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Residents’ Podcast: Pelvic Drain Placement After Robot-Assisted Radical Prostatectomy

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Jesse Ory, Kyle Lehmann, Jeff Himmelman and Scott Bagnell

Department of Urology, Dalhousie University, Halifax, NS, Canada

 

Abstract

Objective

To determine if eliminating the prophylactic placement of a pelvic drain (PD) after robot-assisted radical prostatectomy (RARP) affects the incidence of early (90-day) postoperative adverse events.

Patients and Methods

In this parallel-group, blinded, non-inferiority trial, we randomised patients planning to undergo RARP to one of two arms: no drain placement (ND) or PD placement. Patients with demonstrable intraoperative leakage upon bladder irrigation were excluded. Randomisation sequence was determined a priori using a computer algorithm, and included a stratified design with respect to low vs intermediate/high D’Amico risk classifications. Surgeons remained blinded to the randomisation arm until final eligibility was verified at the end of the RARP. The primary endpoint was overall incidence of 90-day complications which, based on our standard treatment using PD retrospectively, was estimated at 13%. The non-inferiority margin was set at 10%, and the planned sample size was 312. An interim analysis was planned and conducted when one-third of the planned accrual and follow-up was completed, to rule out futility if the delta margin was in excess of 0.1389.

Results

From 2012 to 2016, 189 patients were accrued to the study, with 92 patients allocated to the ND group and 97 to the PD group. Due to lower than expected accrual rates, accrual to the study was halted by regulatory entities, and we did not reach the intended accrual goal. The ND and PD groups were comparable for median PSA level (6.2 vs 5.8 ng/mL, P = 0.5), clinical stage (P = 0.8), D’Amico risk classification (P = 0.4), median lymph nodes dissected (17 vs 18, P = 0.2), and proportion of patients receiving an extended pelvic lymph node dissection (70.7% vs 79.4%, P = 0.3). Incidence of 90-day overall and major (Clavien–Dindo grade >III) complications in the ND group (17.4% and 5.4%, respectively) was not inferior to the PD group (26.8% and 5.2%, respectively; P < 0.001 and P = 0.007 for difference of proportions <10%, respectively). Symptomatic lymphocoele rates (2.2% in the ND group, 4.1% in the PD group) were comparable between the two arms (P = 0.7).

Conclusions

Incidence of adverse events in the ND group was not inferior to the group who received a PD. In properly selected patients, PD placement after RARP can be safely withheld without significant additional morbidity.

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Residents’ Podcast: When to Perform Preoperative Chest CT for RCC Staging

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Jesse Ory, Kyle Lehmann and Jeff Himmelman

Department of Urology, Dalhousie University, Halifax, NS, Canada

 

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Abstract

Objectives

To provide objective criteria for preoperative staging chest computed tomography (CT) in patients diagnosed with renal cell carcinoma (RCC) because, in the absence of established indications, the decision for preoperative chest CT remains subjective.

Patients and Methods

A total of 1 946 patients undergoing surgical treatment of RCC, whose data were collected in a prospective institutional database, were assessed. The outcome of the study was presence of pulmonary metastases at staging chest CT. A multivariable logistic regression model predicting positive chest CT was fitted. Predictors consisted of preoperative clinical tumour (cT) and nodal (cN) stage, presence of systemic symptoms and platelet count (PLT)/haemoglobin (Hb) ratio.

Results

The rate of positive chest CT was 6% (n = 119). At multivariable logistic regression, ≥cT1b, cN1, systemic symptoms and Hb/PLT ratio were all associated with higher risk of positive chest CT (all P < 0.001). After 2000-sample bootstrap validation, the concordance index was found to be 0.88. At decision-curve analysis, the net benefit of the proposed strategy was superior to the select-all and select-none strategies. Accordingly, if chest CT had been performed when the risk of a positive result was >1%, a negative chest CT would have been spared in 37% of the population and a positive chest CT would have been missed in 0.2% of the population only.

Conclusions

The proposed strategy estimates the risk of positive chest CT at RCC staging with optimum accuracy and the results were statistically and clinically relevant. The findings of the present study support a recommendation for chest CT in patients with ≥cT1b, cN1, systemic symptoms or anaemia and thrombocythemia. Conversely, in patients with cT1a, cN0 without systemic symptoms, anaemia and thrombocythemia, chest CT could be omitted.

