Keys to Successful Orthotopic Bladder Substitution, 2014
One of the key goals of continent urinary diversion is to preserve renal function by creating a l... more One of the key goals of continent urinary diversion is to preserve renal function by creating a low-pressure reservoir with a minimal risk of mechanical or functional obstruction of the lower urinary tract. There are many potential reasons for deterioration of renal function following urinary diversion, including physical or functional obstruction at various levels, urinary tract infections, and stone formation. Other causes may contribute to declining renal function, including a natural age-related decline, estimated to be 1 mL/min per 1.73 m2 each year [1, 2], and non-urologic causes such as hypertension, diabetes, and drugs.
Seminal vesical sparing cystectomy in bladder cancer patients is feasible with good functional re... more Seminal vesical sparing cystectomy in bladder cancer patients is feasible with good functional results without impairing oncological outcomes: A longitudinal long-term propensity-matched single center study.
To evaluate risk factors for urethral recurrence (UR) in women with neobladder. From 1994 to 2011... more To evaluate risk factors for urethral recurrence (UR) in women with neobladder. From 1994 to 2011, 297 women (median age = 54y; interquartile range: 47-57) underwent radical cystectomy with ileal neobladder for bladder cancer in 4 centers. None of the patients had bladder neck involvement at preoperative assessment. Univariable and multivariable analyses were used to estimate recurrence-free survival and overall survival. The median follow-up was 64 months (interquartile range: 25-116). Of the 297 patients, 81 developed recurrence (27%). The 10- and 15-year recurrence-free survival rates were 66% and 66%, respectively. The 10- and 15-year overall survival rates were 57% and 55%, respectively. UR occurred in 2 patients (0.6%) with solitary urethral, 4 (1.2%) with concomitant urethral and distant recurrence, and 1 with concomitant urethral and local recurrence (0.3%). Bladder tumors were located at the trigone in 27 patients (9.1%). None of these patients developed UR. Lymph node tumo...
With the introduction of orthotopic bladder substitution after radical cystectomy in patients wit... more With the introduction of orthotopic bladder substitution after radical cystectomy in patients with invasive bladder cancer urethral recurrences have become a therapeutic challenge. We retrospectively evaluated our patients with urethral recurrences treated with a urethra sparing approach after orthotopic bladder substitution. Depending on the extension of recurrence and eventual concomitant metastases patients were treated with urethrectomy, no treatment, systemic chemotherapy or intraurethral bacillus Calmette-Guerin (BCG). Three times the common dose of BCG (ImmuCyst, Aventis, Paris, France or OncoTICE, Organon, West Orange, New Jersey) in 150 ml NaCl 0.9% was used for intraurethral BCG perfusion therapy according to an institutional protocol using a modified Foley catheter. This regimen was repeated weekly for 6 weeks and patients were followed prospectively. Between 1985 and 2001, 15 of 371 patients (4%) who received an orthotopic bladder substitute had urethral recurrence. Two patients were treated with systemic chemotherapy (methotrexate, vinblastine, doxorubicin and cisplatin) alone due to metastatic disease and 10 received intraurethral BCG therapy. Five of 6 patients (83%) with carcinoma in situ remained free of recurrence following treatment with BCG, while in 4 with papillary or invasive disease treatment failed. Three patients underwent urethrectomy, including 2 following failed BCG therapy for papillary disease. Carcinoma in situ urethral recurrence following orthotopic bladder substitution can be treated successfully with intraurethral BCG perfusion therapy in approximately 80% of patients. However, papillary and invasive transitional cell urethral recurrence should be treated with urethrectomy.
We assessed factors influencing urinary continence and erectile function after radical cystoprost... more We assessed factors influencing urinary continence and erectile function after radical cystoprostatectomy and ileal orthotopic bladder substitution. Of 381 consecutive men undergoing radical cystoprostatectomy and ileal orthotopic bladder substitution between April 1985 and June 2003, 331 (87%) met the inclusion criteria and were enrolled in the analysis. Kaplan-Meier models and multivariate analysis applying Cox regression were used to evaluate factors influencing postoperative urinary continence and erectile function. In univariate analysis, attempted nerve sparing and age younger than 65 years were significantly associated with better daytime (p = 0.002 and p = 0.007, respectively) and nighttime continence (p = 0.036 and p = 0.005, respectively). In multivariate analysis the rate of daytime continence was significantly higher in patients with attempted nerve sparing (hazards ratio [HR] 1.4, 95% confidence interval [CI] 1.05-1.87) and nighttime continence was significantly better in patients younger than 65 years (HR 1.39, 95% CI 1.07-1.8). Daytime continence was significantly better (p <0.0001) and was achieved more quickly than nighttime continence (p <0.0001). The time to achieve daytime continence was shorter for patients with attempted nerve sparing (p = 0.012). In multivariate analysis erectile function recovered significantly more often in patients with attempted nerve sparing (HR 2.59, 95% CI 1.24-5.39) and in those younger than 65 years (HR 2.98, 95% CI 1.83-4.85). After radical cystoprostatectomy and ileal orthotopic bladder substitution, attempted nerve sparing and age younger than 65 years are associated with improved urinary continence. Attempted nerve sparing has the greatest impact on daytime continence and age has the greatest impact on nighttime continence. Attempted nerve sparing and younger age are both associated with more frequent recovery of erectile function.
Purpose: In this retrospective nonrandomized study we compared the long-term outcome in patients ... more Purpose: In this retrospective nonrandomized study we compared the long-term outcome in patients with newly diagnosed stage T1G3 bladder cancer treated with transurethral resection and bacillus Calmette-Guerin or immediate cystectomy. Materials and Methods: Of 121 patients with a median age of 67 years (range 36 to 88) diagnosed with primary T1G3 bladder cancer between 1976 and 1999, 92 were treated by transureteral resection with additional intravesical bacillus Calmette-Guerin and 29 were treated with immediate cystectomy. Results: Of the 92 patients treated with an organ preserving approach 29 remained diseasefree, local recurrence developed in 33 (36%) and progression developed in 30 (33%) at a median followup of 6.9 years (range 0.6 to 16.5). Of these 92 patients 27 (29%) underwent deferred cystectomy at a median of 12.9 months (range 4.8 to 136), of whom 10 (37%) with a median postoperative followup of 19 months (range 2 to 173) died of progressive disease with a median survival of 13 months (range 3 to 34) after cystectomy. The majority of patients who died of progressive disease refused cystectomy, were referred too late for cystectomy, were inoperable or had upper urinary tract disease. Six of the 29 patients (21%) undergoing immediate cystectomy had progression at a median of 13.2 months (range 5.5 to 37). Overall and tumor specific survival at 5 years in patients treated with an organ preserving approach was 69% and 80%, and in those treated with immediate cystectomy it was 54% and 69%, respectively. Conclusions: The results of this analysis demonstrate that the concept of an organ preserving approach is acceptable and spares the bladder in approximately half of the patients with primary T1G3 bladder cancer. Of the patients 30% require deferred cystectomy, making meticulous, close followup mandatory.
