Hamed Ahmadi

Enhanced Recovery Protocol after Radical Cystectomy for Bladder Cancer

PURPOSEnEnhanced recovery after surgery protocols aim to improve patient care and decrease complications and hospital stay. We evaluated our enhanced recovery after surgery protocol, focusing on length of stay, early complication and readmission rates after radical cystectomy for bladder cancer.nnnMATERIALS AND METHODSnFrom May 2012 to July 2013 a perioperative protocol was applied in 126 consecutive patients who underwent open radical cystectomy and urinary diversion. Nonconsenting patients (2), those with previous diversion (2) and prolonged postoperative intubation (3), and those who underwent additional surgery (9) were excluded from study. The protocol focuses on avoiding bowel preparation and nasogastric tube, early feeding, nonnarcotic pain management and the use of cholinergic and μ-opioid antagonists. Outcomes were compared to those in matched controls from our bladder cancer database.nnnRESULTSnA total of 110 patients with a median age of 69 years were included in analysis, of whom 68% underwent continent urinary diversion. Of the patients 82% had a bowel movement by postoperative day 2. Median length of stay was 4 days. The 30-day minor and major complication rates were 64% and 14%, respectively. The most common minor complication was anemia requiring transfusion in 19% of patients, urinary tract infection in 13% and dehydration in 10%. The latter 2 complications were the most common etiologies for readmission. The 30-day readmission rate was 21% (23 patients). Patients 75 years old or older had a longer length of stay (5 vs 4 days, p = 0.03) and a higher minor complication rate (72% vs 51%, p = 0.04) than younger patients.nnnCONCLUSIONSnOur enhanced recovery after surgery protocol expedites bowel function recovery and shortens hospital stay after RC and urinary diversion without an increase in the hospital readmission rates.

Androgen deprivation therapy: evidence-based management of side effects.

The benefits of androgen deprivation therapy (ADT) are well recognized and a multitude of studies have documented the benefits of ADT in conjunction with other therapies. Given the widespread use of ADT due to its important clinical implications, it is imperative that clinicians understand the side effects to limit treatment‐related morbidity. There are numerous well recognized adverse effects of ADT, including vasomotor flushing, loss of libido and impotence, fatigue, gynaecomastia, anaemia, osteoporosis and metabolic complications, as well as effects on cardiovascular health and bone density. Present study focuses on the most recent evidence‐based treatment options for various side effects of ADT.

Urinary Functional Outcome Following Radical Cystoprostatectomy and Ileal Neobladder Reconstruction in Male Patients

PURPOSEnOrthotopic neobladder reconstruction is the preferred method of urinary diversion after radical cystoprostatectomy. We evaluated urinary functional outcomes in male patients after orthotopic neobladder using a patient questionnaire.nnnMATERIALS AND METHODSnBetween 2002 and 2009 patients with bladder cancer were enrolled in a clinical trial, randomly assigned to undergo T pouch or Studer pouch diversion after radical cystoprostatectomy. Male patients were mailed a questionnaire 12 or more months after surgery including items on urinary function, intermittent catheterization, number/size/wetness of pads and mucus leakage.nnnRESULTSnThe questionnaire response rate was 68%. Mean followup was 4.5 years (range 1 to 8). Only 22.3% of patients did not use pads. In the daytime 47% of patients used at least 1 pad, 32.2% used small/mini pads and 22.6% used diapers. At night 72% used pads, 14.7% used small/mini pads and 38.9% used diapers. During the day and night 47% said their pads were dry/barely wet. Overall 62.5% of patients reported mucus leakage. Only 9.5% of patients performed clean intermittent self-catheterization, of whom 70.6% started clean intermittent self-catheterization within the first year after surgery. Increasing age and diabetes mellitus were predictors of urinary function (p = 0.005 and 0.03, respectively) but did not affect pad use.nnnCONCLUSIONSnIleal orthotopic neobladder offers good functional results but most patients wear at least 1 pad and many require diapers at night. Increasing age and diabetes mellitus predict worse urinary function but are not associated with pad use. Emptying failure is uncommon and occurs early in the postoperative period. Pad size/wetness and mucus leakage should be considered when evaluating urinary incontinence.

