Hypoxemia of the lower limbs during robot‐assisted radical prostatectomy in Trendelenburg position

Abstract Objectives The objective of this study is to assess frequency and risk factors for intraoperative hypoxemia of the lower limbs during robot‐assisted radical prostatectomy (RARP). Trendelenburg position during RARP may contribute to hypoxemia and compartment syndrome (CS) of the lower limbs as a major but rare complication. Patients and methods This prospective study included patients undergoing RARP for prostate cancer. Preoperative calculation of the ankle‐brachial‐index (ABI) was performed. Peripheral oxygen saturation (SpO2) at the toes was routinely measured. Occurrence of SpO2 levels of <90% was defined as hypoxemic events and treated immediately. Blood pressure, intraabdominal pressure, SpO2 of the upper limb and surgery time were monitored in case of hypoxemia. A multivariable logistic regression model was performed with age, BMI, nicotine abuse, MAP, comorbidities as covariates and hypoxemia of the lower limbs as the outcome. Results A total of 207 patients were included. Among these, 126 patients had ABI measurements with 10.6% having an abnormal ABI value. One, two or at least three events of lower limb hypoxemia occurred intraoperatively in 19.7%, 14.8% and 16.9%, respectively. In 20 events, surgical instruments were affecting vascular perfusion by compression. None of the covariates were statistically significant associated with lower limb hypoxemia. No patient developed a compartment syndrome. Conclusion Decrease in oxygen saturation of the lower extremities was observed frequently during RARP, without revealing any risk factors for its occurrence. Routine oximetry leads to an early detection of hypoxemia of the lower extremities, giving the anaesthesiologist and surgeon the opportunity to make adequate adjustments (increasing blood pressure and ending iliac vessel compression)

Association between the surgical apgar score and perioperative complications after radical prostatectomy

$\textit {Objective:}$ To evaluate whether the Surgical Apgar Score (SAS) can identify patients who are at risk for perioperative adverse events (PAE) following radical prostatectomy for prostate cancer. $\textit {Patients and Methods:}$ At a single academic institution, 994 patients undergoing radical prostatectomy between 2010 and 2013 were analyzed retrospectively. The SAS was calculated from anesthesia records, evaluated to predict PAE within a 30-day time period postoperatively; these events were classified according to standardized classification systems. $\textit {Results:}$ We observed adverse events in 45.4% (451/994) of patients with a total of 694 events. Overall, 41% (408/994) had low- and 9.9% (98/994) had highgrade events. A lower SAS was identified as an independent predictor of any (p < 0.001) and low-grade adverse events (p = 0.001) for those patients who had undergone open retropubic radical prostatectomy (ORRP). Each 1-point increment resulted in a 24% decrease in the odds of any (95% CI 0.66–0.88) and a 21% decrease in the odds of a low-grade (95% CI 0.69–0.91) event. Adverse events of robot-assisted prostatectomy were not associated with the SAS. $\textit {Conclusions:}$ Lower SAS values indicate patients at risk for adverse events after ORRP. The SAS might serve as one variable for outcome assessment, reflecting the challenge of mutual surgical and anesthesiology procedure management

Hypoxemia of the lower limbs during robot-assisted radical prostatectomy in Trendelenburg position

$\bf Objectives$ The objective of this study is to assess frequency and risk factors for intraoperative hypoxemia of the lower limbs during robot-assisted radical prostatectomy (RARP). Trendelenburg position during RARP may contribute to hypoxemia and compartment syndrome (CS) of the lower limbs as a major but rare complication. $\textbf {Patients and methods}$ This prospective study included patients undergoing RARP for prostate cancer. Preoperative calculation of the ankle-brachial-index (ABI) was performed. Peripheral oxygen saturation (SpO2) at the toes was routinely measured. Occurrence of SpO2 levels of <90% was defined as hypoxemic events and treated immediately. Blood pressure, intraabdominal pressure, SpO2 of the upper limb and surgery time were monitored in case of hypoxemia. A multivariable logistic regression model was performed with age, BMI, nicotine abuse, MAP, comorbidities as covariates and hypoxemia of the lower limbs as the outcome. $\bf Results$ A total of 207 patients were included. Among these, 126 patients had ABI measurements with 10.6% having an abnormal ABI value. One, two or at least three events of lower limb hypoxemia occurred intraoperatively in 19.7%, 14.8% and 16.9%, respectively. In 20 events, surgical instruments were affecting vascular perfusion by compression. None of the covariates were statistically significant associated with lower limb hypoxemia. No patient developed a compartment syndrome. $\bf Conclusion$ Decrease in oxygen saturation of the lower extremities was observed frequently during RARP, without revealing any risk factors for its occurrence. Routine oximetry leads to an early detection of hypoxemia of the lower extremities, giving the anaesthesiologist and surgeon the opportunity to make adequate adjustments (increasing blood pressure and ending iliac vessel compression)

