Same-Day Discharge Protocol for Robot-Assisted Radical Prostatectomy: Experience of a High-Volume Referral Center.

Objective: As the coronavirus disease 2019 (COVID-19) global pandemic continues, there is increased value in performing same-day discharge (SDD) protocols to minimize viral exposure and maintain the appropriate surgical treatment for oncologic patients. In this scenario, we performed a prospective analysis of outcomes of our patients undergoing SDD protocol after robot-assisted radical prostatectomy (RARP). Materials and Methods: The SDD criteria included patients with no intraoperative complications, stable postoperative hemoglobin levels (compared with preoperative values), stable vital signs, normal urine output, ambulation with assistance and independently without dizziness, tolerance of clear liquids without nausea or vomiting, pain control with oral medication, and patient/family confidence with SDD. Patients older than 70 years, concomitant general surgery operations, multiple comorbidities, and complex procedures such as salvage surgery were excluded from our protocol. Results: Of the 101 patients who met the criteria for SDD, 73 (72%) had an effective SDD. All SDF (same day discharge failure) patients were discharged one day after surgery. Intraoperative characteristics were not statistically different with a median operative time of 92 (81-107) vs 103 (91-111) minutes for SDD and SDF, respectively. Of the 28 SDF patients, the most common reasons for staying were anesthesia-related factors of nausea (35%), drowsiness (7%), patient/caregiver preference (25%), pain (14%), labile blood pressure (7%), arrhythmia (7%), and dizziness (7%). There was no significant difference in readmission rates, complication rates, or postoperative pain scores between SDD and SDF patients. Conclusions: In our experience, SDD for patients undergoing RARP can be safely and feasibly incorporated into a clinical care pathway without increasing readmission rates. We were effective in 72% of cases because of coordinated care between anesthetics, nursing staff, and appropriate patient selection. We also believe that incorporating pre- and postoperative patient education and assurance is crucial to minimize their exposure to COVID-19 during the surgical treatment for prostate cancer.

Pro-inflammatory cytokines and chemokines initiate multiple prostate cancer biologic pathways of cellular proliferation, heterogeneity and metastasis in a racially diverse population and underlie the genetic/biologic mechanism of racial disparity: Update.

Pro-inflammatory cytokine and chemokines genes drive prostate cancer progression and metastasis: molecular mechanism update and the science that underlies racial disparity. comprehensive review article. Isaac J. Powell, S. Chinni, S.S. Reddy, Alexander Zaslavsky, Navnath Gavande Introduction: In 2013 we reported that with the use of bioinformatics and ingenuity pathway network analysis we were able to identify functional driver genes that were differentially expressed among a large population of African American men (AAM) and European American men (EAM). Pro-inflammatory cytokine genes were found to be more interactive and more expressed among AAM and have been found to be functional drivers of aggressive prostate cancer (CaP) and aggressiveness in other solid tumors. We examined these genes and biological pathways initiated by these cytokines in primary CaP tissue. Method We unravel the gene network and identified biologic pathways that impacted activation of the androgen receptor, mesenchymal epithelial transition (invasion) and chemokines associated with metastasis in the CaP tissue from 639 radical prostatectomy specimens. Results Biologic pathways identified by unraveling pro-inflammatory genes from our network, more expressed among AAM compared to EAM, were tumor necrosis factor (TNF), IL1b, IL6, and IL8. IL6 and IL8 are downstream of TNF activity and are known activators of androgen receptor and through mediators promote CaP cell proliferation. TNF and IL1b mediate tumor cell invasiveness through the activation of MMP (matrix metalloproteinase) which down regulates E-Cadherin to initiate epithelial mesenchymal transition which allows cells to become invasive in the microenvironment. Ultimately our network analysis indicates that TNF and IL1b activate CXCR4 receptor on CaP cells, which facilitates metastatic progression reportedly by binding to CXCL12 on lipid rafts and tumor implantation in the bone marrow. Conclusion Our retrospective biologic mechanistic model reveals a set of pro-inflammatory cytokines and chemokines that drive CaP aggressiveness, tumor heterogeneity, progression and metastasis. A prospective multi-institutional study needs to be conducted for clinical validation as well consideration of targeted therapy.

Patient-Reported Impact of Pelvic Organ Prolapse on Continence and Sexual Function in Women With Exstrophy-Epispadias Complex.

