Transurethral En Bloc Resection Versus Standard Resection of Bladder Tumour: A Randomised, Multicentre, Phase 3 Trial.

BACKGROUND: Conventionally, standard resection (SR) is performed by resecting the bladder tumour in a piecemeal manner. En bloc resection of the bladder tumour (ERBT) has been proposed as an alternative technique in treating non-muscle-invasive bladder cancer (NMIBC). OBJECTIVE: To investigate whether ERBT could improve the 1-yr recurrence rate of NMIBC, as compared with SR. DESIGN, SETTING, AND PARTICIPANTS: A multicentre, randomised, phase 3 trial was conducted in Hong Kong. Adults with bladder tumour(s) of ≤3 cm were enrolled from April 2017 to December 2020, and followed up until 1 yr after surgery. INTERVENTION: Patients were randomly assigned to receive either ERBT or SR in a 1:1 ratio. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome was 1-yr recurrence rate. A modified intention-to-treat analysis on patients with histologically confirmed NMIBC was performed. The main secondary outcomes included detrusor muscle sampling rate, operative time, hospital stay, 30-d complications, any residual or upstaging of disease upon second-look transurethral resection, and 1-yr progression rate. RESULTS AND LIMITATIONS: A total of 350 patients underwent randomisation, and 276 patients were histologically confirmed to have NMIBC. At 1 yr, 31 patients in the ERBT group and 46 in the SR group developed recurrence; the Kaplan-Meier estimate of 1-yr recurrence rates were 29% (95% confidence interval, 18-37) in the ERBT group and 38% (95% confidence interval, 28-46) in the SR group (p = 0.007). Upon a subgroup analysis, patients with 1-3 cm tumour, single tumour, Ta disease, or intermediate-risk NMIBC had a significant benefit from ERBT. None of the patients in the ERBT group and three patients in the SR group developed progression to muscle-invasive bladder cancer; the Kaplan-Meier estimates of 1-yr progression rates were 0% in the ERBT group and 2.6% (95% confidence interval, 0-5.5) in the SR group (p = 0.065). The median operative time was 28 min (interquartile range, 20-45) in the ERBT group and 22 min (interquartile range, 15-30) in the SR group (p < 0.001). All other secondary outcomes were similar in the two groups. CONCLUSIONS: In patients with NMIBC of ≤3 cm, ERBT resulted in a significant reduction in the 1-yr recurrence rate when compared with SR (funded by GRF/ECS, RGC, reference no.: 24116518; ClinicalTrials.gov number, NCT02993211). PATIENT SUMMARY: Conventionally, non-muscle-invasive bladder cancer is treated by resecting the bladder tumour in a piecemeal manner. In this study, we found that en bloc resection, that is, removal of the bladder tumour in one piece, could reduce the 1-yr recurrence rate of non-muscle-invasive bladder cancer.

Addressing the risk and management of cardiometabolic complications in prostate cancer patients on androgen deprivation therapy and androgen receptor axis-targeted therapy: consensus statements from the Hong Kong Urological Association and the Hong Kong Society of Uro-Oncology.

Background: Androgen deprivation therapy (ADT) is the foundational treatment for metastatic prostate cancer (PCa). Androgen receptor (AR) axis-targeted therapies are a new standard of care for advanced PCa. Although these agents have significantly improved patient survival, the suppression of testosterone is associated with an increased risk of cardiometabolic syndrome. This highlights the urgency of multidisciplinary efforts to address the cardiometabolic risk of anticancer treatment in men with PCa. Methods: Two professional organizations invited five urologists, five clinical oncologists, and two cardiologists to form a consensus panel. They reviewed the relevant literature obtained by searching PubMed for the publication period from April 2013 to April 2023, to address three discussion areas: (i) baseline assessment and screening for risk factors in PCa patients before the initiation of ADT and AR axis-targeted therapies; (ii) follow-up and management of cardiometabolic complications; and (iii) selection of ADT agents among high-risk patients. The panel convened four meetings to discuss and draft consensus statements using a modified Delphi method. Each drafted statement was anonymously voted on by every panelist. Results: The panel reached a consensus on 18 statements based on recent evidence and expert insights. Conclusion: These consensus statements serve as a practical recommendation for clinicians in Hong Kong, and possibly the Asia-Pacific region, in the management of cardiometabolic toxicities of ADT or AR axis-targeted therapies in men with PCa.

Early postoperative outcome of bipolar transurethral enucleation and resection of the prostate.