Purpose: Mismatch repair genes are responsible for the coordinated correction of misincorporated ... more Purpose: Mismatch repair genes are responsible for the coordinated correction of misincorporated nucleotides formed during DNA replication. Mismatch repair expression is altered in a subset of prostate cancers (PCs) and a recent study suggested that time to biochemical recurrence following prostatectomy correlated with the degree of hMSH2 immunohistochemical staining. We compared hMSH2 expression and survival in clinically organ confined PC. Materials and Methods: A prostate tissue microarray was constructed using 243 specimens from patients who underwent radical prostatectomy with extended lymph node dissection for clinically organ confined PC with up to 12 years of followup. Immunohistochemistry was performed with anti-human MSH2 monoclonal antibody. Three independent observers evaluated hMSH2 expression on a scale of 0 to 4. Low expression was defined as a score of less than 2 and high expression was defined as a score of 2 or higher. Statistical analysis used the Fisher exact test, and Goodman and Kruskal ␥ coefficient. Results: Higher Gleason score significantly correlated with higher hMSH2 expression (p Ͻ0.0002). Low hMSH2 expression correlated with increased overall, disease-free and biochemical disease-free survival (all p Ͻ0.01). Analysis comparing low vs high hMSH2 expression was significant with respect to overall (p ϭ 0.0004), disease-free (p ϭ 0.005) and biochemical disease-free (p ϭ 0.0177) survival. Conclusions: hMSH2 is differentially expressed in malignant prostate tissue and hMSH2 immunohistochemical staining intensity correlates with Gleason score, overall and disease-free survival. Taken together our results suggest that hMSH2 expression may be a useful prognostic biomarker for outcome in men with clinically organ confined PC.
We investigated the long-term efficacy of the second generation Targis thermotherapy device (Urol... more We investigated the long-term efficacy of the second generation Targis thermotherapy device (Urologix, Inc., Minneapolis, Minnesota) for decreasing outflow obstruction caused by benign prostatic hyperplasia. At a minimum followup of 24 months 200 patients with bladder outlet obstruction documented on urodynamics and cystoscopy document with preserved detrusor function underwent transurethral microwave therapy while under local anesthesia. In 45% of cases the general American Society of Anesthesiologists health score was 3 or greater. After a median observation time of 42 months (range 2 to 72) 43 patients (22%) who required additional treatment (repeat thermotherapy, transurethral prostate resection or permanent cystostomy) were excluded from further analysis, as were 15 (7.5%) who died of causes unrelated to treatment during followup and 13 (6.5%) who were lost to followup or refused followup investigations. In the 162 patients evaluated 6 months after treatment the median International Prostate Symptom Score decreased from 23 points (range 10 to 34) before treatment to 3 (range 0 to 21) and remained stable at 12 and 24 months. Median maximum flow increased from 6 ml. per second (range 1 to 15) before treatment to 14.5 (range 4 to 50) 6 months after treatment and remained stable at 12 and 24 months. Median post-void residual urine volume decreased from 170 ml. (range 35 to 720) before treatment to 17 (range 0 to 327) after 6 months and then remained unchanged. Urodynamic evaluation in the 162 patients after 6 months showed a decrease from pretreatment median detrusor opening pressure of 87.5 to 53 cm. water. Median detrusor pressure at maximum flow decreased from 86 to 58 cm. water 6 (p <0.0001). At the 24-month followup 59 of the 129 evaluable patients agreed to undergo repeat urodynamic evaluation. Pressure flow analysis in these 59 cases revealed a decrease in median minimal urethral opening pressure from 70 to 40 cm. water at 6 months and to 38 cm. water at 24 months (p <0.0001). Median detrusor pressure at maximum flow decreased significantly from the pretreatment value of 86 to 55 cm. water at 6 months and 58 cm. water at 24 months (p <0.0001). In patients with a good initial response to treatment, which is achieved in approximately 80%, transurethral microwave therapy provides excellent long-term subjective and objective results. Improved urinary flow, decreased post-void residual urine volume and urodynamic parameters remain stable at 2 years. Transurethral microwave therapy with second generation microwave equipment did not compromise any conventional treatment needed in the 22% of patients who were nonresponders at 6 months.
geon volume. Data on extent of lymphadenectomy was available for 576 patients. Logistic regressio... more geon volume. Data on extent of lymphadenectomy was available for 576 patients. Logistic regression was used to correlate variables to the likelihood of undergoing extended lymphadenectomy. RESULTS: Of the 1078 patients, 1038 (96%) underwent lymphadenectomy. A mean of 19 (range 1-74) lymph nodes were examined. High volume institutions (Ͼ100 cases) had a higher mean LNY (21 vs 15, pϽ0.001). Sixty-seven percent of patients (390/576) underwent extended lymphadenectomy. There was no difference in LNY by age group (pϭ0.383), pathologic stage (pϭ0.407), and gender (pϭ0.784). Patients with prior abdominal surgery had a lower mean LNY (18 vs 21, pϭ0.004), while obese patients had a higher mean LNY (21 vs 19, pϭ0.014). Twenty-two percent (nϭ206) of patients had positive lymph nodes. On univariable analysis, surgeon volume, increasing age, institutional volume, and sequential case number were associated with likelihood of undergoing extended lymphadenectomy. On multivariable analysis, surgeon volume Ն51 cases (OR 6.52, 95% CI 1.34-31.7, pϭ0.020) and advanced clinical stage (OR 1.87, 95% CI 1.13-3.10, pϭ0.015) were independently associated with undergoing extended lymphadenectomy. CONCLUSIONS: Robot-assisted lymphadenectomy can achieve similar lymph node yields to those of open lymphadenectomy after radical cystectomy. High volume surgeons are more likely to perform an extended lymphadenectomy, reflecting a correlation between increasing surgeon comfort with advanced vascular dissection and their growing experience.
