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.

Nail patella syndrome: Knee symptoms and surgical outcomes. A questionnaire-based survey.

BACKGROUND: Patellofemoral instability and dysfunction are frequent symptoms in Nail patella syndrome (NPS). In this article, the first large series of NPS patients is presented in which these knee symptoms were assessed using validated outcome scores. Additionally, the need for surgical interventions, percentage of patients who received surgical treatment and patient reported outcomes are reported. METHODS: A questionnaire based survey was conducted in 139 Dutch NPS patients. Symptoms of the knees were assessed by the Knee injury and Osteoarthritis Outcome Score (KOOS) and Kujala knee score. The questionnaire addressed whether surgical intervention was currently considered, history of past surgeries, type of surgical procedures performed and results of these procedures. RESULTS: Response rate was 74%. Mean KOOS (73.04) and Kujala (74.01) scores showed a wide range and variability between patients. Patellofemoral instability was present in 48.5% of patients. Surgical intervention was currently considered by 12% of patients. Their KOOS and Kujala scores were significantly lower compared to those not considering surgery and they experienced more patellar instability. Surgery was performed on 31 knees in 23 patients. KOOS and Kujala scores were lower in surgically treated versus nonoperated patients but no difference in patellar instability was present. An improvement in pain in 87% and in function in 30% of knees was reported after surgery. Patient satisfaction with the surgical results was 61% and 10% was dissatisfied. Patellar realignment procedures showed similar results, although persistent patellar instability was reported in 40% of patients, not different from nonoperated patients. CONCLUSIONS: Knee symptoms in NPS patients vary widely, with patellar instability present in nearly half of the patients. Although surgical treatment appears unfavourable as surgically treated patients have lower KOOS and Kujala scores, the patient reported surgical results are generally good with a high patient satisfaction. LEVEL OF EVIDENCE: Level IV.

Recommendations for diagnosis and treatment of spondylodiscitis.

BACKGROUND: Spondylodiscitis, also known as vertebral osteomyelitis, is a destructive disease with high morbidity and mortality. Diagnosis is often delayed because of the rarity of the disease and the fact that early symptoms are often non-specific. There are currently no national guidelines on the diagnosis and treatment of spondylodiscitis in the Netherlands. METHODS: We performed a single-centre retrospective cohort study examining 49 patients over 18 years of age treated for spondylodiscitis in a six-year time period. RESULTS: Mean age of patients was 69 years (range 40-89). Most patients underwent an MRI scan to confirm diagnosis (n=30). In 39 patients a microorganism was found, most commonly Staphylococcus aureus (n=14), Streptococcus species (n=11) and Gram-negative bacteria (n=11). All patients were treated with antibiotics. Thirty-seven patients received antibiotic treatment for at least six weeks, while 17 patients were treated for 90 days or longer. In 13 patients no adequate treatment was started until culture results were available. Eleven patients underwent surgery after their diagnosis. Two patients had a recurrence. CONCLUSION: We recommend that, when considering spondylodiscitis as a possible diagnosis, all patients should undergo thorough physical examination, neurological screening, blood tests for infection and blood cultures. An MRI scan should be performed, followed by a PET-CT scan when results are inconclusive. Ideally a CT-guided biopsy is performed before treatment is started. Awaiting culture results all patients should receive broad-spectrum antibiotics. Targeting only Gram-positive microorganisms in empiric treatment will lead to a delay in adequate treatment in a substantial group of patients. A multidisciplinary approach is advocated.