Surgical techniques to preserve continence after robot-assisted radical prostatectomy.

Radical prostatectomy significantly impacts the inherent anatomy of the male pelvis and the functional mechanisms of urinary continence. Incontinence has a considerable negative influence on the quality of life of patients, as well as their social and psychological wellbeing. Numerous surgical techniques have been demonstrated to support the preservation of continence during robot-assisted radical prostatectomy (RARP). In this in-depth analysis, we give a general summary of the surgical techniques used in RARP and their impact on incontinence rates.

Digital Tracking of Patients Undergoing Radical Cystectomy for Bladder Cancer: Daily Step Counts Before and After Surgery Within the iROC Randomised Controlled Trial.

BACKGROUND: Efforts to improve recovery after radical cystectomy (RC) are needed. OBJECTIVE: To investigate wrist-worn wearable activity trackers in RC participants. DESIGN, SETTING, AND PARTICIPANTS: An observational cohort study was conducted within the iROC randomised trial. INTERVENTION: Patients undergoing RC at nine cancer centres wore wrist-based trackers for 7 days (d) at intervals before and after surgery. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Step counts were compared with participant and operative features, and recovery outcomes. RESULTS AND LIMITATIONS: Of 308 participants, 284 (92.2%) returned digital activity data at baseline (median 17 d [interquartile range: 8-32] before RC), and postoperatively (5 [5-6] d) and at weeks 5 (43 [38-43] d), 12 (94 [87-106] d), and 26 (192 [181-205] d) after RC. Compliance was affected by the time from surgery and a coronavirus disease 2019 pandemic lockdown (return rates fell to 0-7%, chi-square p < 0.001). Step counts dropped after surgery (mean of 28% of baseline), before recovering at 5 weeks (wk) (71% of baseline) and 12 wk (95% of baseline; all analysis of variance [ANOVA] p < 0.001). Baseline step counts were not associated with postoperative recovery or death. Patients with extended hospital stays had reduced postoperative step counts, with a difference of 2.2 d (95% confidence interval: 0.856-3.482 d) between the lowest third and highest two-third tertiles (linear regression analysis; p < 0.001). Additionally, they spent less time out of the hospital within 90 d of RC (80.3 vs 74.3 d, p = 0.013). Lower step counts at 5, 12, and 26 wk were seen in those seeking medical help and needing readmission (ANOVA p ≤ 0.002). CONCLUSIONS: Baseline step counts were not associated with recovery. Lower postoperative step counts were associated with longer length of stay at the hospital and postdischarge readmissions. Studies are required to determine whether low step counts can identify patients at a risk of developing complications. PATIENT SUMMARY: Postoperative step counts appear to be a promising tool to identify patients in the community needing medical help or readmission. More work is needed to understand which measures are most useful and how best to collect these.

Complications After Radical Cystectomy: A Systematic Review and Meta-analysis of Randomized Controlled Trials with a Meta-regression Analysis.

CONTEXT: Radical cystectomy is considered a procedure of high complexity with a relative high complication rate. OBJECTIVE: To systematically summarize the literature regarding the complications of radical cystectomy and the factors that contribute to them. EVIDENCE ACQUISITION: We searched MEDLINE/PubMed, ClinicalTrials.gov, and Cochrane Library, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines for randomized controlled trials (RCTs) on complications related to radical cystectomy. EVIDENCE SYNTHESIS: A total of 3766 studies were screened, and 44 studies were included in this systematic review and meta-analysis. Complications following radical cystectomy are quite common. The most common complications were gastrointestinal complications (20%), infectious complications (17%), and ileus (14%). The majority of complications occurring were Clavien I-II (45%). Specific measurable patient factors are related to certain complications and can be used to stratify risk and assist in preoperative counseling, while proper design of high-quality RCTs may better reflect real-life complication rates. CONCLUSIONS: In our study, RCTs with a low risk of bias had higher complication rates than studies with a high risk of bias, underlining the need for further improvement on complication reporting in order to refine surgical outcomes. PATIENT SUMMARY: Radical cystectomy is usually followed by high complication rates, which affect patients and are, in turn, strongly associated with patients' preoperative health status.

Secondary spindle cell sarcoma following external beam radiotherapy for prostate cancer: a rare but devastating complication.

