Polyethylene glycol-based hydrogel rectal spacers for prostate brachytherapy: a systematic review with a focus on technique.

INTRODUCTION: Radiation dose to the rectum in prostate brachytherapy (PBT) can be reduced by the use of polyethylene glycol (PEG) hydrogel spacers. This reduces the rate of rectal toxicity and allows dose escalation to the prostate. Our objectives were to provide an overview of technique for injection of a PEG hydrogel spacer, reduction in rectal dosimetry, gastrointestinal toxicity and potential complications. METHODS: We systematically reviewed the role of PEG hydrogel spacers in PBT using the Cochrane and PRISMA methodology for all English-language articles from January 2013 to December 2019. Data was extracted for type of radiotherapy, number of patients, type of PEG-hydrogel used, mean prostate-rectum separation, rectal dosimetry, acute and late GI toxicity, procedure-related complications and the technique used for hydrogel insertion. RESULTS: Nine studies (671 patients and 537 controls) met our inclusion criteria. Of these 4 used DuraSeal® and 5 used SpaceOAR®. The rectal spacing achieved varied between 7.7-16 mm. Failure of hydrogel insertion was seen only in 12 patients, mostly related to failure of hydrodissection in patients undergoing salvage PBT. Where reported, the rectal D2 cc was reduced by between 21.6 and 52.6% and the median rectal V75% cc was reduced by between 91.8-100%. Acute GI complications were mostly limited to grade 1 or 2 toxicity (n = 153, 33.7%) with low levels of grade 3 or 4 toxicity (n = 1, 0.22%). Procedure-related complications were limited to tenesmus (0.14%), rectal discomfort (1.19%), and bacterial prostatitis (0.44%). CONCLUSIONS: PEG hydrogel spacers are safe to insert. Gel insertion is easy, fast and has a low rate of failure. These studies convincingly demonstrate a significant reduction in rectal dosimetry. Although the results of spacers in reducing rectal toxicity is promising, these need to be confirmed in prospective randomised trial.

[Management of ureteral strictures and hydronephrosis]. / Management von Harnleiterstrikturen und Harnstauung.

Patients who develop hydronephrosis due to an acute cause often have colic-like pain but hydronephrosis secondary to a chronic cause is often asymptomatic. Ureteral obstruction can be due to a variety of intrinsic and extrinsic causes, such as trauma, radiation, iatrogenic injury, urolithiasis, malignancies and congenital causes. Management planning is dictated by the underlying cause, patient comorbidity and life expectancy. Malignant ureteral obstructions can be managed with segmental metal stents with advantages in the quality of life and provide an alternative to long-term treatment with a DJ stent. Endoscopic balloon dilatation and endoureterotomy are options for benign ureteral strictures up to 2 cm in length. For longer benign strictures there are a number of reconstructive techniques, which can also be performed by laparoscopic or robot-assisted approaches at specialized centers.

[Laparascopic radical prostatectomy]. / Laparoskopische radikale Prostatektomie.

BACKGROUND: Since its initial description 20 years ago, laparoscopic radical prostatectomy (LRP) is now a standard treatment option for localized prostate cancer. However, in recent years robot-assisted laparoscopic radical prostatectomy (RALP) has been gradually replacing LRP, despite high costs incurred with RALP. OBJECTIVES: The purpose of this work was to determine the oncological outcomes of LRP from selected series with a follow-up of around 10 years and to compare oncological and functional outcomes between LRP and RALP. MATERIAL AND METHODS: The outcomes of a case series of LRP with a median follow-up of at least 3 years were reviewed. In addition, the outcomes of comparative studies between LRP and RALP were reviewed. RESULTS: The first case series of LRP with follow-ups of 10 years after LRP are available and show favorable oncologic outcomes. Current data show that RALP offers superior functional results (recovery of erectile function) following bilateral nerve sparing when compared to LRP. CONCLUSION: The first review a few years ago showed comparable oncologic and functional outcomes between open prostatectomy, LRP, and RALP. Recent data from comparative studies show superiority of RALP over LRP for potency following bilateral nerve sparing. The potency outcomes between LRP and RALP are, however, similar following wide excision of both neurovascular bundles. Therefore, both treatment options can be recommended for the treatment of localized PC.

Socio-economic deprivation and outcomes following radical nephroureterectomy for clinically localized upper tract transitional cell carcinoma.