The holmium laser allows bloodless enucleation of the prostate. A problem is how to remove a whol... more The holmium laser allows bloodless enucleation of the prostate. A problem is how to remove a whole enucleated, free floating, large prostatic lobe from the bladder. A mechanical morcellator has been used to achieve tissue fragmentation but aspiration of and damage to the bladder wall are risks. Using the mushroom technique holmium laser enucleation and electrocautery resection can be combined without compromising the bloodless advantages of the laser procedure. We treated 156 patients with benign prostatic hyperplasia using a holmium laser with the mushroom technique. Preoperatively all patients were assessed using the International Prostate Symptom Score, maximum urine flow, ultrasound estimation of prostate volume and post-void residual urine, and pressure flow study. Laser enucleation of the prostatic lobes was performed at 66 W. Instead of releasing the lobes into the bladder they were left attached at the bladder neck by a narrow mushroom-like pedicle. At that point the vascular supply was almost completely interrupted and the lobes could easily be electroresected into small pieces without bleeding. Patients were followed 6, 12 and 24 months after the procedure. No patient had significant blood loss or signs of the transurethral resection syndrome. A total of 19 patients were treated while under oral anticoagulation without major bleeding problems. Complete followup was available on 125 patients. Median baseline International Prostate Symptom Score decreased from 20 to 3 at 6 months (p <0.05) and remained stable at 12 and 24 months. Median maximum urine flow increased from 8 to 20 ml. per second at 6, 12 and 24 months (p <0.05). Median baseline post-void residual urine decreased from 190 to 30 ml. at 6 months (p <0.05) and remained low at 20 and 30 ml. at 12 and 24 months, respectively. Urodynamic evaluation preoperatively and 6 months postoperatively was available in 83 cases. Relief of obstruction was documented with a statistically significant decrease in median detrusor pressure at maximum urine flow from 87 to 48 cm. water (p <0.05). Combining holmium laser enucleation and prostate electroresection with the mushroom technique is safe, efficient and bloodless surgical treatment for benign prostatic hyperplasia with sustained relief of obstruction. With this technique there is no need for additional devices, such as a mechanical tissue morcellator.
Purpose: We identified differentially expressed genes in the rabbit bladder after partial outlet ... more Purpose: We identified differentially expressed genes in the rabbit bladder after partial outlet obstruction. Materials and Methods: Differential display polymerase chain reaction (PCR) was performed on smooth muscle tissue from normal, 2 and 6-week obstructed rabbit bladders. Semiquantitative reverse transcriptase PCR, Western and RNA blot analysis were done to confirm messenger RNA and protein up-regulation. Results: A signal transducing protein human tumor necrosis factor receptor associated factor 6 (TRAF6)-like protein was identified on differential display PCR. TRAF6-like protein was up-regulated in rabbit bladders after 2 weeks of partial outlet obstruction. Reverse transcriptase PCR demonstrated TRAF6-like protein in bladder muscle tissue and semiquantitative analysis confirmed up-regulation in 2-week obstructed tissue. These findings were confirmed by RNA and Western blot analysis. Conclusions: TRAF6-like protein is up-regulated during the early phase of bladder outlet obstruction in rabbits. To our knowledge involvement of this gene in bladder outlet obstruction has not been described previously. TRAF6 may have a role in the regulation of molecular changes during the early bladder response to outlet obstruction, such as the up-regulation of growth factors and proto-oncogenes. Further understanding of this signaling pathway and its role in bladder outlet obstruction may open new avenues for treating detrusor dysfunction.
We prospectively assessed the role of nerve sparing surgery on urinary continence after open radi... more We prospectively assessed the role of nerve sparing surgery on urinary continence after open radical retropubic prostatectomy. Materials and Methods: We evaluated a consecutive series of 536 patients who underwent open radical retropubic prostatectomy with attempted bilateral, unilateral or no nerve sparing, as defined by the surgeon, without prior radiotherapy at a minimum followup of 1 year with documented assessment of urinary continence status. Because outlet obstruction may influence continence rates, its incidence and management was also evaluated. Results: One year after surgery 505 of 536 patients (94.2%) were continent, 27 (5%) had grade I stress incontinence and 4 (0.8%) had grade II stress incontinence. Incontinence was found in 1 of 75 (1.3%), 11 of 322 (3.4%) and 19 of 139 patients (13.7%) with attempted bilateral, attempted unilateral and without attempted nerve sparing, respectively. The proportional differences were highly significant, favoring a nerve sparing technique (p Ͻ0.0001). On multiple logistic regression analysis attempted nerve sparing was the only statistically significant factor influencing urinary continence after open radical retropubic prostatectomy (OR 4.77, 95% CI 2.18 to 10.44, p ϭ 0.0001). Outlet obstruction at the anastomotic site in 33 of the 536 men (6.2%) developed at a median of 8 weeks (IQR 4 to 12) and was managed by dilation or an endoscopic procedure. Conclusions: The incidence of incontinence after open radical retropubic prostatectomy is low and continence is highly associated with a nerve sparing technique. Therefore, nerve sparing should be attempted in all patients if the principles of oncological surgery are not compromised.
We present the long-term results of a large consecutive series of patients undergoing ileal ortho... more We present the long-term results of a large consecutive series of patients undergoing ileal orthotopic bladder substitution following radical cystectomy. Materials and Methods: Between April 1985 and 2005 orthotopic bladder substitution with an ileal low pressure reservoir was performed in 482 patients (including 40 women) after radical and, if possible, nerve sparing cystectomy. In 447 cases the procedure was combined with an afferent ileal isoperistaltic tubular segment. The patients were followed prospectively. Results: In the 482 patients 61 early (less than 30 days) diversion related complications requiring prolonged hospital stay or readmission were noted and 115 late complications required treatment. At 1 year continence was good in 92% of patients during the day and in 79% at night. At last followup 93% of patients could void spontaneously. Of 442 evaluable men 99 (22.4%) reported having erections without and 68 (15.4%) with medical assistance. Ureteroileal stenosis was observed in 12 of 447 (2.7%) patients. Urethral recurrence was detected in 25 of 482 (5%) patients. A total of 15 (5%) patients received vitamin B12 substitution. Renal parenchyma decreased only in patients with preoperative or postoperative ureteral obstruction. After 10 years patients with normal renal function had no long-term acidosis and in 20 patients the incidence of osteoporosis resembled that of the normal population. Conclusions: Ileal orthotopic bladder substitution combined with an afferent ileal tubular segment allows for good long-term functional results provided patients are restrictively selected, postoperative instructions are followed carefully, and typical complications such as outlet obstruction and hernias are treated early.
