Anastomosis quality score during robot-assisted radical prostatectomy: a new simple tool to maximize postoperative management.

PURPOSE: The urethro-vesical anastomosis represents one of the most challenging steps of robotic prostatectomy (RARP). To maximize postoperative management, we specifically designed our anastomosis quality score (AQS), based on the intraoperative characteristics of the urethra and bladder neck. METHODS: This is a prospective study, conducted from April 2019 to March 2020. All the patients were classified into three different AQS categories (low, intermediate, high) based on the quality of the anastomosis. The postoperative management was modulated accordingly. RESULTS: We enrolled 333 patients. According to AQS, no differences were recorded in intraoperative complications (p = 0.9). Median hospital stay and catheterization time were longer in AQS 1 group (p < 0.001). Additionally, the occurrence of postoperative complication was higher in AQS 1 category (p = 0.002) but, when focusing on the complications related to the quality of the anastomosis, no differences were found neither for acute urinary retention (p = 0.12) nor urine leakage (p = 0.11). Finally, concerning the continence recovery, no significant differences were found among the three groups for each time point. The highest potency recovery rate at one month of follow-up was recorded in AQS 3 category (p = 0. 03). CONCLUSION: The AQS proposed revealed to be a valid too to intraoperatively categorize patients who underwent RARP on the basis of the urethral and bladder neck features. The modulated postoperative management for each specific score category allowed to limit the occurrence of complications and to maximize the functional outcomes.

Effect of Preoperative Dutasteride on Holmium Laser Enucleation of the Prostate.

PURPOSE: The aim of this study was to compare and investigate the efficacy of using the 5α-reductase inhibitor dutasteride after holmium laser enucleation of the prostate (HoLEP) to improve postoperative urination and surgery-related complications. METHODS: This is a retrospective observational study comparing patients who received or did not receive 5α-reductase inhibitors prior to HoLEP. Of a total of 270 patients, 40 received the 5α-reductase inhibitor dutasteride. We compared the factors including age, postoperative maximal flow rate (MFR; mL/s), postoperative prostate-specific antigen (PSA) (ng/mL), preoperative MFR (mL/s), preoperative PSA (ng/mL), prostate cancer (%), operative time (min), preoperative residual urine (mL), postoperative residual urine (mL), urinary incontinence (day 1; %), urinary incontinence (1 month; %), urinary incontinence (3 months; %), urethral catheter indwelling period (days), morcellation time (min), enucleation time (min), intraoperative complications (%), postoperative complications (%), prostate volume (mL), enucleated weight (g), and hospitalization period (days). RESULTS: Postoperative PSA (p = 0.0071), morcellation time (p = 0.0444), postoperative complications (p = 0.0350) and prostate volume (p = 0.0069), but not enucleated prostate weight (p = 0.8809), were significantly lower in the dutasteride group. Importantly, enucleation efficiency and morcellation efficiency did not show any significant difference between the dutasteride and the non-dutasteride groups. CONCLUSIONS: Use of a preoperative 5α-reductase inhibitor significantly correlated with surgery-related factors, with less morcellation time, fewer postoperative complications, and lower postoperative PSA. Surgeons performing HoLEP may wish to take these findings into account.

Do patients have to choose between ejaculation and miction? A systematic review about ejaculation preservation technics for benign prostatic obstruction surgical treatment.

PURPOSE: Ejaculatory dysfunction is the most common side effect related to surgical treatment of benign prostatic obstruction (BPO). Nowadays, modified surgical techniques and non-ablative techniques have emerged with the aim of preserving antegrade ejaculation. Our objective was to conduce a systematic review of the literature regarding efficacy on ejaculatory preservation of modified endoscopic surgical techniques, and mini-invasive non-ablatives techniques for BPO management. METHODS: A systematic review of the literature was carried out on the PubMed database using the following MESH terms: "Prostatic Hyperplasia/surgery" and "Ejaculation", in combination with the following keywords: "ejaculation preservation", "photoselective vaporization of the prostate", "photoselective vapo-enucleation of the prostate", "holmium laser enucleation of the prostate", "thulium laser", "prostatic artery embolization", "urolift", "rezum", and "aquablation". RESULTS: The ejaculation preservation rate of modified-TURP ranged from 66 to 91%. The ejaculation preservation rate of modified-prostate photo-vaporization ranged from 87 to 96%. The only high level of evidence studies available compared prostatic urethral lift (PUL) and aquablation versus regular TURP in prospective randomized-controlled trials. The ejaculation preservation rate of either PUL or aquablation compared to regular TURP was 100 and 90 versus 34%, respectively. CONCLUSIONS: Non-ablative therapies and modified endoscopic surgical techniques seemed to be reasonable options for patients eager to preserve their ejaculatory functions.

