Predictive factors for lymph node positivity in patients undergoing extended pelvic lymphadenectomy during robot assisted radical prostatectomy

Introduction: Pelvic lymphadenectomy during radical prostatectomy (RP) improves staging and may provide a therapeutic benefit. However, there is no clear consensus on the selection criteria for subjecting patients to this additional procedure. With a growing adoption of robot assisted radical prostatectomy (RARP) in India, it has become imperative to study the incidence and predictive factors for lymph node involvement in our patients. Materials and Methods: From February 2010 to February 2014, 452 RARP procedures were performed at our institution. A total of 100 consecutive patients from July 2011 to August 2012 were additionally subjected to a robotic extended pelvic lymphadenectomy (EPLND). Lymph node positivity rates and lymph node density were analyzed on the basis of preoperative prostate specific antigen (PSA), Gleason score, clinical stage, D′Amico risk category and magnetic resonance imaging (MRI) findings. Multivariate analysis was performed to ascertain factors associated with lymph node positivity in our cohort. Results: The mean age of the patients was 65.5 (47-77) years and the body mass index was 26.3 (16.3-38.7) kg/m 2 . The mean console time for EPLND was 45 (32-68) min. A median of 17 (two to 40) lymph nodes were retrieved. Seventeen patients (17%) had positive lymph nodes (median of 1, range 1-6). Median lymph node density in these patients was 10%. When stratified by PSA, Gleason score, clinical stage, D′Amico risk category and features of locally advanced disease on MRI, a trend towards increasing incidence of lymph node positivity was observed, with an increase in adverse factors. However, on multivariate analysis, clinical stage > T2a was the only significant factor impacting lymph node positivity in our cohort. Conclusions: A significant proportion of men undergoing RARP in India have positive lymph nodes on EPLND. While other variables may also have a potential impact, a higher clinical stage predisposes to an increased incidence of lymph node metastases

Chronic infection following total hip arthroplasty: Any role for ilizarov?

Context: Treatment of chronic infection following total hip arthroplasty (THA) poses challenges in revision and in salvage surgeries such as resection arthroplasty. Aims: We evaluated the results and role of Ilizarov fixator in resection and revision for infected hip arthroplasty. Settings and Design: This was a retrospective descriptive study. Subjects and Methods: We reviewed 73 patients treated between 2004 and 2014 with follow-up of 4.3 ± 1.8 years. Forty-three patients underwent two-stage revision (with interim antibiotic spacer), whereas 30 patients underwent Ilizarov-assisted resection arthroplasty. We supplemented eight patients with unstable spacers with Ilizarov apparatus. We evaluated patients for recurrence of infection, hip function and stability. Statistical Analysis Used: Descriptive methods. Results: Eight patients with Ilizarov supplementation of spacer went on to have stable hips. Two patients who had intraoperative stable spacers developed spacer dislocation. Pseudarthroses in resection group remained stable in all patients except one who had early dislocation which we managed by realigning the fixator. There was no mortality. We eradicated infection in 68/73 patients (93.2%). We converted three patients of spacer application to resection arthroplasty. The mean Harris Hip Score improved from preoperative value of 43.3 ± 18.8 to 67 ± 10.4 (81.4 ± 9 in revision and 52.6 ± 11.8 in resection groups). Conclusions: We recommend Ilizarov supplementation in temporary spacers with intraoperative instability. Ilizarov fixator improves stability and helps mobilization of resection arthroplasty and staged revision using spacers done for chronic post-THA infections

Guidelines for safe bilateral tibial lengthening for stature

Context: Limb lengthening has its own share of problems, obstacles, and complications, which is of great concern when used for a cosmetic indication. Aims: This study explores safe limits for cosmetic tibial lengthening and examines how age of the patient and length gained influences osteogenesis and complications. Settings and Design: This was a retrospective analytical study. Subjects and Methods: We reviewed 70 consecutive cases (140 segments) of monofocal tibial cosmetic lengthening with minimum of 1-year follow-up operated between 2006 and 2010. Statistical Analysis Used: We correlated patient's age and percentage by which bone was lengthened with external fixator index (EFI) and occurrence of obstacles and complications and did receiver operator characteristic (ROC) curve analysis to determine the safe limit. Results: Mean age of patients was 27 (16–52) years. Mean tibial lengthening was by 16.5% (4.1–27.9) of the preoperative length. Sixty segments faced 76 difficulties comprising 16 problems, 47 obstacles, and 13 complications. Patient's age positively correlated with EFI, but did not correlate with the incidence of obstacles and complications. Percentage by which bone was lengthened negatively correlated with EFI and positively correlated with incidence of obstacles and complications. ROC curve analyses (with optimum balance of sensitivity and specificity) revealed lengthening by more than 18.1% and 16.4% to be significantly associated with the occurrence of complication and more than one obstacle, respectively. Conclusions: In cosmetic tibial lengthening, increasing age increases the duration of external fixation and increased lengthening increases obstacles and complications. Great caution must be exercised in cosmetic tibial lengthening beyond 16%

