Safety of maintaining elective and emergency surgery during the COVID-19 pandemic with the introduction of a Protected Elective Surgical Unit (PESU): A cross-specialty evaluation of 30-day outcomes in 9,925 patients undergoing surgery in a University Health Board.

Background: The COVID-19 pandemic has caused unprecedented health care challenges mandating surgical service reconfiguration. Within our hospital, emergency and elective streams were separated and self-contained Protected Elective Surgical Units were developed to mitigate against infection-related morbidity. Aims of this study were to determine the risk of COVID-19 transmission and mortality and whether the development of Protected Elective Surgical Units can result in significant reduction in risk. Methods: A retrospective observational study of consecutive patients from 18 specialties undergoing elective or emergency surgery under general, spinal, or epidural anaesthetic over a 12-month study period was undertaken. Primary outcome measures were 30-day postoperative COVID-19 transmission rate and mortality. Secondary adjusted analyses were performed to ascertain hospital and Protected Elective Surgical Unit transmission rates. Results: Between 15 March 2020 and 14 March 2021, 9,925 patients underwent surgery: 6,464 (65.1%) elective, 5,116 (51.5%) female, and median age 57 (39-70). A total of 69.5% of all procedures were performed in Protected Elective Surgical Units. Overall, 30-day postoperative COVID-19 transmission was 2.8% (3.4% emergency vs 1.2% elective P < .001). Protected Elective Surgical Unit postoperative transmission was significantly lower than non-Protected Elective Surgical Unit (0.42% vs 3.2% P < .001), with an adjusted likely in-hospital Protected Elective Surgical Unit transmission of 0.04%. The 30-day all-cause mortality was 1.7% and was 14.6% in COVID-19-positive patients. COVID-19 infection, age > 70, male sex, American Society of Anesthesiologists grade > 2, and emergency surgery were all independently associated with mortality. Conclusion: This study has demonstrated that Protected Elective Surgical Units can facilitate high-volume elective surgical services throughout peaks of the COVID-19 pandemic while minimising viral transmission and mortality. However, mortality risk associated with perioperative COVID-19 infection remains high.

The effect of radiotherapy on urethral obstruction from carcinoma of the prostate.

OBJECTIVE: To assess the impact of radiotherapy on the relief of complete bladder outlet obstruction requiring catheterization secondary to prostatic carcinoma. PATIENTS AND METHODS: From a consecutive series of 151 patients treated with radiotherapy for localized carcinoma of the prostate, 19 (12.6%; median age 72 years, range 59-83) who had an indwelling catheter in situ at the time of irradiation because of urinary retention, were analysed retrospectively and grouped according to the stage and grade of tumour and the irradiation dose delivered. RESULTS: The catheter was removed following radiotherapy in all but two patients, who both had stage 4 tumours, and normal urinary function was restored. The grade and stage of tumour did not influence the duration of catheterization. The median time from completion of radiotherapy to catheter removal was 10 weeks (range 0-46). Recatheterization was required in two patients at 3 and 64 months after radiotherapy and three patients, including these two, required transurethral prostatectomy (TURP) to relieve outlet obstruction. CONCLUSION: Prostatic radiotherapy is effective in relieving bladder neck obstruction caused by prostate cancer. Most patients will achieve normal urinary function without requiring TURP after treatment.

Tumor enzymes and prognosis in transitional cell carcinoma of the bladder: prediction of risk of progression in patients with superficial disease.

The activities of 6 enzymes of carbohydrate metabolism were estimated in superficial transitional cell carcinomas from 103 patients undergoing transurethral resection of the bladder for the first time. The patients were followed by quarterly endoscopic examinations for a maximum of 81 months (median 33 months). During followup 24 patients had progressive disease. The activities of phosphofructokinase and phosphohexose isomerase were significantly lower in tumors from patients whose disease had superficially invaded the lamina propria (stage pT1) than in others in whom it was confined to the bladder mucosa (stage pTa). Similarly the activities of the 2 enzymes were significantly higher in well differentiated (grade 1) than in moderately well differentiated (grade 2) carcinomas. Univariate analyses using the log rank test showed that neither pathological stage nor malignancy grade of the carcinoma was a significant factor in predicting the risk of progression. Of the 6 enzymes, below median activities of phosphofructokinase, lactate dehydrogenase and phosphohexose isomerase were associated with a significantly increased risk of progression in these patients. Multivariate analyses using Cox's proportional hazards model showed that the activity of lactic dehydrogenase in superficial transitional cell carcinoma is an independent prognostic factor in predicting the risk of progression. It is postulated that the measurements of the activities of the 3 enzymes in tumors from patients with superficial transitional cell carcinoma might help to select individual patients with a high risk of progression for adjuvant intravesical treatments.

Effects of flutamide and hydroxy-flutamide on the growth of human benign prostatic hyperplasia cells in primary culture: a preliminary report.

Tissues from human benign prostatic hyperplasia [BPH] were collected from twelve patients undergoing routine transurethral resection of the prostate to relieve urine out-flow obstruction. Viable epithelial organoids were obtained after enzymatic digestion of the tissue. Primary cultures of epithelium were successfully maintained on collagen gel for up to 21 days. Immunocytochemical staining revealed that there was no expression of either desmin or vimentin in these cells; however, the anticytokeratin antibodies LP-34 (cytokeratins 4, 5, 6, 10, 13, 16, 17 and 18), LE-61 (cytokeratin 18) and CAM 5.2 (cytokeratins 7 and 8) all showed positive responses, indicating the epithelial nature of the cells. Cell growth was significantly increased in the presence of 3 x 10(-10) M testosterone propionate [TP] in the culture medium. The presence of the non-steroidal anti-androgens, Flutamide and Hydroxy-Flutamide [Flu-OH], in the concentration range 1.0-0.001 micrograms per ml of medium inhibited the growth in the presence of androgens in a dose-dependent manner. The anti-androgens failed to affect cell growth in the absence of TP. In view of these preliminary findings, it is postulated that the antiandrogens might be acting either by displacing the androgen from its receptor or alternately by inhibiting the activity of prostatic 5 alpha-reductase.