Reconsideration of the Anterior Surgical Plane of Total Mesorectal Excision for Rectal Cancer.

INTRODUCTION: Previous studies on total mesorectal excision suggested dissection anterior to Denonvilliers' fascia, which might lead to intraoperative pelvic autonomic nerves injury and a high incidence of urogenital dysfunction. TECHNIQUE: We dissected 4 cases of cadavers, mainly focusing on anatomy of Denonvilliers' fascia, to study the relationship between Denonvilliers' fascia and rectum. In practice, instead of dissection 1 cm above peritoneal reflection, dissection of the peritoneum was performed at the lowest level of peritoneal reflection during laparoscopic resection for mid-low rectal cancer. RESULTS: The cadaveric study revealed that there were loose tissues between Denonvilliers' fascia and rectal specimen, thus a surgical plane posterior to Denonvilliers' fascia did exist. During laparoscopic resection for mid-low rectal cancer, some loose reticulate structures between Denonvilliers' fascia and proper fascia of rectum would present after dissection of peritoneum at the lowest level of peritoneal reflection. Then dissection within the surgical plane posterior to Denonvilliers' fascia became easy and feasible. In this plane, both the pelvic nerves and postoperative urogenital function could be well protected by Denonvilliers' fascia. CONCLUSIONS: The anterior surgical plane for total mesorectal excision should be reconsidered, and dissection posterior to Denonvilliers' fascia is feasible and practicable for patients without risk of positive anterior circumferential resection margin.

Nerve-sparing radical hysterectomy compared to standard radical hysterectomy for women with early stage cervical cancer (stage Ia2 to IIa).

BACKGROUND: Radical hysterectomy is one of the standard treatments for stage Ia2 to IIa cervical cancer. Bladder dysfunction caused by disruption of the pelvic autonomic nerves is a common complication following standard radical hysterectomy and can affect quality of life significantly. Nerve-sparing radical hysterectomy is a modified radical hysterectomy, developed to permit resection of oncologically relevant tissues surrounding the cervical lesion, while preserving the pelvic autonomic nerves. OBJECTIVES: To evaluate the benefits and harms of nerve-sparing radical hysterectomy in women with stage Ia2 to IIa cervical cancer. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 4), MEDLINE via Ovid (1946 to May week 2, 2018), and Embase via Ovid (1980 to 2018, week 21). We also checked registers of clinical trials, grey literature, reports of conferences, citation lists of included studies, and key textbooks for potentially relevant studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs) evaluating the efficacy and safety of nerve-sparing radical hysterectomy compared to standard radical hysterectomy for women with early stage cervical cancer (stage Ia2 to IIa). DATA COLLECTION AND ANALYSIS: We applied standard Cochrane methodology for data collection and analysis. Two review authors independently selected potentially relevant RCTs, extracted data, evaluated risk of bias of the included studies, compared results and resolved disagreements by discussion or consultation with a third review author, and assessed the certainty of evidence. MAIN RESULTS: We identified 1332 records as a result of the search (excluding duplicates). Of the 26 studies that potentially met the review criteria, we included four studies involving 205 women; most of the trials had unclear risks of bias. We identified one ongoing trial.The analysis of overall survival was not feasible, as there were no deaths reported among women allocated to standard radical hysterectomy. However, there were two deaths in among women allocated to the nerve-sparing technique. None of the included studies reported rates of intermittent self-catheterisation over one month following surgery. We could not analyse the relative effect of the two surgical techniques on quality of life due to inconsistent data reported. Nerve-sparing radical hysterectomy reduced postoperative bladder dysfunctions in terms of a shorter time to postvoid residual volume of urine ≤ 50 mL (mean difference (MD) -13.21 days; 95% confidence interval (CI) -24.02 to -2.41; 111 women; 2 studies; low-certainty evidence) and lower volume of postvoid residual urine measured one month following operation (MD -9.59 days; 95% CI -16.28 to -2.90; 58 women; 2 study; low-certainty evidence). There were no clear differences in terms of perioperative complications (RR 0.55; 95% CI 0.24 to 1.26; 180 women; 3 studies; low-certainty evidence) and disease-free survival (HR 0.63; 95% CI 0.00 to 106.95; 86 women; one study; very low-certainty evidence) between the comparison groups. AUTHORS' CONCLUSIONS: Nerve-sparing radical hysterectomy may lessen the risk of postoperative bladder dysfunction compared to the standard technique, but the certainty of this evidence is low. The very low-certainty evidence for disease-free survival and lack of information for overall survival indicate that the oncological safety of nerve-sparing radical hysterectomy for women with early stage cervical cancer remains unclear. Further large, high-quality RCTs are required to determine, if clinically meaningful differences of survival exist between these two surgical treatments.

