Fluorine-18 Prostate-Specific Membrane Antigen-1007 PET/CT vs Multiparametric MRI for Locoregional Staging of Prostate Cancer.

Importance: Prostate-specific membrane antigen (PSMA) demonstrates overexpression in prostate cancer and correlates with tumor aggressiveness. PSMA positron emission tomography (PET) is superior to conventional imaging for the metastatic staging of prostate cancer per current research but studies of second-generation PSMA PET radioligands for locoregional staging are limited. Objective: To determine the accuracy of fluorine-18 PSMA-1007 PET/computed tomography (18F-PSMA-1007 PET/CT) compared to multiparametric magnetic resonance imaging (MRI) in the primary locoregional staging of intermediate-risk and high-risk prostate cancers. Design, Setting, and Participants: The Next Generation Trial was a phase 2 prospective validating paired cohort study assessing the accuracy of 18F-PSMA-1007 PET/CT and MRI for locoregional staging of prostate cancer, with results of histopathologic examination as the reference standard comparator. Radiologists, nuclear medicine physicians, and pathologists were blinded to preoperative clinical, pathology, and imaging data. Patients underwent all imaging studies and radical prostatectomies at 2 tertiary care hospitals in Alberta, Canada. Eligible participants included men with intermediate-risk or high-risk prostate cancer who consented to radical prostatectomy. Participants who underwent radical prostatectomy were included in the final analysis. Patients were recruited between March 2022 and June 2023, and data analysis occurred between July 2023 and December 2023. Exposures: All participants underwent both 18F-PSMA-1007 PET/CT and MRI within 2 weeks of one another and before radical prostatectomy. Main Outcomes and Measures: The primary outcome was the correct identification of the prostate cancer tumor stage by each imaging test. The secondary outcomes were correct identification of the dominant nodule, laterality, extracapsular extension, and seminal vesical invasion. Results: Of 150 eligible men with prostate cancer, 134 patients ultimately underwent radical prostatectomy (mean [SD] age at prostatectomy, 62.0 [5.7] years). PSMA PET was superior to MRI for the accurate identification of the final pathological tumor stage (61 [45%] vs 38 [28%]; P = .003). PSMA PET was also superior to MRI for the correct identification of the dominant nodule (126 [94%] vs 112 [83%]; P = .01), laterality (86 [64%] vs 60 [44%]; P = .001), and extracapsular extension (100 [75%] vs 84 [63%]; P = .01), but not for seminal vesicle invasion (122 [91%] vs 115 [85%]; P = .07). Conclusions and Relevance: In this phase 2 prospective validating paired cohort study, 18F-PSMA-1007 PET/CT was superior to MRI for the locoregional staging of prostate cancer. These findings support PSMA PET in the preoperative workflow of intermediate-risk and high-risk tumors.

PEG-coated patch parenchymal closure technique and initial outcomes during minimally invasive partial nephrectomy.

INTRODUCTION: The Hemopatch® is a novel polyethylene glycol-coated (PEG-coated) collagen patch that acts as a topical hemostatic agent. It has been applied to a variety of surgical techniques. Here, we present our series and technique using a PEG-coated patch for minimally invasive partial nephrectomy (MIPN). METHODS: We conducted a retrospective chart review of all patients undergoing MIPN by a single surgeon at a tertiary Canadian medical center between July and December 2018. We included patients if a PEG-coated patch was used to close the renal parenchymal defect. We also describe in detail our technique for laparoscopic patch deployment. RESULTS: A total of 17 patients met inclusion criteria, of whom 12 were male. Mean age was 63 years old. Median size of renal mass was 2.85 cm in largest dimension and median RENAL score was 6. Hilar clamping was carried out in 12 (70.9%) cases, with an average warm ischemic time of 16.1 minutes. The remainder of cases were performed off-clamp. Median estimated blood loss was 238 mL and the mean change in hemoglobin on postoperative day 1 compared to preoperatively was 21.2 g/L. The average length of stay was 1.76 days. No patient required blood transfusion or underwent angioembolization or re-operation for bleeding within 90 days. There were no Clavien-Dindo grade 3 or greater complications. CONCLUSIONS: A PEG-coated patch can be used safely and effectively in lieu of traditional two-layer renorrhaphy with acceptable outcomes. Larger, prospective series are required to ascertain its true value and cost-effectiveness.

Canadian Update on Surgical Procedures (CUSP) Urology Group consensus for intraoperative hemostasis during minimally invasive partial nephrectomy.

