Diagnosis and management of malignant spinal cord compression: part 1.

Malignant spinal cord compression (MSCC) is a particularly challenging area of cancer care where early diagnosis and expert multidisciplinary care and rehabilitation are paramount in optimising quality of life for the affected individual. The effects of MSCC can range from minor sensory, motor and autonomic changes to severe pain and complete paralysis that significantly affects the remainder of a patient's quality of life. When caught early, the symptoms of MSCC can be prevented, minimised or possibly reversed. However, failure to recognise the condition and its serious nature, together with limited awareness of the importance of early referral for treatment, can result in irreversible paralysis. Therefore, it is essential that nurses providing clinical care for these at-risk patients are able to identify early symptoms, and undertake a thorough patient history and examination, educating the patient and their family about the signs and symptoms, which should be reported as soon as they occur.

Diagnosis and management of malignant spinal cord compression: part 2.

Malignant spinal cord compression (MSCC) is a particularly challenging area of cancer care where early diagnosis and expert multidisciplinary care and rehabilitation are paramount in optimising quality of life for the affected individual. The effects of MSCC can range from minor sensory, motor and autonomic changes to severe pain, and complete paralysis that significantly affects the remainder of a patient's quality of life. When caught early, the symptoms of MSCC can be prevented, minimised or possibly reversed. However, failure to recognise the condition and its serious nature, together with limited awareness of the importance of early referral for treatment, can result in irreversible paralysis. Therefore, it is essential that nurses providing clinical care for these at-risk patients are able to identify early symptoms, and undertake a thorough patient history and examination; educating the patient and their family about the signs and symptoms of MSCC that need to be reported as soon as they occur.

Laparoscopic partial nephrectomy with saline-irrigated KTP laser in a porcine model.

PURPOSE: To evaluate the feasibility of using the potassium titanyl phosphate (KTP) laser to perform laparoscopic partial nephrectomy in a porcine model, with saline irrigation to reduce intraoperative smoke formation. MATERIALS AND METHODS: A high-power (80 W) KTP laser was used without hilar occlusion in 14 laparoscopic partial nephrectomies in four pigs. During laser discharge, the cutting plane was irrigated continuously with saline. RESULTS: Thirteen partial nephrectomies were completed. Hemostasis was obtained without the need for any non-laser techniques. Only minimal smoke was produced, not affecting visibility or the progress of surgery. Histologic examination of the resection margin showed only minimal tissue destruction. One procedure failed because the laser fiber broke and occluded the suction during the operation. The mean partial nephrectomy time was 13.14 minutes (range 7-19 minutes) with a mean estimated blood lost of 28.57 mL (range 5-80 mL). The mean saline irrigation used for each operation was 2600 mL (range 1500-3400 mL), and the amount of saline drained out was 1700 mL (range 900-3200 mL). CONCLUSION: Laparoscopic partial nephrectomy using the 80 W KTP laser is feasible and effective in the porcine model. Saline irrigation dramatically reduces smoke formation. The technique is deserving of clinical studies after the laser-application device and suction irrigation are refined.

Determining the composition of urinary tract calculi using stone-targeted dual-energy CT: evaluation of a low-dose scanning protocol in a clinical environment.

OBJECTIVE: This study will evaluate the accuracy of dual-energy CT (DECT) in characterizing urinary tract stone composition on patients presenting to a UK hospital with renal colic. The study will also assess the additional radiation dose burden of DECT over standard protocol. METHODS: Data from 106 DECTs between October 2011 and October 2015 were retrospectively analyzed. Patients were imaged using a Toshiba Aquilion ONE™ CT scanner (Toshiba Medical Systems, Otawara-shi, Japan). All patients received a low-dose non-contrast CT of the abdomen and pelvis prior to stone-targeted DECT at 80 and 135 kVp and 40-mm field of view. Radiation dose output was evaluated using dose-length product (DLP). 19 stones were recovered and their compositions were analyzed using Fourier transform infrared spectroscopy. RESULTS: 137 stones were characterized. Mean stone diameter was 8.8 mm (range 3-48 mm). There was an 18.7% increase in mean DLP for DECT over standard CT protocol (319.4 vs 269.1 mGy cm; p < 0.001). Infrared spectroscopy analysis of 19 recovered stones identified 15 stones as calcium, 2 stones as cystine and 2 stones as mixed composition. Dual energy correctly predicted 11 (78.6%) of 14 calcium stones, 2 (100%) of 2 mixed composition stones and 0 (0%) of 2 cystine stones, resulting in a fair agreement (Cohen's κ = 0.374, p = 0.009). CONCLUSION: DECT is able to determine the composition of urinary tract stones with fair accuracy. Its utility is offset by a small but significant supplementary radiation exposure. Advances in knowledge: DECT can provide urological surgeons with useful diagnostic stone material information prior to planning optimal management of stone disease.

Robotic or open radical cystectomy, which is safer? A systematic review and meta-analysis of comparative studies.