OBJECTIVE: This study aimed to characterize long-term urogynecologic issues of women with a history of bladder exstrophy and pelvic organ prolapse (POP) and to assess the impact of POP repair on continence and sexual function. DESIGN: Patient demographics and surgical history related to exstrophy and POP were collected through chart review. Patient perceptions regarding sexual function, urinary continence, and quality of life were assessed through Web-based administration of validated questionnaires: International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form and POP-Urinary Incontinence Sexual Questionnaire. SETTING: Maryland, United States. PARTICIPANTS: Review of a single-institution exstrophy-epispadias complex database resulted in 25 adult female patients with a history of POP treated at the authors' institution. Eleven patients participated and were included in the analysis. MAIN OUTCOME MEASURES: Urinary continence and sexual function. RESULTS: All participants underwent surgical repair for prolapse, with 7 (63.6%) experiencing unsuccessful initial repair and subsequent recurrence. Median total number of POP repairs was 2.5 (1-4). After correction of POP, patients reported a median improvement in International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form scores of 11 (21 to -1) of 21 and in POP-Urinary Incontinence Sexual Questionnaire scores of 9.5 (6.5-33.0) of 48.0. With regard to urinary continence, 6 (54.5%) patients presently reported no incontinence, 3 (27.3%) reported mild incontinence, and 2 (18.2%) reported continuous incontinence. CONCLUSIONS: Pelvic organ prolapse poses significant reductions in quality of life for women born with exstrophy, with effects on urinary continence and sexual function. Identification and correction of prolapse seems to result in notable improvements in the lives of these patients.

The Tunica Vaginalis Flap as an Adjunct to Epispadias Repair: A Preliminary Report.

OBJECTIVE: To report our preliminary institutional experience of incorporating a tunica vaginalis flap (TVF) as an adjunct into primary or secondary epispadias repair. PATIENTS AND METHODS: A prospectively maintained institutionally approved database of exstrophy-epispadias complex patients was used to identify and retrospectively review male patients who underwent epispadias repair from September 2010 to October 2014 at the authors' institution. Patients who underwent epispadias repair with TVF were identified and their clinical outcomes were measured. RESULTS: A total of 49 male patients were identified as meeting inclusion criteria, of which 15 (2 isolated epispadias, 13 classic bladder exstrophy) underwent epispadias repair incorporating a TVF. Median age at time of repair was 12 months (interquartile range [IQR] 10-15.5). A median of 4 layers (IQR 4-5) was incorporated into each repair closure, applying EVICEL Fibrin Sealant as an additional layer in all patients. All patients received preoperative testosterone injection therapy of 2 mg/kg 5 and 2 weeks before surgery for penile growth. There were no intraoperative complications. Median follow-up of 19 months (IQR 12-23) revealed 5 patients who underwent epispadias revision, 3 (20%) of which developed a urethrocutaneous fistula. All patients had a successful repair without recurrence. CONCLUSION: The authors have found the utilization of a TVF with epispadias repairs to be beneficial but no better than the repair with our routine soft-tissue coverage in primary epispadias repair. However, in patients presenting with complex anatomy and limited tissue reserves, a TVF is an important adjunct to epispadias repair and/or revision and may lead to improved outcomes.

Sexual Health Outcomes in Adults with Complete Male Epispadias.

PURPOSE: Complete male epispadias is a rare congenital anomaly characterized by failed closure of the entire penopubic dorsal urethra. Epispadias repair is typically performed during infancy, and resultant genitourinary abnormalities can have a marked impact on adult life. We assess long-term post-reconstruction sexual health and fertility outcomes in adults with complete male epispadias. MATERIALS AND METHODS: A total of 132 patients 18 years or older with complete male epispadias who had undergone reconstruction were identified from a prospectively maintained, institutionally approved database. Patients who could be contacted were asked to complete a telephone survey regarding sexual function. Reconstructive history and clinical details were obtained by chart/database review. RESULTS: Of 132 patients with complete male epispadias 74 met inclusion criteria and 15 (20%) completed the questionnaire. Seven patients (47%) reported currently being in a relationship. Although 12 patients (80%) reported overall satisfactory sexual intercourse, 11 (73%) admitted to 1 or more problems with sexual function, including abnormal ejaculation (53%), diminished sensation (20%) and difficulty maintaining an erection (20%). When questioned regarding the importance of fertility on a scale of 0 to 5 using a Likert-type item the response of 10 patients (67%) was 4 points or greater. Five patients (33%) reported having impregnated a sexual partner. Although 4 patients (27%) had suspicion of fertility problems, only 2 (13%) reported having abnormal semen analyses. CONCLUSIONS: This is one of few studies examining post-reconstruction sexual health and function in adults with complete male epispadias. Although small, our study demonstrates that patients are able to engage in relationships, participate in sexual intercourse and impregnate their partners. These results highlight sexual concerns and outcomes that may be of use when counselling patients with complete male epispadias and their families.