We report a case of rapidly growing sarcoma that resulted in mortality only 6 years after radiotherapy for low-grade prostate cancer.At the age of 69 years and a prostate-specific antigen (PSA) that had risen to 9.0 µg/L, transrectal ultrasound-guided biopsy of the prostate found a single core of Gleason 3+3 disease involving 4 mm of a 10 mm core. The patient declined active surveillance and completed 78 Gy of external beam radiotherapy over 39 fractions to a prostate volume of 46 mL.His PSA nadir was 0.62 µg/L 1-year postradiation; however, in April 2017, his PSA began to rise satisfying the definition of biochemical recurrence. He underwent cystoscopy, biopsy favoured an undifferentiated pleomorphic sarcoma. Restaging scans (CT/bone scan) were completed showing no metastasis, and repeat MRI showed rapid growth of the lesion in 3 months.He underwent palliative pelvic exenteration, however, 1 month later presented with large volume tumour recurrence and was subsequently palliated and died.

Genome-wide measures of DNA methylation in peripheral blood and the risk of urothelial cell carcinoma: a prospective nested case-control study.

BACKGROUND: Global DNA methylation has been reported to be associated with urothelial cell carcinoma (UCC) by studies using blood samples collected at diagnosis. Using the Illumina HumanMethylation450 assay, we derived genome-wide measures of blood DNA methylation and assessed them for their prospective association with UCC risk. METHODS: We used 439 case-control pairs from the Melbourne Collaborative Cohort Study matched on age, sex, country of birth, DNA sample type, and collection period. Conditional logistic regression was used to compute odds ratios (OR) of UCC risk per s.d. of each genome-wide measure of DNA methylation and 95% confidence intervals (CIs), adjusted for potential confounders. We also investigated associations by disease subtype, sex, smoking, and time since blood collection. RESULTS: The risk of superficial UCC was decreased for individuals with higher levels of our genome-wide DNA methylation measure (OR=0.71, 95% CI: 0.54-0.94; P=0.02). This association was particularly strong for current smokers at sample collection (OR=0.47, 95% CI: 0.27-0.83). Intermediate levels of our genome-wide measure were associated with decreased risk of invasive UCC. Some variation was observed between UCC subtypes and the location and regulatory function of the CpGs included in the genome-wide measures of methylation. CONCLUSIONS: Higher levels of our genome-wide DNA methylation measure were associated with decreased risk of superficial UCC and intermediate levels were associated with reduced risk of invasive disease. These findings require replication by other prospective studies.

Testicular torsion and the acute scrotum: current emergency management.

The acute scrotum is a challenging condition for the treating emergency physician requiring consideration of a number of possible diagnoses including testicular torsion. Prompt recognition of torsion and exclusion of other causes may lead to organ salvage, avoiding the devastating functional and psychological issues of testicular loss and minimizing unnecessary exploratory surgeries. This review aims to familiarize the reader with the latest management strategies for the acute scrotum, discusses key points in diagnosis and management and evaluates the strengths and drawbacks of history and clinical examination from an emergency perspective. It outlines the types and mechanisms of testicular torsion, and examines the current and possible future roles of labwork and radiological imaging in diagnosis. Emergency departments should be wary of younger males presenting with the acute scrotum.

Increased prostate cancer specific mortality following radical prostatectomy in men presenting with voiding symptoms-A whole of population study.

BACKGROUND: Whole of population studies reporting long-term outcomes following radical prostatectomy (RP) are scarce. We aimed to evaluate the long-term outcomes in men with prostate cancer (PC) treated with RP in a whole of population cohort. A secondary objective was to evaluate the influence of mode of presentation on PC specific mortality (PCSM). METHODS: A prospective database of all cases of RP performed in Victoria, Australia between 1995 and 2000 was established within the Victorian Cancer Registry. Specimen histopathology reports and prostate-specific antigen (PSA) values were obtained by record linkage to pathology laboratories. Mode of presentation was recorded as either PSA screened (PSA testing offered in absence of voiding symptoms) or symptomatic (diagnosis of PC following presentation with voiding symptoms). Multivariate Cox and competing risk regression models were fitted to analyze all-cause mortality, biochemical recurrence, and PCSM. RESULTS: Between 1995 and 2000, 2,154 men underwent RP in Victoria. During median follow up of 10.2 years (range 0.26-13.5 years), 74 men died from PC. In addition to Gleason score and pathological stage, symptomatic presentation was associated with PCSM. After adjusting for stage and PSA, no difference in PCSM was found between men with Gleason score ≤ 6 and Gleason score 3 + 4 = 7. Men with Gleason score 4 + 3 had significantly greater cumulative incidence of PCSM compared with men with Gleason score 3 + 4. CONCLUSIONS: Primary Gleason pattern in Gleason 7 PC is an important prognosticator of survival. Our findings suggest that concomitant voiding symptoms should be considered in the work-up and treatment of PC.

Predictors of prostate cancer specific mortality after radical prostatectomy: 10 year oncologic outcomes from the Victorian Radical Prostatectomy Registry.