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Residents’ Podcast: sRPLND+PLND for ‘node-only’ recurrent PCa

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Jesse Ory, Kyle Lehmann and Jeff Himmelman

Department of Urology, Dalhousie University
Halifax, NS, Canada

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Abstract

Objectives

To describe the technique of robot-assisted high-extended salvage retroperitoneal and pelvic lymphadenectomy (sRPLND+PLND) for ‘node-only’ recurrent prostate cancer.

Patients and Methods

In all, 10 patients underwent robot-assisted sRPLND+PLND (09/2015–03/2016) for ‘node-only’ recurrent prostate cancer, as identified by 11C-acetate positron emission tomography/computed tomography imaging. Our anatomical template extends from bilateral renal artery/vein cranially up to Cloquet’s node caudally, completely excising lymphatic-fatty tissue from aorto-caval and iliac vascular trees; RPLND precedes PLND. Meticulous node-mapping assessed nodes at four prospectively assigned anatomical zones.

Results

The median operative time was 4.8 h, estimated blood loss 100 mL and hospital stay 1 day. No patient had an intraoperative complication, open conversion or blood transfusion. Three patients had spontaneously resolving Clavien–Dindo grade II postoperative complications. The mean (range) number of nodes excised per patient was 83 (41–132) and mean (range) number of positive nodes per patient was 23 (0–109). Seven patients (70%) had positive nodes on final pathology. Node-positive rates per anatomical level I, II, III and IV were 28%, 32%, 33% and 33%, respectively. In patients with positive nodes, the median PSA level had decreased by 83% at the 2-month follow-up.

Conclusion

The initial series of robot-assisted sRPLND+PLND is presented, wherein we duplicate open surgery with superior nodal counts and decreased morbidity. Robot-assisted technical details for an anatomical LND template up to the renal vessels are presented. Longer follow-up is necessary to assess oncological outcomes.

BJUI Podcasts now available on iTunes, subscribe here https://itunes.apple.com/gb/podcast/bju-international/id1309570262

Residents’ Podcast: Ureteric stent dwelling time – a risk factor for post-ureteroscopy sepsis

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Jesse Ory, Kyle Lehmann and Jeff Himmelman

Department of Urology, Dalhousie University
Halifax, NS, Canada

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Abstract

Objectives

To evaluate the association between stent dwelling time and sepsis after ureteroscopy, and identify risk factors for sepsis in this setting.

Patients and Methods

The prospectively collected database of a single institution was queried for all patients who underwent ureteroscopy for stone extraction between 2010 and 2016. Demographic, clinical, preoperative and operative data were collected. The primary study endpoint was sepsis within 48 h of ureteroscopy. Logistic regressions were performed to identify predictors of post-ureteroscopy sepsis in the ureteroscopy cohort and specifically in patients with prior stent insertion.

Results

Between October 2010 and April 2016, 1 256 patients underwent ureteroscopy for stone extraction. Risk factors for sepsis included prior stent placement, female gender and Charlson comorbidity index. A total of 601 patients had a ureteric stent inserted before the operation and were included in the study cohort, in which the median age was 56 years, 90 patients were women (30%), and 97 patients were treated for positive preoperative urine cultures (16.1%). Postoperative sepsis, <48 h after surgery, occurred in eight (1.2%) non-stented patients and in 28 patients (4.7%) with prior stent insertion. Sepsis rates after stent dwelling times of 1, 2, 3 and >3 months were 1, 4.9, 5.5 and 9.2%, respectively. On multivariate analysis, stent dwelling time, stent insertion because of sepsis, and female gender were significantly associated with post-ureteroscopy sepsis in patients with prior stent placement.

Conclusions

Patients who undergo ureteroscopy after ureteric stent insertion have a higher risk of postoperative sepsis. Prolonged stent dwelling time, sepsis as an indication for stent insertion, and female gender are independent risk factors. Stent placement should be considered cautiously, and if inserted, ureteroscopy should be performed within 1 month.

 

Residents’ Podcast: Long term follow up of erectile dysfunction after RP using nerve grafts

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 Jesse Ory, Kyle Lehmann and Jeff Himmelman

Department of Urology, Dalhousie University
Halifax, NS, Canada

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Abstract

Objective

To study a novel penile reinnervation technique using four sural nerve grafts and end-to-side neurorraphies connecting bilaterally the femoral nerve and the cavernous corpus and the femoral nerve and the dorsal penile nerves.