UNLABELLED: Robotic radical cystectomy (RRC) has been growing in popularity across the world as a treatment option for bladder cancer. OBJECTIVES: To compare early surgical outcomes for RRC and open radical cystectomy (ORC) with an emphasis on complications and postoperative mortality rates. EVIDENCE ACQUISITION: A literature review was conducted from 2000 to 2013, including studies comparing RRC and ORC. The main outcome measures analyzed were the complications and mortality rates, in addition to patient demographics, pathological parameters, operating time, estimated blood loss (EBL), transfusion rates, and type of urinary diversion. A meta-analysis was conducted. For continuous data, the Mantel-Haenszel chi-square test was used, and for dichotomous data, inverse variance was used and each expressed as risk ratio with 95% CI. RESULTS: In total, 748 patients were included, 461 patients in the robotic group and 287 patients in the open group (seven studies). There were no significant differences in the demographic parameters of the two groups, except for age (age: p=0.03). There was no difference in the number of muscle-invasive diseases: p=0.47. No difference in positive surgical margin rates (p=0.21). PRIMARY OUTCOMES: The overall (p=0.32) and lower grade (Clavien I-II) (p=0.10) complication rates between the two cohorts did not achieve statistical significance. The high-grade (Clavien III-IV) (p=0.007) complication rates in the ORC group were significantly higher. The mortality rate (Clavien V) was higher in the ORC group (2.2%) compared with the RRC group (0.35%) and this did achieve statistical significance on a meta-analysis (p=0.04). SECONDARY OUTCOMES: The EBL and transfusion rates were statistically significantly lower in the RRC cohort (p<0.00001). The operating time was statistically significantly higher in the RRC cohort (p<0.00001). There was no statistically significant difference in the margin positivity between the two cohorts (p=0.08). CONCLUSION: In early experience, RRC appears to be feasible and a safe alternative to the ORC. RRC appears to have lower high-grade complications and mortality rates compared with the open approach. Although these results are promising, the authors would suggest caution while interpreting these results due to concerns with methodological flaws in the included studies in this review.

Photoselective vaporization of the prostate with the potassium-titanyl-phosphate laser in men with prostates of >100 mL.

OBJECTIVES: To assess the efficacy of photoselective vaporization of the prostate (PVP) in men with prostates of >100 mL and causing bladder outlet obstruction (BOO), using the high-power 80 W potassium-titanyl-phosphate laser (GreenLight PV, Laserscope, San Jose, CA, USA), which offers rapid tissue ablation with minimal bleeding. PATIENTS AND METHODS: We assessed 54 consecutive patients with prostates of >100 mL (mean 135, SD 42, range 100-300) who had PVP between May 2003 and August 2005. Evaluations before PVP included urine flowmetry, the International Prostate Symptom Score (IPSS), a quality-of life (QoL) score, prostate-specific antigen (PSA) level, and prostate volume measured by transrectal ultrasonography (TRUS). RESULTS: The mean (SD, range) duration of PVP was 81.6 (22.9, 39-150) min, the mean energy used for PVP was 278 (60, 176-443) kJ and the mean duration of catheterization after PVP was 23.0 (17.1, 0-72) h. The mean (sd) maximum urinary flow rate improved from 8.0 (3.1) to 18.2 (8.1), 18.5 (9.2), 17.9 (7.8) and 19.3 (9.8) mL/s at 3, 6, 12 and 24 months, respectively. The IPSS and QoL scores showed similar improvements, and there was a statistically significant reduction in PSA level and prostate volume after PVP. There was no major complication and no patient had transurethral resection syndrome or a blood transfusion. CONCLUSIONS: The 80 W KTP laser PVP offers rapid tissue ablation in patients with BOO caused by a large prostate. The short- and medium-term outcomes show that this technique can be a viable alternative to open prostatectomy.

Preliminary evidence that the allogeneic response might trigger antitumour immunity in patients with advanced prostate cancer.

OBJECTIVE: To explore the possibility that allogeneic responses might, by chance, encompass cross-reactive T cell clones specific for neo-antigenic tumour determinants, and thereby activate antitumour immunity; such cross-reactions are well documented for antiviral immunity, and genetic instability in developing cancers generates many neo-antigenic determinants as potential targets for immune responses, but the biology inevitably favours tumour progression. PATIENTS AND METHODS: Fourteen patients with hormone-refractory prostate cancer received full-thickness skin allografts from different, unrelated donors (fellow patients) until each had received six grafts. Serum prostate-specific antigen (PSA) level was used as a surrogate for tumour mass. RESULTS: One patient had a remarkable decline in PSA level, with levels at 1 year lower than before grafting. A second patient had stable PSA levels for almost 2 years. A third patient had stable PSA levels for 10-12 months before they resumed an exponential rise. Of four patients with PSA levels of > 10 ng/mL, three required surgery or radiotherapy for obstructive symptoms during or shortly after grafting. CONCLUSION: Transplant rejection involves mechanistically atypical T cell recognition of allogeneic major histocompatibility complex antigens, with massive polyclonal T cell activation. This unique aspect of T cell biology might represent a novel approach for initiating cross-reactive antitumour responses.