Archive for year: 2015

Article of the Week: Frozen Section During Partial Nephrectomy: Does it Predict Positive Margins?

Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Frozen Section During Partial Nephrectomy: Does it Predict Positive Margins?

Jennifer Gordetsky, Michael A. Gorin*, Joe Canner, Mark W. Ball*, Phillip M. Pierorazio*, Mohamad E. Allaf* and Jonathan I. Epstein*

 

Departments of Pathology and Urology, The University of Alabama, Birmingham, AL , *Department of UrologyDepartment of Surgery, Center for Surgical Trials and Outcomes Research, and Department of Pathology, The Johns Hopkins Hospital, Baltimore, MD, USA

 

OBJECTIVE

To investigate the clinical utility of frozen section (FS) analysis performed during partial nephrectomy (PN) and its influence on intra-operative management.

PATIENTS AND METHODS

We performed a retrospective analysis of consecutive PN cases from 2010 to 2013. We evaluated the concordance between the intra-operative FS diagnosis and the FS control diagnosis, a postoperative quality assurance measure performed on all FS diagnoses after formalin fixation of the tissue. We also evaluated the concordance between the intra-operative FS diagnosis and the final specimen margin. Operating reports were reviewed for change in intra-operative management for cases with a positive or atypia FS diagnosis, or if the mass was sent for FS.

RESULTS

A total of 576 intra-operative FSs were performed in 351 cases to assess the PN tumour bed margin, 19 (5.4%) of which also had a mass sent for FS to assess the tumour type. The concordance rate between the FS diagnosis and the FS control diagnosis was 98.3%. There were 30 (8.5%) final positive specimen margins, of which four (13.3%) were classified as atypia, 17 (56.7%) as negative and nine (30%) as positive on FS diagnosis. Intra-operative management was influenced in six of nine cases with a positive FS diagnosis and in one of nine cases with an FS diagnosis of atypia.

CONCLUSIONS

The relatively high false-negative rate, controversy over the prognosis of a positive margin, and inconsistency in influencing intra-operative management are arguments against the routine use of FS in PN cases.

Editorial: Frozen section during partial nephrectomy: an unreliable test that changes nothing

A core goal of oncological surgery is complete removal of the neoplastic mass. Conventional wisdom with regards to partial nephrectomy (PN) is that a minimal tumour-free margin is sufficient to achieve adequate cancer clearance, minimises loss of normal renal parenchyma and avoids local tumour recurrence [1]. Does this maximisation of nephron preservation and reported positive surgical margin rates after PN ranging from 0% to 7% [2] make intraoperative frozen sections a prerequisite? The results of the paper by Gordetsky et al. [3] in this month’s issue of BJU International suggest that frozen section results from the tumour bed of patients undergoing a PN may be both unreliable and result in subsequent inconsistent management decisions by the operating surgeon.

A recent survey of 197 American urologists revealed that up to 69% (‘always’ or ‘sometimes’) undertake a frozen section during PN [4]. In view of such high penetrance of this test with a resulting high workload for the uro-pathologist, it is critical that the test is reliable and the results are positively and consistently acted upon by the operating urologist.

Gordetsky et al. [3] present interesting data from an expert uro-pathology service, on a consecutive cohort of patients undergoing PN. Reassuringly the pathologist’s skill at making the correct call on the frozen-section specimen was extremely high with a 98% concordance between the actual frozen section and the subsequently created formalin-fixed paraffin-embedded tissue block from the very same piece of tissue. However, despite this high level of accuracy, the sensitivity of the tumour bed frozen section in predicting the actual presence of a positive surgical margin in the resected tumour was only 30% (in other words, of all the patients who actually had positive surgical margins only 30% were identified by frozen section analysis of the tumour bed). As tumour bed biopsies only represent a small fraction of the resection margin this is perhaps unsurprising.