PURPOSE: To identify the ability of multiple variables to predict prostate cancer specific mortality (PCSM) in a whole of population series of all radical prostatectomies (RP) performed in Victoria, Australia. MATERIALS & METHODS: A total of 2154 open RPs were performed in Victoria between July 1995 and December 2000. Subjects without follow up data, Gleason grade, pathological stage were excluded as were those who had pT4 disease or received neoadjuvant treatment. 1967 cases (91.3% of total) met the inclusion criteria for this study. Tumour characteristics were collated via a central registry. We used competing hazards regression models to investigate associations. RESULTS: At median follow up of 10.3 years pT stage of RP (P < 0.001) and high Gleason score of the RP specimen (P < 0.001 for ≥8 [Subhazard ratio (SHR) 11.19] and 4 + 3 = 7 [SHR 7.10]) compared with Gleason score 6 disease were strong predictors of progression to PCSM. Gleason score 3 + 4 = 7 was not at this time a significant predictor of PCSM (P = 0.08, SHR 1.84). Predictors of PCSM, independent of stage and grade, included rural residency (P = 0.003), primary surgeon contributing less than 40 cases (low-volume) to the VRPR (P = 0.025) and the involvement of a trainee surgeon in the operation (P = 0.031). CONCLUSION: The significant prediction of PCSM by pT cancer stage, Gleason score and primary Gleason pattern at RP in this whole of population study suggests a need to avoid understaging/grading in the process of cancer diagnosis and active surveillance protocols. Multi-modality therapy is likely to have a greater impact on PCSM in higher stage and Gleason grade disease. Identification of increased PCSM with rural residency and with involvement of a trainee urologist, and reduction in PCSM with higher surgeon volume all suggest potential for improved PC outcomes to be achieved with changes to surgical training and service delivery.

Rural residency and prostate cancer specific mortality: results from the Victorian Radical Prostatectomy Register.

OBJECTIVE: To present long-term survival data from the Victorian Radical Prostatectomy Register (VRPR), 1995-2000, and analyse the effect of rural residence on survival. METHODS: Men who underwent open radical prostatectomy (RP) in Victoria from 1995 to 2000 were recorded in a population register co-ordinated by the Victorian Cancer Registry and Cancer Council Victoria. Baseline clinical, pathological and demographic information such as location were recorded and linked to mortality and recurrence data. Men who had neoadjuvant therapy or missing data for socioeconomic status (SES), tumour grade and stage were excluded leaving 1984 patients in the analyses (92.1% of total register). RESULTS: Follow-up concluded in 2009 with 238 deaths observed, of which 77 were prostate cancer (PCa) specific. Cox and competing risk regressions were used for analysis. Living in a rural area was associated with higher odds of PCa specific mortality after RP (trend p<0.001) and a higher hazard of PCa death, the discrepancy rising up to four-fold (SHR=4.09, p=0.004) with increasing remoteness of residence. This effect is apparent after adjustment for SES, age, private or public hospital treatment, PSA level and tumour-specific factors. CONCLUSION: Rural men in Victoria have a shorter time to PCa death following definitive treatment, even after adjustment for SES and adverse tumour characteristics. IMPLICATION: Rural men are faring worse than their urban counterparts following the same cancer treatment.

Contemporary management of renal cell carcinoma (RCC) in Victoria: implications for longer term outcomes and costs.

OBJECTIVE: To describe the contemporary patterns of care for renal cell carcinoma (RCC) using a whole of population series from Victoria. PATIENTS AND METHODS: Retrospective review of medical records of all patients diagnosed and treated for RCC in Victoria in 2009. Patients were identified via the State-wide Victorian Cancer Registry. Patient demographic characteristics, symptoms, stage, and first-line treatment were assessed. Associations between case residential location (metropolitan or rural) and treatment were examined using multivariate logistic regression after adjusting for age, sex, socioeconomic status, treatment in private or public hospital and comorbidity. RESULTS: Data were obtained for 499 of 577 eligible patients. In all, 413 patients (83%) underwent surgery. Laparoscopic radical nephrectomy (RN) was the most common procedure for Stage I pT1a/pT1b tumours (51.2%); partial nephrectomy (PN) was performed for 27% of Stage I RCC In multivariate analysis, regional patients were less likely to receive PN (odds ratio [OR] 0.39, 95% confidence interval [CI] 0.18-0.85) for Stage I RCC, and less likely to receive systemic therapy for Stage IV RCC (OR 0.06, 95% CI 0.01-0.41). Multidisciplinary team meetings were recorded for only 25% of patients and 3% were enrolled in a clinical trial. CONCLUSION: Most contemporary patients diagnosed with RCC are still treated with RN, including those with smaller tumours amenable to PN. This may impact future outcomes, including increased risk of chronic kidney disease and its potential financial healthcare burden. Patterns of treatment also appear to differ between metropolitan and regional populations.