Purpose: We determined changes in contractile protein expression before and after the relief of p... more Purpose: We determined changes in contractile protein expression before and after the relief of partial bladder outlet obstruction in the rabbit model and assessed their potential role as predictors of recovery. Materials and Methods: We examined the ratio of the smooth muscle myosin heavy chain isoforms SM2-to-SM1, caldesmon isoform expression and bladder function in obstructed and unobstructed adult rabbit bladders. Cystometry, sodium dodecyl sulfate-polyacrylamide gel electrophoresis and Western blot analysis were done to determine changes in bladder function and contractile protein expression. Results: Overall we observed significant correlation of bladder weight with the SM2-to-SM1 ratio (p Ͻ0.05). Regardless of the duration of obstruction (up to 10 weeks) the ratio appeared to stabilize around a value comparable to that in fetal rabbit smooth muscle cells, suggesting a reversal of SM2 and SM1 expression to a level similar to that at the fetal stage. The pattern of h and l-caldesmon isoform expression showed an increase in l-caldesmon expression in obstructed bladders. Except for decreased leak point pressure in the obstructed group we noted no statistically significant urodynamic changes in bladder capacity or compliance. Conclusions: There is significant correlation of bladder weight, which is the best known marker of obstruction, with the SM2-to-SM1 ratio. The myosin heavy chain isoform expression ratio appears to be an indicator of phenotypic modulation in bladder smooth muscle before and after the relief of bladder outlet obstruction. Thus, it may be useful as a marker of bladder dysfunction and predictor of functional recovery. Regression to a fetal pattern of protein expression may suggest irreversible damage to smooth muscle cells, possibly limiting recovery.
Background: Conflicting results exist regarding the value of an extended pelvic lymph node dissec... more Background: Conflicting results exist regarding the value of an extended pelvic lymph node dissection (PLND) in node-positive patients undergoing radical retropubic prostatectomy (RRP) for clinically localized prostate cancer. Objective: To assess the long-term outcome in node-positive patients who underwent extended PLND followed by RRP. Design, setting, and participants: A consecutive series of 122 node positive patients with negative preoperative staging examinations, no neoadjuvant hormonal or radiotherapy, and who underwent extended PLND (10 lymph nodes in the surgical specimen) followed by RRP were analyzed. None of the patients received immediate androgen deprivation therapy (ADT). Intervention: All patients underwent extended PLND followed by RRP. Measurements: Biochemical recurrence-free survival, cancer-specific, and overall survival were assessed using the Kaplan-Meier technique. Results and limitations: Median prostate-specific antigen (PSA) was 16 ng/ml. At pathological examination 76% of the 122 patients had pT3-pT4 tumours, 50% seminal vesicle infiltration. A median of 22 nodes were removed per patient. Median cancer-specific survival at 5 and 10 yr was 84.5% and 60.1%, respectively. In patients with 2 or 3 positive nodes removed, median cancer-specific survival at 10 yr was 78.6% and 33.4%, respectively (p < 0.001). After a median period of 33 mo, 61 of the 122 patients (50%) received ADT, particularly those (69%) with 3 positive nodes removed. This retrospective study includes a significant percentage of patients with high tumour burden, and therefore may not reflect current patient series. Conclusions: Patients with 2 positive nodes detected after extended PLND followed by RRP had good long-term results and should not be denied treatment with curative intent. In contrast, prognosis was poor in patients with 3 positive nodes, despite extended PLND and despite ADT in 69% of patients.
Background: Open radical cystectomy (ORC) is associated with substantial blood loss and a high in... more Background: Open radical cystectomy (ORC) is associated with substantial blood loss and a high incidence of perioperative blood transfusions. Strategies to reduce blood loss and blood transfusion are warranted. Objective: To determine whether continuous norepinephrine administration combined with intraoperative restrictive hydration with Ringer's maleate solution can reduce blood loss and the need for blood transfusion. Design, setting, and participants: This was a double-blind, randomised, parallel-group, single-centre trial including 166 consecutive patients undergoing ORC with urinary diversion (UD). Exclusion criteria were severe hepatic or renal dysfunction, congestive heart failure, and contraindications to epidural analgesia. Intervention: Patients were randomly allocated to continuous norepinephrine administration starting with 2 mg/kg per hour combined with 1 ml/kg per hour until the bladder was removed, then to 3 ml/kg per hour of Ringer's maleate solution (norepinephrine/low-volume group) or 6 ml/kg per hour of Ringer's maleate solution throughout surgery (control group). Outcome measurements and statistical analysis: Intraoperative blood loss and the percentage of patients requiring blood transfusions perioperatively were assessed. Data were analysed using nonparametric statistical models. Results and limitations: Total median blood loss was 800 ml (range: 300-1700) in the norepinephrine/low-volume group versus 1200 ml (range: 400-2800) in the control group (p < 0.0001). In the norepinephrine/low-volume group, 27 of 83 patients (33%) required an average of 1.8 U (AE0.8) of packed red blood cells (PRBCs). In the control group, 50 of 83 patients (60%) required an average of 2.9 U (AE2.1) of PRBCs during hospitalisation (relative risk: 0.54; 95% confidence interval [CI], 0.38-0.77; p = 0.0006). The absolute reduction in transfusion rate throughout hospitalisation was 28% (95% CI, 12-45). In this study, surgery was performed by three high-volume surgeons using a standardised technique, so whether these significant results are reproducible in other centres needs to be shown. Conclusions: Continuous norepinephrine administration combined with restrictive hydration significantly reduces intraoperative blood loss, the rate of blood transfusions, and the number of PRBC units required per patient undergoing ORC with UD.