The second issue addressed by Gordetsky et al. [3] is the matter of an inconsistent response of the surgeon to a positive frozen section. In five cases no action was taken, in three cases the tumour bed was re-resected and in a single case a subsequent radical nephrectomy was performed. These results can be compared with those of Sidana et al. [4], where there was a similar inconsistency of management strategies. This inconsistency can be explained by the controversy surrounding the oncological importance of a positive surgical. There is evidence that a positive margin may be associated with an increased risk of recurrence; however, it does not appear to infer a poorer long-term oncological outcome for the patient [5]. It is intriguing that at the time of a completion nephrectomy following a positive surgical margin, residual malignant cells were not found in any of the patients who underwent a re-resection or nephrectomy in this and other studies [3, 6]. It should, however, be noted that published series of conservative management of positive margins are few with only medium-term follow-up. As we know that the natural history of the small renal mass is one of slow growth, any microscopic residual disease may take several years to become clinically apparent and these studies are therefore underpowered.

We think there are several practical arguments against routine use of frozen section. Whilst waiting for the frozen section result some surgeons have been known to keep the kidney ischaemic (16%) resulting in consequent loss of renal function [4]. To avoid this many urologists will undertake the renorrhaphy whilst waiting for the result, a practice becoming increasingly more common with the move towards laparoscopic and robot-assisted PN, where tumour extraction is usually the final step. This practice inevitably influences the subsequent enthusiasm of the surgeon to go back and perform a re-resection and re-do renorrhaphy. It is known that the surgeons’ gross interpretation of the surgical margin approaches the sensitivity of the permanent section and has low false-negative rates, apparently superior to tumour bed frozen section [7]. Routine cautery of the resection bed may also provide an additional safety margin and render any microscopic positive margin clinically insignificant.

It is our opinion that this work by Gordetsky et al. [3] adds credence to the stand that there is no need for a routine tumour bed frozen section in PN and that careful examination of the resected tumour with selected frozen section analysis of suspicious areas is a safe strategy, saves time and provides adequate information for intraoperative decision making.

Grant D. Stewart, *† and Grenville Oades

 

*Clinical Senior Lecturer, Edinburgh Urological Cancer GroupUniversity of Edinburgh,Honorary Consultant in Urological Surgery, Department of Urology, NHS Lothian, Edinburgh, and ‡Consultant Urological Surgeon, Department of Urology, NHS Greater Glasgow and Clyde, Glasgow, UK

 

References

 

1 Sutherland SE, Resnick MI, Maclennan GT, Goldman HB. Does the size of the surgical margin in partial nephrectomy for renal cell cancer really matter? J Urol 2002; 167: 614

 

2 Marszalek M, Carini M , Chlosta P et al. Positive surgical margins after nephron-sparing surgery. Eur Urol 2012; 61: 75763

 

3 Gordetsky J, Gorin M, Canner J et al. Frozen section during partial nephrectomy: does it predict positive margins? BJU Int 2015; 116: 86872

 

 

 

 

 

Article of the Week: Recourse to RP and associated short-term outcomes in Italy

Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Mr. Julian Hanske, discussing his editorial. 

If you only have time to read one article this week, it should be this one.

Recourse to radical prostatectomy and associated short-term outcomes in Italy: a country-wide study over the last decade

Giacomo Novara, Vincenzo Ficarra*, Filiberto Zattoni and Ugo Fedeli

 

Department of Surgery, Oncology, and Gastroenterology, Urology Clinic, University of Padova, Padova, *Department of Experimental and Clinical Medical Sciences, Urologic Clinic, University of Udine, Udine, and †Epidemiological Department, Veneto Region, Italy

 

Read the full article
OBJECTIVE

To estimate time trends in the recourse to radical prostatectomy (RP) and associated short-term outcomes after RP in Italy, as population-based data on RP adoption and outcomes are available mainly from Northern America and Northern Europe.

PATIENTS AND METHODS

All RPs for prostate cancer performed between 2001 and 2010 were extracted from the Italian national archive of hospital discharge records. Age-specific and age-standardised RP rates were computed. The effect of procedural volume on in-hospital mortality, complications, and length of stay (LOS) was estimated by multilevel regression models.

