Is chest imaging needed as part of pT1a renal cell carcinoma surveillance after surgical resection?

INTRODUCTION: Following surgical excision of pT1a renal cell carcinoma (RCC), 2% to 5% will recur, with 50% to 60% being lung metastases. The ideal surveillance strategy to identify recurrences is unclear. Guidelines are mixed, with NCCN and AUA recommending surveillance via chest x-ray (CXR) at least annually for 5 years, while EAU guidelines do not specifically recommend the use of CXR. In an effort to clarify the utility of surveillance CXR, we retrospectively evaluated pT1a patients following surgical treatment at a single institution. METHODS: We performed retrospective analysis of unique patients who underwent surgical excision of pT1 RCC between January 2000 and January 2020. In addition to demographic information, we collected RCC pathology, recurrence details, and most recent chest imaging. We excluded non-RCC pathology, and patients with pulmonary nodules on baseline imaging. RESULTS: We identified 463 unique patients (mean age 58.3 years, range 23-87) that underwent surgical excision of pT1a RCC with mean follow-up of 47.6 months (range 1-201). On the most recent pulmonary surveillance imaging, 72.4% (335/463) had CXR while 27.6% (128/463) had chest CT performed. Regardless of modality, pulmonary recurrence was not detected on any surveillance imaging (0/463). CONCLUSION: In patients without baseline preoperative lung pathology, we found that there is questionable clinical value in surveillance for pulmonary recurrence after resection of pT1a RCC.

Is a 50% improvement threshold adequate to justify progression from sacral neuromodulation testing to implant?

PURPOSE: A ≥50% subjective improvement in urinary symptoms during sacral neuromodulation testing (SNM-I) is currently used as the indication for progression to second-stage implantation (SNM-II). While most patients will have successful SNM-I and proceed to SNM-II, deterioration in efficacy over time has been reported. It remains unclear if the durability of efficacy is related to the initial symptom reduction. We sought to determine if the degree of improvement after SNM-I is sufficient to predict long-term success. METHODS: The records of all patients who underwent sacral neuromodulation (SNM) for overactive bladder were reviewed. Subjects were divided into those who reported 50%-75% improvement (Group 1) and more than 75% improvement (Group 2) after SNM-I. Differences in clinical variables and long-term device efficacy were compared between groups. RESULTS: Of 213 patients who underwent SNM-I, 137 underwent permanent device implantation. A total of 76 (55%) and 61 (45%) patients reported 50%-75% (Group 1) and more than 75% (Group 2) symptomatic improvement, respectively. With a mean follow-up of 46 months, 44% of Group 1 patients and 68% of Group 2 patients still had a functioning device providing the symptomatic benefit (p = 0.007). Univariate analyses identified the presence of stress urinary incontinence at baseline and having a more than 75% improvement after SNM-I as predictors of long-term functional success. CONCLUSIONS: Compared to patients reporting 50%-75% symptomatic reduction after SNM-I, individuals with a more than 75% improvement during SNM-I were more likely to maintain device efficacy over time. Additional study is warranted to determine if the improvement threshold for progression to SNM-II should be increased.

Pain management following robotic-assisted radical prostatectomy: transitioning to an opioid free regimen.

Few studies demonstrate the safety and efficacy of postoperative pain regimens that exclude opioids altogether in patients undergoing robot-assisted radical prostatectomy (RARP). To reduce opioid use, we sought to develop an opioid-free regimen for RARP and determine perioperative outcomes before and after implementation. A retrospective, pre-post-interventional study was performed at a single institution between 8/2018 and 10/2019. An opioid-free pain regimen was developed and instituted on 3/7/2019, and all patients received preoperative counseling regarding pain expectations and management. Postoperative pain score was the primary outcome. Secondary outcomes included postoperative opioid use, length of stay, adverse events and unplanned health encounters within 30 days of discharge. Pearson's chi-squared and Student's t-tests were performed on categorical and continuous variables, respectively. Multivariable analysis was performed to determine risk factors for postoperative opioid use in the opioid-free cohort. A total of 89 patients were included for analysis; consisting of 47 (53%) pre-intervention and 42 (47%) post-intervention patients. Baseline characteristics were similar between groups. A significantly lower proportion of patients in the post-intervention group were administered opioids postoperatively (5% vs 53%, p < 0.01), despite having similar postoperative pain scores (2.69 vs 3.11, p = 0.19) and length of stay (1.0 days vs 1.2 days, p = 0.07). The post-intervention group had a significantly lower rate of opioid discharge prescriptions (14% vs 96%, p < 0.01). The rate of ED visits (12% vs 15%, p = 0.68), pain-related phone calls (17% vs 19%, p = 0.76) or adverse events (19% vs 13%, p = 0.42) were similar between groups. Among the opioid-free group, older patients were less likely to be administered postoperative opioids (OR 0.84, p = 0.046). A structured opioid-free pain regimen following RARP is non-inferior compared to traditional opioid-based standard of care. Adoption of similar regimens can help address the ongoing opioid epidemic in the United States and future work is needed to apply these principles broadly.