Multimodal enhanced recovery after surgery (ERAS) regimens have improved outcomes from colorectal surgery.
We report the application of ERAS to patients undergoing radical cystectomy (RC).
...Prospective collection of outcomes from consecutive patients undergoing RC at a single institution.
Twenty-six components including prehabilitation exercise, same day admission, carbohydrate fluid loading, targeted intraoperative fluid resuscitation, regional local anaesthesia, cessation of nasogastric tubes, omitting oral bowel preparation, avoiding drain use, early mobilisation, chewing gum use, and audit.
Primary outcomes were length of stay and readmission rate. Secondary outcomes included intraoperative blood loss, transfusion rates, survival, and histopathological findings.
Four hundred and fifty-three consecutive patients underwent RC, including 393 (87%) with ERAS. Length of stay was shorter with ERAS (median interquartile range: 8 6–13 d) than without (18 13–25, p<0.001). Patients with ERAS had lower blood loss (ERAS: 600 383–969 ml vs 1050 900–1575 ml for non-ERAS, p<0.001), lower transfusion rates (ERAS: 8.1% vs 25%, chi-square test, p<0.001), and fewer readmissions (ERAS: 15% vs 25%, chi-square test, p=0.04) than those without. Histopathological parameters (eg, tumour stage, node count, and margin state) and survival outcomes did not differ with ERAS use (all p>0.1). Multivariable analysis revealed ERAS use was (p=0.002) independently associated with length of stay.
The use of ERAS pathways was associated with lower intraoperative blood loss and faster discharge for patients undergoing RC. These changes did not increase readmission rates or alter oncological outcomes.
Recovery after major bladder surgery can be improved by using enhanced recovery pathways. Patients managed by these pathways have shorter length of stays, lower blood loss, and lower transfusion rates. Their adoption should be encouraged.
We found that changes to the radical cystectomy recovery pathway made dramatic improvements to patient outcomes. In particular, changing recovery pathways lead to shorter length of stay, lower blood loss and transfusion rates, and fewer readmissions after surgery, without impacting on cancer treatment outcomes.
The COVID-19 pandemic has had rapid and inevitable effects on health care systems and the training and work plans of urology residents. Smart learning is a valuable strategy for maintaining the ...learning curve of residents.
Urethral stricture disease (USD) is initially managed with minimally invasive techniques such as urethrotomy and urethral dilatation. Minimally invasive techniques are associated with a high ...recurrence rate, especially in recurrent USD. Adjunctive measures, such as local drug injection, have been used in an attempt to reduce recurrence rates.
To systematically review evidence for the efficacy and safety of adjuncts used alongside minimally invasive treatment of USD.
A systematic review of the literature published between 1990 and 2020 was conducted in accordance with the PRISMA checklist.
A total of 26 studies were included in the systematic review, from which 13 different adjuncts were identified, including intralesional injection (triamcinolone, n = 135; prednisolone, n = 58; mitomycin C, n = 142; steroid-mitomycin C-hyaluronidase, n = 103, triamcinolone-mitomycin C-N-acetyl cysteine, n = 50; platelet-rich plasma, n = 44), intraluminal instillation (mitomycin C, n = 20; hyaluronic acid and carboxymethylcellulose, n = 70; captopril, n = 37; 192-iridium brachytherapy, n = 10), application via a lubricated catheter (triamcinolone, n = 124), application via a coated balloon (paclitaxel, n = 106), and enteral application (tamoxifen, n = 30; deflazacort, n = 36). Overall, 13 randomised controlled trials were included in the meta-analysis. Use of any adjunct was associated with a lower rate of USD recurrence (odds ratio OR 0.37, 95% confidence interval CI 0.27–0.50; p < 0.001) compared to no adjunct use. Of all the adjuncts, mitomycin C was associated with the lowest rate of USD recurrence (intralesional injection: OR 0.23, 95% CI 0.11–0.48; p < 0.001; intraluminal injection: OR 0.11, 95% CI 0.02–0.61; p = 0.01). Urinary tract infection (2.9–14%), bleeding (8.8%), and extravasation (5.8%) were associated with steroid injection; pruritis of the urethra (61%) occurred after instillation of captopril; mild gynaecomastia (6.7%) and gastrointestinal side effects (6.7%) were associated with oral tamoxifen.
Adjuncts to minimally invasive treatment of USD appear to lower the recurrence rate and are associated with a low adjunct-specific complication rate. However, the studies included were at high risk of bias. Mitomycin C is the adjunct supported by the highest level of evidence.
We reviewed studies on additional therapies (called adjuncts) to minimally invasive treatments for narrowing of the urethra in men. Adjuncts such as mitomycin C injection result in a lower recurrence rate compared to no adjunct use. The use of adjuncts appeared to be safe and complications are uncommon; however, the studies were small and of low quality.
Adjuncts to minimally invasive treatment of urethral strictures may reduce recurrence rates and thereby avoid the need for urethroplasty. Further adequately powered studies are needed to establish the safety, efficacy, and cost effectiveness of adjuncts and optimal drug dosing and delivery protocols.
Fournier's gangrene is a rare, rapidly progressive, fulminant form of infective necrotising fasciitis of the genital, perianal and perineal regions. We present a case of Fournier's gangrene of the ...penis complicating acute genital ulceration and recurrent paraphimosis that was secondary to contemporaneous COVID-19 and Mpox infection in an otherwise healthy 41-year-old man. It is important for clinicians to be aware of Fournier's gangrene, as early detection remains the cornerstone of effective tissue and indeed life conserving management.