RESULTS

In all, 144 432 RPs were analysed. Country-wide RP rates increased between 2001 and 2004, and thereafter remained stable, with large differences between geographical areas. The mean hospital volume increased in the first study years, without centralisation but due to increasing RP numbers at the population level. The median LOS declined from 10 to 8 days over the study period (mean from 11.7 to 9.2 days). In-hospital mortality declined from 0.16% in 2001 to 0.07% in 2010. In-hospital mortality, LOS, and the prevalence of complications increased with age, and decreased with year of surgery. Compared with very low-volume hospitals, procedures performed in high-volume hospitals were associated with decreased in-hospital mortality, in-hospital complications, and LOS.

CONCLUSIONS

The study adds evidence on rapidly changing trends in RP rates in Italy, on improving in-hospital outcomes, and on their association with procedural volume.

Editorial: How Can We Improve Surgical Outcomes?

How to improve surgical outcomes for all is a long-standing health policy/services research question. There are generally two perspectives to the debate. One reasonable approach would be to regionalise, or centralise, the performance of a procedure, in this case radical prostatectomy (RP), to ‘specialised’ surgeons or institutions. Data from the USA show that regionalisation of prostate cancer care initially occurred in the late 1990s and even further more recently after the introduction of robotic surgery. The improvement of surgical outcomes after RP in the USA has been partially attributed to such phenomena [1]. Conversely, it may be impossible to centralise a common procedure, such as RP, to a small number of hospitals, concerns that were raised in an review on improving surgical care by Hollenbeck et al. [2]. Alternatively, large state or national quality improvement initiatives, with incremental advances in process-of-care adoption/compliance, may improve the care of prostate cancer for all. This collaborative and inclusive approach is, for example, employed by the Michigan Urological Surgery Improvement Collaborative (MUSIC). However, one has to factor in that this type of approach demands funding, collaboration and patience. Regardless, there is little doubt that both approaches, enforced by health policy or not, are needed in large and diverse countries such as the USA.

In this issue of BJU International, Novara et al. [3] examine the trends in RP utilisation within Italy. The authors have to be commended for their efforts to raise awareness of the need for concerted cancer registries and centralised treatments. They corroborated previous studies on the relationship between hospital volume and perioperative outcomes, such as in-hospital mortality, complications and length of stay [4]. They also found an improvement in perioperative outcomes over time. Although their study design may only allow us to speculate on the reasons for these improvements, they are likely to be the result of many factors, such as improved surgical technique, improved perioperative medical/anaesthetic care and regionalisation of care. For surgical technique, the only significant advance over the past decade was the introduction of robot-assisted RP. Given the late adoption of robotic surgery in Italy and the controversy about its benefits, this is unlikely to be the major driver behind the recorded trends. On perioperative medical/anaesthetic care, the past decade has seen major advances and standardisation of thromboembolic prevention, perioperative care of patients with pre-existing heart conditions and significant comorbidities. Finally, centralisation of care may have played an important role in the decreasing rates of adverse outcomes after RP. Although the authors specify that there was no policy-driven regionalisation of RP care in Italy (relative to the UK, for example), the increase in average hospital volume should translate into better outcomes, as discussed above [4]. Further regionalisation should be expected in Italy with the adoption of robotic surgery, as only a few centres have the means and logistics to support a da Vinci system [5].

Read the full article
Julian Hanske *, Christian P. Meyer†‡ and Quoc-Dien Trinh

 

*Department of Urology, Marien Hospital, Ruhr-University Bochum, Herne, Germany, Division of Urologic Surgery and Center for Surgery and Public Health, Brigham and WomenHospital, Harvard Medical School, Boston, MA, USA and Department of Urology, University Medical Centre HamburgEppendorf, Hamburg, Germany

 

References

 

 

2 Hollenbeck BK, Miller DC, Wei JT, Montie JE. Regionalization of care:centralizing complex surgical procedures. Nat Clin Pract Urol 2005; 2: 461

 

 

4 Trinh QD, Bjartell A, Freedland SJ et al. A systematic review of the volumeoutcome relationship for radical prostatectomy. Eur Urol 2013; 64: 78698

 

5 Makarov DV, Yu JB, Desai RA, Penson DF, Gross CP. The association between diffusion of the surgical robot and radical prostatectomy rates. Med Care 2011; 49: 3339

 

Video: How Can We Improve Surgical Outcomes?

