Cancer Care Ontario Guidelines for radical prostatectomy: striving for continuous quality improvement in community practice.

OBJECTIVE: : Cancer Care Ontario has published an evidence-based guideline on their website "Guideline for Optimization of Surgical and Pathological Quality Performance for Radical Prostatectomy in Prostate Cancer Management: Surgical and Pathological Guidelines." The evidentiary base for this guideline was recently published in CUAJ. The CCO guideline proposes the following: a positive surgical margin (PSM) rate of <25% for organ-confined disease (pT2), a perioperative mortality of <1%, a rate of rectal injury <1%, and a blood transfusion rate <10% in non-anemic patients. The objective of this study was to review the radical prostatectomy practice at the Grey Bruce Health Services, an Ontario community hospital, and to compare our performance in relation to the Cancer Care Ontario guideline and the literature. METHODS: : We conducted a retrospective review of all radical prostatectomies performed at the Grey Bruce Health Services from January 1, 2006 to December 31, 2007. The following data were obtained from clinical records and pathology reports: patient age, pre-biopsy prostate-specific antigen, biopsy Gleason score, resected prostate gland weight, radical prostatectomy Gleason score, surgical margin status, pathological tumour stage (pT), lymph node dissection status, perioperative incidence of transfusion of blood products and if the patient was anemic (hemoglobin <140 g/L) preoperatively, incidence of rectal injury, and perioperative mortality within 30 days following surgery. RESULTS: : Using the method proposed by D'Amico, most patients undergoing radical prostatectomy were intermediate risk (62%), with a minority of low-risk (24%) and high-risk (14%) patients. The overall PSM rate was 37%. The rate of PSMs in organ-confined disease (pT2) was 26%. There was a statistically significant trend between increasing D'Amico risk category and increasing rate of PSM (Cochran-Armitage trend test, p = 0.023). There was a strong correlation between the pathological tumour stage and the rate of PSM (Cochran-Armitage trend test, p = 0.0003). The rate of blood transfusion in non-anemic patients was 6%. There was 1 patient (0.8%) who experienced a rectal injury. There were no perioperative deaths in our study group. CONCLUSION: : Our results show that a community hospital group can appropriately select patients to undergo radical prostatectomy, as well as achieve an acceptable rate of PSMs. We believe that ongoing critical appraisal and reflective practice are essential to improving surgical outcomes and providing quality care.

Prostate gland biopsies and prostatectomies: an Ontario community hospital experience.

OBJECTIVE: Transrectal ultrasound-guided core biopsies of the prostate gland and prostatectomies have become common procedures at many community hospitals in Canada, especially in the era of serum prostate-specific antigen (PSA) screening for prostate cancer. The Gleason grading of prostate cancer in biopsies and prostatectomies is a major determinant used for treatment planning. There is evidence in the literature that suggests important discordance between community hospital pathologists and urological pathologists with respect to the Gleason grading of prostate cancer. Our objective was to determine the diagnostic rates and Gleason scoring patterns for prostate gland biopsies and prostatectomies at our institution compared with the literature. METHODS: We conducted a retrospective review of all prostate gland biopsies and prostatectomies performed at the Grey Bruce Health Services from January 2005 to September 2005. We collected data from 194 biopsies and 44 prostatectomies. We obtained prebiopsy serum PSA levels and digital rectal exam results for all patients from urologists' office records. RESULTS: The average age for men having biopsies was 65.8 (standard deviation [SD] 8.6) years, and the average prebiopsy serum PSA level was 8.7 (median 7.1, SD 6.2) mug/L. The rates of diagnosis from prostate gland biopsies of benign (17.6%), high-grade prostatic intraepithelial neoplasia (11.0%), atypical small acinar proliferation suspicious for invasive malignancy (13.2%) and invasive prostatic adenocarcinoma (58.2%) at our institution were significantly different than those reported in the literature (p < 0.001). We observed a significant variation in the rates of these diagnoses among the community hospital pathologists in our study (p = 0.004). There was a strong correlation between the increasing number of positive core biopsy sites and increasing Gleason scores in biopsies (p < 0.001). There was also a strong correlation between increasing pre-biopsy serum PSA levels and increasing Gleason scores in biopsies (p < 0.001). A substantial proportion (21.9%) of the biopsies given the Gleason score of 6 had a Gleason score of 7 in the prostatectomy specimen. CONCLUSION: Our results showed a significant difference in prostate gland biopsy categorical diagnoses compared with the literature. There were also significant differences in categorical diagnoses of prostate gland biopsies among the community hospital pathologists in our study. The data identify a strong positive correlation between the increasing number of positive core biopsy sites and increasing Gleason scores in biopsies, as well as a strong positive correlation between increasing prebiopsy serum PSA levels and increasing Gleason scores in biopsies that revealed cancer. We would encourage other community hospital pathologists, in collaboration with their urologists, to review periodically their prostate gland pathology practices in an attempt to improve the uniformity of diagnoses.