OBJECTIVES: To report the early postoperative outcome of bipolar transurethral enucleation and resection of the prostate. Our results were compared with those published from various centres. SETTING: Regional hospital, Hong Kong. PATIENTS: A total of 28 consecutive patients who had undergone bipolar transurethral enucleation and resection of the prostate by a single surgeon between January and June 2014. All patients were evaluated preoperatively by physical examination, digital rectal examination, transrectal ultrasonography, and laboratory studies, including measurement of haemoglobin, sodium, and prostate-specific antigen levels. Patients were assessed perioperatively and at 4 weeks and 3 months postoperatively. RESULTS: The mean resected specimen weight of prostatic adenoma in 28 patients was 48.2 g with a mean enucleation and resection time of 13.6 and 47.7 minutes, respectively. There was a mean decrease in serum prostate-specific antigen by 85.9% (from 6.4 ng/mL to 0.9 ng/mL) postoperatively. Prostate volume was decreased by 68.2% (from 71.9 cm(3) to 22.9 cm(3)) at 4 weeks postoperatively. The mean postoperative haemoglobin drop was 11.5 g/L. The rate of transient urinary incontinence at 3 months was 3.6%. Patients who underwent bipolar transurethral enucleation and resection of the prostate had a short catheterisation time and hospital stay, which is comparable to conventional transurethral resection of the prostate. CONCLUSIONS: Bipolar transurethral enucleation and resection of the prostate should become the endourological equivalent to open adenomectomy with fewer complications and short convalescence. The technique of bipolar transurethral enucleation and resection of the prostate can be acquired safely with a relatively short learning curve.

Validation of the modified radiosurgery-based arteriovenous malformation score in a linear accelerator radiosurgery experience in Hong Kong.

The modified radiosurgery-based arteriovenous malformation (AVM) score (modified AVM score or Pollock-Flickinger AVM score [PFAS]) is a simplified grading system developed to predict outcome after gamma knife radiosurgery for cerebral AVM. The purpose of this study was to test the PFAS in a cohort of patients managed with linear accelerator (LINAC) radiosurgery. We analyzed 70 consecutive patients with cerebral AVM treated with LINAC radiosurgery in Hong Kong. The scores were determined by the following equation: Modified AVM score=(0.1×volume [cm(3)])+(0.02×age [years])+(0.5×location). The location values are as follows: hemispheric/corpus callosum/cerebellar=0; basal ganglia/thalamus/brainstem=1. A total of 74% of patients presented with ruptured AVM before radiosurgery. The overall obliteration rate was 86%. Five (7%) patients developed new permanent neurological deficits from delayed bleeding or radiation-induced complications. Modified AVM score correlated with the percentage of patients with AVM obliteration without new neurological deficits (≤1, 96%; 1.01-1.50, 78%; 1.51-2.00, 90%; >2, 50%; Spearman's rho 0.354, p=0.003). In conclusion, the modified AVM score is a good predictor of patient outcome after LINAC radiosurgery in our cohort. The modified AVM score can be used to guide treatment selection for cerebral AVM and stratify patients for future comparative analyses.

Phylo: a citizen science approach for improving multiple sequence alignment.

BACKGROUND: Comparative genomics, or the study of the relationships of genome structure and function across different species, offers a powerful tool for studying evolution, annotating genomes, and understanding the causes of various genetic disorders. However, aligning multiple sequences of DNA, an essential intermediate step for most types of analyses, is a difficult computational task. In parallel, citizen science, an approach that takes advantage of the fact that the human brain is exquisitely tuned to solving specific types of problems, is becoming increasingly popular. There, instances of hard computational problems are dispatched to a crowd of non-expert human game players and solutions are sent back to a central server. METHODOLOGY/PRINCIPAL FINDINGS: We introduce Phylo, a human-based computing framework applying "crowd sourcing" techniques to solve the Multiple Sequence Alignment (MSA) problem. The key idea of Phylo is to convert the MSA problem into a casual game that can be played by ordinary web users with a minimal prior knowledge of the biological context. We applied this strategy to improve the alignment of the promoters of disease-related genes from up to 44 vertebrate species. Since the launch in November 2010, we received more than 350,000 solutions submitted from more than 12,000 registered users. Our results show that solutions submitted contributed to improving the accuracy of up to 70% of the alignment blocks considered. CONCLUSIONS/SIGNIFICANCE: We demonstrate that, combined with classical algorithms, crowd computing techniques can be successfully used to help improving the accuracy of MSA. More importantly, we show that an NP-hard computational problem can be embedded in casual game that can be easily played by people without significant scientific training. This suggests that citizen science approaches can be used to exploit the billions of "human-brain peta-flops" of computation that are spent every day playing games. Phylo is available at: http://phylo.cs.mcgill.ca.

