Effectiveness of ESPITO analgesia in enhancing recovery in patients undergoing open radical cystectomy when compared to a contemporaneous cohort receiving standard analgesia: an observational study.

OBJECTIVES: Bowel dysfunction is a major complication following open surgery for invasive cancer of the bladder that results in significant discomfort; complications and can prolong the length of stay. The incidence of postoperative ileus following open radical cystectomy has been reported as 23-40%. The median length of hospital stay after this surgery in the United Kingdom is 11 days. Standard analgesic techniques include wound infusion analgesia combined with systemic morphine or thoracic epidural analgsia. Combined erector spinae plane and intrathecal opioid analgesia is a novel technique that has been reported to be an effective method of providing perioperative analgesia thereby enhancing recovery after open radical cystectomy. METHODS: We performed a prospective study on the effectiveness of the novel analgesic technique (combined erector spinae plane and intrathecal opioid analgesia) in reducing the incidence of postoperative ileus, thereby facilitating early discharge following open radical cystectomy when compared to a contemporaneous control group receiving standard analgesia. Twenty-five patients received the novel analgesia while 31 patients received standard analgesia as a part of enhanced recovery programme. Standard analgesia arm included 14 patients who recived thoracic epidural analgesia (14/31, 45%) and 17 patients who received combined wound infusion analgesia and patient controlled analgesia with morphine (17/31, 55%). Primary outcome was the incidence of postoperative ileus. Secondary outcomes included length of hospital stay, tramadol consumption and time to bowel opening. RESULTS: Combined erector spinae plane and intrathecal opioid analgesia was associated with a reduced incidence of postoperative ileus (16 [4/25] vs. 65% [20/31], p<0.001), reduced time to first open bowel (4.4 ± 2.3 vs. 6.6 ± 2.3, p<0.001) and reduced median (IQR) length of hospital stay (7[6, 12] vs. 10[8, 15], p=0.007). There was no significant difference in rescue analgesia (intravenous tramadol) consumption. Complete avoidance of systemic morphine played a key role in improved outcomes. CONCLUSIONS: ESPITO was successful in reducing postoperative ileus and length of hospital stay after open radical cystectomy when compared to standard analgesia within an enhanced recovery programme.

Erector spinae plane and intra thecal opioid (ESPITO) analgesia in radical nephrectomy utilising a rooftop incision: novel alternative to thoracic epidural analgesia and systemic morphine: a case series.

Background Open radical nephrectomy and inferior vena cava exploration through a roof top incision involves significant peri-operative morbidity including severe postoperative pain. Although thoracic epidural analgesia provides excellent pain relief, recent trends suggest search for effective alternatives. Systemic morphine is often used as an alternative analgesic technique. However, it does not provide dynamic analgesia and can often impede recovery in patients undergoing major surgery on the abdomen. The authors present the first report of a novel analgesic regimen in this cohort with good outcomes. Methods Five patients undergoing open radical nephrectomy and inferior vena cava exploration received erector spinae plane infusion and intra thecal opioid analgesia at a tertiary care university teaching hospital. Outcomes included dynamic analgesia, length of hospital stay and complications Results Five adult patients undergoing major upper abdominal surgery, who refused thoracic epidural analgesia, received erector spinae plane infusion and intrathecal opioid analgesia. Patients reported effective dynamic analgesia, minimal use of rescue analgesia, early ambulation and enhanced recovery. Conclusion The novel regimen that avoids both epidural analgesia and systemic morphine can be an option in enabling enhanced recovery in this cohort.

Is Immediate Radical Cystectomy Necessary for All Patients with Non-Muscle-Invasive Micropapillary Bladder Cancer?

INTRODUCTION: We aim to review the outcomes of micropapillary urothelial carcinoma (MPUC) of the bladder from a single institution. The hypothesis is that non-muscle-invasive (NMI) MPUC may have a heterogeneous prognosis, and detailed pathological analysis may identify patients that could be managed without immediate cystectomy. PATIENTS AND METHODS: This is a retrospective analysis of patients presenting with MPUC in a primary transurethral resection specimen (n = 40). The pattern of micropapillary (MP) differentiation [surface/non-invasive (sMP) or invasive (iMP)], extent of MP differentiation and lymphovascular invasion (LVI) were correlated with overall survival (OS), recurrence-free survival and upstaging at re-resection. RESULTS: Sixteen of 40 patients died after a median follow-up of 37 months. Tumour stage was strongly predictive of OS (p < 0.0001). LVI was associated with increased mortality (hazard ratio 12.4, 95% CI: 3.5-44.5, p = 0.0001), higher pathological stage (p = 0.001), lymph node involvement (p = 0.001) and iMP differentiation (p = 0.006). In NMI patients not undergoing cystectomy (n = 17), NMI-sMP compared with NMI-iMP differentiation was associated with an improved OS when compared with iMP (63 vs. 47 months, p = 0.05). CONCLUSIONS: MPUC is an aggressive variant of urothelial carcinoma (UC). Similar to conventional UC, LVI associated with MPUC is an adverse prognostic indicator. iMP is a morphological marker for LVI. Histopathological reports should distinguish between sMP and iMP differentiation.

