Martin Jonsson

Early Cardiopulmonary Resuscitation in Out-of-Hospital Cardiac Arrest

BACKGROUND Three million people in Sweden are trained in cardiopulmonary resuscitation (CPR). Whether this training increases the frequency of bystander CPR or the survival rate among persons who have out-of-hospital cardiac arrests has been questioned. METHODS We analyzed a total of 30,381 out-of-hospital cardiac arrests witnessed in Sweden from January 1, 1990, through December 31, 2011, to determine whether CPR was performed before the arrival of emergency medical services (EMS) and whether early CPR was correlated with survival. RESULTS CPR was performed before the arrival of EMS in 15,512 cases (51.1%) and was not performed before the arrival of EMS in 14,869 cases (48.9%). The 30-day survival rate was 10.5% when CPR was performed before EMS arrival versus 4.0% when CPR was not performed before EMS arrival (P<0.001). When adjustment was made for a propensity score (which included the variables of age, sex, location of cardiac arrest, cause of cardiac arrest, initial cardiac rhythm, EMS response time, time from collapse to call for EMS, and year of event), CPR before the arrival of EMS was associated with an increased 30-day survival rate (odds ratio, 2.15; 95% confidence interval, 1.88 to 2.45). When the time to defibrillation in patients who were found to be in ventricular fibrillation was included in the propensity score, the results were similar. The positive correlation between early CPR and survival rate remained stable over the course of the study period. An association was also observed between the time from collapse to the start of CPR and the 30-day survival rate. CONCLUSIONS CPR performed before EMS arrival was associated with a 30-day survival rate after an out-of-hospital cardiac arrest that was more than twice as high as that associated with no CPR before EMS arrival. (Funded by the Laerdal Foundation for Acute Medicine and others.).

Mobile-Phone Dispatch of Laypersons for CPR in Out-of-Hospital Cardiac Arrest

BACKGROUND Cardiopulmonary resuscitation (CPR) performed by bystanders is associated with increased survival rates among persons with out-of-hospital cardiac arrest. We investigated whether rates of bystander-initiated CPR could be increased with the use of a mobile-phone positioning system that could instantly locate mobile-phone users and dispatch lay volunteers who were trained in CPR to a patient nearby with out-of-hospital cardiac arrest. METHODS We conducted a blinded, randomized, controlled trial in Stockholm from April 2012 through December 2013. A mobile-phone positioning system that was activated when ambulance, fire, and police services were dispatched was used to locate trained volunteers who were within 500 m of patients with out-of-hospital cardiac arrest; volunteers were then dispatched to the patients (the intervention group) or not dispatched to them (the control group). The primary outcome was bystander-initiated CPR before the arrival of ambulance, fire, and police services. RESULTS A total of 5989 lay volunteers who were trained in CPR were recruited initially, and overall 9828 were recruited during the study. The mobile-phone positioning system was activated in 667 out-of-hospital cardiac arrests: 46% (306 patients) in the intervention group and 54% (361 patients) in the control group. The rate of bystander-initiated CPR was 62% (188 of 305 patients) in the intervention group and 48% (172 of 360 patients) in the control group (absolute difference for intervention vs. control, 14 percentage points; 95% confidence interval, 6 to 21; P<0.001). CONCLUSIONS A mobile-phone positioning system to dispatch lay volunteers who were trained in CPR was associated with significantly increased rates of bystander-initiated CPR among persons with out-of-hospital cardiac arrest. (Funded by the Swedish Heart-Lung Foundation and Stockholm County; ClinicalTrials.gov number, NCT01789554.).

Robot-Assisted Radical Cystectomy with Intracorporeal Urinary Diversion in Patients with Transitional Cell Carcinoma of the Bladder

