Canadian Journal of Urology最新文献

Radical cystectomy is a preferred treatment for muscle-invasive bladder cancer.  Despite known complications, rapid onset, severe hyperkalemia necessitating abortion of surgery has not been reported.  In this case report, a patient with end stage renal disease (ESRD) undergoing attempted cystectomy developed severe intraoperative hyperkalemia and acidosis that led to abortion of surgery and transfer to the medical intensive care unit for emergent hemodialysis.  The multifactorial etiology was related to respiratory acidosis, ESRD, patient positioning, clipping of ureters, and body habitus, as well as an idiopathic element.  Knowledge of hyperkalemia etiologies can assist in diagnosis and treatment of this serious condition.

The Hem-o-lok Weck clip is part of a polymer locking ligation system often employed for hemostasis in surgical practices. Its use is routine in a wide array of surgical subspecialties. Surgeons have limited options in removing these clips when they are aberrantly positioned. Herein, we describe a novel, cost-effective approach for removing a Hem-o-lok clip using standard robotic instruments. This simple approach will allow surgeons to remove a Hem-o-lok clip precisely and quickly if it is not adequately placed. During a routine robotic-assisted laparoscopic prostatectomy a Hem-o-lok Weck clip was noted to be in juxtaposition to the rectal wall, and it was deemed appropriate to remove it. Ultimately, the indwelling Prograsp forceps was moved from the right fourth arm position to the left arm position. This allowed the Prograsp forceps to compress the scissors in the right hand port, which was insufficient in cutting the hinge of the clip. This provided sufficient force to cut through the clip at its hinge with ease. The Hem-o-lok Weck clip is used in various surgical specialties. It is occasionally placed suboptimally and requires removal. Given the challenge of finding and using the clip removal device, surgeons should be aware of this simple and cost-effective way of removing a Hem-o-lok clip if desired.

Introduction: We aim to identify factors associated with surgical refusal and non-surgical candidacy in clinical stage I kidney masses and to evaluate their impact on overall survival (OS).

Materials and methods: We conducted a retrospective cohort study using the National Cancer Database of patients with clinical stage I kidney cancer between 2004 and 2017. Logistic regression was used to determine baseline sociodemographic-, clinical-, and treatment facility-related factors associated with surgical refusal and non-surgical candidacy. Patients were 1.1 propensity score-matched and Cox regression analysis evaluated the impact of surgical refusal and non-surgical candidacy on OS.

Results: Compared to those who underwent surgery, those who refused surgery and those who were non-surgical candidates were more likely to be older, female, non-Hispanic (NH) Black, uninsured, have multiple comorbidities, and traveled a shorter distance to care. Similarly, compared to non-surgical candidates, those who refused surgery were more likely to be younger and have a tumor size ≥ 4.0 cm. Those who refused surgery had significantly lower median survival time and worse OS than those who underwent surgery (HR: 3.18, 95% CI: 2.85, 3.54). Non-surgical candidates had significantly lower median survival time and lower OS than those who had surgery (HR: 4.16, 95% CI: 3.84, 4.51).

Conclusion: Various socioeconomic, demographic, and clinical factors are associated with patients refusing to undergo surgery, which in turn leads to lower overall survival rates in stage I kidney cancer patients. Recognizing these factors will enable healthcare professionals to address and potentially alleviate these issues, ultimately ensuring that patients receive the most appropriate care.

Pelvic organ prolapse (POP) is a common condition that significantly impairs a woman's quality of life.  Currently a range of interventions from non-surgical to surgical options exist, all with their unique advantages and disadvantages.  Among these, the EnPlace system stands out as a truly minimally invasive transvaginal percutaneous device designed to repair apical POP by bilaterally anchoring sutures to the sacrospinous ligaments.  Readers will familiarize themselves with the EnPlace, relevant historical studies, and the technique for EnPlace transvaginal percutaneous sacrospinous ligament fixation for hysteropexy or colposuspension.

Introduction: Patients seek support from online resources when facing a troubling urologic cancer diagnosis. Physician-written resources exceed the recommended 6-8th grade reading level, creating confusion and driving patients towards unregulated online materials like AI chatbots. We aim to compare the readability and quality of patient education on ChatGPT against Epic and Urology Care Foundation (UCF).

Materials and methods: We analyzed prostate, bladder, and kidney cancer content from ChatGPT, Epic, and UCF. We further studied readability-adjusted responses using specific AI prompting (ChatGPT-a) and Epic material designated as Easy to Read. Blinded reviewers completed descriptive textual analysis, readability analysis via six validated formulas, and quality analysis via DISCERN, PEMAT, and Likert tools.