Keys to Successful Orthotopic Bladder Substitution, 2014
One of the key goals of continent urinary diversion is to preserve renal function by creating a l... more One of the key goals of continent urinary diversion is to preserve renal function by creating a low-pressure reservoir with a minimal risk of mechanical or functional obstruction of the lower urinary tract. There are many potential reasons for deterioration of renal function following urinary diversion, including physical or functional obstruction at various levels, urinary tract infections, and stone formation. Other causes may contribute to declining renal function, including a natural age-related decline, estimated to be 1 mL/min per 1.73 m2 each year [1, 2], and non-urologic causes such as hypertension, diabetes, and drugs.
Seminal vesical sparing cystectomy in bladder cancer patients is feasible with good functional re... more Seminal vesical sparing cystectomy in bladder cancer patients is feasible with good functional results without impairing oncological outcomes: A longitudinal long-term propensity-matched single center study.
To evaluate risk factors for urethral recurrence (UR) in women with neobladder. From 1994 to 2011... more To evaluate risk factors for urethral recurrence (UR) in women with neobladder. From 1994 to 2011, 297 women (median age = 54y; interquartile range: 47-57) underwent radical cystectomy with ileal neobladder for bladder cancer in 4 centers. None of the patients had bladder neck involvement at preoperative assessment. Univariable and multivariable analyses were used to estimate recurrence-free survival and overall survival. The median follow-up was 64 months (interquartile range: 25-116). Of the 297 patients, 81 developed recurrence (27%). The 10- and 15-year recurrence-free survival rates were 66% and 66%, respectively. The 10- and 15-year overall survival rates were 57% and 55%, respectively. UR occurred in 2 patients (0.6%) with solitary urethral, 4 (1.2%) with concomitant urethral and distant recurrence, and 1 with concomitant urethral and local recurrence (0.3%). Bladder tumors were located at the trigone in 27 patients (9.1%). None of these patients developed UR. Lymph node tumo...
With the introduction of orthotopic bladder substitution after radical cystectomy in patients wit... more With the introduction of orthotopic bladder substitution after radical cystectomy in patients with invasive bladder cancer urethral recurrences have become a therapeutic challenge. We retrospectively evaluated our patients with urethral recurrences treated with a urethra sparing approach after orthotopic bladder substitution. Depending on the extension of recurrence and eventual concomitant metastases patients were treated with urethrectomy, no treatment, systemic chemotherapy or intraurethral bacillus Calmette-Guerin (BCG). Three times the common dose of BCG (ImmuCyst, Aventis, Paris, France or OncoTICE, Organon, West Orange, New Jersey) in 150 ml NaCl 0.9% was used for intraurethral BCG perfusion therapy according to an institutional protocol using a modified Foley catheter. This regimen was repeated weekly for 6 weeks and patients were followed prospectively. Between 1985 and 2001, 15 of 371 patients (4%) who received an orthotopic bladder substitute had urethral recurrence. Two patients were treated with systemic chemotherapy (methotrexate, vinblastine, doxorubicin and cisplatin) alone due to metastatic disease and 10 received intraurethral BCG therapy. Five of 6 patients (83%) with carcinoma in situ remained free of recurrence following treatment with BCG, while in 4 with papillary or invasive disease treatment failed. Three patients underwent urethrectomy, including 2 following failed BCG therapy for papillary disease. Carcinoma in situ urethral recurrence following orthotopic bladder substitution can be treated successfully with intraurethral BCG perfusion therapy in approximately 80% of patients. However, papillary and invasive transitional cell urethral recurrence should be treated with urethrectomy.
We assessed factors influencing urinary continence and erectile function after radical cystoprost... more We assessed factors influencing urinary continence and erectile function after radical cystoprostatectomy and ileal orthotopic bladder substitution. Of 381 consecutive men undergoing radical cystoprostatectomy and ileal orthotopic bladder substitution between April 1985 and June 2003, 331 (87%) met the inclusion criteria and were enrolled in the analysis. Kaplan-Meier models and multivariate analysis applying Cox regression were used to evaluate factors influencing postoperative urinary continence and erectile function. In univariate analysis, attempted nerve sparing and age younger than 65 years were significantly associated with better daytime (p = 0.002 and p = 0.007, respectively) and nighttime continence (p = 0.036 and p = 0.005, respectively). In multivariate analysis the rate of daytime continence was significantly higher in patients with attempted nerve sparing (hazards ratio [HR] 1.4, 95% confidence interval [CI] 1.05-1.87) and nighttime continence was significantly better in patients younger than 65 years (HR 1.39, 95% CI 1.07-1.8). Daytime continence was significantly better (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.0001) and was achieved more quickly than nighttime continence (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.0001). The time to achieve daytime continence was shorter for patients with attempted nerve sparing (p = 0.012). In multivariate analysis erectile function recovered significantly more often in patients with attempted nerve sparing (HR 2.59, 95% CI 1.24-5.39) and in those younger than 65 years (HR 2.98, 95% CI 1.83-4.85). After radical cystoprostatectomy and ileal orthotopic bladder substitution, attempted nerve sparing and age younger than 65 years are associated with improved urinary continence. Attempted nerve sparing has the greatest impact on daytime continence and age has the greatest impact on nighttime continence. Attempted nerve sparing and younger age are both associated with more frequent recovery of erectile function.
Purpose: In this retrospective nonrandomized study we compared the long-term outcome in patients ... more Purpose: In this retrospective nonrandomized study we compared the long-term outcome in patients with newly diagnosed stage T1G3 bladder cancer treated with transurethral resection and bacillus Calmette-Guerin or immediate cystectomy. Materials and Methods: Of 121 patients with a median age of 67 years (range 36 to 88) diagnosed with primary T1G3 bladder cancer between 1976 and 1999, 92 were treated by transureteral resection with additional intravesical bacillus Calmette-Guerin and 29 were treated with immediate cystectomy. Results: Of the 92 patients treated with an organ preserving approach 29 remained diseasefree, local recurrence developed in 33 (36%) and progression developed in 30 (33%) at a median followup of 6.9 years (range 0.6 to 16.5). Of these 92 patients 27 (29%) underwent deferred cystectomy at a median of 12.9 months (range 4.8 to 136), of whom 10 (37%) with a median postoperative followup of 19 months (range 2 to 173) died of progressive disease with a median survival of 13 months (range 3 to 34) after cystectomy. The majority of patients who died of progressive disease refused cystectomy, were referred too late for cystectomy, were inoperable or had upper urinary tract disease. Six of the 29 patients (21%) undergoing immediate cystectomy had progression at a median of 13.2 months (range 5.5 to 37). Overall and tumor specific survival at 5 years in patients treated with an organ preserving approach was 69% and 80%, and in those treated with immediate cystectomy it was 54% and 69%, respectively. Conclusions: The results of this analysis demonstrate that the concept of an organ preserving approach is acceptable and spares the bladder in approximately half of the patients with primary T1G3 bladder cancer. Of the patients 30% require deferred cystectomy, making meticulous, close followup mandatory.