Robotic versus laparoscopic surgery for rectal cancer in male urogenital function preservation, a meta-analysis.

BACKGROUND: Urogenital dysfunction after rectal cancer surgery can largely affect patients' postoperative quality of life. Whether robotic surgery can be a better option when comparing with laparoscopic surgery is still not well-known. METHODS: Comprehensive search in PubMed, Embase, Cochrane Library, and Clinical Trials was conducted to identify relevant studies in March 2018. Studies comparing robotic surgery with laparoscopic surgery were included. Measurement of urogenital function was through the International Prostate Symptom Score and International Index of Erectile Function. RESULTS: Six studies with 386 patients in robotic group and 421 patients in laparoscopic group were finally included. Pooled analysis indicated that bladder function was better at 12 months in the robotic group after the procedures (mean difference, - 0.30, 95% CI, - 0.52 to - 0.08). No significant difference was found at 3 and 6 months postoperatively (mean difference, - 0.37, 95% CI, - 1.48 to 0.73; mean difference, - 1.21, 95% CI, - 2.69 to 0.28). Sexual function was better at 3 months in the robotic group after surgery (mean difference, - 3.28, 95% CI, - 6.08 to - 0.49) and not significantly different at 6 and 12 months. (mean difference, 3.78, 95% CI, - 7.37 to 14.93; mean difference, - 2.82, 95% CI, - 8.43 to 2.80). CONCLUSION: Robotic surgery may offer faster recovery in urogenital function compared to laparoscopic surgery for rectal cancer.

A Modified Supine Position Facilitates Bladder Function in Patients Undergoing Percutaneous Coronary Intervention: A Randomized Controlled Clinical Trial.

BACKGROUND: Percutaneous coronary intervention (PCI) is currently the most common intervention for cardiovascular disease. Standard care after PCI typically involves a period of bed rest in the supine position, but this position creates voiding difficulties. OBJECTIVE: This study aimed to determine whether a modified supine position could facilitate bladder emptying after PCI. METHOD: A randomized controlled trial involving 300 patients was conducted. Patients in the intervention group were nursed in the supine position with the bed tilted 20° upright and with a pillow between their feet and the end of the bed. Patients in the control group received standard care, which was supine positioning. RESULTS: One hundred fifty patients were allocated to the intervention group (100 men, 50 women), and 150 were allocated to the control group (103 men, 47 women). Baseline data did not differ between the 2 groups. Patients in the intervention group had significantly better bladder function as evidenced by a shorter time to the first void (5 vs 15 minutes) and fewer patients requiring voiding assistance (8.6% vs 35.3%). Residual urinary volumes were also much lower in the intervention group (88.71 vs 248.22 mL, P < .001). CONCLUSIONS: This study demonstrates that a modified supine position can reduce the incidence of impaired micturition and the preservation of normal bladder function after PCI.

