: We have found that laparoscopic radical cystectomy can be performed without any compromise in lymph node dissection. The technique of lymph node dissection (LND) during laparoscopic cystectomy (LRC) resulted in sufficient resected lymphatic tissue, especially in patients with bladder-confined tumours with a low volume of lymph nodes.