Determinants of self-reported functional status (EPIC-26) in prostate cancer patients prior to treatment

Purpose!#!The self-reported functional status (sr-FS) of prostate cancer (PCa) patients varies substantially between patients and health-care providers before treatment. Information about this issue is important for evaluating comparisons between health-care providers and to assist in treatment decision-making. There have been few reports on correlates of pretherapeutic sr-FS. The objective of the article, therefore, is to describe clinical and sociodemographic correlates of pretherapeutic sr-FS, based on a subset of the TrueNTH Global Registry, a prospective cohort study.!##!Methods!#!A total of 3094 PCa patients receiving local treatment in 44 PCa centers in Germany were recruited between July 2016 and April 2018. Multilevel regression models were applied to predict five pretherapeutic sr-FS (EPIC-26) scores based on clinical characteristics (standard set suggested by the International Consortium for Health Outcomes Measurement), sociodemographic characteristics, and center characteristics.!##!Results!#!Impaired pretherapeutic sr-FS tended to be associated with lower educational level and poorer disease characteristics-except for 'urinary incontinence' which was only associated with age. Notably, age was a risk factor ('urinary incontinence,' 'urinary irritative/obstructive,' 'sexual') as well as a protective factor ('hormonal') for pretherapeutic sr-FS. Pretherapeutic sr-FS varies little across centers.!##!Conclusions!#!Pretherapeutic sr-FS varies by clinical patient characteristics and age as well as by socioeconomic status. The findings point out the benefit of collecting and considering socioeconomic information in addition to clinical and demographic patient characteristics for treatment decision-making and fair comparisons between health-care providers

Effect of Hospital and Surgeon Case Volume on Perioperative Quality of Care and Short-term Outcomes After Radical Cystectomy for Muscle-invasive Bladder Cancer: Results From a European Tertiary Care Center Cohort

This prospective multicenter study analyzed the effect of hospital and surgeon case volume on perioperative quality of care and short-term complications and mortality in 479 patients undergoing radical cystectomy for bladder cancer. We found that hospital volume might represent an at least equally important factor regarding postoperative complications as the surgeon case volume itself at European tertiary care centers. Background Case volume has been suggested to affect surgical outcomes in different arrays of procedures. We aimed to delineate the relationship between case volume and surgical outcomes and quality of care criteria of radical cystectomy (RC) in a prospectively collected multicenter cohort. Patients and Methods This was a retrospective analysis of a prospectively collected European cohort of patients with bladder cancer treated with RC in 2011. We relied on 479 and 459 eligible patients with available information on hospital case volume and surgeon case volume, respectively. Hospital case volume was divided into tertiles, and surgeon volume was dichotomized according to the median annual number of surgeries performed. Binomial generalized estimating equations controlling for potential known confounders and inter-hospital clustering assessed the independent association of case volume with short-term complications and mortality, as well as the fulfillment of quality of care criteria. Results The high-volume threshold for hospitals was 45 RCs and, for high-volume surgeons, was > 15 cases annually. In adjusted analyses, high hospital volume remained an independent predictor of fewer 30-day (odds ratio, 0.34; P = .002) and 60- to 90-day (odds ratio, 0.41; P = .03) major complications but not of fulfilling quality of care criteria or mortality. No difference between surgeon volume groups was noted for complications, quality of care criteria, or mortality after adjustments. Conclusion The coordination of care at high-volume hospitals might confer a similar important factor in postoperative outcomes as surgeon case volume in RC. This points to organizational elements in high-volume hospitals that enable them to react more appropriately to adverse events after surgery. (C) 2017 Elsevier Inc. All rights reserved