New developments in chyluria after global programs to eliminate lymphatic filariasis.

Chyluria, commonly seen in south Asian countries, is mainly a manifestation of lymphatic filariasis as a result of infestation with Wuchereria bancrofti, although many other causes can contribute. Many patients can be effectively treated with dietary modifications and drug therapy. The most widely used drug is diethyl carbamazine. The recurrences are common after such treatment. Such patients would benefit from sclerotherapy to obliterate the lympatico-renal fistulae located mainly in the renal pelvicalyceal system. The commonly used sclerosing agent is a combination of 5% povidone-iodine and 50% dextrose instilled through a ureteric catheter. A small percentage of patients who recur after sclerotherapy and those with systemic complications, such as hypoproteinemia and edema, might require surgery in the form of renal hilar lymphatic disconnection. Although it is a major operation, the success rates are >90%. Laparoscopic and robotic techniques have minimized the morbidity related to such surgery. With the advent of the global program for eradication of filariasis initiated by the World Health Organization, the incidence of the disease is decreasing. Mass chemotherapy with diethyl carbamazine is the mainstay of this global program. Many years after eliminating filariasis, chyluria continue to occur in such populations, though in dwindling numbers. Future research should aim at finding more efficacious sclerosing agents with minimal recurrences.

Early catheter removal following laparoscopic radical hysterectomy for cervical cancer: assessment of a new bladder care protocol.

Evidence to support prolonged catheterisation after radical hysterectomy is lacking. We sought to assess feasibility of a new protocol of early post-operative catheter removal following laparoscopic radical hysterectomy for cervical cancer. A retrospective review of post-operative bladder care in patients who underwent laparoscopic radical hysterectomy for cervical cancer was carried out. The post-operative bladder care protocol recommended catheter removal after 24-72 hours. Three consecutive post-void residual scans of less than 150 millilitres (ml) were considered evidence of normal voiding function. First line management of voiding dysfunction was clean intermittent self-catheterisation (CISC). Ninety-eight patients underwent laparoscopic radical hysterectomy for cervical cancer of whom 78 patients had catheter removal 24-72 hours post-operatively. The incidence of post-operative voiding dysfunction in this group was 44%, of whom 88% were managed with CISC and 82% regained normal voiding function. Average hospital stay was 4.2 days. The overall rate of long-term voiding dysfunction was 6%. Early catheter removal after laparoscopic radical hysterectomy appears to be both feasible and effective and compliments the ethos of enhanced patient recovery.

Electrophysiology-based quality assurance of nerve-sparing in laparoscopic rectal cancer surgery: Is it worth the effort?

BACKGROUND: After low anterior resection for rectal cancer, visual assessment of pelvic autonomic nerve preservation can be difficult due to the complexity of neuroanatomy, as well as surgery- and patient-related factors. The present study aimed to evaluate nerve-sparing quality assurance using the laparoscopic neuromapping (LNM) technique. METHODS: We prospectively investigated a series of 30 patients undergoing laparoscopic low anterior resection. Nerve-sparing was evaluated both visually and electrophysiologically. LNM was performed using stimulation of pelvic autonomic nerves under simultaneous cystomanometry and processed electromyography of the internal anal sphincter. Urogenital and anorectal functions were evaluated using validated and standardized questionnaires preoperatively, at short-term follow-up, and at mid-term follow-up at a median of 9 months (range 6-12 months) after surgery. RESULTS: One patient reported new onset of urinary dysfunction, and another patient reported new onset of anorectal dysfunction. Of the 20 sexually active patients, five reported sexual dysfunction. Visual assessment by laparoscopy confirmed complete nerve preservation in 28 of 30 cases. For prediction of urinary and anorectal function, LNM sensitivity, specificity, positive and negative predictive value, and overall accuracy were each 100 %. LNM with combined assessment for prediction of sexual function yielded a sensitivity of 80 %, specificity of 93 %, positive predictive value of 80 %, negative predictive value of 93 %, and overall accuracy of 90 %. CONCLUSIONS: LNM is an appropriate method for reliable quality assurance of laparoscopic nerve-sparing.