Measuring the true success of laparoscopic pyeloplasty.

BACKGROUND AND PURPOSE: Laparoscopic pyeloplasty (LP) is a highly successful minimally invasive management option for ureteropelvic junction obstruction (UPJO) with success rates equaling or surpassing open repair. Definitions of success have varied greatly among reports of series in the literature. We propose that true success or failure be strictly defined by resolution of obstruction on objective physiologic testing (diuretic renography or Whitaker testing) and accordingly present our results. PATIENTS AND METHODS: We prospectively gathered data on all LP from December 2001 to November 2006. Ninety-two patients have matured to follow-up testing (> 3 months). Primary uncomplicated procedures were completed in 62/92 (67%) while secondary and/or complex repairs were performed in 30/92 (33%). Rigorous follow-up with physiologic testing was performed postoperatively. Patients with equivocal diuretic renal scans were evaluated with Whitaker pressure-flow studies. The subjective symptom score was assessed for our first 47 patients using a visual analog scale (VAS). Treatment in patients who lacked objective evidence of resolution of UPJO was considered a failure. RESULTS: The mean age of the cohort was 39 years (range 18-69 yrs). Average operating room time was 250 minutes (range 138-488 min), and estimated blood loss was 63 mL (range 10-500 mL). Average hospital length of stay was 1.2 days (range 1-6 d). Crossing vessels were identified in 47/92 (51%) patients. Overall mean follow-up was 13 months (range 2-54 months). There were no intraoperative complications and three perioperative complications. Overall, 85/92 (92%) patients were found to have resolution of UPJO on postoperative physiologic testing. The primary uncomplicated cohort success rate was 98%, while that for the secondary or complex repair cohort was 80%. The mean overall VAS pain score was 84%. CONCLUSION: Objective physiologic testing should be used as the measurement of true success after LP. A uniform definition of success will allow improved comparison of results with literature series and comparison with alternative management modalities.

Intraoperative blood loss and transfusion requirements for robotic-assisted radical prostatectomy versus radical retropubic prostatectomy.

OBJECTIVES: To compare intraoperative blood loss, perioperative hematocrit, and transfusion requirements in patients undergoing radical retropubic prostatectomy (RRP) versus robotic-assisted laparoscopic prostatectomy (RALP) by a single surgeon. METHODS: During a 14-month period, 279 patients with localized carcinoma of the prostate were prospectively enrolled in this comparative study. The decision of which surgical approach to use was by patient choice. Of the 279 patients, 176 underwent RALP and 103 underwent RRP. The serum hematocrit was obtained preoperatively and 24 hours postoperatively in all patients. The intraoperative blood loss was recorded, and transfusion requirements were noted. RESULTS: Patients in the RALP group had significantly less intraoperative blood loss compared with the RRP group (mean 191 mL versus 664 mL, P < 0.001). Additionally, the difference in the discharge hematocrit (36.8% versus 32.8%, P < 0.001) and the mean perioperative change in hematocrit (8.0% decrease versus 10.7% decrease, P < 0.001) were significant between the RALP and RRP groups, respectively. Three patients in the RRP group (2.9%) and one in the RALP group (0.5%) required transfusion of blood products (P = 0.14). CONCLUSIONS: The results of this study have shown that RALP is associated with less intraoperative bleeding than RRP, and patients undergoing RALP have a greater serum hematocrit at hospital discharge. The lack of a statistically significant difference in blood transfusion was partially attributable to the low transfusion rate in both groups in this series.

Second prize: simple method for achieving renal parenchymal hypothermia for pure laparoscopic partial nephrectomy.