Supraclavicular block evaluation in oncoorthopedic patients under general anesthesia using perfusion index: A prospective cohort study

Background: Supraclavicular brachial plexus blocks (SCBPB) are routinely placed prior to anaesthetic induction for post-operative pain relief after prolonged orthopaedic oncosurgery, since patients are required to remain awake for sensorimotor evaluation of block. If the window period after surgery but before anesthesia-reversal is employed for administering SCBPB, it bestows the quadruple advantage of being painless, not augmenting surgical bleed, longer post-operative analgesia and reduced opioid-related side effects. The problem spot is assessing SCBPB-efficacy under general anesthesia. Methods: This prospective, single-centric, observational cohort study included 30 patients undergoing upper limb orthopaedic oncosurgery under general anesthesia. Perfusion index (PI) was assessed using two separate units of Radical-7™ finger pulse co-oximetry devices simultaneously in both the upper limbs and PI ratios calculated. Skin temperature was noted. Results: After successful block, PI values in blocked limb suddenly increased after 5 min, progressively increasing for next 10 min, whereas PI failed to increase further above that attained post anaesthetic-induction in unblocked limb. PI values in the blocked limb were 4.32, 4.49, 4.95, 7.25, 7.71, 7.90, 7.94, 7.89, and 7.93 at 0, 2, 3, 5, 10, and 15 min post block-institution at reversal and 2 min, 5 min post-reversal, respectively. PI ratios at 2, 3, 5, 10, and 15 min post block-administration in the blocked limb, taking PI at local anaesthetic injection as denominator were 1.04, 1.15, 1.67, 1.78, and 1.83, respectively. Correlation between PI and skin temperature in the blocked limb gave a repeated measures correlation coefficient of 0.79. Conclusion: Monitoring trends in PI and PI-ratio in the blocked limb is a quantitative, non-invasive, inexpensive, simple, effective technique to monitor SCBPB-onset in anaesthetised patients

Robot-assisted retroperitoneal lymph node dissection for post-chemotherapy residual mass in testicular cancer: Long-term experience from a tertiary care centre

Objectives: To present our intermediate to long-term oncological and functional outcomes of robot-assisted retroperitoneal lymph node dissection (RA-RPLND) in post-chemotherapy (PC) residual mass in testicular cancers. To the best of our knowledge, this is the largest single-centre experience of RA-RPLND for in such setting. Methods: Prospectively maintained database of carcinoma testis patients undergoing RA-RPLND from February 2012 to September 2021 was reviewed. Patient demographics, tumour stage and risk groups and chemotherapy details were recorded. Intraoperative details and post-operative complications were also noted. Pathological outcomes included were lymph node yield and histopathology report. Further, follow-up was done for recurrence and antegrade ejaculation status. Results: Total of 37 cases were done for PC residual masses. International germ cell cancer collaborative group good, intermediate and poor risk proportion was 18 (48.6%), 14 (37.8%) and 5 (13.5%), respectively. Bilateral full template dissection, unilateral modified template dissection and residual mass excision was performed in 59.5% (22/37), 35.1% (13/37) and 5.4% (2/37) patients, respectively. The median size of the excised residual mass was 3.45 cm interquartile range (IQR 2–6 cm), with the largest being 9 cm. The median lymph nodal yield was 19. The most common histology was necrosis (n = 24, 65%), followed by teratoma (n = 11, 30%) and viable malignancy (n = 2, 5%). Antegrade ejaculation was reported in 32 patients (86.4%). After a median follow-up of 41 (IQR 14–64) months, only one patient had a recurrence. Conclusions: RA-PC-RPLND is thus a safe, feasible and oncologically effective option for selected patients. With increasing experience, larger masses can also be dealt with efficiently