Purpose: Mismatch repair genes are responsible for the coordinated correction of misincorporated ... more Purpose: Mismatch repair genes are responsible for the coordinated correction of misincorporated nucleotides formed during DNA replication. Mismatch repair expression is altered in a subset of prostate cancers (PCs) and a recent study suggested that time to biochemical recurrence following prostatectomy correlated with the degree of hMSH2 immunohistochemical staining. We compared hMSH2 expression and survival in clinically organ confined PC. Materials and Methods: A prostate tissue microarray was constructed using 243 specimens from patients who underwent radical prostatectomy with extended lymph node dissection for clinically organ confined PC with up to 12 years of followup. Immunohistochemistry was performed with anti-human MSH2 monoclonal antibody. Three independent observers evaluated hMSH2 expression on a scale of 0 to 4. Low expression was defined as a score of less than 2 and high expression was defined as a score of 2 or higher. Statistical analysis used the Fisher exact test, and Goodman and Kruskal ␥ coefficient. Results: Higher Gleason score significantly correlated with higher hMSH2 expression (p Ͻ0.0002). Low hMSH2 expression correlated with increased overall, disease-free and biochemical disease-free survival (all p Ͻ0.01). Analysis comparing low vs high hMSH2 expression was significant with respect to overall (p ϭ 0.0004), disease-free (p ϭ 0.005) and biochemical disease-free (p ϭ 0.0177) survival. Conclusions: hMSH2 is differentially expressed in malignant prostate tissue and hMSH2 immunohistochemical staining intensity correlates with Gleason score, overall and disease-free survival. Taken together our results suggest that hMSH2 expression may be a useful prognostic biomarker for outcome in men with clinically organ confined PC.
We investigated the long-term efficacy of the second generation Targis thermotherapy device (Urol... more We investigated the long-term efficacy of the second generation Targis thermotherapy device (Urologix, Inc., Minneapolis, Minnesota) for decreasing outflow obstruction caused by benign prostatic hyperplasia. At a minimum followup of 24 months 200 patients with bladder outlet obstruction documented on urodynamics and cystoscopy document with preserved detrusor function underwent transurethral microwave therapy while under local anesthesia. In 45% of cases the general American Society of Anesthesiologists health score was 3 or greater. After a median observation time of 42 months (range 2 to 72) 43 patients (22%) who required additional treatment (repeat thermotherapy, transurethral prostate resection or permanent cystostomy) were excluded from further analysis, as were 15 (7.5%) who died of causes unrelated to treatment during followup and 13 (6.5%) who were lost to followup or refused followup investigations. In the 162 patients evaluated 6 months after treatment the median International Prostate Symptom Score decreased from 23 points (range 10 to 34) before treatment to 3 (range 0 to 21) and remained stable at 12 and 24 months. Median maximum flow increased from 6 ml. per second (range 1 to 15) before treatment to 14.5 (range 4 to 50) 6 months after treatment and remained stable at 12 and 24 months. Median post-void residual urine volume decreased from 170 ml. (range 35 to 720) before treatment to 17 (range 0 to 327) after 6 months and then remained unchanged. Urodynamic evaluation in the 162 patients after 6 months showed a decrease from pretreatment median detrusor opening pressure of 87.5 to 53 cm. water. Median detrusor pressure at maximum flow decreased from 86 to 58 cm. water 6 (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.0001). At the 24-month followup 59 of the 129 evaluable patients agreed to undergo repeat urodynamic evaluation. Pressure flow analysis in these 59 cases revealed a decrease in median minimal urethral opening pressure from 70 to 40 cm. water at 6 months and to 38 cm. water at 24 months (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.0001). Median detrusor pressure at maximum flow decreased significantly from the pretreatment value of 86 to 55 cm. water at 6 months and 58 cm. water at 24 months (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.0001). In patients with a good initial response to treatment, which is achieved in approximately 80%, transurethral microwave therapy provides excellent long-term subjective and objective results. Improved urinary flow, decreased post-void residual urine volume and urodynamic parameters remain stable at 2 years. Transurethral microwave therapy with second generation microwave equipment did not compromise any conventional treatment needed in the 22% of patients who were nonresponders at 6 months.
geon volume. Data on extent of lymphadenectomy was available for 576 patients. Logistic regressio... more geon volume. Data on extent of lymphadenectomy was available for 576 patients. Logistic regression was used to correlate variables to the likelihood of undergoing extended lymphadenectomy. RESULTS: Of the 1078 patients, 1038 (96%) underwent lymphadenectomy. A mean of 19 (range 1-74) lymph nodes were examined. High volume institutions (Ͼ100 cases) had a higher mean LNY (21 vs 15, pϽ0.001). Sixty-seven percent of patients (390/576) underwent extended lymphadenectomy. There was no difference in LNY by age group (pϭ0.383), pathologic stage (pϭ0.407), and gender (pϭ0.784). Patients with prior abdominal surgery had a lower mean LNY (18 vs 21, pϭ0.004), while obese patients had a higher mean LNY (21 vs 19, pϭ0.014). Twenty-two percent (nϭ206) of patients had positive lymph nodes. On univariable analysis, surgeon volume, increasing age, institutional volume, and sequential case number were associated with likelihood of undergoing extended lymphadenectomy. On multivariable analysis, surgeon volume Ն51 cases (OR 6.52, 95% CI 1.34-31.7, pϭ0.020) and advanced clinical stage (OR 1.87, 95% CI 1.13-3.10, pϭ0.015) were independently associated with undergoing extended lymphadenectomy. CONCLUSIONS: Robot-assisted lymphadenectomy can achieve similar lymph node yields to those of open lymphadenectomy after radical cystectomy. High volume surgeons are more likely to perform an extended lymphadenectomy, reflecting a correlation between increasing surgeon comfort with advanced vascular dissection and their growing experience.
