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Enhanced Recovery After Robot-assisted Radical Cystectomy: EAU Robotic Urology Section Scientific Working Group Consensus View

Abstract Context

Radical cystectomy (RC) is associated with frequent morbidity and prolonged length of stay (LOS) irrespective of surgical approach. Increasing evidence from colorectal surgery indicates that minimally invasive surgery and enhanced recovery programmes (ERPs) can reduce surgical morbidity and LOS. ERPs are now recognised as an important component of surgical management for RC. However, there is comparatively little evidence for ERPs after robot-assisted radical cystectomy (RARC). Due to the multimodal nature of ERPs, they are not easily validated through randomised controlled trials.

Objective

To provide a European Association of Urology (EAU) Robotic Urology Section (ERUS) policy on ERPs to guide standardised perioperative management of RARC patients.

Evidence acquisition

The guidance was formulated in four phases: (1) systematic literature review of evidence for ERPs in robotic, laparoscopic, and open RC; (2) an online questionnaire survey formulated and sent to ERUS Scientific Working Group members; (3) achievement of consensus from an expert panel using the Delphi process; and (4) a standardised reporting template to audit compliance and outcome designed and approved by the committee.

Evidence synthesis

Consensus was reached in multiple areas of an ERP for RARC. The key principles include patient education, optimisation of nutrition, RARC approach, standardised anaesthetic, analgesic, and antiemetic regimens, and early mobilisation.

Conclusions

This consensus represents the views of an expert panel established to advise ERUS on ERPs for RARC. The ERUS Scientific Working Group recognises the role of ERPs and endorses them as standardised perioperative care for patients undergoing RARC. ERPs in robotic surgery will continue to evolve with technological and pharmaceutical advances and increasing understanding of the role of surgery-specific ERPs.

Patient summary

There is currently a lack of high-level evidence exploring the benefits of enhanced recovery programmes (ERPs) in patients undergoing robot-assisted radical cystectomy (RARC). We reported a consensus view on a standardised ERP specific to patients undergoing RARC. It was formulated by experts from high-volume RARC hospitals in Europe, combining current evidence for ERPs with experts’ knowledge of perioperative care for robotic surgery.

Take Home Message

There is currently a lack of level 1 evidence for an enhanced recovery programme (ERP) in patients undergoing robot-assisted radical cystectomy (RARC). Combining current understanding of ERPs and perioperative care for robotic surgery, a committee of experts developed a consensus on an ERP specific to RARC.

Keywords: Enhanced recovery protocol, Robot-assisted radical cystectomy, RARC, Radical cystectomy, Enhanced recovery after surgery, ERAS.

Footnotes

a Department of Urology, Karolinska University Hospital, Stockholm, Sweden

b Department of Urology, University Hospital of Northern Norway, Tromsø, Norway

c Department of Urology, Stockholm Urology Clinic, Stockholm, Sweden

d Department of Urology, Guys Hospital, London, UK

e Department of Urology, Verona University Hospital, Verona, Italy

f Clinique Saint Augustin, Bordeaux, France

g Department of Urology, Sheffield University Hospital, Sheffield, UK

h Department of Urology, Bristol Urological Institute, Bristol, UK

i Department of Urology, St Georges, London, UK

j Department of Urology, Royal Devon and Exeter Hospital, Exeter, UK

k Department of Urology, UCL, London, UK

l Department of Urology, Hirslanden Klinik, Aarau, Switzerland

m Department of Urology, Rijnstate, Arnhem, Netherlands

n Department of Urology, Ankara Ataturk Hospital, Ankara, Turkey

o Department of Urology, Memorial Sisli Hospital, Istanbul, Turkey

p Department of Urology, Ghent University, Ghent, Belgium

q Department of Urology, University of Tuebingen, Tubingen, Germany

r Department of Urology, Da Vinci Zentrum, Hanover, Germany

s Department of Urology, Universittatsklinikum des Saarlandes, Homburg, Germany

t Department of Urology, L’Institut Mutualiste Montsouris, Paris, France

u Department of Urology, Royal Liverpool Hospital, Liverpool, UK

v Department of Urology, Newcastle upon Tyne Hospitals, Newcastle, UK

w Department of Urology, O.L.V, Aalst, Belgium

Corresponding author. Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, 171 76 Stockholm, Sweden. Tel. +46 8 517 728 54; Fax: +46 8 517 735 99.

Article information

PII: S0302-2838(16)30184-1
DOI: 10.1016/j.eururo.2016.05.020
© 2016 European Association of Urology, Published by Elsevier B.V.