The protective effect of diabetes mellitus against prostate cancer: Role of sex hormones

Diabetes mellitus (DM) has been associated with decreased risk of prostate cancer (PC) in several reports. Hormonal environment of diabetic patients is believed to be an important contributing factor in this regard.

Animated Biofeedback: An Ideal Treatment for Children With Dysfunctional Elimination Syndrome

PURPOSEnAnimated biofeedback is an established treatment for pediatric dysfunctional voiding. Bowel dysfunction is closely associated with dysfunctional voiding. We evaluated the efficacy of animated biofeedback urotherapy in bowel and voiding dysfunction in children with dysfunctional elimination syndrome.nnnMATERIALS AND METHODSnA total of 80 children with dysfunctional elimination syndrome were randomly assigned to undergo animated biofeedback (group A, 40 patients) or conservative therapy (group B, 40 patients). Group A underwent animated biofeedback along with pelvic floor muscle exercises and behavioral modification (hydration, high fiber diet, scheduled voiding). Group B underwent behavioral modification only. Dysfunctional voiding symptom score, constipation and fecal soiling episodes per week (according to Paris Consensus on Childhood Constipation Terminology criteria), and uroflowmetry parameters were evaluated before and 6 and 12 months after treatment in both groups.nnnRESULTSnSubjective and objective voiding problems were significantly improved. Vesicoureteral reflux resolved in 7 of 9 children (78%) and urinary tract infection did not recur in 10 of 14 children (71%) within 1 year. Bladder capacity and voided volume did not significantly improve. Post-void residual and voiding time decreased considerably, while maximum and average urine flow increased significantly. All children with fecal soiling and 17 of 25 with constipation (68%) in group A were symptom-free within 1 year after treatment. Animated biofeedback therapy was more efficient than nonbiofeedback management regarding objective and subjective voiding problems and bowel dysfunction (p <0.05).nnnCONCLUSIONSnAnimated biofeedback effectively treats bowel and voiding dysfunction in children with dysfunctional voiding. Pelvic floor muscle exercises coordinate breathing and pelvic floor muscle contractions, and are beneficial in improving bowel dysfunction.

Preoperative Staging of Invasive Bladder Cancer With Dynamic Gadolinium-enhanced Magnetic Resonance Imaging: Results From a Prospective Study

OBJECTIVEnTo evaluate the accuracy of dynamic gadolinium-enhanced magnetic resonance imaging (DGE-MRI) to detect extravesical bladder cancer (BC) and lymph node-positive disease in patients with invasive BC.nnnMATERIAL AND METHODSnIn a prospective single-center study from 2004 to 2009, patients with clinically invasive BC, who were candidates for curative surgery, underwent preoperative DGE-MRI. Radiologic T and N staging was determined by 2 MRI expert radiologists, and the interobserver agreement was calculated. The sensitivity, specificity, positive and negative predictive values, and accuracy of radiologic staging in differentiating lymph node-negative organ-confined vs nonorgan-confined BC and negative vs positive nodal disease was determined and compared with the postoperative pathologic staging as the reference standard method.nnnRESULTSnA total of 122 patients (72 men) with a mean age of 67.8 years were included. Pathologic examination revealed invasive BC in 80/122 (65.5%), including stage pT4 in 15/122 (12.3%), pT3 in 27/122 (22.1%), and pT2 in 38/122 (31.1%), and 27 patients (22.1%) had node-positive disease. The interobserver agreement for T and N staging according to the κ score was 0.44 and 0.49, respectively. The sensitivity, specificity, and accuracy of DGE-MRI in differentiating lymph node-negative organ-confined from nonorgan-confined BC was 87.5%, 47.6%, and 74% and for the detection of positive nodal disease was 40.7%, 91.5%, and 80.3%, respectively.nnnCONCLUSIONnWe have presented the results of the largest cohort of patients with invasive BC underwent preoperative DGE-MRI. Although DGE-MRI improved T and N staging of invasive BC, it is still not the ideal modality and needs a standardized protocol for interpretation of the imaging findings.

