Nancy Wells

ANALYSIS OF EARLY COMPLICATIONS AFTER RADICAL CYSTECTOMY: RESULTS OF A COLLABORATIVE CARE PATHWAY

PURPOSE We examined our recent series of patients who underwent radical cystectomy to determine and analyze the early perioperative morbidity of the procedure in a contemporary series treated with the guidance of a clinical pathway. MATERIALS AND METHODS We reviewed the records of 304 consecutive patients who underwent radical cystectomy from December 1995 to July 2000. We specifically evaluated complications that developed within 30 days of the procedure. Potential variables predictive of early morbidity were analyzed, including patient age, gender, race, American Society of Anesthesiologists score, type of urinary diversion, smoking history, estimated blood loss, transfusion requirement, pathological stage and operative time. RESULTS The overall minor complication rate was 30.9% (94 of 304 patients). Postoperative ileus was the most common minor complication, affecting 54 patients (18%). Increased blood loss and major complications predicted a significantly higher likelihood of ileus on multivariate analysis (p = 0.02 and 0.001, respectively). Major complications in 15 patients (4.9%) correlated with higher American Society of Anesthesiologists score, surgical intensive care unit admission and transfusion requirement (p = 0.01, <0.001 and 0.001, respectively). The early mortality rate was 0.3% (1 patient). CONCLUSIONS Within the framework of a clinical pathway, radical cystectomy can be performed safely with an acceptable rate of early minor and major complications. Delay in the return of bowel function is the most common minor complication. Increased estimated blood loss, transfusion requirement and a major complication predicted a higher likelihood of postoperative ileus. The acceptable rate of early morbidity in this series in a 5-year period validates its use in patients undergoing radical cystectomy.

Randomized Prospective Evaluation of Extended Versus Limited Lymph Node Dissection in Patients With Clinically Localized Prostate Cancer

PURPOSE The low rate of pelvic node metastasis in most contemporary series of patients undergoing radical prostatectomy for carcinoma of the prostate has been attributed to earlier and better patient selection than historical series. Alternatively, it has been suggested that the limited dissection commonly performed misses nodal metastasis in a substantial number of patients. To assess the value of an extended node dissection in detecting nodal metastasis, we performed a randomized prospective study. MATERIALS AND METHODS A total of 123 patients undergoing radical prostatectomy were randomized to an extended node dissection on the right versus the left side of the pelvis with the other side being a limited dissection. The extended dissection included removal of all external iliac nodes to a point above the bifurcation of the common iliac artery, the obturator nodes and the presacral nodes. The limited dissection included only the nodes along the external iliac vein and obturator nerve. RESULTS Mean patient age was 61 years. Clinical stage was T1c in 88 patients (72%), T2a in 26 (21%), T2b in 7 (6%) and T3 in 2 (1%). Mean preoperative prostate specific antigen was 7.4 ng./ml. Pelvic lymph node metastasis was histologically confirmed in 8 patients (6.5%). Positive nodes were found on the side of the extended dissection in 4 patients, on the side of the limited dissection in 3 and on both sides in 1. Complications possibly attributable to the node dissection included lymphocele in 4 patients, lower extremity edema in 5, deep venous thrombosis in 2, ureteral injury in 1 and pelvic abscess in 1. These complications occurred 3 times more often on the side of the extended dissection (p = 0.08). CONCLUSIONS Extended node dissection in contemporary series of patients undergoing radical prostatectomy identifies few with nodal metastases not found by a more limited dissection. A trend toward an increased risk of complications attributable to the lymphadenectomy occurs with an extended dissection.

