Effectiveness and safety of inpatient versus extended venous thromboembolism (VTE) prophylaxis with heparin following major pelvic surgery for malignancy: protocol for a systematic review.

BACKGROUND: Venous thromboembolism (VTE) is a common postoperative complication associated with significant morbidity and mortality. The use of prophylactic heparin postoperatively reduces this risk, and the use of extended duration prophylaxis is becoming increasingly common. Malignancy and pelvic surgery both independently further increase the risk of postoperative VTE and patients undergoing major pelvic surgery for malignancy are at particularly high risk of VTE. However, the optimum duration of prophylaxis specifically in this population currently remains unclear. METHODS: We will conduct a systematic review of literature in accordance with the Cochrane Handbook for Systematic Reviews of Interventions (Higgins JPT, Green S. Cochrane Handbook for Systematic Reviews of Interventions version 5.1.0.,2011) to evaluate current evidence of the effectiveness and safety of inpatient versus extended VTE prophylaxis with heparin (all forms) following major pelvic surgery for malignancy. We will search PubMed, EMBASE, and the Cochrane Library. Regarding safety, Food and Drug Administration (FDA), and Therapeutic Goods Administration (TGA) websites will be searched, including all levels of evidence. Results will be the postoperative timeframe in which a VTE event can be considered to have been provoked by the surgery, and the number of patients needed to treat with both inpatient and extended prophylaxis to prevent a VTE event in this timeframe, comparing these to determine if there is a significant benefit from extended prophylaxis. DISCUSSION: This systematic review will aim to identify the postoperative period in which patients undergoing major pelvic surgery for malignancy are at further increased risk of VTE as a result of their surgery and the optimum duration of heparin VTE prophylaxis with heparin to reduce this risk. Determining this will allow evidence-based recommendations to be made for the optimum duration of heparin VTE prophylaxis post major pelvic surgery for malignancy, leading to improved standards of care that are consistent between different providers and institutions. SYSTEMATIC REVIEW REGISTRATION: In accordance with guidelines, our systematic review was submitted to PROSPERO for consideration of registration on 16/12/17 and was registered on 12/1/18 with the registration number CRD42018068961 , and it was last updated on December 1, 2018.

The impact of intra-operative cell salvage during open nephrectomy.

OBJECTIVE: To assess the impact of intra-operative cell salvage on outcomes in open nephrectomy. METHODS: A retrospective cohort study was performed of all patients undergoing open nephrectomy for suspected malignancy from 1 October 2013 to 1 October 2017. Patients were grouped and compared based on whether they received intra-operative cell salvage (ICS). Primary outcomes were allogeneic transfusion rates (ATRs), and if histology confirmed cancer, disease recurrence. Secondary outcomes were complications and transfusion-related cost. RESULTS: Forty patients underwent open nephrectomy for suspected malignancy during the enrolment period. Sixteen patients received ICS while 24 did not (standard group). Compared with the standard group, ICS patients had similar median age (63.5 vs. 61.0 years; p = 0.83) but fewer females (19% vs. 58%; p = 0.013). The groups were similar in pre-operative and discharge haemoglobin, Charlson Comorbidity Index, length of hospital stay and proportion with thoracoabdominal surgical approach. The ICS group had a smaller proportion undergoing partial nephrectomy (19% vs. 54%; p = 0.025) and shorter median follow-up (278 vs. 827 days; p = 0.0005). Histology was malignant for 14 ICS and 15 standard patients. The ICS group had more frequent ≥T2 disease (79% vs. 27%; p = 0.005). There were no positive margins. Both groups had similar ATRs (6% vs. 4%; p = 0.96), complication rates (19% vs. 29%; p = 0.46) and recurrence rates (18% vs. 7%; p = 0.40). Transfusion costs were higher amongst ICS patients (AUD $878.18 vs. $49.65 per patient). CONCLUSION: ICS appears safe, with low rates of recurrence and complication. Both groups had low ATRs, and therefore cost benefit for ICS was not seen.

Fournier's gangrene: not as lethal as previously thought? A case series.