Comparison of Visual Prostate Symptom Score and International Prostate Symptom Score in the evaluation of men with benign prostatic hyperplasia: A prospective study from an Indian population

Background: Lower urinary tract symptoms (LUTSs) due to benign prostatic hyperplasia (BPH) are common conditions in middle-age or older men. The International Prostate Symptom Score (IPSS) is a useful and validated questionnaire to evaluate LUTS secondary to BPH. Van der Walt et al have developed an alternative questionnaire named the Visual Prostate Symptom Score (VPSS) questionnaire. This study aimed to evaluate the relationship between the VPSS and IPSS in the evaluation of men with LUTSs due to BPH in an Indian population. Materials and methods: This was a prospectively designed study conducted at Sri Sathya Sai Institute of Higher Medical Sciences, Prashanthigram (Anantapur, Andhra Pradesh, India). A total of 121 patients who presented to the urology outpatient department with LUTS due to BPH were enrolled in the study. Patients were followed up at 1-month and 3-month intervals. All patients were given both questionnaires. The correlation test was used to assess the correlation between two symptom scores and various parameters. Observations with a P value < 0.05 were considered statistically significant. Results: There was a statistically significant difference in the number of patients requiring assistance to fill the questionnaires according to their education level. There was a positive correlation between IPSS total score and VPSS total score (r = 0.7235; P < 0.0001), VPSS total score and VPSS quality of life (Qol; r = 0.70753; p < 0.0001), IPSS total versus IPSS Qol (r = 0.65583; P < 0.0001), and IPSS Qol versus VPSS Qol (r = 0.84093; P < 0.0001). A negative correlation was observed between total VPSS with Qmax, total IPSS with Qmax, IPSS total versus Qavg (r = −0.479; P < 0.0001), and VPSS total versus Qavg (r = −0.5; P < 0.0001). All VPSS questions showed statistically significant correlation with the corresponding IPSS questions. Conclusion: There is a statistically significant correlation between the VPSS and IPSS and it can be completed by a greater number of patients without assistance

Stepwise case selection using Guy′s stone score reduces complications during percutaneous nephrolithotomy training

Introduction: Traditional percutaneous nephrolithotomy (PCNL) training involved subjective award of cases to the trainee. We restructured this according to the Guy's stone score (GSS) such that each trainee stepwise completed 25 cases of each grade before progressing. This study compares the outcomes of training with traditional versus stepwise approach. Methods: Four hundred consecutive cases equally distributed for two trainees in each group were compared in terms of complications (Clavien-Dindo), stone free rate (SFR), operative and fluoroscopy time. External comparison was also done against a benchmark surgeon. Multivariable regression model was created to compare SFR and complications while adjusting for comorbidity, Amplatz size, access tract location, number of punctures, body mass index, stone complexity, and training approach. Results: The distribution of cases in terms of calculus complexity was similar. Overall, in comparison to traditional training, stepwise training had significantly shorter median operative time (100 vs. 120 min, P < 0.05), fluoroscopy time (136 vs. 150 min, P < 0.05) and fewer overall (29.5% vs. 43.5%, P < 0.005) as well as major complications (3% vs. 8.5%, P - 0.029), though initial SFR was higher but not statistically significant (77% vs. 71.5%). On multivariable analyses, stepwise training was independently associated with lower complications (odds ratio 0.46 [0.20–0.74], P - 0.0013) along with GSS grade, number of punctures, and Amplatz size. Stepwise training had similar fluoroscopy time, major complications and final clearance rate compared to expert surgeon. Conclusions: PCNL has a learning curve specific for each grade of calculus complexity and stepwise training protocol improves outcomes

Circulating Chromosome Conformation Signatures Significantly Enhance PSA Positive Predicting Value and Overall Accuracy for Prostate Cancer Detection