Results: Epic met the recommended grade level, while UCF and ChatGPT exceeded it (5.81 vs. 8.44 vs. 12.16, p < 0.001). ChatGPT text was longer with more complex wording (p < 0.001). Quality was fair for Epic, good for UCF, and excellent for ChatGPT (49.5 vs. 61.67 vs. 64.33). Actionability was overall poor but particularly lowest (37%) for Epic. On qualitative analysis, Epic lagged on all quality measures. When adjusted for user education level (ChatGPT-a and Epic Easy to Read), readability improved (7.50 and 3.53), but only ChatGPT-a retained high quality.

Conclusions: Online urologic oncology patient materials largely exceed the average American's literacy level and often lack real-world utility for patients. Our ChatGPT-a model indicates that AI technology can improve accessibility and usefulness. With development, a healthcare-specific AI program may help providers create content that is accessible and personalized to improve shared decision-making for urology patients.

Introduction: Local disease recurrence following focal therapy (FT) for prostate cancer may be due to failure to eradicate focal disease or development of disease in the untreated prostate (in- and out-of-field recurrences). Several studies suggest in-field contrast enhancement (CE) on post-treatment multi-parametric (mp) MRI between 6-12 months following FT indicates residual disease. The present study assesses the incidence and oncologic implications of early CE observed following primary partial gland cryoablation (PPGCA).

Material and methods: The surveillance protocol for men enrolled in our prospective outcomes study following PPGCA included mpMRI at 6-12 months, 2 years, 3.5 years, and 5 years. All cases of in-field early CE were re-reviewed retrospectively and graded using the previously described Prostate Imaging after Focal Ablation scoring system. All patients exhibiting early CE were re-evaluated by a single radiologist at 2-year mpMRI Results: A total of 320 men enrolled in our PPGCA outcomes study had at least 6 months of follow up. Three hundred fifteen (98%) of these men had undergone post-PPGCA mpMRI at 6-12 months. Of these men, 9 were found to have early in-field CE and 8 underwent repeat MRI at 2 years. In all 8 cases, the CE resolved on the 2-year mpMRI. Of these 8 patients, seven underwent repeat protocol biopsy at 2 years and in-field significant disease was detected in only 1 case.

Conclusions: The most compelling evidence that early CE is not indicative of prostate cancer recurrence is that all lesions resolved within 24 months. While incidence of early CE is low, its consistent resolution calls into question the clinical significance of this finding after PPGCA.

Introduction: Niraparib, a PARP1/2 inhibitor, is newly approved in combination with abiraterone acetate (AA) plus prednisone or prednisolone (niraparib/AA+P) for the treatment of adult patients with BRCA-mutated, treatment-naïve metastatic castration resistant prostate cancer (mCRPC). Detailed guidance beyond the prescribing information may be helpful in managing the side effect profile and dosing practicalities of this combination therapy.

Materials and methods: A panel of specialists convened to design management algorithms for four common niraparib/AA+P treatment-related adverse events (AEs) in mCRPC; anemia, thrombocytopenia, hypertension, and nausea. The algorithms build on Health Canada-approved prescribing information to highlight practical considerations related to monitoring, treatment adjustment, and specialist referral to support clinical practice.

Results: The panel's recommendations were largely aligned with the niraparib/AA+P product monograph. Single agent AA+P followed by reintroduction niraparib/AA+P using the low dose formulation of niraparib/AA were common strategies for managing higher grade AE's. Recommendations for hypertension management were expanded to include a sequence of anti-hypertensive medication trials prior to a change in anti-cancer therapy, where feasible.

Conclusion: These algorithms are intended to provide practical assistance to Canadian clinicians managing the most common AEs encountered with the novel combination, niraparib/AA+P, for mCRPC.

Introduction: The evidence on the effectiveness of prehabilitation in patients undergoing bladder cancer surgery remains lacking. Thus, the aim of this study is to determine the effectiveness of prehabilitation on reducing postoperative morbidity and length of hospital stay in patients undergoing bladder cancer surgery.

Materials and methods: This systematic review included randomized controlled trials investigating the effect of prehabilitation on postoperative outcomes in patients undergoing bladder cancer surgery. A comprehensive search was conducted, with two reviewers independently screening articles and extracting data. The Cochrane Collaboration's tool was used to assess risk of bias, and GRADE to rate the quality of evidence. When possible, a random effects meta-analysis was conducted. Estimates were presented as risk ratios or mean differences with their 95% confidence intervals.

Results: Of the 2764 articles identified, five trials comprising 282 patients met the eligibility criteria. Prehabilitation modalities included preoperative exercise (3), preoperative nutrition (1), and multimodal (1). The mean age of patients ranged from 66.0 to 72.1 years. All included trials presented some or high risk of bias. Pooled analyses according to the different prehabilitation modalities demonstrated low to very low quality of evidence of no effect on postoperative complications and length of hospital stay.

Conclusion: This study revealed a small number of trials investigating the effectiveness of prehabilitation on patients undergoing bladder cancer surgery. Whether prehabilitation, including preoperative exercise, nutrition and multimodal interventions reduce postoperative morbidity and length of hospital stay following bladder cancer surgery is uncertain, as the quality of evidence is very low.