BACKGROUND: Little is known about the effects of socio-economic deprivation on the oncological outcomes of surgically treated upper tract transitional cell carcinoma. METHODS: From January 1998 to December 2012, 161 patients underwent nephroureterectomy for upper urinary tract cancer at our tertiary medical centre. We included 124 patients where complete data were available for further analysis. This study also analysed the impact of the reported risk factors such as grade, stage, multifocality in addition to socio-economic deprivation on the long-term oncological outcomes after nephroureterectomy. RESULTS: One hundred and twenty-four (77 %) patients with complete data for socio-economic status were analysed in this study. The median age of the cohort was 73 years (interquartile range 45-86). There were 20, 18, 17, 40 and 29 patients in different socio-economic categories ranging from 1 to 5, respectively. The median duration of follow-up was 68 months (9-174). A statistically higher grade (p value 0.005) and higher stage (p value 0.0005) disease was seen in patients from less deprived categories on both univariate and multivariate analyses. The cancer-specific mortality and follow-up recurrences, however, did not significantly differ between the different socio-economic categories on multivariate analysis (p value 0.13; 0.6) and on univariate and multivariate analyses. A higher number of patients with multifocal disease and concomitant carcinoma in situ (CIS) had disease recurrences which were statistically significant (p values 0.026 and 0.014, respectively) on multivariate analysis. CONCLUSIONS: A lower recurrence-free survival was observed in patients with multifocal disease and those with concomitant CIS following nephroureterectomy for clinically localized disease. Long-term follow-up did not show any significant differences in cancer-specific survival between different deprivation categories.

Complementary approaches to decreasing discomfort during shockwave lithotripsy (SWL).

Shock wave lithotripsy (SWL) is an established treatment for renal stones. Although non-invasive, it can cause significant pain and anxiety during the procedure. Our purpose was to review the literature to look at the effect of complimentary therapy in patients undergoing SWL and whether it led to a reduction in the requirement of analgesics and anxiolytics. A systematic review was performed on the use of acupuncture, auricular acupressure, transcutaneous electrical nerve stimulation (TENS) and music during SWL. Only prospective randomized controlled trials were selected. Two reviewers independently extracted the data from each study. Outcomes relating to analgesia requirement, anxiety and stone-free rates (SFR) were compared. Seven papers were identified reporting on 591 patients (acupuncture-3, TENS-1 and music-3). Pain control/analgesia requirement was significantly better in four studies (music-2, acupuncture-1, TENS-1). Significantly lower anxiety was noted in one study with music and two using acupuncture. No difference in SFR was noted with the use of complementary therapy. No major or minor side effects were noted. Complementary therapy for SWL can help lower analgesia requirement and the anxiety associated with it. However, it does not have any effect on the SFR.

Impact of multiple deprivations on detection, progression and interventions in small renal masses (less than 4 cm) in a population based study.

BACKGROUND AND OBJECTIVES: A relatively unknown associations exists between the detection, progression and rate of interventions in small renal masses in the context of socioeconomic status. The study explored the impact of socioeconomic status on the detection, progression and intervention rate in SRMs. PARTICIPANTS AND METHODS: A population-based cohort of patients with SRMs was identified using various hospital databases in well-defined geographical area between January 2007 and December 2011. A list of patients with unique 10-digits Community Health Index (CHI) number and their follow-up was recorded on a pre-designed electronic database sheet. Correlation between the socioeconomic status and detection, progression and pattern of interventions of small renal masses was the primary outcome. The postcode of each patient was identified and linked to the Scottish Index of Multiple Deprivation (SIMD) scoring system, and a deprivation category number assigned to each patient, allowing potential links to become apparent between small renal masses and deprivation. RESULTS: Two hundred and seventeen patients were diagnosed with small renal masses in 150,820 abdominal imaging carried out in a population of 117,600. The detection of SRMs in relation to SIMD status showed no statistically significant differences across different categories. Similarly, interventions, type of surgery and progression remained unaffected by socioeconomic status. The group on active surveillance showed slow or no-growth at a mean follow-up of more than 2 years. CONCLUSIONS: The detection of small renal masses is very small compared with the amount of imaging investigations of abdomen in 5 years in this cohort. Detection, progression and rate of intervention did not differ in different socioeconomic strata of the cohort. The majority of small renal masses on active surveillance did not change or grew in size very slowly when observed over time.