Recourse to radical prostatectomy and associated short-term outcomes in Italy: a country-wide study over the last decade

Giacomo Novara, Vincenzo Ficarra*, Filiberto Zattoni and Ugo Fedeli

 

Department of Surgery, Oncology, and Gastroenterology, Urology Clinic, University of Padova, Padova, *Department of Experimental and Clinical Medical Sciences, Urologic Clinic, University of Udine, Udine, and †Epidemiological Department, Veneto Region, Italy

 

Read the full article
OBJECTIVE

To estimate time trends in the recourse to radical prostatectomy (RP) and associated short-term outcomes after RP in Italy, as population-based data on RP adoption and outcomes are available mainly from Northern America and Northern Europe.

PATIENTS AND METHODS

All RPs for prostate cancer performed between 2001 and 2010 were extracted from the Italian national archive of hospital discharge records. Age-specific and age-standardised RP rates were computed. The effect of procedural volume on in-hospital mortality, complications, and length of stay (LOS) was estimated by multilevel regression models.

RESULTS

In all, 144 432 RPs were analysed. Country-wide RP rates increased between 2001 and 2004, and thereafter remained stable, with large differences between geographical areas. The mean hospital volume increased in the first study years, without centralisation but due to increasing RP numbers at the population level. The median LOS declined from 10 to 8 days over the study period (mean from 11.7 to 9.2 days). In-hospital mortality declined from 0.16% in 2001 to 0.07% in 2010. In-hospital mortality, LOS, and the prevalence of complications increased with age, and decreased with year of surgery. Compared with very low-volume hospitals, procedures performed in high-volume hospitals were associated with decreased in-hospital mortality, in-hospital complications, and LOS.

CONCLUSIONS

The study adds evidence on rapidly changing trends in RP rates in Italy, on improving in-hospital outcomes, and on their association with procedural volume.

The British Association of Urological Surgeons nephrectomy audit for T1 renal tumours

It is hard to believe that 3 years have elapsed since my new team took over publishing the BJUI, aiming to make it the most read surgical journal on the web. Many of our readers believe that we have achieved that and a number of web statistics indicate that we are not far away. Complacency is not in our DNA and this year you will notice a number of subtle changes to www.bjui.org to make it even more attractive and user friendly. Of course we rely heavily on feedback from o ur authors and readers. The January 2016 issue includes our Thank you to reviewers online, listing all 785 people who have reviewed for us in 2015. We just cannot achieve our high standards without you. Each reviewer is entitled to Continuing Professional Development (CPD) points as a recompense for the time they spend helping us select only the very best papers. 
Last year, we published a fantastic selection of Articles of the Month. If you missed any, you can nd them collected together in our free online virtual issue (https://bit.ly/ZrWA6q). The end of 2015 was dominated by falling PSA testing and prostate cancer detection rates, as highlighted in David Pensons editorial in JAMA [1]. In the UK and many other parts of the world we have already been through this. I remember during my training years that the majority of men presented with locally advanced or metastatic disease. And while we look towards smart screening of high-risk groups, particularly those with a relevant family history of prostate and breast cancer, I urge you again to look at the summary table of our Guideline of Guidelines by Loeb [2] on this thorny subject.
The BAUS has taken the lead on public reporting of surgical outcomes. The BJUI is proud to publish our nephrectomy audit [3], which has >6000 patients. Radical nephrectomy (RN) was performed mostly for T1b and partial nephrectomy (PN) for T1a tumours. Over 90% of RNs were minimally invasive an established standard of care. Only 43% of PNwere minimally invasive of which one-third were robotic, with no obvious difference between the robotic and laparoscopic arms. As expected, the complication rates of PN were higher than RN. All of us as surgeons can learn a lot from large national datasets such as this and, more importantly, strive to improve continuously. I hope you enjoy reading this important paper and look forward to interacting with many of you in 2016.

