An 82-year-old Caucasian man with a ductal prostate adenocarcinoma with unusual cystoscopic appearance: a case report

<p>Abstract</p> <p>Introduction</p> <p>Ductal adenocarcinoma is a rare variety of the common acinar adenocarcinoma. It usually presents with refractory symptoms, and during cystoscopy, it is seen as an exophytic lesion at the area of the verumontanum.</p> <p>Case presentation</p> <p>An 82-year-old Caucasian man was diagnosed with ductal adenocarcinoma of the prostate after undergoing transurethral resection of the prostate for urinary retention. Immunohistochemistry confirmed the nature of the tumor. The patient was treated with triptorelin, 3.75 mg once/month, and bicalutamide, 50 mg 1 × 1. The serum prostate-specific antigen at three, six and 12 months after transurethral resection of the prostate was 0.1 ng/ml. The patient remains asymptomatic, and he entered a six-month follow-up protocol.</p> <p>Conclusion</p> <p>Ductal adenocarcinoma often involves the central ducts of the gland and may present as an exophytic papillary lesion in the prostatic urethra. This is why it usually presents with refractory symptoms. The outcome for men with prostatic ductal adenocarcinoma is, in most studies, worse than the outcome for men with prostatic acinar adenocarcinoma. Aggressive management is indicated, even with low-volume metastatic disease.</p

Spinal versus General Anaesthesia in Postoperative Pain Management during Transurethral Procedures

We compared the analgesic efficacy of spinal and general anaesthesia following transurethral procedures. 97 and 47 patients underwent transurethral bladder tumour resection (TUR-B) and transurethral prostatectomy (TUR-P), respectively. Postoperative pain was recorded using an 11-point visual analogue scale (VAS). VAS score was greatest at discharge from recovery room for general anaesthesia (P = 0.027). The pattern changed significantly at 8 h and 12 h for general anaesthesia's efficacy (P = 0.017 and P = 0.007, resp.). A higher VAS score was observed in pT2 patients. Patients with resected tumour volume >10 cm3 exhibited a VAS score >3 at 8 h and 24 h (P = 0.050, P = 0.036, resp.). Multifocality of bladder tumours induced more pain overall. It seems that spinal anaesthesia is more effective during the first 2 postoperative hours, while general prevails at later stages and at larger traumatic surfaces. Finally, we incidentally found that tumour stage plays a significant role in postoperative pain, a point that requires further verification

Associations between intraoperative factors and surgeons' self-assessed operative satisfaction.

To access publisher's full text version of this article, please click on the hyperlink in Additional Links field or click on the hyperlink at the top of the page marked DownloadBackground: Little is known concerning what may influence surgeon satisfaction with a surgical procedure and its associations with intraoperative factors. The objective was to explore the relationships between surgeons' self-assessed satisfaction with performed radical prostatectomies and intraoperative factors such as technical difficulties and intraoperative complications as reported by the surgeon subsequent to the operation. Methods: We utilized prospectively collected data from the controlled LAPPRO trial where 4003 patients with prostate cancer underwent open (ORP) or robot-assisted laparoscopic (RALP) radical prostatectomy. Patients were included from fourteen centers in Sweden during 2008-2011. Surgeon satisfaction was assessed by questionnaires at the end of each operation. Intraoperative factors included time for the surgical procedure as well as difficulties and complications in various steps of the operation. To model surgeon satisfaction, a mixed effect logistic regression was used. Results were presented as odds ratios (OR) with 95% confidence intervals (CI). Results: The surgeons were satisfied in 2905 (81%) and dissatisfied in 702 (19%) of the surgical procedures. Surgeon satisfaction was not statistically associated with type of surgical technique (ORP vs. RALP) (OR 1.36, CI 0.76; 2.43). Intraoperative factors such as technical difficulties or complications, for example, suturing of the anastomosis was negatively associated with surgeon satisfaction (OR 0.24, CI 0.19; 0.30). Conclusions: Our data indicate that technical difficulties and/or intraoperative complications were associated with a surgeon's level of satisfaction with an operation. Keywords: Intraoperative factors; Prostate cancer; Self-assessment; Surgeon; Surgical performance; Surgical satisfaction.Swedish Cancer Society Swedish Research Council Region Vastra Gotaland, Sahlgrenska University Hospital (ALF) Mrs. Mary von Sydow Foundation Anna and Edvin Berger Foundatio

Comparative study of the effects of prolonged narm and cold ischemia on renal function and cellular structure during a partial nephrectomy