The holmium laser allows bloodless enucleation of the prostate. A problem is how to remove a whol... more The holmium laser allows bloodless enucleation of the prostate. A problem is how to remove a whole enucleated, free floating, large prostatic lobe from the bladder. A mechanical morcellator has been used to achieve tissue fragmentation but aspiration of and damage to the bladder wall are risks. Using the mushroom technique holmium laser enucleation and electrocautery resection can be combined without compromising the bloodless advantages of the laser procedure. We treated 156 patients with benign prostatic hyperplasia using a holmium laser with the mushroom technique. Preoperatively all patients were assessed using the International Prostate Symptom Score, maximum urine flow, ultrasound estimation of prostate volume and post-void residual urine, and pressure flow study. Laser enucleation of the prostatic lobes was performed at 66 W. Instead of releasing the lobes into the bladder they were left attached at the bladder neck by a narrow mushroom-like pedicle. At that point the vascular supply was almost completely interrupted and the lobes could easily be electroresected into small pieces without bleeding. Patients were followed 6, 12 and 24 months after the procedure. No patient had significant blood loss or signs of the transurethral resection syndrome. A total of 19 patients were treated while under oral anticoagulation without major bleeding problems. Complete followup was available on 125 patients. Median baseline International Prostate Symptom Score decreased from 20 to 3 at 6 months (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.05) and remained stable at 12 and 24 months. Median maximum urine flow increased from 8 to 20 ml. per second at 6, 12 and 24 months (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.05). Median baseline post-void residual urine decreased from 190 to 30 ml. at 6 months (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.05) and remained low at 20 and 30 ml. at 12 and 24 months, respectively. Urodynamic evaluation preoperatively and 6 months postoperatively was available in 83 cases. Relief of obstruction was documented with a statistically significant decrease in median detrusor pressure at maximum urine flow from 87 to 48 cm. water (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.05). Combining holmium laser enucleation and prostate electroresection with the mushroom technique is safe, efficient and bloodless surgical treatment for benign prostatic hyperplasia with sustained relief of obstruction. With this technique there is no need for additional devices, such as a mechanical tissue morcellator.
Purpose: We identified differentially expressed genes in the rabbit bladder after partial outlet ... more Purpose: We identified differentially expressed genes in the rabbit bladder after partial outlet obstruction. Materials and Methods: Differential display polymerase chain reaction (PCR) was performed on smooth muscle tissue from normal, 2 and 6-week obstructed rabbit bladders. Semiquantitative reverse transcriptase PCR, Western and RNA blot analysis were done to confirm messenger RNA and protein up-regulation. Results: A signal transducing protein human tumor necrosis factor receptor associated factor 6 (TRAF6)-like protein was identified on differential display PCR. TRAF6-like protein was up-regulated in rabbit bladders after 2 weeks of partial outlet obstruction. Reverse transcriptase PCR demonstrated TRAF6-like protein in bladder muscle tissue and semiquantitative analysis confirmed up-regulation in 2-week obstructed tissue. These findings were confirmed by RNA and Western blot analysis. Conclusions: TRAF6-like protein is up-regulated during the early phase of bladder outlet obstruction in rabbits. To our knowledge involvement of this gene in bladder outlet obstruction has not been described previously. TRAF6 may have a role in the regulation of molecular changes during the early bladder response to outlet obstruction, such as the up-regulation of growth factors and proto-oncogenes. Further understanding of this signaling pathway and its role in bladder outlet obstruction may open new avenues for treating detrusor dysfunction.
We prospectively assessed the role of nerve sparing surgery on urinary continence after open radi... more We prospectively assessed the role of nerve sparing surgery on urinary continence after open radical retropubic prostatectomy. Materials and Methods: We evaluated a consecutive series of 536 patients who underwent open radical retropubic prostatectomy with attempted bilateral, unilateral or no nerve sparing, as defined by the surgeon, without prior radiotherapy at a minimum followup of 1 year with documented assessment of urinary continence status. Because outlet obstruction may influence continence rates, its incidence and management was also evaluated. Results: One year after surgery 505 of 536 patients (94.2%) were continent, 27 (5%) had grade I stress incontinence and 4 (0.8%) had grade II stress incontinence. Incontinence was found in 1 of 75 (1.3%), 11 of 322 (3.4%) and 19 of 139 patients (13.7%) with attempted bilateral, attempted unilateral and without attempted nerve sparing, respectively. The proportional differences were highly significant, favoring a nerve sparing technique (p Ͻ0.0001). On multiple logistic regression analysis attempted nerve sparing was the only statistically significant factor influencing urinary continence after open radical retropubic prostatectomy (OR 4.77, 95% CI 2.18 to 10.44, p ϭ 0.0001). Outlet obstruction at the anastomotic site in 33 of the 536 men (6.2%) developed at a median of 8 weeks (IQR 4 to 12) and was managed by dilation or an endoscopic procedure. Conclusions: The incidence of incontinence after open radical retropubic prostatectomy is low and continence is highly associated with a nerve sparing technique. Therefore, nerve sparing should be attempted in all patients if the principles of oncological surgery are not compromised.
We present the long-term results of a large consecutive series of patients undergoing ileal ortho... more We present the long-term results of a large consecutive series of patients undergoing ileal orthotopic bladder substitution following radical cystectomy. Materials and Methods: Between April 1985 and 2005 orthotopic bladder substitution with an ileal low pressure reservoir was performed in 482 patients (including 40 women) after radical and, if possible, nerve sparing cystectomy. In 447 cases the procedure was combined with an afferent ileal isoperistaltic tubular segment. The patients were followed prospectively. Results: In the 482 patients 61 early (less than 30 days) diversion related complications requiring prolonged hospital stay or readmission were noted and 115 late complications required treatment. At 1 year continence was good in 92% of patients during the day and in 79% at night. At last followup 93% of patients could void spontaneously. Of 442 evaluable men 99 (22.4%) reported having erections without and 68 (15.4%) with medical assistance. Ureteroileal stenosis was observed in 12 of 447 (2.7%) patients. Urethral recurrence was detected in 25 of 482 (5%) patients. A total of 15 (5%) patients received vitamin B12 substitution. Renal parenchyma decreased only in patients with preoperative or postoperative ureteral obstruction. After 10 years patients with normal renal function had no long-term acidosis and in 20 patients the incidence of osteoporosis resembled that of the normal population. Conclusions: Ileal orthotopic bladder substitution combined with an afferent ileal tubular segment allows for good long-term functional results provided patients are restrictively selected, postoperative instructions are followed carefully, and typical complications such as outlet obstruction and hernias are treated early.