Major Dietary Factors and Prostate Cancer Risk: A Prospective Multicenter Case-Control Study

The association between diet and prostate cancer (PC) risk, although suggestive, still remains largely elusive particularly in the Asian population. This study sought to further evaluate the possible effects of different dietary factors on risk of PC in Iran. Using data from a prospective hospital-based multicenter case-control study, dietary intakes of red meat, fat, garlic, and tomato/tomato products, as well as thorough demographic and medical characteristics, were determined in 194 cases with the newly diagnosed, clinicopathologically confirmed PC and 317 controls, without any malignant disease, admitted to the same network of hospitals. Odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were obtained after adjustment for major potential confounders, including age, body mass index, smoking, alcohol, education, occupation, family history of PC, and total dietary calories. Comparing the highest with the lowest tertile, a significant trend of increasing risk with more frequent consumption was found for dietary fat (OR: 1.79, 95% CI: 1.71–4.51), whereas inverse association was observed for tomato/tomato products (OR: 0.33, 95% CI: 0.16–0.65). A nonsignificant increase in PC risk was revealed for dietary red meat (OR: 1.69, 95% CI: 0.93–3.06). For garlic consumption, a borderline reduction in risk was observed (OR: 0.58, 95% CI: 0.32–1.01; P = 0.05). In conclusion, our study supports the hypothesis that total fat may increase PC risk and tomatoes/tomato products and garlic may protect patients against PC.

Intravesical Electromotive Botulinum Toxin Type A Administration—Part II: Clinical Application

OBJECTIVESnTo assess the effect of electromotive botulinum toxin type A administration on urodynamic variables, urinary/fecal incontinence, and vesicoureteral reflux (VUR) due to refractory neurogenic detrusor overactivity in children with myelomeningocele.nnnMETHODSnA total of 15 children (mean age 7.8 years) were included. Using a specially designed catheter, 10 IU/kg of electromotive botulinum toxin type A was inserted into the distended bladder. While connected to the indwelling catheter and 2 dispersive pads, a pulsed current generator delivered 10 mA for 15 minutes. The urodynamic parameters, including reflex volume, maximal bladder capacity, maximal detrusor pressure, and end-fill pressure, and the urinary/fecal incontinence status and VUR grade were evaluated before and at 1, 4, and 9 months after treatment.nnnRESULTSnThe mean reflex volume and maximal bladder capacity had increased considerably (99 ± 35 mL versus 216 ± 35 mL and 121 ± 39 mL versus 262 ± 41 mL, respectively; P < .001). In contrast, the mean maximal detrusor pressure and end-fill pressure had significantly decreased (75 ± 16 cm H(2)O versus 39 ± 10 cm H(2)O and 22 ± 7 cm H(2)O versus 13 ± 2 cm H(2)O) after treatment. The difference was statistically significant (P < .001). Urinary incontinence improved in 12 patients (80%). The VUR grade substantially decreased in 7 of the 12 children (mean VUR grade 2.25 ± 1.3 versus 1.37 ± 0.7; P = .001), and none of the children required surgical intervention. Fecal incontinence was alleviated in 10 (83.3%) of the 12 children. Skin erythema and burning sensation were observed in 6 children.nnnCONCLUSIONSnThe results of our study have shown that electromotive botulinum toxin type A administration is a feasible and safe method with no need for anesthesia. This novel delivery system resulted in considerable improvement in the urodynamic parameters, urinary/fecal incontinence, and VUR in patients with refractory neurogenic detrusor overactivity.