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Expanding the Armamentarium for Castrate-resistant Prostate Cancer

Refers to article:

Comprehensive Drug Testing of Patient-derived Conditionally Reprogrammed Cells from Castration-resistant Prostate Cancer

Khalid Saeed, Vesa Rahkama, Samuli Eldfors, Dmitry Bychkov, John Patrick Mpindi, Bhagwan Yadav, Lassi Paavolainen, Tero Aittokallio, Caroline Heckman, Krister Wennerberg, Donna M. Peehl, Peter Horvath, Tuomas Mirtti, Antti Rannikko, Olli Kallioniemi, Päivi Östling and Taija M. af Hällström

Accepted 15 April 2016

Footnotes

Centre for Cancer Research and Cell Biology, Queen's University Belfast, Belfast, Northern Ireland

Centre for Cancer Research and Cell Biology, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7AE, Northern Ireland. Tel. +44 0 2890 972763.

Article information

PII: S0302-2838(16)30186-5
DOI: 10.1016/j.eururo.2016.05.022
© 2016 Published by Elsevier B.V.

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Integrating Molecular Profiling of Liquid Biopsy Samples with a Calculator Algorithm To Detect High-risk Prostate Cancer

Refers to article:

Detection of High-grade Prostate Cancer Using a Urinary Molecular Biomarker–Based Risk Score

Leander Van Neste, Rianne J. Hendriks, Siebren Dijkstra, Geert Trooskens, Erik B. Cornel, Sander A. Jannink, Hans de Jong, Daphne Hessels, Frank P. Smit, Willem J.G. Melchers, Gisèle H.J.M. Leyten, Theo M. de Reijke, Henk Vergunst, Paul Kil, Ben C. Knipscheer, Christina A. Hulsbergen-van de Kaa, Peter F.A. Mulders, Inge M. van Oort, Wim Van Criekinge and Jack A. Schalken

Accepted 7 April 2016

Footnotes

a University of Queensland Centre for Clinical Research at Royal Brisbane & Women's Hospital, Brisbane, Australia

b Division of Surgery, University of Queensland, Brisbane, Australia

c Department of Urology, Royal Brisbane & Women's Hospital, Brisbane, Australia

d ICON Cancer Care, Brisbane, Australia

Corresponding author. University of Queensland Centre for Clinical Research at Royal Brisbane & Women's Hospital, Herston, Brisbane, Queensland 4029, Australia. Tel. +61 7 3346 6046; Fax: +61 7 32071205.

Article information

PII: S0302-2838(16)30176-2
DOI: 10.1016/j.eururo.2016.05.012
© 2016 Published by Elsevier B.V.

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Safety and Early Oncologic Effectiveness of Primary Robotic Retroperitoneal Lymph Node Dissection for Nonseminomatous Germ Cell Testicular Cancer

Abstract Background

Primary robot-assisted retroperitoneal lymph node dissection (R-RPLND) has been studied as an alternative to open RPLND in single-institution series for patients with low-stage nonseminomatous germ cell tumors (NSGCT).

Objective

To evaluate a multicenter series of primary R-RPLND for low-stage NSGCT.

Design, setting, and participants

Between 2011 and 2015, 47 patients underwent primary R-RPLND at four centers for Clinical Stage (CS) I-IIA NSGCT.

Surgical procedure

R-RPLND was performed using the da Vinci surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA).

Outcome measurements and statistical analysis

Data were collected regarding patient demographics, primary tumor characteristics, pathologic findings, and clinical outcomes.

Results and limitations

Forty-two patients (89%) were CS I and five (11%) were CS IIA. The median operative time was 235 min (interquartile range [IQR]: 214–258 min), estimated blood loss was 50 ml (IQR: 50–100 ml), node count was 26 (IQR: 18–32), and length of stay was 1 d. There were two intraoperative complications (4%), four early postoperative complications (9%), no late complications, and the rate of antegrade ejaculation was 100%. Of the eight patients (17%) with positive nodes (seven pN1and one pN2), five (62%) received adjuvant chemotherapy. The one recurrence was out of template in the pelvis after adjuvant chemotherapy (resected teratoma). The median follow-up was 16 mo and the 2-yr recurrence-free survival rate was 97% (95% confidence interval: 82–100%). Limitations include retrospective design and limited follow-up.

Conclusions

Our multicenter experience supports R-RPLND as a potential option at experienced centers in select patients with low-stage NSGCT. Informal comparison to open and laparoscopic series suggests R-RPLND has an acceptably low morbidity profile, but oncologic efficacy evaluation requires further evaluation.

Patient summary

We examined outcomes after robot-assisted retroperitoneal lymph node dissection for patients with low-stage nonseminomatous testicular cancer with our data suggesting the robotic approach has acceptable morbidity and early oncologic outcomes.

