Efficacy of Degarelix in the Neoadjuvant Setting in Managing Locally Advanced Prostate Cancer.

Background Prostate cancer holds a substantial presence in the global cancer landscape, and a considerable proportion of diagnoses occur at late stages, particularly in India. Management of locally advanced prostate cancer necessitates a multimodal treatment strategy. A critical part of this strategy is neoadjuvant androgen deprivation therapy, typically administered via luteinizing hormone-releasing hormone (LHRH) analogs. This study explores the potential of an alternative approach: neoadjuvant therapy with degarelix, an LHRH antagonist, and its impact on perioperative and postoperative outcomes in patients undergoing radical prostatectomy for locally advanced or high-risk prostate cancer. Methodology We conducted a retrospective, non-randomized clinical study at Apollo Hospitals in Chennai, India. Patients diagnosed with locally advanced or high-risk prostate cancer who underwent radical prostatectomy were included. Participants were patients treated with neoadjuvant degarelix and subsequent radical prostatectomy between March 2020 and June 2022. We excluded patients receiving radical radiotherapy, those switching from LHRH agonists to antagonists, and those contraindicated for androgen deprivation therapy due to existing comorbidities. For comparison, we selected a group from the institutional database who received conventional treatment (i.e., without neoadjuvant therapy). Results The study compared two groups, each with 32 patients. The groups had no significant difference in total operative duration and console times. The postoperative pathological assessment showed significantly lower margin positivity rates and notable pathological downstaging in the group receiving neoadjuvant degarelix compared to the control group. The incidence of node positivity, prostate-specific antigen levels at three months postoperative, and number of pads used per day at one month did not differ significantly between the two groups. Conclusions Our study suggests that neoadjuvant degarelix could notably enhance patient outcomes in locally advanced prostate cancer management. The benefits include improved symptom control, significant reductions in margin positivity rates, and facilitated surgical procedures. Neoadjuvant degarelix therapy could potentially enhance the feasibility of the surgical intervention in locally advanced prostate cancer management, thus suggesting a promising pathway for improved patient care.

The Chennai port closure method: A novel simple technique for laparoscopic port closure.

PURPOSE: Large-size ports used for laparoscopic and robotic procedures will require appropriate closure to reduce the probability of trocar site complications including hematoma and hernia. Closure of these ports is done by various methods like the open method extending skin incisions, S-retractor, Carter Thomason method, and so on. Chennai port closure (CHC) method, a novel technique that had been in practice in our unit for more than 2 years, ensures direct visualization of the suture placement, and hence, the abdominal wall fascia and peritoneum are secured. MATERIALS AND METHOD: We herein describe an easy technique for fascial closure in port size (≥ 10 cm) after minimally invasive surgery, including both laparoscopic and robotic procedures, using a cobbler needle in 151 patients in the study period between February 2017 and March 2020 for various urological procedures. This technique was done before the introduction of the trocar sheath and ensures direct visualization of the abdominal fascial closure. RESULTS: There were no major intraoperative events, additional operating time, and need for any costly instruments. No bowel injuries or trocar site hernias were documented during a mean follow-up of 28 months. Presently, this technique is used by many surgeons in our hospital without much difficulty. CONCLUSION: The Chennai port site closure technique is an effective, simple, easy-to-apply, and safe procedure.

Prevalence of Vitamin D Inadequacy in Urolithiasis Patients.

Introduction The role of vitamin D in kidney stone disease is unclear. Current evidence and existing studies are inconsistent and inconclusive. The objective of this study is to assess the prevalence of vitamin D (VD) inadequacy (VDI) and metabolic abnormalities in urolithiasis patients presenting to a tertiary care center. Materials and methods This is a prospective case-control study of 200 patients divided into two groups - Group 1: 100 urolithiasis patients (case group), and Group 2: 100 non-urolithiasis patients (control group) - which was conducted from January 2016 to January 2017. Demographic, clinical data, parathyroid level, serum 25-hydroxy VD [25(OH)D], and metabolic stone work-up were recorded and analyzed.  Results Patient demographics were comparable in both groups. The prevalence of vitamin D inadequacy in urolithiasis patients was 95% as compared to 57% in the control group. The mean value ± SD of serum vitamin D in urolithiasis patients (16.5 ± 8.6 ng/mL) was significantly lower than in non-urolithiasis patients (28.7 ± 8.3 ng/mL) (p = <0.0001). Thirty-seven percent of the patients were recurrent stone formers. Hyperparathyroidism was observed in 77% of the patients and 71% of them were secondary to VDI. Conclusion Urolithiasis patients were found to have an increased prevalence of deficient VD related to secondary hyperparathyroidism.

A Single Tertiary Center Experience in a South Asian Population: Does Tobacco Use Influence Bladder Cancer?

