Post-chemotherapy robot-assisted retroperitoneal lymph node dissection for metastatic germ cell tumors: safety and perioperative outcomes.

PURPOSE: To evaluate the feasibility, safety, and early oncologic outcomes after post-chemotherapy robot-assisted retroperitoneal lymph node dissection (PC-RARPLND) for metastatic germ cell tumors (mGCT). METHODS: We retrospectively analyzed patients from four tertiary centers who underwent PC-RARPLND for mGCT, from 2011 to 2021. Previous treatment of mGCT, intraoperative and postoperative complications, and early oncologic outcomes were assessed. RESULTS: Overall, 66 patients were included. The majority of patients had non-seminoma mTGCT (89%). Median size of retroperitoneal lymph node (RLN) before surgery was 26 mm. Templates of PC-RARPLND were left modified, right modified, and full bilateral in 56%, 27%, and 14%, respectively. Median estimated blood loss and length of stay were 50 mL [50-150] and 2 [1-3] days. Four patients (6.1%) had a vascular injury, only one with significant blood loss and conversion to open surgery (OS). Two other patients had a conversion to OS for difficulty of dissection. No patient had transfusion, most frequent complications were ileus (10.6%) and symptomatic lymphorrea (7.6%) and no complications grade IIIb or more occurred. With a median follow-up of 16 months, two patients had a relapse, all outside of the surgical template (one in the retrocrural space with reascending markers, one in lungs). CONCLUSION: PC-RARPLND is a challenging surgery. In expert centers and for selected patients, it seemed safe and feasible, with a low morbidity. Further prospective evaluation of this procedure and long-term oncologic results are needed.

A simple CT score to quantify pelvic and retroperitoneal hematoma associated with pelvic fractures predicts transfusion needs, pelvic hemostatic procedures, and outcome.

BACKGROUND: Pelvic and retroperitoneal hematoma (PRH) in case of pelvic fracture may lead to early hemorrhagic shock. Quantifying PRH remains challenging in clinical practice. The goal of this study was to determine the statistical association between a semi-quantitative scoring system for PRH assessed with computed tomography (CT) and transfusion needs, pelvic hemostatic procedures, and outcome. METHODS: All consecutive severe trauma patients with pelvic ring fracture between 2010 and 2015 were included in this retrospective study. PRH was quantified using semi-quantitative analysis on admission CT scan. The pelvis and retroperitoneal cavity was assessed as 10 compartments. Hematoma was counted as 0 (absent), 1 (minimal or moderate), and 2 (large or bilateral) for each compartment (maximum score of 20). The patients were divided into the following 3 groups: no or minimal PRH (score 0-5), moderate PRH (6-9), and large PRH (10-20). These groups were compared in terms of initial transfusion needs, massive transfusion, hemostatic procedures, and outcome. Logistic regression and receiver operating characteristic (ROC) curves were analyzed. RESULTS: The study included 311 patients with pelvic fracture (mean age 41.9, [SD] 19.9 years; mean ISS 27.4, [SD] 19.4; unstable fractures, 32%; ≥5 units of packed red blood cells, 37%; massive transfusion, 19%; multiple organ failure, 29%; mortality, 13%), divided into no or minimal PRH group (128 (22%)), moderate PRH group (115 (37%)), and large PRH group (68 (22%)). Increasing PRH was found to increase transfusion needs and massive transfusions, with a higher number of pelvic hemostatic procedures, multiple organ failures, increasing need for mechanical ventilation, and prolonged hospitalization; mortality was also increased. These significant statistical associations were confirmed by logistic regression models (odds ratio, 1.2-12.1 for moderate PRH, 3.1-30.2 for large PRH) and ROC curve analysis (area under the ROC curve, 0.59-0.76). CONCLUSION: Semi-quantitative assessment of PRH on admission CT scan allows to predict transfusion needs, hemostatic procedures, and worse outcome of severe trauma patients with pelvic fracture.

Limits of intravascular contrast extravasation on computed tomography scan to define the need for pelvic angioembolization in pelvic blunt trauma: a specific assessment on the risk of false positives.