Perioperative outcomes of cytoreductive nephrectomy in the UK in 2012.

OBJECTIVES: To define the perioperative morbidity and 30-day mortality of cytoreductive nephrectomy (CN) using the British Association of Urological Surgeons (BAUS) nephrectomy dataset for 2012, the first year of public reporting of individual surgeon outcomes in the UK. PATIENTS AND METHODS: All nephrectomies recorded in the database in 2012 were analysed, and cytoreductive cases identified. Outcome measures were: blood loss of >1000 mL, transfusion requirement, intra- and postoperative complications assessed by Clavien-Dindo score, and 30-day mortality (including failure-to-rescue rate). Univariate and multivariate logistic regression analysis was used to assess predictors of adverse outcomes. RESULTS: In all, 279 cases were undertaken by 141 surgeons in 90 centres. World Health Organization (WHO) Performance Status (PS) was 0 or 1 in 72.4% (202 cases). Open nephrectomy was performed in 59% (163 cases), with the remainder laparoscopic. The conversion rate for laparoscopy was 14% (16 cases). In all, 40 patients underwent preoperative tyrosine-kinase inhibitor treatment. No significant differences in outcome were observed for this group. The 30-day mortality was 1.79%. Intraoperative complications occurred in 11.9% and postoperative complications in 20.8%. Complications of Clavien-Dindo grade ≥ III occurred in 8%. Blood loss of >1000 mL occurred in 15.4% of cases and 24.1% of patients required a perioperative transfusion. Tumour of >10 cm was an independent risk factor for blood loss of >1000 mL (P = 0.021) and intraoperative complications (P = 0.021). The number of metastatic sites was an independent predictor of blood loss of >1000 mL (P = 0.001) and transfusion requirement (P = 0.026) WHO PS of ≥2 was also independently associated with intraoperative complication risk (P = 0.021). CONCLUSIONS: CN in contemporary UK practice appears to have excellent perioperative outcomes overall. Risk factors for adverse perioperative outcomes include tumours of >10 cm, number of metastatic sites and WHO PS of ≥2. The balance of risk and benefit for CN should be carefully considered for patients with poor PS or extensive metastases.

MicroRNA in prostate cancer: functional importance and potential as circulating biomarkers.

BACKGROUND: This non-systematic review article aims to summarise the progress made in understanding the functional consequences of microRNA (miRNA) dysregulation in prostate cancer development, and the identification of potential miRNA targets as serum biomarkers for diagnosis or disease stratification. RESULTS: A number of miRNAs have been shown to influence key cellular processes involved in prostate tumourigenesis, including apoptosis-avoidance, cell proliferation and migration and the androgen signalling pathway. An overlapping group of miRNAs have shown differential expression in the serum of patients with prostate cancer of varying stages compared with unaffected individuals. The majority of studies thus far however, involve small numbers of patients and have shown variable and occasionally conflicting results CONCLUSION: MiRNAs show promise as potential circulating biomarkers in prostate cancer, but larger prospective studies are required to validate particular targets and better define their clinical utility.

Botulinum toxin type A for the treatment of non-neurogenic overactive bladder: does using onabotulinumtoxinA (Botox(®) ) or abobotulinumtoxinA (Dysport(®) ) make a difference?

OBJECTIVE: To compare the clinical effects of two different commercially available botulinum toxin type A products, onabotulinumtoxinA (Botox(®) ; Allergan Inc., Irvine, CA, USA) and abobotulinumtoxinA (Dysport(®) ; Ipsen Ltd, Slough, UK), on non-neurogenic overactive bladder (OAB). PATIENTS AND METHODS: We included 207 patients, who underwent treatment with botulinum toxin type A for non-neurogenic OAB from January 2009 to June 2012 at our institution, in a prospective database that recorded details of their presentation, treatment and outcomes. In December 2009, our institution switched from using onabotulinumtoxinA to using abobotulinumtoxinA. RESULTS: Results from the onabotulinumtoxinA cohort (n = 101) and the abobotulinumtoxinA cohort (n = 106) were compared. Similar reductions in daytime frequency, nocturia and incontinence episodes were observed after treatment, with no difference in duration of effect. The abobotulinumtoxinA cohort had almost twice the rate of symptomatic urinary retention (23 vs 42%) requiring intermittent self-catheterisation (ISC). CONCLUSIONS: AbobotulinumtoxinA use was complicated by a significantly higher risk of requiring ISC. The study suggests that these two toxins are not interchangeable at the doses used.

Delayed presentation of small bowel injury during suprapubic catheterisation.

We present a case of small intestine injury resulting from suprapubic catheter insertion. This case is of particular interest for three reasons. Firstly, the presentation of the injury was delayed by three months, until the time of the first catheter exchange. Secondly, the injury was managed conservatively, without surgical exploration. Finally, the injury occurred using a newer, Seldinger-type suprapubic catheter insertion kit.