Patients and Methods

Ten patients (mean [± sd; range] age 60.3 [± 4.8; 54–68] years), who had undergone radical prostatectomy (RP) at least 2 years previously, underwent penile reinnervation in the present study. Four patients had undergone radiotherapy after RP. All patients reported satisfactory sexual activity prior to RP. The surgery involved bridging of the femoral nerve to the dorsal nerve of the penis and the inner part of the corpus cavernosum with sural nerve grafts and end-to-side neurorraphies. Patients were evaluated using the International Index of Erectile Function (IIEF) questionnaire and pharmaco-penile Doppler ultrasonography (PPDU) preoperatively and at 6, 12 and 18 months postoperatively, and using a Clinical Evolution of Erectile Function (CEEF) questionnaire, administered after 36 months.

Results

The IIEF scores showed improvements with regard to erectile dysfunction (ED), satisfaction with intercourse and general satisfaction. Evaluation of PPDU velocities did not reveal any difference between the right and left sides or among the different time points. The introduction of nerve grafts neither caused fibrosis of the corpus cavernosum, nor reduced penile vascular flow. CEEF results showed that sexual intercourse began after a mean of 13.7 months with frequency of sexual intercourse varying from once daily to once monthly. Acute complications were minimal. The study was limited by the small number of cases.

Conclusions

A total of 60% of patients were able to achieve full penetration, on average, 13 months after reinnervation surgery. Patients previously submitted to radiotherapy had slower return of erectile function. We conclude that penile reinnervation surgery is a viable technique, with effective results, and could offer a new treatment method for ED after RP.

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Residents’ Podcast: NICE Guidance – GreenLight XPS for treating benign prostatic hyperplasia

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Veeru Kasivisvanathan

SpR in Urology & NIHR Doctoral Fellow, University College London & University College Hospital London.

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This National Institute for Health and Care Excellence (NICE) guidance is the current, unaltered NICE guidance at time of publication. BJUI publishes selected NICE guidance relevant to urologists to extend their distribution and promote best practice.

 Recommendations

  • 1.1
    The case for adopting GreenLight XPS for treating benign prostatic hyperplasia is supported in non-high-risk patients. GreenLight XPS is at least as effective in these patients as transurethral resection of the prostate (TURP), but can more often be done as a day-case procedure, following appropriate service redesign.
  • 1.2

    There is currently insufficient high-quality, comparative evidence to support the routine adoption of GreenLight XPS in high-risk patients, that is those who:

    • have an increased risk of bleeding or
    • have prostates larger than 100 ml or
    • have urinary retention.

    NICE recommends that specialists collaborate in collecting and publishing data on the comparative effectiveness of GreenLight XPS for high-risk patients to supplement the currently limited published evidence.

  • 1.3
    Cost modelling indicates that in non-high-risk patients, cost savings with GreenLight XPS compared with TURP are determined by the proportion of procedures done as day cases. Assuming a day-case procedure rate of 36%, and that the GreenLight XPS console is provided at no cost to the hospital (based on a contracted commitment to fibre usage), the estimated cost saving is £60 per patient. NICE’s resource impact report estimates that the annual cost saving for the NHS in England is around £2.3 million. In a plausible scenario of 70% of treatments being done as day cases, the cost saving may be up to £3.2 million.
  • 1.4
    NICE recommends that hospitals adopting GreenLight XPS plan for service redesign to ensure that day-case treatment can be delivered appropriately.
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Beyond our wildest dreams

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In this podcast Prokar Dasgupta summarises the success of the BJUI over 2013. For more on podcasts, including how to record your own, go to Podcasts Made Simple.

 

If anyone had suggested to me in January 2013 that our full article downloads would increase by 15% and the Melbourne Consensus Statement on PSA testing would be viewed over 5000 times @ BJUI.org, I would have stared at them in disbelief. The launch of our web portal in addition to an innovative paper journal, has achieved just that. And much more. We remain one of the Big Three in urology with a Klout score greater than any of our colleagues. These are impossible to achieve via papyrus alone.

The common theme amongst all the fantastic innovation that our Associate Editors have introduced is the highest quality of original articles that we have attracted and published this year. I wanted to take this opportunity to highlight them and thank all our authors for sending us their best manuscripts.

