Intermediate-term survival of robot-assisted versus open radical cystectomy for muscle-invasive and high-risk non-muscle invasive bladder cancer in The Netherlands.

BACKGROUND: Radical cystectomy with pelvic lymph node dissection is the recommended treatment in non-metastatic muscle-invasive bladder cancer (MIBC). In randomised trials, robot-assisted radical cystectomy (RARC) showed non-inferior short-term oncological outcomes compared with open radical cystectomy (ORC). Data on intermediate and long-term oncological outcomes of RARC are limited. OBJECTIVE: To assess the intermediate-term overall survival (OS) and recurrence-free survival (RFS) of patients with MIBC and high-risk non-MIBC (NMIBC) who underwent ORC versus RARC in clinical practice. METHODS AND MATERIALS: A nationwide retrospective study in 19 Dutch hospitals including patients with MIBC and high-risk NMIBC treated by ORC (n = 1086) or RARC (n = 386) between January 1, 2012 and December 31, 2015. Primary and secondary outcome measures were median OS and RFS, respectively. Survival outcomes were estimated using Kaplan-Meier curves. A multivariable Cox regression model was developed to adjust for possible confounders and to assess prognostic factors for survival including clinical variables, clinical and pathological disease stage, neoadjuvant therapy and surgical margin status. RESULTS: The median follow-up was 5.1 years (95% confidence interval ([95%CI] 5.0-5.2). The median OS after ORC was 5.0 years (95%CI 4.3-5.6) versus 5.8 years after RARC (95%CI 5.1-6.5). The median RFS was 3.8 years (95%CI 3.1-4.5) after ORC versus 5.0 years after RARC (95%CI 3.9-6.0). After multivariable adjustment, the hazard ratio for OS was 1.00 (95%CI 0.84-1.20) and for RFS 1.08 (95%CI 0.91-1.27) of ORC versus RARC. Patients who underwent ORC were older, had higher preoperative serum creatinine levels and more advanced clinical and pathological disease stage. CONCLUSION: ORC and RARC resulted in similar intermediate-term OS and RFS in a cohort of almost 1500 MIBC and high-risk NMIBC.

Arterial thrombosis enhanced by an acute phase response.

Induction of an acute phase response causes changes in the levels of specific plasma proteins. Fibrinogen is elevated to approximately twice its normal concentration by trauma, inflammation, or infection. In this study, an acute phase response was induced by subcutaneous turpentine injection in rats. Twenty-four hours later, an arterial model of thrombosis was created bilaterally in the femoral arteries. Patency at 1 and 7 days postoperatively was 24% (9/38) in comparison to 56% (20/36) in control (saline-injected) rats undergoing the same thrombosis model. Fibrinogen levels were elevated in the turpentine group to 5.3 +/- 0.8 mg/ml at the time of the surgery and 7.2 +/- 0.3 mg/ml 24 hours after surgery. In contrast, the control group had plasma fibrinogen levels of 2.5 +/- 0.2 mg/ml at the time of surgery and 5.4 +/- 0.5 mg/ml 24 hours postoperatively. These findings suggest that when an acute phase reaction has been induced several hours prior to a microvascular procedure, there may be an increased risk for development of arterial thrombosis.

Topical heparin enhances patency in a rat model of arterial thrombosis.

Heparin added to irrigation solutions and used in microvascular surgery may have activity as a topical antithrombotic agent. A rat model of arterial thrombosis was used to evaluate topical heparin for preventing thrombosis. A crush injury was applied to both femoral arteries, and then they were transected and anastomosed. The vessel on one side of each rat was washed out and the wound irrigated with physiological saline containing one of three concentrations of heparin: 0, 100, or 500 U/ml. The vessel on the contralateral side was irrigated with unheparinized saline throughout. Patency rates at 24 hours were 63% (10 of 16) for vessels irrigated with either 100 or 500 U/ml of heparin. The contralateral vessels had 24-hour patencies of 19% (3 of 16) for each group (p < 0.05). The group receiving bilateral, unheparinized irrigation had a 24-hour patency of 29% (8 of 28). Activated partial thromboplastin times were significantly prolonged (p < 0.05) 20 minutes into the recirculation for the groups receiving 100 or 500 U/ml of heparin: 44 +/- 3 and 62 +/- 6 seconds (mean +/- standard error of the mean), respectively, in comparison to averages of 33 to 35 seconds at 24 hours in all groups and at 20 minutes after reflow in the control group. This study indicates that heparin added to the irrigation solution significantly enhances patency in compromised arterial anastomoses. The results also indicate a pitfall with studying topical heparin for microvascular surgery in rat models: acute elevation of activated partial thromboplastin time values.

Survey of analgesia regimens in burns centres in the UK.

A survey of the analgesia regimens used in burns units throughout the UK was performed. Continuous intravenous opiate infusions remain the mainstay for providing pain relief in patients in severe pain as a result of burn injuries. Other methods include: patient-controlled analgesia in appropriate patients, bolus doses of opiates combined with Entonox for control of peaks of pain and a wide variety of oral analgesics for less painful burn injuries.

Decreased vitamin B12 and folate levels in cerebrospinal fluid and serum of multiple sclerosis patients after high-dose intravenous methylprednisolone.

Twenty-one patients (15 women, 6 men) with definite multiple sclerosis (MS) were treated with 1000 mg intravenous methylprednisolone-succinate (MP) daily for 10 days. Before MP treatment there was a negative correlation (r = 0.59, P = 0.0084) between serum vitamin B12 and progression rate, defined as the ratio of the score on Kurtzke's Expanded Disability Status Scale and disease duration. A significant decrease was demonstrated in the cerebrospinal fluid (CSF) and serum levels of folate and in the CSF level of vitamin B12 after MP treatment. The decrease in serum B12 was not statistically significant. After MP treatment all median levels of vitamin B12 and folate were below the reference medians. We hypothesize that low or reduced vitamin B12/folate levels found in MS patients may be related to previous corticosteroid treatments. Otherwise a more causal relationship between low vitamin B12/folate and MS cannot be excluded. Further studies may be required to clarify the vitamin B12 and folate metabolism in patients with MS.

Axonal regeneration rate through cross-face nerve grafts.

The disfigurement of irreversible unilateral facial paralysis can be corrected by cross-face nerve grafting in conjunction with muscle transplantation. A total of 33 patients underwent cross-face nerve grafting using the sural nerve prior to undergoing the second stage of the procedure. Before a muscle transplant can be successfully connected to the distal end of the cross-face nerve graft, the regenerating axons need to have grown from the contralateral facial nerve to the distal end of the nerve graft. This can be tested by the Tinel sign. A retrospective study was performed to determine the rate of growth of regenerating axons through the cross-face nerve graft. A rate of axon growth of 1.8 mm/day was found, and also an inverse relationship between the age of the patient and the regeneration rate. These results can be used as a guide in planning patients' treatment.