Ten cases of transitional cell carcinoma of bladder causing ureteric obstruction.

A review was carried out on 10 patients with superficial transitional cell carcinoma of the bladder (Ta lesions) that were causing ureteric obstruction. Evidence of upper tract obstruction did not necessarily indicate deep invasion.

Enzyme studies in human transitional cell carcinoma of the urinary bladder.

The activities of six enzymes of carbohydrate metabolism were estimated in tissue samples from 99 patients with transitional cell carcinoma of the urinary bladder undergoing transurethral resection. The results were analysed according to the stage of the disease and the malignancy grade of the carcinoma. There were statistically significant differences in the activities of three enzymes between various stages and grades. The activities of phosphofructokinase (PFK), alpha-glycerolphosphate dehydrogenase (alpha-GPDH), and phosphohexose isomerase (PHI) showed significant decreases with increased stage and grade. Of the total of 64 patients with superficial disease at presentation, five developed progressive disease during the course of this investigation. The activities of the three enzymes in these patients were compared to the median values for the group of patients with superficial disease. The activity of PFK was observed to be below the median value in all the five patients whereas the activities of alpha-GPDH and PHI showed similar patterns in four of the five patients. These preliminary data indicate that, in association with established clinical parameters, the measurement of the activity of these three enzymes may prove useful in selecting patients with an increased potential for developing progressive disease.

Divergent effects of interferons on the growth of human benign prostatic hyperplasia cells in primary culture.

Epithelial cells from human benign prostatic hyperplasia tissues were grown in primary cultures for up to 21 days and the effects of interferons on the growth of the cells were investigated. Interferon-alpha (Wellferon) showed growth inhibition both in the presence and in the absence of 3 x 10(-10)M testosterone propionate (TP) whereas interferon-gamma stimulated growth in a dose dependent manner under similar conditions. Interferon-beta had little effect on growth at the dose levels used in the study. The growth inhibition by interferon-alpha can be induced after stimulation of growth is achieved either with TP or with interferon-gamma. Implications of these findings for clinical use of these lymphokines is discussed.

The effects of interferons on the activity of alpha-glycerolphosphate dehydrogenase in benign prostatic hyperplasia cells in primary culture.

Human benign prostatic hyperplasia (BPH) tissues were obtained from patients undergoing transurethral resection of the prostate and viable cells from these were successfully maintained in primary cultures grown on collagen gel. The prostatic origin of the cells was confirmed by the measurement of prostate specific acid phosphatase and by scanning and transmission electron microscopy before and after immunostaining with human prostate specific antigen-antibody. The cell cultures were treated with various interferons (IFNs), both in the presence and absence of testosterone propionate (TP), for 72 hours and the activities of seven enzymes of carbohydrate metabolism were estimated in the cytosolic fraction of the cells. Treatment with TP induced a significant decrease in the activity of alpha-glycerolphosphate dehydrogenase (alpha-GPDH). Using this enzyme activity as a marker, the effects of various types of IFNs were investigated. IFN-alpha (wellferon) increased the activity of the enzyme both in the presence of one microgram./ml. of TP and in its absence whereas IFN-gamma inhibited the activity under similar conditions. The effect of treatment with IFN-beta in the presence of TP was biphasic in that there was an increase in the activity of the enzyme at the lowest concentration while at higher concentrations an inhibition of enzymic activity was observed. In the absence of TP IFN-beta inhibited the activity. The significance of these findings in terms of the clinical usefulness of IFNs is discussed and it is postulated that IFN-alpha (wellferon) might be effective in the treatment of metastatic carcinoma of the prostate in selected patients.

Enzyme studies in human prostatic tissues.

The activities of six enzymes associated with carbohydrate metabolism were measured in 24 benign prostatic hyperplasias and 29 carcinomas of the prostate with the intention of investigating whether these measurements might eventually predict the clinical course of the disease. The following findings are recorded: the activities of PFK, alpha-GPDH and PHI were significantly lower in carcinomas. Comparison between well and poorly-differentiated carcinomas indicated a significantly lower activity of 6PGDH and higher alpha-GPDH/6PGDH ratios in the latter. These findings are the opposite of those observed in carcinomas of the breast.

An assessment of computerised isotopic renal section scanning.

The basic non-invasive investigation of renal space occupying lesions by excretion pyelography was coupled with ultrasonic scanning. Forty-one patients who have undergone isotopic section scanning as part of their investigative assessment were studied. The conditions investigated included solitary cysts, polycystic kidneys, renal tumours, tumefactive xanthomatous pyelonephritis, renal infarct and non-functioning kidneys. An analysis of the accuracy of isotopic section scanning in these different pathological states was made. Computerised isotopic section renal scanning offers a new non-invasive renal investigative technique.

Hyperthermia in the treatment of bladder tumours.

High temperature bladder irrigation was employed in 4 men as an alternative to cystectomy because of their age and frailty. Hyperthermic irrigation of the bladder from 63 degree C for 70 minutes to 82 degree C for 25 minutes caused partial, but not total, necrosis of the bladder. Transitional cell carcinoma appears to be resistant in vivo, in some cases, to heating at temperatures that destroy adjacent normal structures. Hyperthermic irrigation of the bladder at these high temperatures may be hazardous. In view of these findings we cannot recommend high temperature bladder irrigation as an alternative to cystectomy even in poor risk patients.