[Enhanced Recovery After Surgery (ERAS®) after radical cystectomy-current data]. / Aktuelle Studienlage der Enhanced Recovery After Surgery (ERAS®) nach radikaler Zystektomie.

BACKGROUND: Radical cystectomy is associated with considerable morbidity and mortality. Based on the solid evidence in colorectal surgery, fast-track/ERAS® (Enhanced Recovery After Surgery) protocols have been developed to improve the perioperative management of patients undergoing radical cystectomy. OBJECTIVES: To review the literature and guidelines and evaluate the evidence regarding the different components of ERAS® protocols. MATERIALS AND METHODS: Systemic literature search and evaluation of relevant guidelines. RESULTS: The majority of ERAS® recommendations for radical cystectomy are based on extrapolations of abdominal surgery studies. Four randomized, controlled trials and one ERAS® guideline were published for radical cystectomy. ERAS® seems to shorten length of stay without increasing the complication rate. Key elements are no bowel preparation, no nasogastric tube, optimized fluid substitution, multimodal pain management, early mobilization, and oral diet. CONCLUSIONS: Implementation of ERAS® requires multidisciplinary collaboration. Individualization of an ERAS® program, identification of the most important components and adaption to the specific needs of radical cystectomy patients are future goals.

Prospective evaluation of 4-D contrast-enhanced-ultrasound (CEUS) imaging in bladder tumors.

PURPOSE: The evaluation of the potential clinical benefit of four-dimensional ultrasound (4D-US) in the assessment of bladder cancer (BC). MATERIAL AND METHODS: 20 patients with indication for cystoscopy for suspicion of bladder cancer were prospectively included in this study. All patients underwent two-dimensional ultrasound (2D-US), contrast enhanced ultrasound (CEUS) and real-time four-dimensional ultrasound (4D-US). All acquisitions were compared to each other in regard to image quality. This assessment was done using a 6 point scale (1 = best). All patients underwent subsequently cystoscopy with resection of the tumor (TURB), due a histopathological analysis was possible. RESULTS: All examinations were performed successfully and no patient had to be excluded from the study. Patients acceptance of 4D-US was consistently good. No adverse events occurred. Image quality of real time 4D-US (score: 1.27±0.46) was significantly superior (p < 0.001) to both, conventional 2D-US (score: 2.33±0.62) and also to 2D-CEUS (score: 2.00±0.53). In terms of tumor detection no superiority was evident for 4D-US compared to 2D-US or in utilization of CEUS (sensitivity = 0.89; specificity = 1.00; positive predictive value = 1.00; negative predictive value = 0.50; AUC = 0.944; (95% CI: 07.43-0.998)). CONCLUSION: The assessment of bladder cancer using real time 4D-US is feasible and improves the image quality and therefore also the precise anatomical consistency of intravesical tumor masses.

Detection of Gleason 6 prostate cancer in patients with clinically significant prostate cancer on multiparametric magnetic resonance imaging.

INTRODUCTION: Multiparametric-Magnetic Resonance Imaging (mpMRI)-Ultrasound fusion guided biopsy (Fbx) has emerged as the new standard of risk stratification for prostate cancer (PCa) with superior detection rates of clinically significant PCa than randomized biopsy. In the present study, we evaluated patients with suspicion of clinically significant PCa on mpMRI, but histopathologically proven Gleason 6 PCa in Fbx. MATERIAL AND METHODS: Between 2015 and 2019, 849 patients underwent Fbx and concurrent systematic 12-core biopsy at our department. 234 patients were diagnosed with Gleason 6 PCa in either mpMRI-targeted and/or concurrent systematic biopsy. Patients were analyzed regarding PSA, mpMRI findings according to PI-RADS classification, histopathological results of Fbx and systematic 12-core biopsy. 99/234 patients were also analyzed in regards of histopathology of the whole-mount specimen of subsequent radical prostatectomy (RP). RESULTS: In 131/234 patients (56%), Gleason 6 PCa was detected in the mpMRI target. In 103/234 patients (44%), Gleason 6 PCa was detected in the concurrent systematic 12-core biopsy with negative mpMRI-targeted biopsy. Men with evidence of Gleason 6 in the mpMRI target had significantly higher amounts of overall positive biopsies (median 4 vs. 2, p < 0.001) and higher maximum tumor infiltration per biopsy core (30% vs. 20%, p < 0.001) compared to men with negative mpMRI-targeted biopsy. Detection of Gleason 6 in mpMRI Target lesions correlated significantly with the PI-RADS score (p < 0.001). Patients with positive mpMRI-target had significantly higher tumor infiltration in whole-mount specimen after prostatectomy (20% vs. 15%, p = 0.0026) compared to men without detection of Gleason 6 in mpMRI-targeted biopsy but in additional systematic biopsy. CONCLUSION: Detection of Gleason 6 PCa in mpMRI-targeted biopsy indicates higher tumor burden compared to detection of Gleason 6 PCa in concurrent systematic biopsy and negative mpMRI-targeted biopsy.

Sea-level performance in runners using altitude tents: a field study.

In this study of effects of simulated altitude exposure on sea-level performance, 10 competitive runners slept in a hypoxic environment achieved with tents for 9.8+/-1.3 h.d(-1) (mean+/-standard deviation) for 24 days-30 days at 2500-3500 m (PIO2=117-103 mmHg) above sea level. The altitude group and a control group of 10 runners performed usual training (PIO2=149 mmHg). At approximately 4-wk intervals before and after exposure both groups performed an incremental test for lactate threshold. The altitude group performed an additional test, a treadmill run to exhaustion lasting approximately 5 min. One week following exposure lactate threshold speed of the altitude group relative to the control group increased by 1.2% (90% likely limits +/-3.1%), but the effect became slightly negative after controlling for baseline differences in running speed between the groups. A 16% increase in time to exhaustion was observed in the altitude group, equivalent to a 1.9% (+/-1.4%) increase in speed in a time trial. Change in performance had an unclear relationship to total altitude exposure, genotype for angiotensin converting enzyme, and change in haemoglobin concentration. Our findings are consistent with little or no effect of use of altitude tents on sea-level performance.

The reliability of lactate measurements during exercise.

The purpose of this study was to establish the reliability of lactate threshold (LT) measurement across days. Twelve endurance-trained males aged 21-44 years participated in the study. Blood lactate concentration in capillary whole blood was measured at rest and at completion of 5 minute stages on a treadmill at 60%, 65%, 71%, 77%, 83% and 89% of VO2max during 3 separate days of testing. Velocity at LT (LT(VEL)), oxygen consumption at LT (LT(VO2)), and heart rate at LT (LT(HR)) are determined using each of the following criteria: fixed lactate concentrations of 2.0 mmol, 2.5 mmol, and 4.0 mmol, the breakpoint of the lactate-intensity curve, 1 mmol above rest, and 1 mmol above exercise baseline. A one factor repeated measures ANOVA model was used to calculate intraclass reliability coefficients across the 3 testing sessions. Confidence intervals (95%) were calculated around the point estimates of reliability for each LT criterion. Intraclass correlation coefficients ranged from 0.98 to 0.99 LT(VEL) (SEM 0.06 to 0.14 km x hr(-1)), from 0.91 to 0.96 for LT(VO2) (SEM 0.34 to 0.72 ml x kg(-1) x min(-1)), and from 0.75 to 0.96 for LTHR (SEM 0.7 to 1.9 beats x min(-1)). These results support the reliability of LT(VEL), LT(VO2), and LT(HR) measurement.