Changes of cognitive functioning following mild traumatic brain injury over a 3-month period.

PRIMARY OBJECTIVE: To examine the cognitive functioning in patients with complicated mild traumatic brain injury immediately post-injury and at 1 and 3 months post-injury. RESEARCH DESIGN, METHODS, AND PROCEDURES: Between-group comparisons were adopted for this study. Specifically, both patients and healthy controls were administered neuropsychological assessments measuring attention, memory and executive functions at three time points. RESULTS: Findings indicate that patients performed significantly more poorly in information processing and divided attention, sustained attention, verbal recognition and verbal fluency immediately post-injury. While the information processing and divided attention of mild TBI patients improved at 1 month and returned to normal at 3 months post-injury, their sustained attention remained significantly poorer over the 3-month period. CONCLUSIONS: Findings suggest that attention dysfunction is noticeable immediately following a mild TBI. Different attention functions appear to recover at a different pace over time, suggesting that the condition may have a differential impact on the different sub-types of attention.

Bryan artificial cervical disc arthroplasty in a patient with Klippel-Feil syndrome.

Technological advances have made more options available for surgical intervention in spinal disorders. From spinal fusion to artificial disc implantation, these advancements have brought great benefits, allowing preservation of spinal motion and flexibility after intervertebral discectomy. Yet the use of artificial discs as a treatment for congenital spinal disorders has been documented in only a handful of publications. We report a case where a Bryan artificial cervical disc arthroplasty was used to maintain and preserve the mobility and function of the cervical motion segments adjacent to fused vertebral lesions in a 33-year-old woman with Klippel-Feil syndrome who presented with chronic neck pain and signs of early myelopathy. The rationales for using the Bryan disc prosthesis system in patients with Klippel-Feil syndrome and its advantages over conventional surgical interventions are discussed.

The comparative impact of video consultation on emergency neurosurgical referrals.

OBJECTIVE: Neurosurgical resources are concentrated in tertiary referral centers, whereas emergencies identified from district general hospitals are traditionally referred by telephone consultation (TC). Recent advances in communication technology offer the alternative options of teleradiology (TR) and video consultation (VC). This study aimed to determine the differences among these three consultation methods on the basis of their process-of-care indicators, clinical outcomes, and cost-effectiveness. METHODS: Patients with emergency neurosurgical conditions (head injury, stroke, and miscellaneous) from a district general hospital were randomized to three different modes of consultation: TC, TR, or VC. Process-of-care indicators (postresuscitation Glasgow Coma Scale score, consultation time required, diagnostic accuracy, and transfer decision and safety), 6-month clinical outcome, and cost-effectiveness of the three consultation modes were correlated. RESULTS: In a 3-year period, 710 patients were recruited and randomized to the three consultation modes (n = 235, 239, and 236, respectively). Demographic and clinical data were comparable. TR and VC showed a definite advantage in diagnostic accuracy over TC (89.1 and 87.7% versus 63.8%; P < 0.001). However, duration of the corresponding consultation process was longer for TR and VC than TC (1.01 and 1.3 h versus 0.70 h). A high failure rate (30%) was noted in VC. Thirty-three percent of patients were transferred to the neurosurgical center after consultation. The difference in consultation modes did not have an impact on transfer rate and safety. There was a trend toward more favorable outcome (61%; P = 0.12) and a reduced mortality (25%; P = 0.025) in TR compared with TC (54 and 34%, respectively) and VC (54 and 33%, respectively). The mean cost per patient in the VC group was slightly higher than the other two groups (TC versus TR versus VC = 14,000 US dollars versus 14,400 US dollars versus 16,300 US dollars, respectively), but the differences were not statistically significant. CONCLUSION: Emergency neurosurgical consultation assisted by TR and VC achieved a higher diagnostic accuracy in comparison with conventional TC. Although VC did not show an advantage over TR in process-of-care indicators, clinical outcome, and cost, it has been proven to be a safe mode of consultation in emergency neurosurgery.

Clinical significance of heterotopic ossification in cervical disc replacement: a prospective multicenter clinical trial.