The updated Partin tables (2006–11) remains our most cited paper published in 2013 [1]. It is sheer coincidence that I selected it as our first article of the month in January. It has allowed surgeons to avoid lymphadenectomy during radical prostatectomy in non-palpable Gleason 3+4 disease as the risk of a positive lymph node is <2%. The accompanying 3 minute video on the BJUI Tube channel is an excellent summary for the busy urologist.

I had to appease a number of oncologists when Cooperberg and colleagues showed that radiation for prostate cancer was about 2.5 times more expensive than radical prostatectomy in a comprehensive lifetime cost-utility analysis [2]. Peace was rapidly established at the annual meeting of the British Uro-Oncology group (BUG) where I participated in a balloon debate on the subject this autumn.

The thematic variations continue. It seems that 12 weeks of Tadalafil is effective in ejaculatory and orgasmic dysfunction in patients with ED [3]. Sexual medicine remains an exciting section of the BJUI and I am grateful to the andrologists on our editorial board for diligently reviewing the large number of papers that we receive from investigators in this field.

And finally we had two practice changing randomised trials in stone disease. Plasma vaporisation performed better than balloon dilatation for creating PCNL tracts [4]. For the curious, there is a video demonstrating the method if you wish to learn it.

The Portland trial has a simple message that you just can’t ignore; a single dose of NSAID before ureteric stent removal prevents severe pain afterwards. This is going to become standard of care if it has not already [5].

Many of our readers will wonder why we continue with a paper journal when the web has been so successful? The map here shows our global reach, which includes a number of subscribers who prefer to, or by necessity, read the print journal (∼30%). Moreover in a BJUI Online Poll, 75% of our readers reported taking the paper journal out of its plastic sheath and reading it, with over 50% doing so within a week. The transition will thus take longer and while the web remains our main portal, the beautifully designed paper BJUI will still land on your doorstep.

Prokar Dasgupta
Editor in Chief, BJUI

Guy’s Hospital, King’s Health Partners

References

  1. Eifler JB, Feng Z, Lin BM et al. An updated prostate cancer staging nomogram (Partin tables) based on cases from 2006 to 2011. BJU Int 2013; 111: 22–29
  2. Cooperberg MR, Ramakrishna NR, Duff SB et al. Primary treatments for clinically localised prostate cancer: a comprehensive lifetime cost-utility analysis. BJU Int 2013; 111: 437–450
  3. Paduch DA, Bolyakov A, Polzer PK, Watts SD. Effects of 12 weeks of tadalafil treatment on ejaculatory and orgasmic dysfunction and sexual satisfaction in patients with mild to severe erectile dysfunction: integrated analysis of 17 placebo-controlled studies. BJU Int 2013; 111: 334–343
  4. Chiang PH, Su HH. Randomized and prospective trial comparing tract creation using plasma vaporization with balloon dilatation in percutaneous nephrolithotomy. BJU Int 2013; 112: 89–93
  5. Tadros NN, Bland L, Legg E, Olyaei A, Conlin MJ. A single dose of a non-steroidal anti-inflammatory drug (NSAID) prevents severe pain after ureteric stent removal: a prospective, randomised, double-blind, placebo-controlled trial. BJU Int 2013; 111: 101–105
Original publication of this editorial can be found at: BJU Int 2013; 112: 1051–1052. doi: 10.1111/bju.12524

 

 

 

Face-to-Face with John Fitzpatrick

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An interview with John M. Fitzpatrick
BJUI December 2012, Volume 110, Issue 11

‘Face to Face’ is an interview with personalities in the urology field. As a successor to BJUI’s ‘Conversations’ feature, ‘Face to Face’ is fashioned after the highly acclaimed BBC television series of the same name where former British politician John Freeman interviewed famous men and women with an insightful and probing style.

In this edition of ‘Face to Face’, BJUI Associate Editor Roger Kirby (and a former ‘Face to Face’ interviewee), turns the tables and interviews John M. Fitzpatrick, MCh, FRCSI, FEBU, FRCS, in honour of 10 years of service as outgoing Editor-in-Chief of BJUI. After serving for 25 years as Professor and Chairman of the Department of Surgery at Mater Misericordiae Hospital in Dublin and University College Dublin, where he also received his medical school training, John is now head of research at the Irish Cancer Society. His list of medals, awards, prizes, and honorary degrees are simply too numerous to mention. This year, he was named Honorary Fellow of the Urological Society of Australia and New Zealand and received the Distinguished Career Award from the Société Internationale d’Urologie. His visiting professorships, invited lectures, and charitable work has taken him to the four corners of the world.

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