Introduction Tobacco use, especially cigarette smoking, is a well-documented risk factor for cancer; however, its specific effect on bladder cancer has not been clearly defined. This study aimed to determine the association between tobacco use and bladder cancer in a South Asian population. Materials and methods We conducted a retrospective review of the medical records of 64 patients diagnosed with bladder tumors from February 2018 to March 2020. Patients included in the study were surveyed via a questionnaire regarding tobacco use. All patients received transurethral resection of the bladder tumor, and we analyzed histopathological and clinical outcomes. Results Our study population's median age was 57 years, and the study included twice as many male patients as female patients. Most patients (n=45; 70%) reported not using tobacco products, and 19 patients (30%) reported tobacco use. Thirty-five of 45 nontobacco users (78%) had high-grade cancer, and 10 (22%) had low-grade cancer. Among the tobacco users, 10 (52%) had high-grade cancer, and nine (48%) had low-grade cancer. Conclusions According to our findings, a substantial cohort of bladder cancer patients is not tobacco users, and high-grade bladder cancer was more common to people who are not tobacco users. Other environmental factors play a key role in developing bladder cancer in our South Asian study population. Prevention efforts should focus on reducing bladder cancer risk factors.

Locoregional recurrence after cystectomy in muscle invasive bladder cancer: Implications for adjuvant radiotherapy.

PURPOSE: We report the patterns of locoregional recurrence (LRR) in muscle invasive bladder cancer (MIBC), and propose a risk stratification to predict LRR for optimizing the indication for adjuvant radiotherapy. MATERIALS AND METHODS: The study included patients of urothelial MIBC who underwent radical cystectomy with standard perioperative chemotherapy between 2013 and 2019. Recurrences were classified into local and/or cystectomy bed, regional, systemic, or mixed. For risk stratification modelling, T stage (T2, T3, T4), N stage (N0, N1/2, N3) and lymphovascular invasion (LVI positive or negative) were given differential weightage for each patient. The cohort was divided into low risk (LR), intermediate risk (IR) and high risk (HR) groups based on the cumulative score. RESULTS: Of the 317 patients screened, 188 were eligible for the study. Seventy patients (37.2%) received neoadjuvant chemotherapy (NACT) while 128 patients (68.1%) had T3/4 disease and 66 patients (35.1%) had N+ disease. Of the 55 patients (29%) who had a recurrence, 31 (16%) patients had a component of LRR (4% cystectomy bed, 11.5% regional 0.5% locoregional). The median time to LRR was 8.2 (IQR 3.3-18.8) months. The LR, IR and HR groups for LRR based on T, N and LVI had a cumulative incidence of 7.1%, 21.6%, and 35% LRR, respectively. The HR group was defined as T3, N3, LVI positive; T4 N1/2, LVI positive; and T4, N3, any LVI. The odds ratio for LRR was 3.37 (95% CI 1.16-9.73, P = 0.02) and 5.27 (95% CI 1.87-14.84, P = 0.002) for IR and HR respectively, with LR as reference. CONCLUSION: LRR is a significant problem post radical cystectomy with a cumulative incidence of 35% in the HR group. The proposed risk stratification model in our study can guide in tailoring adjuvant radiotherapy in MIBC.

Extraperitoneal vs. transperitoneal robot-assisted laparoscopic radical prostatectomy-analysis of perioperative outcomes, a single surgeon's experience.

Robot-assisted laparoscopic radical prostatectomy (RRP) has traditionally been done using transperitoneal (TP) approach. This requires patients to be in the steep Trendelenburg position with antecedent risks of high intraoperative ventilatory pressure, post-operative confusion status, corneal and cerebral edema, deep vein thrombosis (DVT), predisposes risk of intestinal injury and slight delay in bowel recovery. Extraperitoneal (EP-RRP) approach circumvents the above given issues. Between July 2013 and October 2016, 57 patients underwent RRP for adenocarcinoma done by a single surgeon (NR). Salvage prostatectomies were excluded. RRP was performed using techniques TP (n = 23) and EP (n = 34). Patients were selected in a non-randomized fashion. Clinico-pathologic parameters and perioperative outcomes were compared in both groups using nonparametric tests. Patient demographics, clinico-pathological features, length of stay and total operative time were similar in both groups. Dock (Trendelenburgh) time was shorter in EP-RRP compared to TP-RRP [median (1st-3rd quartiles) (p value)] [180 (150-220) min vs. 220 (180-230) min (p = 0.039)]. Other significant differences includes EP-RRP vs. TPRRP, ventilatory pressures (cm of H2O) [34 (32-34) vs. 40 (38-40) (p = 0.000)], ETCO2 (mm of Hg) [38 (36-40) vs. 32 (30-34) (p = 0.000)], ambulation (day) [0.00 (0-1) vs. 0.00 (0-2) (p = 0.022)], return of bowel activity (day) [1.0 (1.0-2.0) vs. 2.0 (2.0-2.0) (p = 0.000)] and opening of bowel (day) [2.0 (1.0-2.0) vs. 3.0 (3.0-3.0) (p = 0.000)]. EP-RRP offers similar clinical outcomes to TPRRP but with the advantages of shorter Trendelenburgh time, early recovery of bowel functions with avoidance of bowel injury and intraperitoneal urine leak. Overall, early recovery of patients who had undergone EP-RRP potentiates it to be performed as day care procedure.