PURPOSE: We describe the development of an innovative device and simple technique for achieving renal parenchymal hypothermia during temporary renal-vascular occlusion for pure laparoscopic partial nephrectomy. MATERIALS AND METHODS: The experiment was conceived in four phases: phase 1: design, manufacture, and testing of the cooling coil; phase 2: proof of concept in nonsurvival porcine surgery; phase 3: experimental porcine survival surgery; and phase 4: human trials. RESULTS: Phase 1 testing confirmed that the coil cooled adequately. During phase 2, the average time required for the renal parenchyma to cool to 15 degrees C was 10.7 minutes, providing an average hypothermic window (15 degrees -24 degrees C) of 30.3 minutes. When recooling was required (parenchymal temperature 24 degrees C), temperatures returned to below 15 degrees C in 3 minutes. The core body temperature dropped an average of 1.48 degrees C. Phase 3 demonstrated an average parenchymal temperature of 11.7 degrees C after a mean cooling time of 9.3 minutes. Temperatures remained below 24 degrees C for an average of 26.7 minutes. Recooling took 3 minutes, and in no procedure did the renal parenchyma temperatures ever return to >24 degrees C prior to reperfusion. The core body temperature dropped an average of 2.20 degrees C. At 48 hours after reperfusion, selective renal-vein blood was obtained for creatinine assay, and the kidneys were harvested. Creatinine results were not statistically different in the treated and control groups. Blinded pathologic analysis confirmed a protective effect using our cooling system. CONCLUSION: Our method is simple, effective, and reproducible.

Robotic assisted laparoscopic radical prostatectomy versus retropubic radical prostatectomy: a prospective assessment of postoperative pain.

PURPOSE: Laparoscopic prostatectomy, whether or not coupled with robotic assistance, is often considered less invasive than open radical retropubic prostatectomy (RRP). Minimal postoperative pain has been reported following robot assisted laparoscopic prostatectomy (RALP) but there have been few comparative studies with RRP. We compared perioperative narcotic use and patient reported pain in a prospective patient series. MATERIALS AND METHODS: Between June 2003 and May 2004, 314 patients underwent radical prostatectomy at our institution, including RALP in 159, RRP in 154 and conversion in 1. All patients were treated on a postoperative clinical pathway that included 30 mg ketorolac intravenously immediately postoperatively, followed by 15 mg intravenously every 6 hours. No regional anesthesia (epidural/spinal) narcotics or patient controlled analgesic pumps were used. All narcotic use was converted to morphine sulfate equivalents for purpose of analysis. A Likert scale of 0 to 10 was used to assess pain on the day of surgery, and on postoperative days 1 and 14. RESULTS: The total mean morphine sulfate equivalent +/- SD in patients in the RALP and RRP groups was low and, when corrected for length of stay, it was not statistically different (22.41 +/- 1.13 vs 23.01 +/- 1.16 mg, p = 0.72). Mean Likert pain perception scores were low at all time points in the RALP and RRP groups but statistically lower on the day of surgery in the RALP cohort (2.05 +/- 1.99 vs 2.60 +/- 2.25, p = 0.027). Patient reported mean pain scores were almost identical for RALP vs RRP on postoperative days 1 (1.76 +/- 1.87 vs 1.73 +/- 1.77, p = 0.880) and 14 (2.51 +/- 1.91 vs 2.42 +/- 1.84, p = 0.722). CONCLUSIONS: Perioperative narcotic use and patient reported pain are low regardless of the surgical approach used for radical prostatectomy. RALP did not provide a clinically meaningful decrease in pain compared with RRP, primarily because of the low pain scores reported in each group. Outcomes other than pain will ultimately determine the role of laparoscopic radical prostatectomy and RALP.

A clinical pathway for laparoscopic pyeloplasty decreases length of stay.

PURPOSE: Benefits of minimally invasive procedures include decreased hospitalization and recovery times. Decreased length of stay (LOS) improves hospital efficiency and decreases costs. However, decreasing the LOS at the expense of patient care and satisfaction is not acceptable. A clinical pathway (CP) with structured order sets and imaging was developed for patients undergoing laparoscopic pyeloplasty. This pathway includes a cascade of activities managed closely by the health care team. This study assesses the safety and patient satisfaction with this clinical pathway. MATERIALS AND METHODS: We reviewed all adult pyeloplasties (39) completed laparoscopically since November 2001. All patients were managed according to the CP developed for the laparoscopic pyeloplasty procedure. The length of stay was measured in days. Patient satisfaction was assessed with a standardized questionnaire. Any readmissions or emergency room visits were documented. RESULTS: The mean length of stay was 1.10 days. Of 39 patients 37 (94%) were discharged home on postoperative day 1. One patient with severe postoperative pain required intravenous analgesia. She had undergone complex upper tract reconstruction and stayed a total of 4 days. One patient, who had a previous failed endopyelotomy, remained 2 days for persistent nausea. No patients sought emergency room consultation and there were no readmissions. Of 39 patients 34 (87%) completed the questionnaire and satisfaction was high. CONCLUSIONS: The implementation of a CP at our institution has standardized patient care in this population and decreased LOS in comparison to the literature. This improves bed use and hospital efficiency while maintaining a high degree of patient satisfaction. We conclude that with intensive patient care and education most patients undergoing laparoscopic pyeloplasty may be discharged home safely on postoperative day 1.