BACKGROUND: Fournier's gangrene (FG) is a necrotizing fasciitis involving the perineum, external genitalia or perianal area. A rare condition with a historically high mortality rate (20-40%), our objective was to provide an up to date mortality rate for patients treated with multimodal therapy in a tertiary referral centre. METHODS: A retrospective review of a prospective database of FG patients treated at our tertiary referral centre was conducted. The primary end point was survival. Secondary end points included total hospital and intensive care unit (ICU) length of stay (LOS), number and type of procedures as well as considering co-morbidities at presentation as potential predisposing factor. Results were compared to those in current literature. RESULTS: Between 2012 and 2017, 15 patients were diagnosed with FG at our tertiary referral centre. One was excluded as decision to palliate was made at presentation. Of the remaining 14 patients, 13 survived representing a mortality rate of 7%. In surviving patients, total LOS was between 10 and 71 days, with a mean LOS of 36 days and median LOS of 34 days. Eight required ICU with ICU LOS between 1 and 42 days, with a mean of 10 and median of 4. Number of debridement procedures ranged from 3 to 17 with a mean and median of 6. Six patients required adjunctive procedures and 10 required reconstructive procedures. CONCLUSION: While a prolonged admission and multiple operations are expected, early diagnosis and aggressive multimodal treatment may result in a significantly better survival outcome than those quoted in previous literature.

The impact of intra-operative cell salvage during open radical prostatectomy.

BACKGROUND: To examine the effect of intra-operative cell salvage (ICS) in open radical prostatectomy. METHODS: In this retrospective cohort study, all patients undergoing open radical prostatectomy for malignancy at our institution between 10/04/2013 and 10/04/2017 were enrolled. Patients were grouped and compared based on whether they received ICS. Primary outcomes were allogeneic transfusion rates, and disease recurrence. Secondary outcomes were complications and transfusion-related cost. RESULTS: Fifty-nine men were enrolled; 30 used no blood conservation technique, while 29 employed ICS. There were no significant differences between groups in age, pre- or post-operative haemoglobin, Charlson comorbidity index, operation duration or length of stay. Tumour characteristics were also similar between groups, including pre-operative prostate specific antigen, post-operative Gleason score, T-stage, nodal status and rates of margin positivity. Compared with controls, the ICS group had longer follow up (945 vs. 989 days; P=0.0016). The control and ICS groups were not significantly different in rates of tumour recurrence (6 vs. 3 patients; P=0.30) or complications (10 vs. 5 patients; P=0.16). While the proportion of patients receiving allogenic transfusion was similar (9 vs. 6 patients; P=0.41), fewer red blood products transfused (40 vs. 12 units) meant transfusion related costs were lower in ICS patients (AUD $47,666 vs. $37,429). CONCLUSIONS: ICS reduced transfusion related costs, without affecting allogeneic transfusion rates, tumour recurrence or complication rates. These findings extend the literature supporting ICS in oncological surgery. Prospective randomised studies are needed to confirm the existing level III evidence.

High-dose rate brachytherapy compared with open radical prostatectomy for the treatment of high-risk prostate cancer: 10 year biochemical freedom from relapse.

OBJECTIVE: • To compare long-term biochemical control of high-risk prostate cancer in those men receiving high-dose rate brachytherapy (HDRB) and radical prostatectomy (RP). PATIENTS AND METHODS: • The 10-year biochemical freedom from relapse (BFR) was calculated for 243 patients who underwent either RP or combined therapy with HDRB + external beam radiotherapy + androgen deprivation between 1998 and 2000. • INCLUSION CRITERIA: clinical stage ≥ T2b, or Gleason sum ≥ 8, or PSA level of > 20 ng/mL. Groups were appraised using the Kattan nomogram for surgery to calculate progression-free probability (PFP). RESULTS: • For the RP group (153 patients) the median PSA level was 8.1 ng/mL and the median age was 62.2 years. The median 5- and 10-year predicted PFP for RP was 64% and 56 %, respectively. The 5- and 10-year BFR was 65.5% and 55.4%. There was no significant difference between the predicted and the actual PFP for the RP group (P= 0.525). • For HDRB group (90 patients). The median PSA level was 14.2 ng/mL and the median age was 67.6 years. The median 5- and 10-year predicted PFP for HDRB was 46% and 35%, respectively. The 5- and 10-year BFR was 79.6% and 53.6%. There was a significant improvement between the actual and the predicted PFP for the HDRB group (P= 0.002). CONCLUSIONS: • Amongst a high-risk cohort, patients undergoing RP performed as predicted by the pre-treatment surgical nomogram, whereas the patients undergoing HDRB performed significantly better than was predicted by the surgical nomogram at 10 years.