Purpose: We determined changes in contractile protein expression before and after the relief of p... more Purpose: We determined changes in contractile protein expression before and after the relief of partial bladder outlet obstruction in the rabbit model and assessed their potential role as predictors of recovery. Materials and Methods: We examined the ratio of the smooth muscle myosin heavy chain isoforms SM2-to-SM1, caldesmon isoform expression and bladder function in obstructed and unobstructed adult rabbit bladders. Cystometry, sodium dodecyl sulfate-polyacrylamide gel electrophoresis and Western blot analysis were done to determine changes in bladder function and contractile protein expression. Results: Overall we observed significant correlation of bladder weight with the SM2-to-SM1 ratio (p Ͻ0.05). Regardless of the duration of obstruction (up to 10 weeks) the ratio appeared to stabilize around a value comparable to that in fetal rabbit smooth muscle cells, suggesting a reversal of SM2 and SM1 expression to a level similar to that at the fetal stage. The pattern of h and l-caldesmon isoform expression showed an increase in l-caldesmon expression in obstructed bladders. Except for decreased leak point pressure in the obstructed group we noted no statistically significant urodynamic changes in bladder capacity or compliance. Conclusions: There is significant correlation of bladder weight, which is the best known marker of obstruction, with the SM2-to-SM1 ratio. The myosin heavy chain isoform expression ratio appears to be an indicator of phenotypic modulation in bladder smooth muscle before and after the relief of bladder outlet obstruction. Thus, it may be useful as a marker of bladder dysfunction and predictor of functional recovery. Regression to a fetal pattern of protein expression may suggest irreversible damage to smooth muscle cells, possibly limiting recovery.
Background: Conflicting results exist regarding the value of an extended pelvic lymph node dissec... more Background: Conflicting results exist regarding the value of an extended pelvic lymph node dissection (PLND) in node-positive patients undergoing radical retropubic prostatectomy (RRP) for clinically localized prostate cancer. Objective: To assess the long-term outcome in node-positive patients who underwent extended PLND followed by RRP. Design, setting, and participants: A consecutive series of 122 node positive patients with negative preoperative staging examinations, no neoadjuvant hormonal or radiotherapy, and who underwent extended PLND (10 lymph nodes in the surgical specimen) followed by RRP were analyzed. None of the patients received immediate androgen deprivation therapy (ADT). Intervention: All patients underwent extended PLND followed by RRP. Measurements: Biochemical recurrence-free survival, cancer-specific, and overall survival were assessed using the Kaplan-Meier technique. Results and limitations: Median prostate-specific antigen (PSA) was 16 ng/ml. At pathological examination 76% of the 122 patients had pT3-pT4 tumours, 50% seminal vesicle infiltration. A median of 22 nodes were removed per patient. Median cancer-specific survival at 5 and 10 yr was 84.5% and 60.1%, respectively. In patients with 2 or 3 positive nodes removed, median cancer-specific survival at 10 yr was 78.6% and 33.4%, respectively (p < 0.001). After a median period of 33 mo, 61 of the 122 patients (50%) received ADT, particularly those (69%) with 3 positive nodes removed. This retrospective study includes a significant percentage of patients with high tumour burden, and therefore may not reflect current patient series. Conclusions: Patients with 2 positive nodes detected after extended PLND followed by RRP had good long-term results and should not be denied treatment with curative intent. In contrast, prognosis was poor in patients with 3 positive nodes, despite extended PLND and despite ADT in 69% of patients.
Background: Open radical cystectomy (ORC) is associated with substantial blood loss and a high in... more Background: Open radical cystectomy (ORC) is associated with substantial blood loss and a high incidence of perioperative blood transfusions. Strategies to reduce blood loss and blood transfusion are warranted. Objective: To determine whether continuous norepinephrine administration combined with intraoperative restrictive hydration with Ringer's maleate solution can reduce blood loss and the need for blood transfusion. Design, setting, and participants: This was a double-blind, randomised, parallel-group, single-centre trial including 166 consecutive patients undergoing ORC with urinary diversion (UD). Exclusion criteria were severe hepatic or renal dysfunction, congestive heart failure, and contraindications to epidural analgesia. Intervention: Patients were randomly allocated to continuous norepinephrine administration starting with 2 mg/kg per hour combined with 1 ml/kg per hour until the bladder was removed, then to 3 ml/kg per hour of Ringer's maleate solution (norepinephrine/low-volume group) or 6 ml/kg per hour of Ringer's maleate solution throughout surgery (control group). Outcome measurements and statistical analysis: Intraoperative blood loss and the percentage of patients requiring blood transfusions perioperatively were assessed. Data were analysed using nonparametric statistical models. Results and limitations: Total median blood loss was 800 ml (range: 300-1700) in the norepinephrine/low-volume group versus 1200 ml (range: 400-2800) in the control group (p < 0.0001). In the norepinephrine/low-volume group, 27 of 83 patients (33%) required an average of 1.8 U (AE0.8) of packed red blood cells (PRBCs). In the control group, 50 of 83 patients (60%) required an average of 2.9 U (AE2.1) of PRBCs during hospitalisation (relative risk: 0.54; 95% confidence interval [CI], 0.38-0.77; p = 0.0006). The absolute reduction in transfusion rate throughout hospitalisation was 28% (95% CI, 12-45). In this study, surgery was performed by three high-volume surgeons using a standardised technique, so whether these significant results are reproducible in other centres needs to be shown. Conclusions: Continuous norepinephrine administration combined with restrictive hydration significantly reduces intraoperative blood loss, the rate of blood transfusions, and the number of PRBC units required per patient undergoing ORC with UD.
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Papers by Fiona Burkhard