Core of this study has been the application of prolonged periods of warm and cold ischemia in a novel, animal experimental model with a solitary kidney undergoing partial nephrectomy and the investigation of the effects of the above stress stimuli, as well as the phenomenon of reperfusion in the cellular and subcellular level. The study investigation was 3-fold: 1. Evaluation of the overall survival and the renal function by measuring the serum levels of creatinine and blood-urea-nitrogen (BUN). 2. Evaluation of the morphology of the renal structures with the use of the optical and tandem electron microscopy (TEM). 3. Quantification of the local and systemic production of the most significant growth factor, which is related to ischemia, the vascular endothelial growth factor (VEGF). The results of the above investigation are in accordance between them and specify the major conclusion of this study. The tolerance of the solitary renal unit after a partial nephrectomy reaches the 60 minutes and the 120 minutes for warm and cold ischemia conditions, respectively. These limits were verified by the biochemical determinations, which reflect the postoperative renal function of the animals. The 60 minutes warm and the both of the cold ischemia groups exhibited the highest overall survival rates. On the contrary, the 90 minutes warm ischemia group had 100% mortality due to uremia and acute renal failure. The same pattern of differentiation between the study groups was also presented in the microscopical observations, where the first 3 groups showed excellent preservation of the renal structures. 90 minutes of warm ischemia created detrimental lesions in both optical and electron microscopy. The most important conclusion recorded by the TEM was the crucial role of the glomerular basement membrane and the podocytes, since the alterations in these structures are more impactful than those presented in the endothelial or mesagial cells. To our knowledge, this is the first time that a study investigates the effect of the cold ischemia and the partial nephrectomy with TEM and establishes the major advantage of cold ischemia over warm ischemia in the preservation of the structures Finally, the study of the VEGF concluded the following: 1. The compensatory hypertrophy of the solitary renal unit after a nephrectomy is VEGF-dependent. 2. The systemic synthesis of VEGF represents a local adaptation to hypoxia and especially the renal adaptation. 3. It was once again verified that the 90 minute warm ischemia group was greatly differentiated from the other groups, since the production of VEGF was abolished, while in the other 3 groups it was up-regulated. Our results are not without limitations. The major differences in the anatomy and physiology between humans and rabbits prohibit the application of the results in a clinical level. However, despite the fact that the data presented challenge the contemporary guidelines for the ischemia application during renal sparing surgery, they provide critical information and motives for further research.Kορμό της παρούσας διατριβής αποτέλεσε η εφαρμογή παρατεταμένων χρόνων θερμής και ψυχρής ισχαιμίας στα πλαίσια διενέργειας μερικής νεφρεκτομής, σε ένα καινοτόμο πειραματικό ζωϊκό μοντέλο με μονήρη νεφρό και η μελέτη των επιδράσεων των παραπάνω ερεθισμάτων και του φαινομένου επαναιμάτωσης σε κυτταρικό και υποκυτταρικό επίπεδο. Η μελέτη χαρακτηρίστηκε από 3 βασικές συνιστώσες: 1. Eκτίμηση της νεφρικής λειτουργίας και επιβίωσης με τη μέτρηση βιοχημικών παραμέτρων 2. Εκτίμηση της μορφολογίας των νεφρικών δομών στο οπτικό και ηλεκτρονικό μικροσκόπιο 3. Προσδιορισμός της τοπικής και συστηματικής παραγωγής του κυριότερου αυξητικού παράγοντα της ισχαιμίας, του αγγειακού ενδοθηλιακού αυξητικού παράγοντα (VEGF). Τα αποτελέσματα και από τις 3 εκτιμήσεις συμφωνούν απόλυτα και οριοθετούν ουσιαστικά το βασικό συμπέρασμα της διατριβής. Η μονήρης νεφρική μονάδα έχει ως ανώτερο όριο ανοχής της θερμής ισχαιμίας τα 60 λεπτά και ψυχρής ισχαιμίας τα 120 λεπτά. Τα αναφερόμενα όρια επιβεβαιώθηκαν από τις μετρούμενες βιοχημικές παραμέτρους (ουρία, κρεατινίνη, ηλεκτρολύτες), οι οποίες αντικατοπτρίζουν τη μετεγχειρητική νεφρική λειτουργία των πειραματοζώων. Οι ομάδες των 60 λεπτών θερμής και 90 και 120 λεπτών ψυχρής ισχαιμίας χαρακτηρίστηκαν από τα υψηλότερα ποσοστά επιβίωσης, σε αντίθεση με την ομάδα των 90 λεπτών θερμής ισχαιμίας που απεβίωσαν καθολικά εξαιτίας οξείας νεφρικής ανεπάρκειας. Η ίδια διαφοροποίηση παρουσιάστηκε και στις μικροσκοπικές παρατηρήσεις, όπου οι πρώτες 3 ομάδες είχαν πολύ καλή έως άριστη διατήρηση των νεφρικών δομών ή κάποιες αναστρέψιμες βλάβες, σε αντίθεση με την ομάδα των 90 λεπτών θερμής ισχαιμίας, όπου οι αλλοιώσεις ήταν καταστροφικές. Το ίδιο μοτίβο ακολουθήθηκε και σε υποκυτταρικό επίπεδο. Βασικό συμπέρασμα της μελέτης στο ηλεκτρονικό μικροσκόπιο ήταν η ζωτικής σημασίας για τη νεφρική λειτουργία της βασικής σπειραματικής μεμβράνης και των ποδοκυττάρων, των οποίων οι βλάβες στοιχίζουν περισσότερο από τις αντίστοιχες του ενδοθηλίου ή των μεσαγγειακών κυττάρων. Για πρώτη φορά μελετήθηκε η επίδραση της ψυχρής ισχαιμίας και μερικής νεφρεκτομής με τη χρήση του ηλεκτρονικού μικροσκοπίου και απεδείχθη η σχεδόν τέλεια διατήρηση των δομών, αποδίδοντας έτσι στην ψυχρή ισχαιμία το μεγάλο πλεονέκτημα έναντι της θερμής. Τέλος, η μελέτη του VEGF ανέδειξε τα εξής στοιχεία: α) Η αντιρροπιστική υπερτροφία του μονήρους νεφρού μετά από νεφρεκτομή είναι VEGF-εξαρτώμενη. β) Η συστηματική παραγωγή του VEGF αντιπροσωπεύει μια τοπική προσαρμογή στην ισχαιμία και για την περίπτωσή μας τη νεφρική προσαρμογή. γ) Και σε αυτή τη μελέτη επιβεβαιώθηκε η διαφοροποίηση των ομάδων ισχαιμίας, αφού στα 90 λεπτά θερμής ισχαιμίας η σύνθεση του VEGF καταργήθηκε ολοσχερώς, ενώ στις υπόλοιπες 3 ομάδες η σύνθεση ήταν πολλαπλά μεγαλύτερη με αποκορύφωμα τις ομάδες ψυχρής ισχαιμίας. Τα αποτελέσματά μας υπόκεινται σε περιορισμούς, αφού η ανατομία και η φυσιολογία του πειραματόζωου διαφέρει σημαντικά από αυτή του ανθρώπου. Παρ’ όλ’αυτά, αν και τα δεδομένα μας ανατρέπουν τα μέχρι σήμερα επικρατούντα δόγματα για την εφαρμογή ισχαιμίας κατά τη διάρκεια της μερικής νεφρεκτομής, παρέχουν σημαντικές πληροφορίες και νέα κίνητρα για περαιτέρω έρευνα

