Early urinary catheter removal after rectal surgery: systematic review and meta-analysis.

BACKGROUND: Urinary catheters are placed after rectal surgery to prevent urinary retention, but prolonged use may increase the risk of urinary tract infection (UTI). This review evaluated the non-inferiority of early urinary catheter removal compared with late removal for acute urinary retention risk after rectal surgery. METHODS: MEDLINE, Embase and the Cochrane Central Register of Controlled Trials were searched from January 1980 to February 2019. RCTs comparing early versus late catheter removal after rectal surgery were eligible. Primary outcomes were acute urinary retention and UTI; the secondary outcome was length of hospital stay. Early catheter removal was defined as removal up to 2 days after surgery, with late removal after postoperative day 2. The non-inferiority margin from an included trial was used for analysis of change in urinary retention (ΔNI = 15 per cent). Pooled estimates of risk differences (RDs) were derived from random-effects models. Risk of bias was assessed using a modified Cochrane risk-of-bias tool. RESULTS: Four trials were included, consisting of 409 patients. There was insufficient evidence to conclude non-inferiority of early versus late catheter removal for acute urinary retention (RD 9 (90 per cent c.i. -1 to 19) per cent; PNI = 0·31). Early catheter removal was superior for UTI (RD -11 (95 per cent c.i. -17 to -4) per cent; P = 0·001). Results for length of stay were mixed. There were insufficient data to conduct subgroup analyses. CONCLUSION: The existing literature is inconclusive for non-inferiority of early versus late urinary catheter removal for acute urinary retention. Early catheter removal is superior in terms of reducing the risk of UTI.

ANTECEDENTES: Las sondas urinarias se colocan después de la cirugía rectal para prevenir la retención urinaria, pero su uso prolongado puede aumentar el riesgo de infección del tracto urinario. Esta revisión evaluó si la retirada precoz de la sonda urinaria no fue inferior a la retirada tardía del catéter en cuanto al riesgo de retención urinaria aguda tras cirugía rectal. MÉTODOS: Se realizaron búsquedas en las bases de datos MEDLINE, Embase y en el Registro Central Cochrane de Ensayos Controlados desde enero de 1980 hasta febrero de 2019. Se consideraron elegibles los ensayos controlados aleatorizados que comparaban la retirada precoz y tardía de la sonda tras cirugía rectal. Las variables principales fueron la retención urinaria aguda y la infección del tracto urinario. La variable secundaria fue la duración de la estancia hospitalaria. Se consideró retirada precoz cuando ésta ocurrió hasta el segundo día postoperatorio mientras que más allá de ese tiempo se consideró retirada tardía. El margen de no inferioridad de uno de los ensayos incluidos se utilizó para el análisis de la retención urinaria (ΔNI = 15%). Las estimaciones agrupadas de las diferencias de riesgo se derivaron de los modelos de efectos aleatorios. El riesgo de sesgo se evaluó utilizando una herramienta de riesgo de sesgo Cochrane modificada. RESULTADOS: Se incluyeron cuatro ensayos que incluyeron un total de 409 pacientes. No se encontraron evidencias suficientes para concluir la no inferioridad de la retirada precoz del catéter versus la retirada tardía para la retención urinaria aguda (diferencia de riesgo, risk difference, RD 9%, i.c. del 90% -1% a 19%, valor de la P para no inferioridad, P value for non-inferiority, PNI = 0,31). La retirada precoz del catéter fue superior con relación a la infección del tracto urinario (RD -11%, IC del 95%: -17% a -4%, P = 0,001). Los resultados de la duración de la estancia hospitalaria fueron mixtos. No hubo datos suficientes para realizar análisis de subgrupos. CONCLUSIÓN: La literatura existente no es concluyente para determinar la no inferioridad de la retirada precoz de la sonda urinaria versus la retirada tardía con relación a la retención urinaria aguda. La retirada precoz de la sonda es superior y reduce el riesgo de infección del tracto urinario.

Surgery Versus Chemotherapy and Radiotherapy For Early and Locally Advanced Small Cell Lung Cancer: A Propensity-Matched Analysis of Survival.