Distant effects of unilateral renal ischemia/reperfusion on contralateral kidney but not lung in rats: the roles of ROS and iNOS.

Acute kidney injury is usually associated with distant organ dysfunction. The roles of inducible nitric oxide synthase (iNOS) and reactive oxygen species (ROS) in this phenomenon were investigated following 2 h unilateral renal ischemia and 24 h reperfusion. There were 3 groups of rats subjected to either unilateral ischemia/reperfusion (UIR group), unilateral nephrectomy (UNX group), or sham operation. Two further groups were given α-tocopherol and aminoguanidine with UIR (treated-UIR group) and UNX (treated-UNX group). Plasma nitrite/nitrate and malondialdehyde were elevated only in the UIR group. Creatinine clearance and blood flow increased in non-ischemic kidney of the UIR, but not to the same extent as remnant kidney of the UNX group, while they had equal compensatory rises in absolute Na(+) and K(+) excretion and urine flow. Non-ischemic kidney of the treated-UIR group, but not remnant kidney of the treated-UNX group, showed more elevation in blood flow, whereas both kidneys had reductions in absolute Na(+) excretion and urine flow. Respiratory functional variable were not different between all groups. Therefore, 2 h unilateral renal ischemia and 24 h reperfusion did not affect lung but had distant effects on contralateral kidney partly mediated by ROS and NO-derived from iNOS to dampen compensatory increases in renal hemodynamics and to decrease tubular reabsorption.

Reducing Opioid Adverse Events: A Safe Way to Improve Outcomes.

INTRODUCTION: Opioids are commonly used in the postoperative period to manage postsurgical pain. However, adverse side effects of opioids include respiratory depression, urinary retention, pruritus, vomiting, nausea, constipation, and increased risk of falls. Surgical site infiltration with extended release liposomal bupivacaine is effective in the multimodal care plan of managing postsurgical patients. The purpose of the present study was to examine the possible effects of liposomal bupivacaine on postoperative opioid adverse events following open hernia repair and laparoscopic colon resection surgery. MATERIALS AND METHODS: The study population comprised 82 patients who had undergone open hernia repair or a laparoscopic colon resection. Forty-five of the 82 patients were treated with liposomal bupivacaine. Data were examined retrospectively from January 1, 2012 to August 31, 2012 in comparison with historical controls. Adverse opioid events measured included constipation, pruritus, vomiting, nausea, urinary retention, respiratory depression and fall risk. Statistical tools used were the Mann-Whitney U test, Pearson's chi-squared test, and Fisher's exact test. RESULTS: The addition of liposomal bupivacaine did significantly (p<0.05) reduce urinary retention and respiratory depression. Additionally, from the perspective of hospital safety there was a significant reduction in patients at high risk of falls, from 16% to 8.4% as well as an increase in patients at low risk of falls, from 37.6% to 48.7%. CONCLUSION: The findings of this study demonstrate that using liposomal bupivacaine can significantly reduce high-risk fall patients, increase low-risk fall patients as well as decrease urinary retention and respiratory depression in the postoperative setting. Given heightened consideration of the impact of sentinel events on hospital reimbursement since health care reforms in 2014, these results are important because they can mitigate complications associated with opioids in postsurgical pain management, and thereby reduce the costs of hospitalization.

OnabotulinumtoxinA intradetrusorial injections improve sexual function in female patients affected by multiple sclerosis: preliminary results.