INTRODUCTION: Partial nephrectomy remains the gold standard in the management of small renal masses. However, minimally invasive partial nephrectomy (MIPN) is associated with a steep learning curve, and optimal, standardized techniques for time-efficient hemostasis are poorly described. Given the relative lack of evidence, the goal was to describe a set of actionable guiding principles, through an expert working panel, for urologists to approach hemostasis without compromising warm ischemia or oncological outcomes. METHODS: A three-step modified Delphi method was used to achieve expert agreement on the best practices for hemostasis in MIPN. Panelists were recruited from the Canadian Update on Surgical Procedures (CUSP) Urology Group, which represent all provinces, academic and community practices, and fellowship-and non-fellowship-trained surgeons. Thirty-two (round 1) and 46 (round 2) panellists participated in survey questionnaires, and 22 attended the in-person consensus meeting. RESULTS: An initial literature search of 945 articles (230 abstracts) underwent screening and yielded 24 preliminary techniques. Through sequential survey assessment and in-person discussion, a total of 11 strategies were approved. These are temporally distributed prior to tumor resection (five principles), during tumor resection (two principles), and during renorrhaphy (four principles). CONCLUSIONS: Given the variability in tumor size, depth, location, and vascularity, coupled with limitations of laparoscopic equipment, achieving consistent hemostasis in MIPN may be challenging. Despite over two decades of MIPN experience, limited evidence exists to guide clinicians. Through a three-step Delphi method and rigorous iterative review with a panel of experts, we ascertained a guiding checklist of principles for newly beginning and practicing urologists to reference.

Robotic-assisted laparoscopic sacrocolpopexy: Initial Canadian experience.

INTRODUCTION: Abdominal sacrocolpopexy provides effective long-term outcomes for apical pelvic organ prolapse. The introduction of robotic-assisted laparoscopic sacrocolpopexy (RALS) has mitigated the risks of abdominal surgery. This study aims to evaluate the preoperative patient characteristics, intraoperative surgical parameters, and postoperative outcomes of RALS, which has not been previously performed in Canada. METHODS: A retrospective chart review of 47 patients who have undergone RALS from 2016-2018 by a single surgeon at a tertiary care hospital in Canada was completed. RESULTS: This case series had a mean age of 60.2 years, body mass index (BMI) of 28.3 kg/m2, and Charlson comorbidity index of 2.0. Preoperatively, 13 (28%), 23 (49%), and 11 (23%) patients had Baden-Walker grade 2, 3, and 4 apical prolapse, respectively. Intraoperatively, 45 (96%) patients underwent concomitant procedures, including 36 (77%) with adnexal surgery, 32 (68%) with anti-incontinence surgery, and 25 (53%) with hysterectomy. Intraoperative complications included one ureteric injury, two bladder injuries, and three vaginotomies. The mean robotic console time, surgery time, and total operating room times were 125.6, 148.6, and 190.6 minutes, respectively. Postoperatively, data was analyzed for 32 (68%) patients with greater than 12 weeks' followup. There was no recurrence of apical prolapse on exam after a mean followup of 60.1 weeks. Seven (22%) patients experienced symptomatic prolapse in the posterior compartment. There were two grade 3 Clavien-Dindo complications, including osteomyelitis and mesh exposure. CONCLUSIONS: RALS can be safely and effectively performed with other pelvic procedures with good outcomes. Concurrent posterior repairs may be considered in select patients.

Initial Canadian experience with robotic simple prostatectomy: Case series and literature review.

INTRODUCTION: Robotic-assisted simple prostatectomy (RASP) has been touted as an alternative to open simple prostatectomy (OSP) to treat large gland benign prostatic hyperplasia. Our study assesses our institution's experience with RASP and reviews the literature. METHODS: We performed a retrospective chart review from January 2011 to November 2013 of all patients undergoing RASP and OSP. Operative and 90-day outcomes, including operation time, intraoperative blood loss, length of hospital stay (LOS), transfusion requirements, and complication rates, were assessed. RESULTS: Thirty-two patients were identified: 4 undergoing RASP and 28 undergoing OSP. There was no difference in mean age at surgery (69.3 vs. 75.2 years; p = 0.17), mean Charlson Comorbidity Index (2.5 vs. 3.5; p = 0.19), and mean prostate volume on TRUS (239 vs. 180 mL; p = 0.09) in the robotic and open groups, respectively. There was a significant difference in the mean length of operation, with RASP exceeding OSP (161 vs. 79 min; p = 0.008). The mean intraoperative blood loss was significantly higher in the open group (835.7 vs. 218.8 mL; p = 0.0001). Mean LOS was shorter in the RASP group (2.3 vs. 5.5 days; p = 0.0001). No significant differences were noted in the 90-day transfusion rate (p = 0.13), or overall complication rate at 0% with RASP vs. 57.1% with OSP (p = 0.10). CONCLUSIONS: Our data suggest RASP has a shorter LOS and lower intraoperative volume of blood loss, with the disadvantage of a longer operating time, compared to OSP. It is a feasible technique and deserves further investigation and consideration at Canadian centres performing robotic prostatectomies.