 

References

1 Penson DF. The pendulum of prostate cancer screening. JAMA 2015; 314: 20313

 

2 Loeb S. Guideline of guidelines: prostate cancer screening. BJU Int 2014; 114: 3235

 

 

Prokar Dasgupta, Editor-in-Chief, BJUI

 

Kings College London, Guys Hospital, London, UK

 

Article of the Week: Penile lengthening and widening without grafting according to a modified ‘sliding’ technique

Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Dr. Franklin Kuehhas, discussing his paper. 

If you only have time to read one article this week, it should be this one.

Penile lengthening and widening without grafting according to a modified ‘sliding’ technique

Paulo H. Egydio and Franklin E. Kuehhas*

 

Centre for Peyronies Disease Reconstruction, Sao Paulo, Brazil, and *London Andrology Institute, Suite 7 Exhibition House, Addison Bridge Place, London, UK

 

Read the full article
OBJECTIVE

To present the feasibility and safety of penile length and girth restoration based on a modified ‘sliding’ technique for patients with severe erectile dysfunction (ED) and significant penile shortening, with or without Peyronie’s disease (PD).

PATIENTS AND METHODS

Between January 2013 and January 2014, 143 patients underwent our modified ‘sliding’ technique for penile length and girth restoration and concomitant penile prosthesis implantation. It is based on three key elements: (i) the sliding manoeuvre for penile length restoration; (ii) potential complementary longitudinal ventral and/or dorsal tunical incisions for girth restoration; and (iii) closure of the newly created rectangular bow-shaped tunical defects with Buck’s fascia only.

RESULTS

In all, 143 patients underwent the procedure. The causes of penile shortening and narrowing were: PD in 53.8%; severe ED with unsuccessful intracavernosal injection therapy in 21%; post-radical prostatectomy 14.7%; androgen-deprivation therapy, with or without brachytherapy or external radiotherapy, for prostate cancer in 7%; post-penile fracture in 2.1%; post-redo-hypospadias repair in 0.7%; and post-priapism in 0.7%. In patients with ED and PD, the mean (range) deviation of the penile axis was 45 (0‒100)°. The mean (range) subjective penile shortening reported by patients was 3.4 (1‒7) cm and shaft constriction was present in 53.8%. Malleable penile prostheses were used in 133 patients and inflatable penile prostheses were inserted in 10 patients. The median (range) follow-up was 9.7 (6‒18) months. The mean (range) penile length gain was 3.1 (2‒7) cm. No penile prosthesis infection caused device explantation. The average International Index of Erectile Function (IIEF) score increased from 24 points at baseline to 60 points at the 6-month follow-up.

CONCLUSION

Penile length and girth restoration based on our modified sliding technique is a safe and effective procedure. The elimination of grafting saves operative time and, consequently, decreases the infection risk and costs associated with surgery.

Editorial: Is the modified sliding technique the way forward in Peyronie’s surgery?

The old goal of prosthetic surgery, which aimed to guarantee a hard and straight penis good enough for penetrative intercourse, is likely to have now become obsolete. Various authors have reported that patients with Peyronie’s disease (PD) and severe corporal fibrosis who undergo penile prosthesis implantation tend to report the lowest satisfaction rates, mainly because of significant penile length loss [1, 2]. In particular, according to Kueronya et al. [3], ~80% of patients affected by PD perceive a degree of penile shortening before surgery, and any further loss of length attributable to the surgical correction leads to bother among all the affected patients. All attempts at penile length restoration during prosthetic surgery should therefore be welcomed in order to achieve higher patient satisfaction.

Initial attempts at penile length restoration involved a full disassembly of the penis and the use of a circumferential graft [4]. Then, in 2012, Rolle et al. [5] described the sliding technique, a modification of the circumferential graft that consists of a double dorsal-ventral patch and should therefore provide more stability to the corpora cavernosa than a circumferential graft.