BACKGROUND: The role of surgery in small cell lung cancer (SCLC) is controversial. Survival outcomes for resection of stage I-IIIA SCLC compared to chemotherapy-based non-surgical treatment (NST) were examined using propensity matching. METHODS: 29,994 clinical stage I-IIIA SCLC patients, including 2,619 undergoing surgery, were identified in the National Cancer Database. Stage-specific propensity scores for receipt of surgery were created. Resected patients were matched 1:1 to those undergoing NST. Overall survival (OS) was assessed using Kaplan-Meier and multivariable Cox models. A separate match was performed comparing Stage I/II patients aged <85 with a Charlson score of 0 who underwent lobectomy with adjuvant chemotherapy (and radiotherapy if node positive) to those treated with multiagent chemotherapy and concurrent chest radiotherapy (CRT) of at least 40 gray. RESULTS: 2,089 patients were matched, and cohorts were well balanced. Surgery was associated with longer survival for Stage I (median OS 38.6 months vs. 22.9 months, HR 0.62 95%CI 0.57-0.69, p<0.0001), but survival differences were attenuated for Stage II (median OS 23.4 months vs. 20.7 months, HR 0.84 95%CI 0.70-1.01, p=0.06) and IIIA (median OS 21.7 vs. 16.0 months, HR 0.71 95%CI 0.60-0.83, p <0.0001). In analyses by T and N stage, longer OS was observed in resected patients with stage T3/T4 N0 (median OS 33.0 vs. 16.8 months, p=0.008) and node positivity(N1+ 24.4 vs. 18.3 months p=0.03; N2+ 20.1 vs. 14.6 months p=0.007). In the subgroup analysis, 507 stage I/II patients receiving lobectomy and adjuvant chemotherapy were matched to patients receiving concurrent CRT. In this cohort, lobectomy with adjuvant chemotherapy was associated with significantly longer survival (median OS 48.6 vs. 28.7 months, p<0.0001). CONCLUSIONS: Surgical resection is associated with significantly longer survival for early SCLC. New randomized trials should assess trimodality therapy in stages I/II, and in node negative disease.

Uptake of Cancer Screening Tests Among Recipients of Solid Organ Transplantation.

Population-based cancer screening recommendations are also suggested for solid organ transplant recipients (SOTR); however, recommendation adherence is unknown. In a population-based cohort of SOTR in Ontario between 1997 and 2010, we determined the uptake of breast, cervical, and colorectal cancer screening tests and identified factors associated with up-to-date screening using recurrent event analysis. We identified 4436 SOTR eligible for colorectal, 2252 for cervical, and 1551 for breast cancer screening. Of those, 3437 (77.5%), 1572 (69.8%), and 1417 (91.4%), respectively, were not up-to-date for cancer screening tests during the observation period. However, these rates are likely an overestimate due to the inability to differentiate between tests done for screening or for diagnosis. SOTR with fewer comorbidities had higher rates of becoming screen up-to-date. Assessment by a primary care provider (PCP) was associated with becoming up-to-date with cancer screening (breast relative risk [RR] = 1.40, 95% confidence interval [CI]: 1.12-1.76, cervical RR = 1.29, 95% CI: 1.06-1.57, colorectal RR = 1.30, 95% CI: 1.15-1.48). Similar results were observed for continuity of care by transplant specialist at a transplant center. In conclusion, cancer screening for most SOTR does not adhere to standard recommendations. Involvement of PCPs in posttransplant care and continuity of care at a transplant center may improve the uptake of screening.

Cancer Screening Recommendations for Solid Organ Transplant Recipients: A Systematic Review of Clinical Practice Guidelines.

Solid organ transplant recipients (SOTRs) are at increased risk of developing and dying from cancer. However, controversies exist around cancer screening in this population owing to reduced life expectancy and competing causes of death. This systematic review assesses the availability, quality and consistency of cancer screening recommendations in clinical practice guidelines (CPGs). We systematically searched bibliographic databases and gray literature to identify CPGs and assessed their quality using AGREE II. Recommendations were extracted along with their supporting evidence. Thirteen guidelines were included in the review. CPGs for kidney recipients were the most frequent source of screening recommendations, and recommendations for skin cancer screening were most frequently presented. Some screening recommendations differed from those for the general population, based on literature demonstrating higher cancer incidence among SOTRs versus direct evidence of screening effectiveness. Relevant stakeholders such as oncology specialists, primary care providers and public health experts were not involved in the formulation of the screening recommendations. In conclusion, although several guidelines make recommendations for cancer screening in SOTRs, the availability of cancer screening recommendations varied considerably by transplanted organ. More studies are required to inform cancer screening recommendations in SOTRs, and guideline development should involve transplant patients, oncologists and cancer screening specialists.

Perioperative variables associated with surgical site infection in breast cancer surgery.

Despite the fact that breast operations are usually categorized as clean procedures, higher surgical site infection (SSI) rates are reported. This study aimed to determine the perioperative variables related to SSI in breast cancer patients. Medical records of breast cancer patients undergoing surgery between January 2005 and August 2007 at a university based hospital were reviewed. Preoperative, intraoperative, and postoperative clinical data from 199 patients were extracted and analysed. Overall, the SSI rate was 19.1% (38 cases). SSI was associated with a high body mass index (P=0.001), history of diabetes mellitus (P<0.0001), smoking (P<0.0001), or active skin disorders (P<0.0001). Other SSI-related variables included a tumour at an advanced clinical stage (P=0.003) and neoadjuvant therapy (P=0.003). Breast-conserving operations were less frequently associated with SSI than were radical procedures (mastectomy alone and mastectomy followed by immediate reconstruction) (P=0.0001).