Background: Prostate cancer (PCa) has a high lifetime prevalence (one out of six men), but currently there is no widely accepted screening programme. Widely used prostate specific antigen (PSA) test at cut-off of 3.0 ng/mL does not have sufficient accuracy for detection of any prostate cancer, resulting in numerous unnecessary prostate biopsies in men with benign disease and false reassurance in some men with PCa. We have recently identified circulating chromosome conformation signatures (CCSs, Episwitch&reg; PCa test) allowing PCa detection and risk stratification in line with standards of clinical PCa staging. The purpose of this study was to determine whether combining the Episwitch PCa test with the PSA test will increase its diagnostic accuracy. Methods: n = 109 whole blood samples of men enrolled in the PROSTAGRAM screening pilot study and n = 38 samples of patients with established PCa diagnosis and cancer-negative controls from Imperial College NHS Trust were used. Samples were tested for PSA, and the presence of CCSs in the loci encoding for of DAPK1, HSD3B2, SRD5A3, MMP1, and miRNA98 associated with high-risk PCa identified in our previous work. Results: PSA &gt; 3 ng/mL alone showed a low positive predicted value (PPV) of 0.14 and a high negative predicted value (NPV) of 0.93. EpiSwitch alone showed a PPV of 0.91 and a NPV of 0.32. Combining PSA and Episwitch tests has significantly increased the PPV to 0.81 although reducing the NPV to 0.78. Furthermore, integrating PSA, as a continuous variable (rather than a dichotomised 3 ng/mL cut-off), with EpiSwitch in a new multivariant stratification model, Prostate Screening EpiSwitch (PSE) test, has yielded a remarkable combined PPV of 0.92 and NPV of 0.94 when tested on the independent prospective cohort. Conclusions: Our results demonstrate that combining the standard PSA readout with circulating chromosome conformations (PSE test) allows for significantly enhanced PSA PPV and overall accuracy for PCa detection. The PSE test is accurate, rapid, minimally invasive, and inexpensive, suggesting significant screening diagnostic potential to minimise unnecessary referrals for expensive and invasive MRI and/or biopsy testing. Further extended prospective blinded validation of the new combined signature in a screening cohort with low cancer prevalence would be the recommended step for PSE adoption in PCa screening

Circulating Chromosome Conformation Signatures Significantly Enhance PSA Positive Predicting Value and Overall Accuracy for Prostate Cancer Detection

Background: Prostate cancer (PCa) has a high lifetime prevalence (one out of six men), but currently there is no widely accepted screening programme. Widely used prostate specific antigen (PSA) test at cut-off of 3.0 ng/mL does not have sufficient accuracy for detection of any prostate cancer, resulting in numerous unnecessary prostate biopsies in men with benign disease and false reassurance in some men with PCa. We have recently identified circulating chromosome conformation signatures (CCSs, Episwitch® PCa test) allowing PCa detection and risk stratification in line with standards of clinical PCa staging. The purpose of this study was to determine whether combining the Episwitch PCa test with the PSA test will increase its diagnostic accuracy. Methods: n = 109 whole blood samples of men enrolled in the PROSTAGRAM screening pilot study and n = 38 samples of patients with established PCa diagnosis and cancer-negative controls from Imperial College NHS Trust were used. Samples were tested for PSA, and the presence of CCSs in the loci encoding for of DAPK1, HSD3B2, SRD5A3, MMP1, and miRNA98 associated with high-risk PCa identified in our previous work. Results: PSA > 3 ng/mL alone showed a low positive predicted value (PPV) of 0.14 and a high negative predicted value (NPV) of 0.93. EpiSwitch alone showed a PPV of 0.91 and a NPV of 0.32. Combining PSA and Episwitch tests has significantly increased the PPV to 0.81 although reducing the NPV to 0.78. Furthermore, integrating PSA, as a continuous variable (rather than a dichotomised 3 ng/mL cut-off), with EpiSwitch in a new multivariant stratification model, Prostate Screening EpiSwitch (PSE) test, has yielded a remarkable combined PPV of 0.93 and NPV of 0.95 when tested on the independent combined cohort. Conclusions: Our results demonstrate that combining the standard PSA readout with circulating chromosome conformations (PSE test) allows for significantly enhanced PSA PPV and overall accuracy for PCa detection. The PSE test is accurate, rapid, minimally invasive, and inexpensive, suggesting significant screening diagnostic potential to minimise unnecessary referrals for expensive and invasive MRI and/or biopsy testing. Further extended prospective blinded validation of the new combined signature in a screening cohort with low cancer prevalence would be the recommended step for PSE adoption in PCa screening