Mini-photoselective vaporization of the prostate for difficult intermittent self-catheterization.

Bladder neck incision or transurethral incision of the prostate is a procedure described for men with bladder outflow obstruction associated with a gland size of less than 30 ml. We report a case of a man with detrusor dysfunction who was having increasing difficulty performing clean intermittent self-catheterization of the bladder. The successful use of the 120 W lithium triborate laser to perform a "mini-photoselective vaporization of the prostate" ("mini-PVP") enabled discharge of the patient on the same day as well as resolution of the patient's difficulties in performing self-catheterization. Mini-PVP has proven to be a simple and effective approach to resolution of a prostate configuration impeding the process of clean intermittent self-catheterization.

Location and pathological characteristics of cancers in radical prostatectomy specimens identified by transperineal biopsy compared to transrectal biopsy.

PURPOSE: Anterior tumors are estimated to constitute 20% of prostate cancers. Current data indicate that transperineal biopsy is more reliable than transrectal biopsy in identifying these tumors. If correct, this superior reliability should result in an increased proportion of anterior tumors identified by transperineal biopsy. We investigated this hypothesis with reference to prostatectomy specimens. MATERIALS AND METHODS: Radical prostatectomy histopathology records were retrospectively examined. Patients were grouped based on primary transperineal or transrectal biopsy as the modality used to identify the initial cancer. After grouping, tumor location and size were recorded and, thus, the proportion of anterior tumors was determined. RESULTS: A total of 1,132 (414 transperineal and 718 transrectal) prostatectomy specimens were examined. Overall mean tumor size (1.8 and 2.0 cm(3)), stage (pT2 63.3% and 61%) and significance (5.1% and 5.1%) for the transperineal and transrectal methods were similar. However, the transperineal method was associated with proportionally more anterior tumors (16.2% vs 12%, p = 0.046), and identified them at a smaller size (1.4 vs 2.1 cm(3), p = 0.03) and lower stage (extracapsular extension 13% vs 28%, p = 0.03) compared to the transrectal method. The pT3 positive surgical margin rate for anterior vs other tumors was 69% vs 34.9%, respectively. CONCLUSIONS: Overall transrectal and transperineal biopsy identify cancers that are similar in size, stage and significance. However, transperineal biopsy detected proportionally more anterior tumors (16.2% vs 12%), and identified them at a smaller size (1.4 vs 2.1 cm(3)) and stage (extracapsular extension 13% vs 28%) compared to transrectal biopsy. Identifying anterior tumors early is important because the positive surgical margin rate for anterior pT3 lesions is significantly higher.

Acute management of priapism in men.

UNLABELLED: What's known on the subject? and What does the study add? Priapism is a rare event. However, various medications and medical conditions may increase the risk. Priapism can be ischaemic, non-ischaemic or stuttering. It is paramount to distinguish the type of priapism, as misdiagnosis may lead to significant morbidity. Ischaemic priapism represents a compartment syndrome of the penis and is therefore a medical emergency. A delay in management may significantly affect future erectile function. Stuttering priapism represents recurrent subacute episodes of ischaemic priapism, which may lead to erectile dysfunction. Thus episodes must be minimised. Non-ischaemic priapism is not a medical emergency. However, misdiagnosis and injection with sympathomimetic agents can result in system absorption and toxicity. This review article provides a summary of the evaluation and management of priapism. Furthermore, a step by step flow chart is provided to guide the clinician through the assessment and management of this complex issue. OBJECTIVES: To review the literature regarding ischaemic, non-ischaemic and stuttering priapism. To provide management recommendations. PATIENTS AND METHODS: A Medline search was carried out to identify all relevant papers with management guidelines for priapism. RESULTS: Ischaemic priapism represents a compartment syndrome of the penis and urgent intervention is required to decrease the risk of erectile dysfunction. Non-ischaemic priapism is not a medical emergency; however, it can result in erectile dysfunction. The treatment objective for stuttering priapism is to reduce future episodes with systemic treatments, whilst treating each ischaemic episode as an emergency. CONCLUSIONS: Priapism is a complex condition that requires expert care to prevent complications and irreversible erectile dysfunction.

Urolithiasis--medical therapies.