PURPOSE: To investigate the effects of onabotulinum toxin type A (Onabot/A) intravesical injections on urinary and sexual function in a group of patients affected by multiple sclerosis (MS). METHODS: We enrolled 31 MS female patients with symptoms of overactive bladder and detrusor overactivity. All patients underwent urodynamics and were administered 3-day voiding diary, Incontinence Quality of Life (I-QoL) questionnaire, Female Sexual Function Index (FSFI) questionnaire, Hamilton Anxiety Rating Scale (HAM-A) and Hamilton Depression Rating Scale (HAM-D) before and 3 months after Onabot/A intravesical injection. RESULTS: Onabot/A injection significantly improved urinary symptoms as shown by the 3-day voiding diary, I-QoL questionnaire and the urodynamic variables. In addition, it also significantly improved sexual functioning in continent patients and psychological status as demonstrated by the increase in FSFI, HAM-A and HAM-D scores. CONCLUSIONS: The Onabot/A-induced positive effect on sexual dysfunction in our MS patients is likely due to an indirect effect exerted by the overall urological clinical improvement on sexual function at both the psychological and emotional levels. The positive effect exerted by Onabot/A on the anxiety and depression scale also suggests that urinary symptoms have a negative impact on the psychological status of the patients.

Effect of intra-operative autonomic nerve stimulation on pelvic nerve preservation during radical laparoscopic proctectomy.

AIM: This study assessed the effect of intra-operative electrical nerve stimulation (INS) on pelvic autonomic nerve preservation (PANP) during laparoscopic resection for rectal cancer. METHOD: A total of 189 consecutive cases of radical laparoscopic proctectomy were included. PANP was assessed visually or with INS. Urinary function was evaluated by residual urine volume (RUV), International Prostatic Symptom Score (IPSS) and recatheterization rate. Erectile function was evaluated using the International Index of Erectile Function (IIEF-5) scale. RESULTS: INS successfully confirmed PANP in 65 (91.5%) patients, while direct vision confirmed PANP in only 72 (61.0%) patients. Compared with the successfully confirmed patients, failed patients in the INS group exhibited higher postoperative RUV (100.0 ± 34.6 vs 25.2 ± 13.6 ml, P = 0.003), higher IPSS (7 days, 20.0 ± 8.6 vs 6.5 ± 2.4, P = 0.012; 1 month, 13.5 ± 6.0 vs 5.3 ± 1.9, P = 0.020; 6 months, 11.7 ± 5.1 vs 4.5 ± 1.7, P = 0.018), a greater number of incidences of a micturition disorder (66.7% vs 1.5%, P = 0.000), higher recatheterization rates (33.3% vs 1.5%, P = 0.017) and a lower IIEF score at 3 months (8.25 ± 0.96 vs 10.93 ± 1.99, P = 0.012) and 6 months (12.50 ± 1.29 vs 15.63 ± 1.65, P = 0.001) postoperatively. Compared with the vision group, the INS group had less deterioration in postoperative RUV (31.5 ± 26.4 vs 54.0 ± 46.7 ml, P = 0.000), lower IPSS (7 days, 7.7 ± 5.0 vs 11.0 ± 6.6, P = 0.000; 1 month, 6.0 ± 3.3 vs 7.6 ± 5.4, P = 0.012) and higher IIEF score (3 months, 10.69 ± 2.07 vs 9.42 ± 2.05, P = 0.001; 6 months, 15.36 ± 1.85 vs 13.64 ± 2.00, P = 0.000) as well as a lower incidence of urination disorders (7.0% vs 17.8%, P = 0.038). CONCLUSION: INS is effective for the accurate evaluation of PANP during radical laparoscopic proctectomy. Combined with INS, laparoscopic proctectomy is more effective in urogenital function protection.

Nerve sparing radical hysterectomy in early stage cervical cancer. Latest developments and review of the literature.

BACKGROUND: Cervical cancer is the second most common malignancy of the female genital tract worldwide. Radical hysterectomy with pelvic lymphadenectomy exemplifies the treatment of choice for early stage disease, whereas even if it is performed by gynaecologist-oncologist, still has the drawback of significant postoperative morbidity, especially for urinary bladder function. Nerve-sparing radical hysterectomy (NSRH) is a technique in which the neural part of the cardinal ligament which encloses the inferior hypogastric plexus, as well as the bladder branch (distal part of the plexus), remains intact. By this way, the bladder's innervation is safe and its functional recovery is more rapid. There is sufficient data to support the feasibility of the technique via laparotomy and laparoscopy, as well as the effectiveness related to the postoperative bladder dysfunction compared to conventional radical hysterectomy. On the other hand, the evidence related to survival outcomes is weak and derives from non-randomized trials. However, the low rate of local relapses after NSRH in early stage disease (IA2-IB1) with tumor diameter less than two cm makes the procedure suitable for this group of patients. CONCLUSION: According to the current evidence NSRH seems to be a suitable technique for gynaecologist-oncologist familiar with the method in early stage cervical cancer. It is a technique which improves significantly postoperative bladder recovery and the patients' quality of life (QoL), without compromising the oncological standard.

