To Transect or Not Transect: Results from the Scandinavian Urethroplasty Study, A Multicentre Randomised Study of Bulbar Urethroplasty Comparing Excision and Primary Anastomosis Versus Buccal Mucosal Grafting.

BACKGROUND: Open surgical treatment of short bulbar urethral strictures (urethroplasty) is commonly performed as transecting excision and primary anastomosis (tEPA) or buccal mucosa grafting (BMG). Erectile dysfunction and penile complications have been reported, but there is an absence of randomised trials. OBJECTIVE: To evaluate sexual dysfunction and penile complications after urethroplasty with tEPA versus BMG. DESIGN, SETTING, AND PARTICIPANTS: Centres in Finland, Sweden and Norway participated. Patients with a bulbar urethral stricture of ≤2 cm without previous urethroplasty were randomised. The primary endpoints were the degree of erectile dysfunction and penile complications. Follow-up was 12 mo. INTERVENTION: Patients were randomised to either tEPA or BMG urethroplasty. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Sexual dysfunction was measured using the International Index of Erectile Function, 5-item version (IIEF-5) and a penile complications questionnaire (PCQ) designed for this study. Continuous data were analysed using analysis of covariance and categorical data were compared using a χ2 test. RESULTS AND LIMITATIONS: A total of 151 patients were randomised to either tEPA (n = 75) or BMG (n = 76). The tEPA group reported more penile complications (p = 0.02), especially reduced glans filling (p = 0.03) and a shortened penis (p = 0.001). There were no differences in postoperative IIEF-5 total scores. Recurrence rates were similar in both groups (12.9%) but the study was not designed to detect differences in recurrence rates. The PCQ is not validated, which is a limitation. CONCLUSIONS: More patients reported penile complications after urethroplasty with tEPA than with BMG. This should be considered when choosing the operative method, and patients should be informed accordingly. PATIENT SUMMARY: This study compared two common operations for repair of narrowing of the male urethra. Neither of the two methods seems to cause worsened erections. However, penile problems are more common after the transection technique than after the grafting technique.

Initial experiences with the enhanced recovery after surgery (ERAS) protocol in open radical cystectomy.

OBJECTIVE: This article describes the authors' experiences with the implementation of the Enhanced Recovery After Surgery (ERAS) protocol for open radical cystectomy (ORC). Adherence to the ERAS cystectomy protocol was assessed; secondary outcome measures were impact on perioperative complication rate (Clavien-Dindo classification), time to first defecation, postoperative length of stay and hospital readmission rate. MATERIALS AND METHODS: This retrospective feasibility study compared outcomes with patients in a historical control group. The study group (ERAS) consisted of 31 consecutive patients undergoing ORC and urinary diversion during 1 year from 1 January to 31 December 2011. The control group (pre-ERAS) comprised 39 consecutive patients operated on during 2010. Follow-up was 30 days. RESULTS: There were no significant demographic differences between the two groups, and no differences in complications graded Clavien III or above, or in total length of stay. The ERAS group had statistically significantly shorter mean time to first passage of stool and statistically significantly lower readmission frequency than the pre-ERAS group. The number of patients was small and the study was not randomized; moreover, the use of historical controls inevitably introduced different types of bias. CONCLUSIONS: Introduction of the ERAS protocol is clearly feasible in cystectomy, and may improve clinical outcomes in terms of faster return of bowel function and reduction of readmission within 30 days. However, more and larger studies are needed to prove the efficacy of ERAS for patients undergoing ORC.

Enhanced recovery after surgery: are we ready, and can we afford not to implement these pathways for patients undergoing radical cystectomy?

Enhanced recovery after surgery (ERAS) for radical cystectomy seems logical, but our study has shown a paucity in the level of clinical evidence. As part of the ERAS Society, we welcome global collaboration to collect evidence that will improve patient outcomes.

Guidelines for perioperative care after radical cystectomy for bladder cancer: Enhanced Recovery After Surgery (ERAS(®)) society recommendations.

PURPOSE: Enhanced recovery after surgery (ERAS) pathways have significantly reduced complications and length of hospital stay after colorectal procedures. This multimodal concept could probably be partially applied to major urological surgery. OBJECTIVES: The primary objective was to systematically assess the evidence of ERAS single items and protocols applied to cystectomy patients. The secondary objective was to address a grade of recommendation to each item, based on the evidence and, if lacking, on consensus opinion from our ERAS Society working group. EVIDENCE ACQUISITION: A systematic literature review was performed on ERAS for cystectomy by searching EMBASE and Medline. Relevant articles were selected and quality-assessed by two independent reviewers using the GRADE approach. If no study specific to cystectomy was available for any of the 22 given items, the authors evaluated whether colorectal guidelines could be extrapolated. EVIDENCE SYNTHESIS: Overall, 804 articles were retrieved from electronic databases. Fifteen articles were included in the present systematic review and 7 of 22 ERAS items were studied. Bowel preparation did not improve outcomes. Early nasogastric tube removal reduced morbidity, bowel recovery time and length of hospital stay. Doppler-guided fluid administration allowed for reduced morbidity. A quicker bowel recovery was observed with a multimodal prevention of ileus, including gum chewing, prevention of PONV and minimally invasive surgery. CONCLUSIONS: ERAS has not yet been widely implemented in urology and evidence for individual interventions is limited or unavailable. The experience in other surgical disciplines encourages the development of an ERAS protocol for cystectomy.

The National Penile Cancer Register in Sweden 2000-2003.

OBJECTIVE: This article reviews the first 4 years of operation of the National Penile Cancer Register (NPECR) in Sweden. The register was set up to gain knowledge about the incidence and primary treatment of penile cancer, including the use of and the frequency of lymph node dissection. The register elicits treatment disparities between regions, and aims to determine the impact of clinical practice guidelines introduced in Sweden. MATERIAL AND METHODS: All patients newly diagnosed with penile cancer after the year 2000 have been registered in the NPECR. A total of 454 patients were registered in the period 2000-2003. RESULTS: Registrations in the NPECR were almost complete, with 98.7% of cases registered in the National Cancer Register also being registered in the NPECR. At least 145 clinicians reported to the register. The annual incidence of penile cancer is 2.2/100 000 men. Squamous cell carcinoma accounts for 95% of the cases. The mean age at diagnosis was 65.5 years. Most tumours were classified as Tis, T1 or T2, each class representing 25-30% of the total number of diagnosed cases. Penis-preserving treatment was performed in 58% of the patients (Table I). The number of patients classified as > or = T1/G2-G3 was 206, and 101 of these patients (49%) underwent inguinal lymphadenectomy. CONCLUSIONS: We have introduced a population-based register in Sweden with almost complete registration, and this offers unique possibilities for further studies of both epidemiological and clinical aspects of penile cancer. The results obtained to date indicate that the primary treatment is done in many settings and that guidelines, e.g. to dissect lymph nodes, are not always followed.