UNLABELLED: This review paper provides a summary of medical therapies available for urolithiasis. The summary includes general medical advice, prophylactic medications, dissolution therapy and medical expulsion therapy. The paper is designed to provide a management strategy for all physicians who treat urolithiasis, from general practitioners, to emergency physicians, to urologists. OBJECTIVE: • To provide an up to date review of the literature in relation to the medical management of stone disease. This will encompass prophylaxis, dissolution therapy and medical expulsion therapy. PATIENTS AND METHODS: • First-time stone formers do not regularly have a full urine and electrolyte evaluation due to the low incidence of a reversible metabolic cause. • However, stone disease is common and over a lifetime urolithiasis can affect up to 10-15% of the population. RESULTS: • Medical management of stone disease encompasses preventative measures, medical dissolution and medical expulsion therapy. CONCLUSIONS: • Recurrent stone formers should have dietary optimization to decrease the risk of further stones. • Furthermore, the correct use of prophylactic and therapeutic medications can decrease the morbidity associated with ureteric calculi.

Photoselective vaporization of the prostate in men taking clopidogrel.

AIM: To evaluate the peri-operative morbidity of men taking clopidogrel who underwent photoselective vaporisation of the prostate (PVP). PATIENTS AND METHODS: A prospective database was collected. Between March 2005 and July 2010, 480 men underwent PVP. Of these, 18 men underwent PVP treatment while on clopidogrel. The surgery was carried out with either an 80W KTP laser or a 120W lithium triborate laser. RESULTS: In the peri-operative period there were no complications related to PVP. There were no urinary tract infections, nor did any patient require bladder re-catheterisation. No cardiovascular events were reported within 3 months of the procedure. At 3 months post operatively, the International Prostate Symptom Score±standard deviation had improved from was 17.5±10.6 to 9.2±6.1 P<0.05. While the Quality of Life±standard deviation improved from 4.7±1.2 to 2.2±1.5 P<0.01. The maximum flow rate (Qmax), and post void residual volume (PVR) improved from 6.2±3.0 mL/s to 19.7±9.1 mL/s (P<0.01), and 140±102 mL to 59±77 mL (P<0.05), respectively. CONCLUSIONS: PVP is a safe and efficacious in the treatment of high risk patients with bladder outlet obstruction. Further, the ability to continue therapeutic anticoagulation and anti-platelet agents, is a significant advantage over Holmium enucleation of the prostate and conventional transurethral resection of the prostate. Larger studies with greater numbers of patients are required prior to PVP becoming the gold standard for high-risk patients with bladder outlet obstruction.

Hydrodissection of neurovascular bundles during open radical prostatectomy improves postoperative potency.

PURPOSE: Preservation of the neurovascular bundle during radical prostatectomy is important for postoperative erectile function. We determined whether hydrodissection of the neurovascular bundle during radical prostatectomy would result in improved erectile function postoperatively. MATERIALS AND METHODS: Included in the study were 253 consecutive men who underwent nerve sparing radical prostatectomy, as done by 1 high volume surgeon (MIP). The first 117 and the next 136 men underwent standard dissection and hydrodissection, respectively, of the neurovascular bundle. In all men erectile function was evaluated by Sexual Health Inventory for Men score preoperatively, and 6 weeks and 6 months postoperatively. Time needed to achieve successful intercourse was also determined. RESULTS: In men with bilateral neurovascular bundle preservation mean Sexual Health Inventory for Men scores in the hydrodissection group were higher than in the standard dissection group by 2.8 at 6 weeks and by 3.5 at 6 months (p <0.05). In men with unilateral partial neurovascular bundle resection there was also significant improvement between the hydrodissection and standard dissection groups at 6 weeks and 6 months (p <0.05). Men with bilateral neurovascular bundle preservation who underwent hydrodissection and standard dissection required a median of 3 and 6 months, respectively, to achieve successful sexual intercourse with or without a phosphodiesterase-5 inhibitor (p <0.05). A difference was also observed in men who underwent partial neurovascular bundle resection. Hydrodissection was an independent predictor of time to successful intercourse on multivariate Cox regression analysis. CONCLUSIONS: Hydrodissection of the neurovascular bundle during open radical prostatectomy improves postoperative Sexual Health Inventory for Men scores and the time needed to achieve successful intercourse.