BACKGROUND: The objective was to assess the predictive performance of different intravascular contrast extravasation (ICE) characteristics for need for pelvic transarterial embolization (TAE) to determine the risk factors of false positives. METHODS: A retrospective study was performed in our trauma center between 2010 and 2015. All severe trauma patients with pelvic fracture were included. Pelvic ICE characteristics on computed tomography (CT) scan were studied: arterial (aSICE), portal surface (pSICE), and extension (exSICE) anatomic relationships. The overall predictive performance of ICE surfaces for pelvic TAE was analyzed using receiver operating characteristic curves. The analysis focused on risk factors for false positives. RESULTS: Among 311 severe trauma patients with pelvic ring fracture (mean age, 42 ± 19 years; mean Injury Severity Score, 27 ± 19), 94 (30%) had at least one pelvic ICE on the initial CT scan. Patients requiring pelvic TAE had significantly larger aSICE and pSICE than others (p = 0.001 and p = 0.035, respectively). The overall ability of ICE surfaces to predict pelvic TAE was modest (aSICE area under the receiver operating characteristic curve, 0.76 [95% confidence interval, 0.64-0.90]; p = 0.011) or nonsignificant (pSICE and exSICE). The high-sensitivity threshold was defined as aSICE 20 mm or more. Using this threshold, 76% of patients were false positives. Risk factors for false positives were admission systolic blood pressure of 90 mm Hg or greater (63% vs 20%; p = 0.03) and low transfusion needs (63% vs 10%; p = 0.009), extravasation in contact with complex bone fracture (78% vs 30%; p = 0.008), or the absence of a direct relationship between extravasation and a large retroperitoneal hematoma (100% vs 38%; p < 0.001). CONCLUSION: A significant pelvic ICE during the arterial phase does not guarantee the need for pelvic TAE. Three quarters of patients with aSICE of 20 mm or more did not need pelvic TAE. Several complementary CT scan criteria will help to identify this risk of false positives to determine adequate hemostatic pelvic procedures. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Prostate cancer incidence on cystoprostatectomy specimens is directly linked to age: results from a multicentre study.

OBJECTIVE: To assess the incidence and age-related histopathological characteristics of incidentally diagnosed prostate cancer from specimens obtained via radical cystoprostatectomy (RCP) for muscle-invasive bladder cancer. PATIENTS AND METHODS: A retrospective review of the histopathological features of 2424 male patients who underwent a RCP for bladder cancer was done at eight centres between January 1996 and June 2012. No patient had preoperative suspicion of prostate cancer. Statistical analyses were performed in different age-related groups. RESULTS: Overall, prostate cancer was diagnosed in 518 men (21.4%). Incidences varied significantly according to age (5.2% in those aged <50 years to 30.5% in those aged >75 years, P < 0.001). Most of the prostate cancers were considered as 'non-aggressive', that is to say organ-confined (≤pT2) and well-differentiated (Gleason score <7). Tumour-Node-Metastasis (TNM) stage and proportion with a Gleason score of ≥7 were significantly greater in older patients (P < 0.001). Apart from age, there were no preoperative predictive factors for 'non-aggressive' prostate-cancer status. At the end of the follow-up, only nine patients (1.7%) had biochemical recurrence of prostate cancer, and no preoperative predictive factors were identified. CONCLUSION: The rate of incidentally diagnosed prostate cancer from RCP specimens is ≈20%, most of them being organ-confined and well-differentiated. The probability of having a 'non-aggressive' prostate cancer decreases in older men.

Clinicopathological characteristics of incidental prostate cancer discovered from radical cystoprostatectomy specimen: a multicenter French study.

PURPOSE: The present study assessed the incidence and histopathological features of incidentally diagnosed prostate cancer (PCa) in specimens from radical cystoprostatectomy (RCP) for bladder cancer. The patient outcomes also were evaluated. METHODS: We retrospectively reviewed the histopathological features and survival data of 4,299 male patients who underwent a RCP for bladder cancer at 25 French centers between January 1996 and June 2012. No patients had preoperative clinical or biological suspicion of PCa. RESULTS: Among the 4,299 RCP specimens, PCa was diagnosed in 931 patients (21.7%). Most tumors (90.1%) were organ-confined (pT2), whereas 9.9% of them were diagnosed at a locally advanced stage (≥pT3). Gleason score was <6 in 129 cases (13.9%), 6 in 575 cases (61.7%), 7 (3 + 4) in 149 cases (16.0%), 7 (4 + 3) in 38 cases (4.1%), and >7 in 40 cases (4.3%). After a median follow-up of 25.5 months (interquartile range 14.2-47.4), 35.4% of patients had bladder cancer recurrence and 23.8% died of bladder cancer. Only 16 patients (1.9%) experienced PCa biochemical recurrence during follow-up, and no preoperative predictive factor was identified. No patients died from PCa. CONCLUSIONS: The rate of incidentally diagnosed PCa in RCP specimens was 21.7%. The majority of these PCas were organ-confined. PCa recurrence occurred in only 1.9% of cases during follow-up.