[LAPAROSCOPIC NERVE-SPARING RADICAL HYSTERECTOMY IN CERVICAL CANCER].

Cervical cancer is the most common cancer of the female reproductive system up to 20% of malignant tumors of the female genital organs. Surgery is the main method in treatment for local cervical cancer but postoperative complications often are associated with dysfunction of the pelvic organs. Some researchers focus their attention on the preservation of the pelvic innervation without loss of surgery's radicalism, which is represented in this survey. The paper presents the results of comparative analysis of 54 cases of surgical treatment for invasive cervical cancer.

Using patient-reported outcomes to assess and improve prostate cancer brachytherapy.

OBJECTIVE: To describe a successful quality improvement process that arose from unexpected differences in control groups' short-term patient-reported outcomes (PROs) within a comparative effectiveness study of a prostate brachytherapy technique intended to reduce urinary morbidity. PATIENTS AND METHODS: Patients planning prostate brachytherapy at one of three institutions were enrolled in a prospective cohort study. Patients were surveyed using a validated instrument to assess treatment-related toxicity before treatment and at pre-specified intervals. Unexpectedly, urinary PROs were worse in one of two standard brachytherapy technique control populations (US-BT1 and US-BT2 ). Therefore, we collaboratively reviewed treatment procedures, identified a discrepancy in technique, made a corrective modification, and evaluated the change. RESULTS: The patient groups were demographically and clinically similar. In the first preliminary analysis, US-BT2 patients reported significantly more short-term post-treatment urinary symptoms than US-BT1 patients. The study's treating physicians reviewed the US-BT1 and US-BT2 treatment protocols and found that they differed in whether they used an indwelling urinary catheter. After adopting the US-BT1 approach, short-term urinary morbidity in US-BT2 patients decreased significantly. Brachytherapy procedures were otherwise unchanged. CONCLUSION: Many procedures in cancer treatments are not evaluated, resulting in practice variation and suboptimal outcomes. Patients, the primary medical consumers, provide little direct input in evaluations of their care. We used PROs, a sensitive and valid measure of treatment-related toxicity, for quality assessment and quality improvement (QA/QI) of prostate brachytherapy. This serendipitous patient-centred QA/QI process may be a useful model for empirically evaluating complex cancer treatment procedures and for screening for substandard care.

Could hyaluronic acid (HA) reduce Bacillus Calmette-Guérin (BCG) local side effects? Results of a pilot study.

BACKGROUND: Bacillus Calmette-Guérin (BCG) is considered the most effective treatment to reduce recurrence and progression of non-muscle invasive bladder cancer (NMIBC) but can induce local side effects leading to treatment discontinuation or interruption. Aim of this exploratory study is to investigate if the sequential administration of Hyaluronic acid (HA) may reduce local side effects of BCG. METHODS: 30 consecutive subjects undergoing BCG intravesical administration for high risk NMIBC were randomized to receive BCG only (Group A) or BCG and HA (Group B). A 1 to 10 Visual Analog Scale (VAS) for bladder pain, International Prostate Symptom Score (IPSS) and number of micturitions per day were evaluated in the two groups before and after six weekly BCG instillations. Patients were also evaluated at 3 and 6 months by means of cystostopy and urine cytology. RESULTS: One out of 30 (3,3%) patients in group A dropped out from the protocol, for local side effects. Mean VAS for pain was significantly lower in group B after BCG treatment (4.2 vs. 5.8, p = 0.04). Post vs. pre treatment differences in VAS for pain, IPSS and number of daily micturitions were all significantly lower in group B. Three patients in group A and 4 in group B presented with recurrent pathology at 6 month follow up. CONCLUSIONS: These preliminary data suggest a possible role of HA in reducing BCG local side effects and could be used to design larger randomized controlled trials, assessing safety and efficacy of sequential BCG and HA administration. TRIAL REGISTRATION: NCT02207608 (ClinicalTrials.gov) 01/08/2014. Policlinico Tor Vergata Ethics Committee, resolution n 69-2011.