Zero ischemia robotic-assisted partial nephrectomy in Alberta: Initial results of a novel approach.

INTRODUCTION: Partial nephrectomy remains the standard of care in early stage, organ-confined renal tumours. Recent evidence suggests that minimally invasive surgery can proceed without segmental vessel clamping. In this study, we review our experience at a Canadian centre with zero ischemia robotic-assisted partial nephrectomy (RAPN). METHODS: A retrospective chart review of zero ischemia RAPN was performed. All surgeries were consecutive partial nephrectomies performed by the same surgeon at a tertiary care centre in Northern Alberta. The mean follow-up period was 28 months. These outcomes were compared against the current standards for zero ischemia (as outlined by the University of Southern California Institute of Urology [USC]). RESULTS: We included 21 patients who underwent zero ischemia RAPN between January 2012 and June 2013. Baseline data were similar to contemporary studies. Twelve (57.1%) required no vascular clamping, 7 (33.3%) required clamping of a single segmental artery, and 2 (9.5%) required clamping of two segmental arteries. We achieved an average estimated blood loss of 158 cc, with a 9.2% average increase in creatinine postoperatively. Operating time and duration of hospital stay were short at 153 minutes and 2.2 days, respectively. CONCLUSION: Zero ischemia partial nephrectomy was a viable option at our institution with favourable results in terms of intra-operative blood loss and postoperative creatinine change compared to results from contemporary standard zero ischemia studies (USC). To our knowledge, this is the first study to review an initial experience with the zero ischemia protocol in robotic-assisted partial nephrectomies at a Canadian hospital.

Robotic radical cystectomy with intracorporeal neobladder: Initial experience and outcomes.

INTRODUCTION: Total intra-corporeal robot-assisted radical cystectomy (RARC) with total intracorporeal neobladder formation is relatively new in the treatment of bladder cancer. We present our experience and believe it is the first Canadian reported series with this technique. METHODS: This is a case series of 4 patients, who underwent total RARC, pelvic lymphadenectomy and creation of an intra-corporeal ileal neobladder. Surgical technique is described and perioperative variables, pathologic data, and complication rates are reported. RESULTS: The mean patient age was 61.8 and the mean body mass index was 27.01 kg/m(2). The mean operative time, estimated blood loss, time to full diet and length of stay were 522.8 minutes (standard deviation [SD] 74.5), 237.5 mL (SD 47.9), 9 days (range: 3-24) and 12.8 days (range: 6-31), respectively. All patients completed postoperative functional evaluation showing a mean neobladder capacity of 575 cc (range: 500-720). Surgical margins and pathological nodal status were negative in all patients with no evidence of disease recurrence or progression on follow-up. Three of the 4 patients suffered a complication within 90 days, with one occurring later in the first year. All early complications were Clavien grade I-II (grade I [n = 1]; grade II [n = 2]) and the later complication was grade IIIa. The mean follow-up was 632 days (range: 562-730). The limitation of our study is its small sample size with highly selected patients to compensate for the learning experience. The follow-up is short; however, the outcomes are comparable to early experiences reported at other institutions. CONCLUSIONS: In our initial experience, RARC with total intracorporeal neobladder formation is safe. We expect that with experience the expense of robotic surgery can be compensated with early ambulation and shorter stay.

Effect of wound closure on buccal mucosal graft harvest site morbidity: results of a randomized prospective trial.

OBJECTIVE: To determine the effect of closure versus nonclosure of the buccal mucosal graft harvest site in men undergoing bulbar urethroplasty in a randomized prospective study. The optimal postoperative management of the buccal mucosal graft donor site remains unknown. METHODS: A total of 50 consecutive patients were randomized to either donor site closure or leaving the donor site open. Postoperatively, questionnaires assessing pain, diet, salivation, perioral sensation, and mouth opening were completed daily for the first week and then monthly for 6 months. The primary endpoint was postoperative oral pain. The secondary endpoints were the interval to a regular diet, perioral numbness, changes in salivation, and interval to full mouth opening. RESULTS: Of the 50 patients, 24 and 26 were randomized to the open and closed groups, respectively. The early postoperative pain scores demonstrated a trend favoring the nonclosure group until day 3 (4.1 vs 2.2; P=.07). At 6 months, no difference was found in the pain scores between the 2 groups (0.2 vs 0.3; P=.63). The return to a regular diet also favored the nonclosure group (70.8% vs 19.2% on day 1; P=.01) as did the return to full mouth opening (79.1% vs 15.3% on day 1; P=.001). Nonclosure resulted in less early perioral numbness (62.5% vs 92.3% on day 1; P=.008) and reduced the occurrence of bothersome numbness at 6 months (4.2% vs 23.2%; P=.05). CONCLUSION: The results of the present randomized prospective trial suggest that leaving the buccal mucosa graft harvest site open leads to lower reported early pain scores, an earlier return to a full diet, an earlier return to full mouth opening, and a decrease in bothersome perioral numbness at 6 months postoperatively.