BACKGROUND Robot-assisted radical cystectomy (RARC) may reduce morbidity after cystectomy. Descriptions of the surgical techniques of RARC with intracorporeal orthotopic neobladder or ileal conduit are sparse and oncologic and functional outcome data have not been reported. OBJECTIVE We present our technique with RARC and intracorporeal urinary diversion (neobladder or ileal conduit) and present oncologic and functional outcomes, as well as complication rates. DESIGN, SETTING, AND PARTICIPANTS Single-hospital institution case-series from 2004 to 2009 including 45 selected patients (38 male, 7 female) with high-grade and/or muscle-invasive urothelial cancer of the bladder. SURGICAL PROCEDURE We performed RARC; pelvic lymph node dissection using three different templates; and a totally intracorporeal urinary diversion, either orthotopic neobladder (n=36) or ileal conduit (n=9). MEASUREMENTS Perioperative variables, pathology data, early and late complication rates, urinary continence, potency, and cancer-specific survival were evaluated as outcome measures. RESULTS AND LIMITATIONS Median patient age, operative time, estimated blood loss, and lymph node yield were 62 yr (range: 37-79), 477 min (range: 325-760), 550 ml (range: 200-2200), and 19 (range: 10-52), respectively. Nine patients were diagnosed with positive lymph nodes. Surgical margins were clear in all but one patient. Early complications occurred in 18 patients (40%). Median postoperative stay was 9 d (range: 4-78), and median postoperative follow-up time was 25 mo. Four patients died due to metastatic disease. The study is limited by a relative small sample size and no comparative group. CONCLUSIONS RARC with totally intracorporeal urinary diversion is technically feasible with good intermediate-term oncologic results. This is a nonrandomised study including a limited number of patients with a restricted follow-up time, however, and so precautions must be considered when interpreting the outcomes.

Surgery-related Complications in 1253 Robot-assisted and 485 Open Retropubic Radical Prostatectomies at the Karolinska University Hospital, Sweden

OBJECTIVES To quantify complications to surgery in patients treated with robot-assisted radical prostatectomy (RARP) and open retropubic radical prostatectomy (RRP) at our institution. Radical prostatectomy is associated with specific complications that can affect outcome results in patients. METHODS Between January 2002 and August 2007, a series of 1738 consecutive patients underwent RARP (n = 1253) or RRP (n = 485) for clinically localized prostate cancer. Surgery-related complications were assessed using a prospective hospital-based complication registry. The baseline characteristics of all patients were documented preoperatively. RESULTS Overall, 170 patients required blood transfusions (9.7%), 112 patients (23%) in the RRP group compared with 58 patients (4.8%) in the RARP group. Infectious complications occurred in 44 RRP patients (9%) compared with 18 (1%) in the RARP group. Bladder neck contracture was treated in 22 (4.5%) patients who had undergone RRP compared with 3 (0.2%) in the RARP group. Clavien grade IIIb-V complications were more common in RRP patients (n = 63; 12.9%) than in RARP patients (n = 46; 3.7%). CONCLUSIONS The introduction of RARP at our institution has resulted in decreased number of patients with Clavien grade IIIb-V complications, such as bladder neck contractures, a decrease in the number of patients who require blood transfusions, and decreased numbers of patients with postoperative wound infections.

Oncologic, Functional, and Complications Outcomes of Robot-assisted Radical Cystectomy with Totally Intracorporeal Neobladder Diversion

BACKGROUND Robot-assisted radical cystectomy (RARC) with totally intracorporeal neobladder diversion is a complex procedure that has been reported with good outcomes in small series. OBJECTIVE To present complications and oncologic and functional outcomes of this procedure. DESIGN, SETTING, AND PARTICIPANTS Between 2003 and 2012 in a tertiary referral center, 70 patients were operated on by two experienced robotic surgeons. Data were collected prospectively and reviewed retrospectively. INTERVENTION RARC with totally intracorporeal modified Studer ileal neobladder formation. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The overall outcome of RARC with a totally intracorporeal neobladder was presented by assessing (1) surgical margins, (2) recurrence or cancer-specific death at 24 mo, (3) 30-d and 90-d complications graded according to the modified Clavien-Dindo system, (4) daytime and nighttime continence (no or one pad per day) at 6 and 12 mo, and (5) satisfactory sexual activity or potency at 6 mo and 12 mo. Survival rates were estimated by Kaplan-Meier plots. RESULTS AND LIMITATIONS Median follow-up of the cohort was 30.3 mo (interquartile range: 12.7-35.6). We recorded negative margins in 69 of 70 patients (98.6%). Clavien 3-5 complications occurred in 22 of 70 patients (31.4%) at 30 d and 13 of 70 (18.6%) at >30 d. At 90 d, the overall complication rate was 58.5%. Clavien <3 and Clavien ≥3 complications were recorded in 15 of 70 patients (21.4%) and 26 of 70 (37.1%), respectively. Kaplan-Meier estimates for recurrence-free, cancer-specific, and overall survival at 24 mo were 80.7%, 88.9%, and 88.9%, respectively. Daytime continence and satisfactory sexual function or potency at 12 mo ranged between 70% and 90% in both men and women. Limitations of this study include its retrospective design, selection bias due to the learning curve phase, and missing data. CONCLUSIONS In this expert center for RARC, outcomes after RARC with totally intracorporeal neobladder diversion appear satisfactory and in line with contemporary open series.