The present series by Egydio et al. [6] describes a modified sliding technique without grafting the defect of the tunica albuginea. This reduces the operating time and theoretically infection rates should therefore be reduced.

Although leaving a defect in the tunica albuginea should, in theory, lead to a haematoma formation and potentially infection of the device, in the present series, no penile prosthesis infections were reported.

Although we believe that cutting corners in surgery is not the way forward, the authors of the present paper should be congratulated because the postoperative results in their series are very encouraging. In fact, the mean penile length gain in their series was 3.1 cm, with no reported infections requiring the explantation of the penile prosthesis and with an average increase in International Index of Erectile Function score of 36.

Certainly, if the results of the present series can be confirmed in the future, this technique will revolutionize the concept that any tunical defect >1 cm in size needs to be grafted to prevent aneurysmal dilatation of the cylinders of an inflatable penile prosthesis [7], as none of the inflatable cylinders in the series developed aneurysms.

Read the full article
Giulio Garaffa, and David J. Ralph
St Peters Andrology and the Institute of Urology, University College London Hospitals, London, UK

 

References

 

1 Akin-Olugbade O, Parker M, Guhring P, Mulhall J. Determinants of patients satisfaction following penile prosthesis surgery. J Sex Med 2006; 3: 7438

 

2 Zacharakis E, Garaffa G, Raheem AA, Christopher AN, Muneer ARalph DJ. Penile prosthesis insertion in patients with refractory ischemic priapism: early versus delayed insertion. BJU Int 2014; 114: 57681

 

 

 

 

 

7 Ralph D, Gonzalez-Cadavid N, Mirone V et al. The management of Peyronies Disease: 2010 guidelines. J Sex Med 2010; 7: 235974

 

 

Video: Penile lengthening and widening without grafting according to a modified ‘sliding’ technique

Penile lengthening and widening without grafting according to a modified ‘sliding’ technique

Paulo H. Egydio and Franklin E. Kuehhas*

 

Centre for Peyronies Disease Reconstruction, Sao Paulo, Brazil, and *London Andrology Institute, Suite 7 Exhibition House, Addison Bridge Place, London, UK

 

Read the full article
OBJECTIVE

To present the feasibility and safety of penile length and girth restoration based on a modified ‘sliding’ technique for patients with severe erectile dysfunction (ED) and significant penile shortening, with or without Peyronie’s disease (PD).

PATIENTS AND METHODS

Between January 2013 and January 2014, 143 patients underwent our modified ‘sliding’ technique for penile length and girth restoration and concomitant penile prosthesis implantation. It is based on three key elements: (i) the sliding manoeuvre for penile length restoration; (ii) potential complementary longitudinal ventral and/or dorsal tunical incisions for girth restoration; and (iii) closure of the newly created rectangular bow-shaped tunical defects with Buck’s fascia only.

RESULTS

In all, 143 patients underwent the procedure. The causes of penile shortening and narrowing were: PD in 53.8%; severe ED with unsuccessful intracavernosal injection therapy in 21%; post-radical prostatectomy 14.7%; androgen-deprivation therapy, with or without brachytherapy or external radiotherapy, for prostate cancer in 7%; post-penile fracture in 2.1%; post-redo-hypospadias repair in 0.7%; and post-priapism in 0.7%. In patients with ED and PD, the mean (range) deviation of the penile axis was 45 (0‒100)°. The mean (range) subjective penile shortening reported by patients was 3.4 (1‒7) cm and shaft constriction was present in 53.8%. Malleable penile prostheses were used in 133 patients and inflatable penile prostheses were inserted in 10 patients. The median (range) follow-up was 9.7 (6‒18) months. The mean (range) penile length gain was 3.1 (2‒7) cm. No penile prosthesis infection caused device explantation. The average International Index of Erectile Function (IIEF) score increased from 24 points at baseline to 60 points at the 6-month follow-up.

CONCLUSION

Penile length and girth restoration based on our modified sliding technique is a safe and effective procedure. The elimination of grafting saves operative time and, consequently, decreases the infection risk and costs associated with surgery.

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