Objective
To report the oncological survival outcomes of men with penile sarcomatoid squamous cell carcinoma (sSCC).
Patients and Methods
A retrospective analysis of men with penile sSCC diagnosed ...between January 2010 and January 2020 in a single centre was conducted. Disease‐specific (DSS), recurrence‐free (RFS) and metastasis‐free (MFS) survival were evaluated. Outcomes were compared with a non‐sarcomatoid penile SCC cohort matched to age, type of surgery and tumour stage. Kaplan–Meier plots were used to estimate survival outcomes.
Results
In all, 1286 men were diagnosed with penile SCC during the study period and of these 38 (3%) men had sSCC. The median (interquartile range) age and follow‐up was 70 (57–81) years and 16 (7–44) months, respectively. Operations performed included: circumcision, one (2.6%); wide local excision, four (10.5%); glansectomy, 11 (29%); partial penectomy, 10 (26%); subtotal/total penectomy, 12 (32%). The Kaplan–Meier estimated 12‐, 24‐ and 36‐month DSS was 62% (vs non‐sarcomatoid, 67%), 43% (vs non‐sarcomatoid, 67%) and 36% (vs non‐sarcomatoid, 67%), respectively (P = 0.03). The Kaplan–Meier estimated 12‐ and 24‐month RFS was 47% (vs non‐sarcomatoid, 60%) and 28% (vs non‐sarcomatoid, 55%), respectively (P = 0.01). The MFS was 52% (vs non‐sarcomatoid, 62%) at 12 months and 37% (vs non‐sarcomatoid, 57%) at 24 months (P = 0.04).
Conclusions
Sarcomatoid differentiation was associated with a lower DSS, RFS and MFS. Due to the rarity of its incidence and aggressiveness, expert histological review and multidisciplinary management is required in a specialist penile cancer centre.
Objectives
To report the management outcomes of men with ≤20‐mm small testicular masses (STMs) and to identify clinical and histopathological factors associated with malignancy.
Patients and methods
...A retrospective analysis of men managed at a single centre between January 2010 and December 2020 with a STM ≤20 mm in size was performed.
Results
Overall, 307 men with a median (interquartile range IQR) age of 36 (30–44) years were included. Of these, 161 (52.4%), 82 (26.7%), 62 (20.2%) and 2 men (0.7%) underwent surveillance with interval ultrasonography (USS), primary excisional testicular biopsy (TBx) or primary radical orchidectomy (RO), or were discharged, respectively. The median (IQR) surveillance duration was 6 (3–18) months. The majority of men who underwent surveillance had lesions <5 mm (59.0%) and no lesion vascularity (67.1%) on USS. Thirty‐three (20.5%) men undergoing surveillance had a TBx based on changes on interval USS or patient choice; seven (21.2%) were found to be malignant. The overall rate of malignancy in the surveillance cohort was 4.3%. The majority of men who underwent primary RO had lesions ≥10 mm (85.5%) and the presence of vascularity (61.7%) on USS. Nineteen men (23.2%) who underwent primary TBx (median lesion size 6 mm) had a malignancy confirmed on biopsy and underwent RO. A total of 88 men (28.7%) underwent RO, and malignancy was confirmed in 73 (83.0%) of them. The overall malignancy rate in the whole STM cohort was 23.8%. Malignant RO specimens had significantly larger lesion sizes (median IQR 11 8–15 mm, vs benign: median IQR 8 5–10 mm; P = 0.04).
Conclusions
Small testicular masses can be stratified and managed based on lesion size and USS features. The overall malignancy rate in men with an STM was 23.8% (4.3% in the surveillance group). Surveillance should be considered in lesions <10 mm in size, with a TBx or frozen‐section examination offered prior to RO in order to preserve testicular function.
Objectives
To demonstrate the efficacy and cost‐effectiveness of acute extracorporeal shockwave lithotripsy (ESWL) for ureteric stones we present our experience of ESWL in 530 ureteric stone cases, ...in the largest UK series we are aware of to date. ESWL is underutilised in ureteric stone management. The Getting It Right First Time (GIRFT) report showed just four units nationally treated >10% of acute ureteric stones with ESWL. Despite guideline recommendations as a first‐line treatment option, few large volume studies have been published.
Patients and Methods
Retrospective review of prospectively collected data between December 2012 and February 2020 was performed. Data relating to patient demographics, stone characteristics, skin‐to‐stone distance, and treatment failure were collected. Cost analysis was conducted by the Trust’s surgical financial manager. Multivariable analyses were performed to assess for predictors of ESWL success.
Results
A success rate of 68% (95% confidence interval 64%–72%) at 6 weeks was observed (n = 530). The median (interquartile range) number of treatment sessions was 2 (1, 2). Stone diameter was observed to be a predictor of ESWL success. The small number of stones treated of >13 mm or >1250 HU had an ~50% chance of successful treatment. Acute ureteric ESWL was less costly than acute ureterorenoscopy, consistent with findings from previous NHS studies.
Conclusion
Acute ESWL is a safe, reliable, and financially viable treatment option for a wider spectrum of patients than reflected in international guidelines based on our large, heterogenous series. In the coronavirus disease 2019 (COVID‐19) era, with theatre access reduced and concerns over aerosol generating procedures, acute ESWL remains an attractive first‐line treatment option.
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