Gone in 24 hours: the feasibility of performing pubovaginal sling surgery with an overnight hospital stay.

INTRODUCTION: Numerous management strategies are available for stress urinary incontinence, a significant problem for many women. The pubovaginal sling (PVS) with rectus fascia has proven efficacy with minimal morbidity. Historically, patients were admitted for an average of 4 days at the Ottawa Hospital. Since November 2001, patients have spent one night in hospital thereby cutting their total length of stay to less than 24 hours. This study assesses the feasibility of this approach. MATERIALS AND METHODS: Ethics approval was obtained. All patient charts were reviewed retrospectively. Exclusion criteria included women booked for combined procedures or patient refusal. Each case was reviewed to determine if admission to hospital following surgery was required or if subsequent visits to emergency occurred. The Financial Department of the Ottawa Hospital provided financial information to estimate cost savings. Each patient was contacted and administered a standard satisfaction questionnaire. RESULTS: The length of stay was less than 24 hours in all but one case. One patient required a 48-hour stay secondary to post operative nausea. No patient returned to the ER for assessment following discharge. The estimated cost savings were $2709 per case. Patients tolerated having this procedure performed on a daycare basis. CONCLUSIONS: PVS may be performed safely as short stay surgery with a high degree of patient satisfaction. This results in increased efficiency and improved utilization of increasingly limited healthcare resources.

Urethral erosion following autologous rectus fascial pubovaginal sling.

Urethral erosion following pubovaginal sling is a rare occurrence. When synthetic sling materials are used urethral erosion often necessitates removal of the sling and urethral reconstruction. The literature is sparse with respect to the best approach to fascial sling erosion. We report a case of a 73 year-old woman who underwent a pubovaginal sling using autologous rectus fascia for treatment of stress urinary incontinence (SUI). She developed urethral erosion following 2 weeks of clean intermittent catheterization (CIC). Visual internal urethrotomy (VIU) was performed to incise the sling and the prolene sutures were removed to eliminate any tension. The patient subsequently voided spontaneously and had resolution of her SUI. This case demonstrates that urethral erosion may occur even when fascial slings are used. Unlike synthetic slings, when autologous fascia is used, the tissue may be left in-situ. A minimally invasive approach may achieve an excellent result without the need for complex surgical repair.

Topical steroid therapy for phimosis.

INTRODUCTION: Circumcision has been the traditional treatment for phimosis. Recent reports of medical management of phimosis with topical steroids quote success rates of 67%-95%. We present our results with topical steroid therapy for treatment of phimosis. MATERIALS AND METHODS: Retrospective review of 69 boys between the age of 3 and 13 years (average 7.4) who were referred to Urology clinic over a one year period (August 1999-2000) with phimosis. Boys without a distal preputial ring were excluded. A course of triamcinolone cream was prescribed and parents/patients were instructed to apply it to the preputial outlet twice daily for one month. Six weeks after treatment initiation patients were reassessed. Results were classified as follows: Full retraction (FR)-entire glans and coronal margin seen, Moderate retraction (MR)-proximal glans seen, residual preputial adhesions, Partial retraction (PR)-distal glans and meatus seen, and Failure (F)-no change. FR, MR, and PR were considered successful outcomes. Statistical analysis was performed with Splus software using the prop.test and ordinal logistic regression procedures. RESULTS: Follow-up ranged from 1-12 months, and 8 patients were lost to follow-up. Of the remaining 61 boys, 82% (12 FR, 26 MR, 12 PR) were successfully managed with topical steroid (95% confidence interval: 69%-90%). Scarring on examination was observed to negatively impact outcome (92% versus 67%) and was statistically significant using ordinal logistic regression (Chi square test=4.48, p-value=0.034). Two boys with severe balanitis xerotica obliterans (BXO) and two boys with buried penis and penoscrotal webbing failed treatment and required surgery. There was an association noted between older age and poorer outcome but this was not statistically significant. There were no local or systemic side effects noted. CONCLUSIONS: Local application of steroid cream to the phimotic foreskin may allow some degree of retraction and avert the need for circumcision. Although the length of follow-up is insufficient to decree ultimate success, topical steroid appears to be a safe and effective treatment for boys over three years of age with evidence of a tight preputial ring. Boys with severe BXO or buried penis and penoscrotal webbing should be considered primarily for surgery.