Incidental Prostate Cancer in Patients with Bladder Urothelial Carcinoma: Comprehensive Analysis of 1,476 Radical Cystoprostatectomy Specimens

PURPOSEnWe identified risk factors and determined the incidence and prognosis of incidental, clinically significant prostatic adenocarcinoma, prostatic urothelial carcinoma and HGPIN in patients treated with radical cystoprostatectomy for urothelial carcinoma of the bladder.nnnMATERIALS AND METHODSnWe analyzed the records of 1,476 patients without a history of prostatic adenocarcinoma. We determined the incidence of clinically significant prostatic adenocarcinoma, prostatic urothelial carcinoma and HGPIN in the total cohort and in select patient subgroups. Prostatic urothelial carcinoma was stratified as prostatic stromal and prostatic urethral/duct involvement. Univariate and multivariate analyses were performed with multiple variables. Recurrence-free and overall survival rates were calculated. Median followup was 13.2 years.nnnRESULTSnOf the 1,476 patients 753 (51.0%) had cancer involving the prostate. Prostatic adenocarcinoma, clinically significant prostatic adenocarcinoma, prostatic urothelial carcinoma and HGPIN were present in 37.9%, 8.3%, 21.1% and 51.2% of patients, respectively. Of the 312 patients (21.1%) with prostatic urothelial carcinoma 163 (11.0%) had prostatic urethral/duct involvement only and 149 (10.1%) had prostatic stromal involvement. We identified risk factors for clinically significant prostatic adenocarcinoma, prostatic urothelial carcinoma and HGPIN but the absence of these risk factors did not rule out their presence. Ten-year overall survival in patients with no prostatic urothelial carcinoma, and prostatic urethral/duct and prostatic stromal involvement was 47.1%, 43.3% and 21.7%, respectively (p<0.001). No patient with clinically significant prostatic adenocarcinoma died of prostatic cancer.nnnCONCLUSIONSnMore than half of the patients undergoing radical cystoprostatectomy had cancer involving the prostate. Prostatic urothelial carcinoma, particularly with prostatic stromal involvement, was associated with a worse prognosis, while clinically significant prostatic adenocarcinoma did not alter survival. Preoperative clinical and histopathological risk factors are not reliable enough to accurately predict clinically significant prostatic adenocarcinoma and/or prostatic urothelial carcinoma.

Intraprostatic botulinum toxin type A injection for the treatment of benign prostatic hyperplasia: Initial experience with Dysport™

Abstract Objective. To evaluate the effect of intraprostatic botulinum toxin type A (BoNTA, Dysport™) injection on lower urinary tract symptoms, prostate-specific antigen (PSA), prostate volume (PV), peak urine flow rate (Qmax) and postvoiding residue (PVR), and to evaluate the role of PV in the treatment outcome. Material and methods. Seventy-two men with PSA <u20094 ng/ml, International Prostate Symptom Score (IPSS) ≥ 8, Qmax <u200912 ml/s and PV <u200960 ml were enrolled. A total of 300–600 U Dysport was injected transperineally under transrectal ultrasound guidance. Initial IPSS, quality of life (QoL) score, Qmax and PVR were compared with their measures at 1, 6 and 12 months after the injection. Initial PSA and PV were compared with their values after 6 months. Parameters were also compared between patients with PV ≤ 30 ml and those with PV >u200930 ml. Results. The mean age of participants was 63.5 years. At follow-up sessions, IPSS and QoL score were significantly decreased (p <u20090.001). PVR reduced significantly and Qmax increased considerably (p <u20090.001). PSA and PV substantially decreased after 6 months (p <u20090.001). No serious complications were reported. Similar to patients with larger prostates, IPSS and QoL score decreased statistically significantly after 12 months in those with PV ≤ 30 ml; however, changes in PV, PSA, PVR and Qmax did not persist during 12 months follow-up. Conclusions. The procedure is safe and efficacious and the results are comparable to previous experiences with Botox®. It seems that the toxin efficacy depends directly on PV in prostates <u200960 ml.