Take Home Message

The first multicenter experience with robot-assisted retroperitoneal lymph node dissection supports the technique as a potential management option at experienced centers in select patients with low-stage nonseminomatous germ cell tumors. Robot-assisted retroperitoneal lymph node dissection has an acceptably low morbidity profile, but oncologic efficacy evaluation requires longer follow-up.

Keywords: Nonseminomatous germ cell tumor, Testicular neoplasms, Lymph node excision, Complications, Treatment outcome.

Footnotes

a Section of Urology, Department of Surgery, University of Chicago, Chicago, IL, USA

b Department of Urology, The Johns Hopkins School of Medicine, Baltimore, MD, USA

c Department of Urology, University of Michigan Health System, Ann Arbor, MI, USA

d Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA

Corresponding author. The University of Chicago Medicine and Biological Sciences, 5841 South Maryland Avenue, MC 6038, Chicago, IL 60637, USA. Tel. +1-608-234-7401; Fax: +1 773 702 1001.

Article information

PII: S0302-2838(16)30181-6
DOI: 10.1016/j.eururo.2016.05.017
© 2016 European Association of Urology, Published by Elsevier B.V.

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Early renal replacement therapy reduces risk of death among critically ill patients with acute kidney injury

MedicalNewsToday - Tue, 05/24/2016 - 10:00
In a study published online by JAMA, Alexander Zarbock, M.D., of University Hospital Munster, Germany, and colleagues examined whether early (compared with delayed) initiation of renal replacement...
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Higher salt intake may increase risk of CVD among patients with chronic kidney disease

MedicalNewsToday - Tue, 05/24/2016 - 10:00
In a study appearing in the May 24/31 issue of JAMA, Jiang He, M.D., Ph.D., of the Tulane University School of Public Health and Tropical Medicine, New Orleans, and colleagues evaluated more than...
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Wide Variation in Radiation Exposure during Computerized Tomography

Urology (Gold Journal) In Press - Tue, 05/24/2016 - 00:00
To determine the variance in Computerized Tomography (CT) radiation measured via dose-length product (DLP) and effective dose (ED), during stone protocol CT scans.
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Transurethral Bougie Guided Placement of Suprapubic Catheter Over Guide Wire Monorail in Females-a Novel Technique

Urology (Gold Journal) In Press - Tue, 05/24/2016 - 00:00
To assess the safety and effectiveness of a novel transurethral bougie guided monorail technique for SPC in females with VVF.
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Survival Comparison between Endoscopic and Surgical Management for Patients with Upper Tract Urothelial Cancer: A Matched Propensity Score Analysis Using SEER-Medicare Data

Urology (Gold Journal) In Press - Tue, 05/24/2016 - 00:00
To determine survival differences among patients receiving endoscopic versus surgical management for upper tract urothelial carcinoma (UTUC).
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A Joint Mechanism of Action for Sacral Neuromodulation for Bladder and Bowel Dysfunction?

Urology (Gold Journal) In Press - Tue, 05/24/2016 - 00:00
Sacral neuromodulation (SNM) is a clinically-effective intervention for treatment of urinary and bowel disorders. The aim is to establish the hypothesis that there is a common mechanism of action for SNM in both systems.Current knowledge:- Therapeutic parameters may be different for the two efficacy measures.- SNM invokes neural circuits that can be observed as neurochemical changes in specific neuroanatomical structures downstream from the therapy delivery site.- There are important central nervous system effects for both therapies.
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DESCRIPTIVE TECHNIQUE AND INITIAL RESULTS FOR ROBOTIC RADICAL PERINEAL PROSTATECTOMY

Urology (Gold Journal) In Press - Tue, 05/24/2016 - 00:00
To minimize technical challenges of radical perineal prostatectomy (RPP), we conceived and applied the robotic approach to this technique in an aim to improve surgical applicability of RPP. Radical prostatectomy via the perineal route, avoiding the intra-abdominal cavity has been shown to be oncologically safe, with excellent functional outcomes and a short hospital stay. We report our initial results with this novel approach.
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Ectopic Vas Deferens Inserting Into Distal Retroiliac Ureter in the Currarino Syndrome.

Urology (Gold Journal) In Press - Tue, 05/24/2016 - 00:00
Vas deferens ectopia is a rare congenital anomaly frequently associated with anorectal abnormalities and hypospadias. We present a Currarino syndrome case with an ectopic vas deferens terminating in a distal retroiliac ureter. A left vasectomy, ureteral decussation over the iliac vessels and a Cohen's type ureteral reimplantation were performed. The objectives are to preserve renal function, prevent epididymitis and preserve fertility. There is no evidence in the literature that recommends surgical correction of the vas deferens.
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Functional Restoration of Erectile Function Using End-to-Side Autonomic-to-Somatic Neurorrhaphy in Rats