Biochemical recurrence after robot-assisted radical prostatectomy in a European single-centre cohort with a minimum follow-up time of 5 years.

BACKGROUND Robot-assisted radical prostatectomy (RARP) is an increasingly commonly used surgical treatment option for prostate cancer (PCa); however, its longer-term oncologic results remain uncertain. OBJECTIVE To report biochemical recurrence-free survival (BRFS) outcomes for men who underwent RARP ≥5 yr ago at a single European centre. DESIGN, SETTING, AND PARTICIPANTS A total of 944 patients underwent RARP as monotherapy for PCa from January 2002 to December 2006 at Karolinska University Hospital, Stockholm, Sweden. Standard clinicopathologic variables were recorded and entered into a secure, ethics-approved database made up of those men with registered domiciles in Stockholm. The median follow-up time was 6.3 yr (interquartile range: 5.6-7.2). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The outcome of this study was biochemical recurrence (BCR), defined as a confirmed prostate-specific antigen (PSA) of ≥0.2 ng/ml. Kaplan-Meier survival plots with log-rank tests, as well as Cox univariable and multivariable regression analyses, were used to determine BRFS estimates and determine predictors of PSA relapse, respectively. RESULTS AND LIMITATIONS The BRFS for the entire cohort at median follow-up was 84.8% (95% confidence interval [CI], 82.2-87.1); estimates at 5, 7, and 9 yr were 87.1% (95% CI, 84.8-89.2), 84.5% (95% CI, 81.8-86.8), and 82.6% (95% CI, 79.0-85.6), respectively. Nine and 19 patients died of PCa and other causes, respectively, giving end-of-follow-up Kaplan-Meier survival estimates of 98.0% (95% CI, 95.5-99.1) and 94.1% (95% CI, 90.4-96.4), respectively. Preoperative PSA >10, postoperative Gleason sum ≥4 + 3, pathologic T3 disease, positive surgical margin status, and lower surgeon volume were associated with increased risk of BCR on multivariable analysis. This study is limited by a lack of nodal status and tumour volume, which may have confounded our findings. CONCLUSIONS This case series from a single, high-volume, European centre demonstrates that RARP has satisfactory medium-term BRFS. Further follow-up is necessary to determine how this finding will translate into cancer-specific and overall survival outcomes.

Robot-assisted Radical Cystectomy: Description of an Evolved Approach to Radical Cystectomy

BACKGROUND Although open radical cystectomy (ORC) remains the gold standard of care for muscle-invasive bladder cancer, robot-assisted radical cystectomy (RARC) continues to gain wider acceptance. In this article, we focus on the steps of RARC, describing our approach, which has been developed over the past 10 yr. Totally intracorporeal RARC aims to offer the benefits of a complete minimally invasive approach while replicating the oncologic outcomes of open surgery. OBJECTIVE We report our outcomes of a totally intracorporeal RARC procedure, describing step by step our technique and highlighting the variations on this standard template of nerve-sparing and female organ-preserving approaches in men and women. DESIGN, SETTING, AND PARTICIPANTS Between December 2003 and October 2012, a total of 113 patients (94 male and 19 female) underwent totally intracorporeal RARC. SURGICAL PROCEDURE We performed RARC, extended pelvic lymph node dissection, and a totally intracorporeal urinary diversion (UD) in all patients. In the accompanying video, we focus on the standard template for RARC, also describing nerve-sparing and female organ-preserving approaches. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Complications and oncologic outcomes are reported, including overall survival (OS) and cancer-specific survival (CSS) using Kaplan-Meier analysis. RESULTS AND LIMITATIONS RARC with intracorporeal UD was performed in 113 patients. Mean age was 64 yr (range: 37-84). Forty-three patients underwent intracorporeal ileal conduit, and 70 had intracorporeal neobladder. On surgical pathology, 48% of patients had ≤ pT1 disease, 27% had pT2 disease, 13% had pT3 disease, and 12% had pT4 disease. The mean number of lymph nodes removed was 21 (range: 0-57). Twenty percent of patients had lymph node-positive disease. Positive surgical margins occurred in six cases (5.3%). Median follow-up was 25 mo (range: 3-107). We recorded a total of 70 early complications (0-30 d) in 54 patients (47.8%), with 37 patients (32.7%) having Clavien grade ≥ 3. Thirty-six late complications (>30 d) were recorded in 30 patients (26.5%), with 20 patients (17.7%) having Clavien grade ≥ 3. One patient (0.9%) died within 90 days of operation from pulmonary embolism. Using Kaplan-Meier analysis, CSS was 81% at 3 yr and 67% at 5 yr. CONCLUSIONS Our structured approach to RARC has enabled us to develop this complex service while maintaining patient outcomes and complication rates comparable with ORC series. Our results demonstrate acceptable oncologic outcomes and encouraging long-term CSS rates.