OBJECTIVE: Heterotopic ossification (HO) is a well-known complication in joint replacements, but its occurrence and clinical effect on cervical artificial discs has not yet been studied. The purpose of this study was to investigate the incidence of HO in cervical disc replacement, to identify any associated risk factors for HO, and to examine the relationship of HO with clinical outcomes. METHODS: The patient data for this observational study were obtained from the original Bryan Disc Study by the European Consortium. Occurrence of HO was defined by the McAfee classification on the cervical lateral x-rays at 12 months after surgery. Secondary outcome measurements included Odom's criteria and the Medical Outcomes Study Short-Form 36-Item Health Survey. RESULTS: Sixteen (17.8%) of the 90 studied patients experienced HO, and 6 (6.7%) of these patients experienced Grade 3 and 4 HO. Ten patients' (11%) artificial discs were shown to have movement of less than 2 degrees on flexion and extension cervical x-ray at 12 months, with 4 of these patients having HO of Grade 3 or 4. Male sex (chi2 = 4.1; P = 0.0407) and older patients (P = 0.023; odds ratio = 1.10; 95% confidence interval = 1.01-1.19) were associated with development of HO. CONCLUSION: There is a strong association of the occurrence of HO with subsequent loss of movement of the implanted cervical artificial disc. We have found that sex and age are two possible risk factors in the development of HO after cervical disc replacement.

Cervical arthroplasty with the Bryan disc.

Cervical arthroplasty is a promising nonfusion alternative for the treatment of degenerative disc disease. After anterior cervical discectomy for neurological decompression, the intervertebral space is reconstructed by use of a metal and polymer prosthesis, allowing semiconstrained motion in multiple planes. This approach allows for preservation of cervical motion, potentially reducing the risk of transitional-level disease.

Cervical spine chordoid meningioma. Case report.

Chordoid meningiomas are a rare but increasingly recognized subtype of meningioma. Although some cases have been associated with systemic symptoms, in many instances the clinical features are indistinguishable from those associated with other subtypes of meningioma. Given the prognostic significance of the diagnosis of chordoid meningioma, careful consideration should be given to the diagnosis during histological assessment. The authors describe a rare case of chordoid meningioma in the cervical spinal region.

Apolipoprotein e genotype and outcome in aneurysmal subarachnoid hemorrhage.

BACKGROUND AND PURPOSE: Active management of ruptured intracranial aneurysm in subarachnoid hemorrhage is indicated in patients with favorable prognosis. Outcome prediction is based on patient characteristics and clinical and radiological factors. Current clinical grading scales are imprecise, with low interobserver reproducibility. Therefore, outcome prediction remains inconsistent and decision making becomes difficult, especially for patients with poor clinical grade. METHODS: The possible relationship between apolipoprotein E genotype and the outcome of patients suffering spontaneous subarachnoid hemorrhage was investigated. A prospective study was conducted on all patients with spontaneous aneurysmal subarachnoid hemorrhage admitted to our unit during a 2-year period. All patients were managed according to standard protocol, and treatments were given according to their clinical grading. Patient characteristics, clinical grade, radiological grade, and apolipoprotein E genotype were documented. The focus of the study was the 6-month neurological outcome for this group of patients after they were discharged. RESULTS: Seventy-two patients with aneurysmal subarachnoid hemorrhage were admitted to the Prince of Wales Hospital in Shatin, Hong Kong, China, from February 1998 to February 2000. Their ages ranged from 24 to 95 years of age, with a mean (SD) age of 58.3 (15.0) years. Apolipoprotein E epsilon4 was found in 15 patients (21%). At 6 months, Glasgow Outcome Scale score < or = 3 was found in 29 patients (40%). Univariate analysis showed that older patients (odds ratio [OR], 1.03; 95% CI, 1.00 to 1.07; P=0.07) and patients with poor Fisher's grade (OR, 4.5; 95% CI, 1.3 to 15.2; P=0.01), poor World Federation of Neurological Surgeons grade (OR, 5.8; 95% CI, 1.9 to 17.8; P=0.002), or apolipoprotein E epsilon4 (OR, 6.0; 95% CI, 1.7 to 21.3; P=0.006) were more likely to attain unfavorable outcome at 6 months. The additional effect of apolipoprotein E epsilon4 remained significant in the multiple logistic regression model (OR, 11.3; 95% CI, 2.2 to 57.0; P=0.003); the gain in predictive performance was not significant (P=0.26). CONCLUSIONS: Apolipoprotein E epsilon4 genotype is related to poor outcome in patients with subarachnoid hemorrhage.