Urology (Gold Journal) In Press - Tue, 05/24/2016 - 00:00
To investigate the feasibility of erectile function rehabilitation using end-to-side autonomic-to-somatic neurorrhaphy in rats.
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Perirenal Involvement of Mantle Cell Lymphoma: Imaging Features

Urology (Gold Journal) In Press - Tue, 05/24/2016 - 00:00
Perirenal lymphoma is a rare disease and accouning for less than 10% of all malignant lymphomas. Mantle cell lymphoma (MCL) is the rarest but one of the most aggressive non-Hodgkin's lymphoma (NHL) subtype. The perirenal involvement of MCL has not been reported previously. A 69-year-old male, who had been diagnosed as having mantle cell lymphoma (MCL) one year ago, presented with recent-onset right back pain. Herein we present the key imaging findings of perirenal soft tissue manifestation of MCL.
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Editorial Comment

Urology (Gold Journal) In Press - Tue, 05/24/2016 - 00:00
The authors have conducted an interesting study of the conditional freedom from biochemical recurrence for men treated with radical prostatectomy.1 What makes this analysis particularly interesting is that it looks at the risk of biochemical failure, given a particular degree of follow-up without failure. In other words, it helps to answer the question of what the future risk is, given that a man has not had failure for a while. An analysis like this has two useful purposes. One is for patient counseling, revising a patient's prognosis as he returns for follow-up.
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Have your kidney function checked before starting a protein shake diet!

MedicalNewsToday - Mon, 05/23/2016 - 11:00
It is well known that decreased protein intake can prevent the advance of renal insufficiency.
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Continued treatment with nivolumab may improve survival in patients with advanced kidney cancer

MedicalNewsToday - Mon, 05/23/2016 - 09:00
Only 12% of kidney cancer patients with advanced disease survive five years after their initial treatment.
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PSMA PET May Improve the Diagnostic Accuracy of mpMRI in Localised Prostate Cancer as Confirmed by Whole-Mount Histopathology

Positron emission tomography (PET) using ligands targeting prostate specific membrane antigen (PSMA) has recently been introduced. PET imaging wwith 68Ga-PSMA-HBED-CC has been shown to detect metastatic prostate cancer lesions with a high detection rate. This study aims to compare mpMRI and PSMA PET of prostate with whole-mount ex-vivo prostate histopathology to determine the true sensitivity and specificity of these imaging modalities for detecting and locating tumour foci within prostate.
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Predictors of Excisional Volume Loss in Partial Nephrectomy: Is There Still Room for Improvement?

Abstract

Since volume loss is the most important modifiable determinant of long-term renal function after partial nephrectomy, there is great interest in ways to reduce the loss of healthy parenchyma. We retrospectively reviewed 880 partial nephrectomies to identify predictors of excisional volume loss (EVL), based on pathologic assessment. After stepwise variable selection, we assessed age, sex, solitary kidney status, tumor size, endophytic property, estimated blood loss, surgical approach, and surgeon volume for association with EVL using multiple regression. Male sex (p < 0.01), larger tumors (p < 0.01), endophytic tumors (p = 0.01), open approach (p < 0.01), increased bleeding (p < 0.01), and higher surgeon volume (p < 0.01) were independently associated with greater EVL. Approach strongly influenced EVL with open surgery having 7.8 cm3 more EVL than robotic surgery. Negative surgical margins (95.7% vs 94.1%, p = 0.32) did not differ between open and robotic approaches, respectively. EVL is associated with patient, tumor, and especially provider factors, suggesting that volume preservation may be improved with surgical optimization. Lack of percent volume loss data, which precluded assessment of EVL's impact on long-term renal function, is a limitation.

Patient summary

We found that surgical approach affects the quantity of healthy kidney removed during cancer surgery, suggesting that there is room for further surgical improvement.

Take Home Message

In a large single institution series, we identified patient, tumor, and provider factors that predict excisional volume loss in partial nephrectomy. In particular, surgical approach and operative bleeding are potentially modifiable factors that may be worthwhile targets for quality improvement.

Keywords: Kidney, Kidney neoplasms, Nephrectomy, Robotic surgical procedures.

Footnotes

Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA

Corresponding author. Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, 9500 Euclid Avenue, Q10-1, Cleveland, OH 44195, USA. Tel. +1-216-444-2976; Fax: +1-216-636-4492.

Article information

PII: S0302-2838(16)30171-3
DOI: 10.1016/j.eururo.2016.05.007
© 2016 European Association of Urology, Published by Elsevier B.V.

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FDA approve immunotherapy drug for bladder cancer

MedicalNewsToday - Fri, 05/20/2016 - 09:00
The FDA have given accelerated approval to Tecentriq (atezolizumab), a PD-1/PD-L1 inhibitor, to treat urothelial carcinoma, the most common type of bladder cancer.
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