Robot-assisted radical cystectomy (RARC) with intracorporeal neobladder – what is the effect of the learning curve on outcomes?

To evaluate the effect of the learning curve on operative, postoperative, and pathological outcomes of the first 67 totally intracorporeal robot‐assisted radical cystectomies (RARCs) with neobladders performed by two lead surgeons at Karolinska University Hospital.

Open retropubic prostatectomy versus robot-assisted laparoscopic prostatectomy: A comparison of length of sick leave

Objective. It remains uncertain whether the increased direct costs of robot-assisted laparoscopic radical prostatectomy (RALP) are outweighed by cost savings due to shorter postoperative hospital care and shorter sick leave. This study compared the length of sick leave after RALP with that after radical retropubic prostatectomy (RRP). Material and methods. In a cohort study, information on length of sick leave was retrieved for 274 working men undergoing radical prostatectomy (127 RALP and 147 RRP). Data on confounders such as physical workload, average salary, body mass index and disease characteristics were collected from the medical records. Cox regression models were used to compare the treatment groups. Results. The median number of days with sick leave was 11 in the RALP group and 49 in the RRP group. After adjustment for confounders, patients in the RALP group were twice as likely to return to work at any time during follow-up (hazard ratio = 2.13, 95% confidence interval 1.62–2.80). High physical workload, low salary and high tumour grade were more common in the RRP group and associated with longer sick leave. Conclusions. Patients in the RALP group had shorter postoperative hospital stay and less need for paid sick leave than patients in the RRP group. These data indicate that RALP shortens the convalescence. Part of this difference may, however, be attributable to different selection of patients and different a priori expectations among patients and their doctors. A prospective randomized study is advocated, although blinding is unfeasible.

Surgery-related Complications of Robot-assisted Radical Cystectomy With Intracorporeal Urinary Diversion

OBJECTIVES To assess the surgery-related complications at robot-assisted radical cystectomy with total intracorporeal urinary diversion during our learning curve in treating 45 patients with bladder cancer. METHODS A total of 45 patients were pooled in 3 consecutive groups of 15 cases each to evaluate the complications according to the Clavien classification. As a surrogate for our learning curve, the following parameters were assessed: operative time, blood loss, urinary diversion type, lymph node yield, surgical margin status, and length of hospital stay. RESULTS Early surgery-related complications were noted in 40% of the patients and late complications in 30%. The early Clavien grade III complications remained significant (27%) and did not decline with time. Overall, fewer complications were observed between the groups over time, with a significant decrease in late versus early complications (P = .005 and P = .058). The mean operative times declined from the first group to the second and third groups (P = .005) and the hospital stays shortened (P = .006). No significant difference was observed between groups regarding the lymph node yield at cystectomy (P = .108), with a mean of 22.5 nodes (range 10-52) removed. More patients received an orthotopic bladder substitute (Studer) in each of the latter 2 groups than in the first. CONCLUSIONS Although robot-assisted radical cystectomy with total intracorporeal urinary diversion is a complex procedure, we observed decreased surgery-related complications and improved outcomes over time in the present series. Our results need to be confirmed by others before robot-assisted radical cystectomy with totally intracorporeal urinary diversion can be accepted as a treatment option for patients with bladder cancer.