All You Need to Know About Urethrovesical Anastomotic Urinary Leakage Following Radical Prostatectomy

Purpose: Radical prostatectomy is a challenging operation demanding a high level of surgical expertise and experience. Urinary leakage at the urethrovesical anastomosis is one of the most common short-term complications of radical prostatectomy, reaching an incidence of 0.3% to 15.4%. In this review we investigate and discuss all matters directly related to urethrovesical anastomotic leak, specifically how to diagnose it properly, how to determine when it is clinically significant and when intervention is required, how to prevent or predict it and, finally, the possible long-term sequelae. Materials and Methods: We conducted a systematic analysis of the literature searching for English and nonEnglish language publications from a preidentified time frame (1985 to 2011) using primary search databases (PubMed (R), Web of Science (R)). Manual selection was performed by 2 authors and the third reviewed the final common selection. We also created an algorithm for the diagnosis and management of urethrovesical anastomotic leak. Results: A total of 72 studies were finally selected, including 48 (67%) observational case series, 16 (22.2%) prospective trials, 1 letter to the editor, 1 review and 1 systematic review which was focused only on laparoscopic radical prostatectomy. We also found 2 experimental studies performed in animal models and 3 case reports. Of these studies 7 reported results from fewer than 20 patients. No consensus was recorded on a strict definition of urethrovesical anastomotic leak. The factors determining possible definitions included postoperative day of urethrovesical anastomotic leak, amount of extravasation on cystography and the need for intervention. Urethrovesical anastomotic leak should be classified according to the Clavien classification system, depending on severity and the need for intervention. To our knowledge the role of the open, laparoscopic or robotic approach in the incidence of urethrovesical anastomotic leak has not been systematically investigated. Risk factors for urethrovesical anastomotic leak include obesity, prostate size, previous prostatic surgery, type of anastomosis technique, suture number and type, eversion of the mucosa, a difficult anastomosis or an anastomosis under tension, reconstruction of the musculofascial plate, blood loss, intraoperative flush test result and postoperative urinary tract infection. Diagnosis can be determined primarily by establishing the nature of the drain output. Retrograde cystography, computerized tomography cystography, transrectal ultrasound, contrast enhanced ultrasound and excretory urography are the indicated imaging modalities, and are not always necessary. Finally, the development of anastomotic stricture and incontinence due to urethrovesical anastomotic leak are additional complications. Conclusions: We gathered all relevant critical information concerning urethrovesical anastomotic leak to encourage standardization in the diagnosis and management of this common complication. Systematic meta-analysis of each debatable issue is required to provide definite answers

The current status of robot-assisted cystectomy

Robot-assistance is being increasingly used for radical cystectomy (RC). Fifteen years of surgical evolution might be considered a short period for a radical procedure to be established as the treatment of choice, but robot assisted radical cystectomy (RARC) is showing promising results when compared with the current gold standard, open RC (ORC). In this review, we describe the current status of RARC and continue the discussion on the on-going RARC versus ORC debate