The impact of repeated prostate biopsies on sexual function and urinary symptoms in patients with diagnosis of Atypical Small Acinar Proliferation (ASAP): can ecoDoppler reduce side effects?

OBJECTIVES: To establish whether repeated trans-rectal ultrasound-guided Prostate Needle Biopsies (PNBx) performed in men with diagnosis of Small Acinar Atypical Proliferation (ASAP) predispose these subjects to Erectile Dysfunction (ED) and to evaluate if EcoColorDoppler (ECD) can help to reduce this side effect. MATERIALS AND METHODS: We performed a retrospective study regarding 190 men with diagnosis of ASAP detected between January 2001 and December 2011, who underwent to repeated prostate needle biopsies (PNBx). These patients were investigated about Erectile Function (EF) and Lower Urinary tract Symptoms (LUTS) using International Index of Erectile Function (IIEF-5) and International Prostate Symptom Score (IPSS) questionnaires before the first PNBx and 3 months after each other one. In particular, among the 89 men without ED before first PNBx, we compared IIEF-5 score between 64 patients who underwent to standard PNBx and 25 patients submitted to a PNBx done with in addition ECD ultrasound imaging. RESULTS: Mean patient age was 65 years (SD 7.7); mean follow-up was 3.2 years (SD 1.8) and the mean number of re-biopsies completed was 2 (SD 1.5). Among the 143 men considered, only 89 resulted with a normal EF (IIEF-5 score > 21): in this group incidence of ED (IIEF-5 score < 21) among patients who underwent to standard PNBx was 4/64 (6.25%) while in patients submitted to a PNBx with ECD was 1/25 (4%). A greater decrease of EF was observed in patients undergone to 3 or more biopsies; no relationship between IPSS score and re-PNBx was identified. CONCLUSION: Repeated PNBx done in patients with diagnosis of ASAP appear to get worse EF; number of biopsies seems to increase the risk of ED. Use of ECD in transrectal ultrasound- guided PNBx may have a role to avoid neurovascular bundles (NVBs) and preserve EF; anyway further studies are highly recommended to validate this hypothesis.

[Urinary functional complications following radical uterine surgery]. / Complications urinaires fonctionnelles après chirurgie utérine radicale.

BACKGROUND AND STUDY OBJECTIVE: Radical hysterectomy is the surgery of reference for cervical cancer at an early stage. However, it causes functional urinary complications. The purpose of this article is to review the literature recalling the anatomy of the pelvic nerves and their relation to the various viscera, to better understand the etiology of urinary functional disorders associated with pelvic autonomic nerve section, and their prevention techniques. METHODOLOGY AND FINDINGS: A systematic search of the medical literature and PubMed from 1950 to 2013 showed that urinary complications are mainly a decreased sensation of need, urine output and bladder compliance, an increase in residual urine volume, and a urinary incontinence. Causes include a vegetative denervation, anatomical changes causing loss of the support of the urethra and the vesical neck as well as the local trauma. The severity of vesico-ureteral dysfunction is associated with the degree of radical hysterectomy. Radiotherapy can increase associated urinary morbidity of radical hysterectomy. These complications can be avoided with conservative surgery for pelvic nerves initiated by the Japanese Yabuki. In the postoperative course of a radical hysterectomy, it is important to avoid and treat bladder overdistensions, diagnose and treat any urinary tract infections that are often asymptomatic. CONCLUSION: Knowledge of the surgical anatomy of the nerves and their relation to other pelvic structures, allows the improvement of postoperative functional urinary outcomes.