Quantitative method to determine sporicidal decontamination of building surfaces by gaseous fumigants, and issues related to laboratory-scale studies.

Chlorine dioxide gas and vaporous hydrogen peroxide sterilant have been used in the cleanup of building interiors contaminated with spores of Bacillus anthracis. A systematic study, in collaboration with the U.S. Environmental Protection Agency, was jointly undertaken by the U.S. Army-Edgewood Chemical Biological Center to determine the sporicidal efficacies of these two fumigants on six building structural materials: carpet, ceiling tile, unpainted cinder block, painted I-beam steel, painted wallboard, and unpainted pinewood. Critical issues related to high-throughput sample processing and spore recovery from porous and nonporous surfaces included (i) the extraction of spores from complex building materials, (ii) the effects of titer challenge levels on fumigant efficacy, and (iii) the impact of bioburden inclusion on spore recovery from surfaces and spore inactivation. Small pieces (1.3 by 1.3 cm of carpet, ceiling tile, wallboard, I-beam steel, and pinewood and 2.5 by 1.3 cm for cinder block) of the materials were inoculated with an aliquot of 50 microl containing the target number (1 x 10(6), 1 x 10(7), or 1 x 10(8)) of avirulent spores of B. anthracis NNR1Delta1. The aliquot was dried overnight in a biosafety cabinet, and the spores were extracted by a combination of a 10-min sonication and a 2-min vortexing using 0.5% buffered peptone water as the recovery medium. No statistically significant drop in the kill efficacies of the fumigants was observed when the spore challenge level was increased from 6 log units to 8 log units, even though a general trend toward inhibition of fumigant efficacy was evident. The organic burden (0 to 5%) in the spore inoculum resulted in a statistically significant drop in spore recovery (at the 2 or 5% level). The effect on spore killing was a function of the organic bioburden amount and the material type. In summary, a high-throughput quantitative method was developed for determining the efficacies of fumigants, and the spore recoveries from five porous materials and one nonporous material ranged between 20 and 80%.

Effect of exercise training on C-reactive protein in postmenopausal breast cancer survivors: a randomized controlled trial.

The objective of this study was to determine the effects of exercise training on changes in C-reactive protein (CRP) and other cardiovascular risk factors in postmenopausal breast cancer survivors. Fifty-three postmenopausal breast cancer survivors were randomly assigned to an exercise (n = 25) or control group (n = 28). The exercise group trained on cycle ergometers 3 times per week for 15 weeks. The control group did not train. The primary end point was change in CRP between baseline and week 15. Secondary end points were changes in RHR, HRR, SBP, DBP, TC, LDL-C, HDL-C, TG, and TC:HDL-C ratio. Fifty-two participants completed the trial. Baseline values did not differ between groups except that TG (p = .007) and TC:HDL-C ratio (p = .023) were higher in the exercise group. Intention-to-treat analysis showed that CRP decreased by 1.39 mg/L in the exercise group whereas it increased by 0.10 mg/L in the control group (mean between group change, -1.49 mg/L; 95% CI, -3.09 to 0.10 mg/L; p = .066). Intention-to-treat analysis also showed a clinically and statistically significant difference between groups for change in HRR (mean change, +10.6 beats/min; 95% CI, +3.4 to +17.7 beats/min; p = .004) and clinically but not statistically significant differences between groups for change in RHR (mean change, -5.5 beats/min; 95% CI, -11.5 to +0.5 beats/min; p = .073), SBP (mean change, -5.5 mmHg; 95% CI, -14.5 to +3.4 mmHg; p = .218), DBP (mean change,-3.6 mmHg; 95% CI, -9.3 to +2.1 mmHg; p = .214), and HDL-C (mean change, +0.05 mmol/L; 95% CI, -0.03 to 0.14 mmol/L; p = .214). These data suggest that exercise training may have beneficial effects on CRP and other cardiovascular risk factors in postmenopausal breast cancer survivors. Larger randomized controlled trials are warranted.