CAUSES OF INCREASED HOSPITAL STAY AFTER RADICAL CYSTECTOMY IN A CLINICAL PATHWAY SETTING

PURPOSE Our institution targets postoperative days 6 to 8 for discharge home after radical cystectomy. We examined this population to determine the causes of increased hospital stay and risk factors that may predict prolonged hospitalization. MATERIALS AND METHODS We reviewed the records of 304 consecutive patients who underwent radical cystectomy from October 1995 to July 2000. The variables examined included age, gender, race, American Society of Anesthesiologists score, urinary diversion type, smoking history, estimated blood loss, transfusion requirement, operative time, hospital stay, perioperative minor and major complications, and the mortality rate. RESULTS Of the 304 patients 144 (47.4%) underwent ileal conduit diversion and 145 (47.7%) underwent orthotopic bladder substitution. Median hospital stay was 7 days (range 4 to 48). Of 302 patients 225 (74%) were discharged home by postoperative day 8, while 52 of the remaining 77 (67.5%) with increased hospital stay were discharged home by day 12. Postoperative ileus was the most common cause of increased hospitalization (53 of 77 cases or 68.8%). Major complications developed in 15 patients (4.9%), of whom 66% required a hospital stay of greater than 12 days. There was a single perioperative death (0.3%). No preoperative variables other than race predicted increased hospitalization. Of the clinical variables increased estimated blood loss, transfusion and minor or major complications correlated with an increased stay (p <0.05). However, on multivariate analysis only complications were associated with prolonged hospitalization. CONCLUSIONS Our cystectomy clinical care pathway targets a hospital discharge date that is safely achieved in the majority of patients. Postoperative ileus is the most common cause of prolonged hospitalization. Age, gender, American Society of Anesthesiologists score, urinary diversion type and pathological stage did not correlate with increased hospital stay.

Complications of radical cystectomy for nonmuscle invasive disease: Comparison with muscle invasive disease

PURPOSE Radical cystectomy is gold standard treatment for muscle invasive bladder cancer and is an option for many patients with nonmuscle invasive disease at high risk for disease progression. We assessed the early complications of radical cystectomy among patients with nonmuscle invasive compared to those with muscle invasive disease. MATERIALS AND METHODS We reviewed the records of 304 consecutive patients who underwent radical cystectomy from December 1995 to July 2000. We evaluated complications that occurred within 30 days of the procedure. Cases were stratified into nonmuscle invasive (PO, Pa, P1 and PIS, N0) or muscle invasive (P2-4, N0-3) tumors based on final specimen pathology. The 2 groups were then compared with respect to age, gender, race, American Society of Anesthesiologists score, type of urinary diversion, estimated blood loss, operative time and length of stay, and major and minor complications. RESULTS Of the 293 available patients 105 (36.8%) had nonmuscle invasive specimen pathology. Overall major and minor complications occurred in 4.9% and 30.4% of cases, respectively. Independent t test revealed no significant difference between groups in terms of age (p = 0.85), gender (p = 0.77), race (p = 1.0), American Society of Anesthesiologists (p = 0.32), type of urinary diversion (p = 0.33), estimated blood loss (p = 0.31), operative time (p = 0.41), length of stay (p = 0.75), or presence of major (p = 0.78) or minor (p = 0.79) complications. CONCLUSIONS The early morbidity associated with radical cystectomy for nonmuscle invasive disease is similar to but not less than that associated with muscle invasive tumors. These acceptable risks as well as the potential benefits should be discussed with patients with nonmuscle invasive bladder cancer at high risk for disease progression.

Genetic Differences in Human Circadian Clock Genes Among Worldwide Populations

The daily biological clock regulates the timing of sleep and physiological processes that are of fundamental importance to human health, performance, and well-being. Environmental parameters of relevance to biological clocks include (1) daily fluctuations in light intensity and temperature, and (2) seasonal changes in photoperiod (day length) and temperature; these parameters vary dramatically as a function of latitude and locale. In wide-ranging species other than humans, natural selection has genetically optimized adaptiveness along latitudinal clines. Is there evidence for selection of clock gene alleles along latitudinal/photoperiod clines in humans? A number of polymorphisms in the human clock genes Per2, Per3, Clock, and AANAT have been reported as alleles that could be subject to selection. In addition, this investigation discovered several novel polymorphisms in the human Arntl and Arntl2 genes that may have functional impact upon the expression of these clock transcriptional factors. The frequency distribution of these clock gene polymorphisms is reported for diverse populations of African Americans, European Americans, Ghanaians, Han Chinese, and Papua New Guineans (including 5 subpopulations within Papua New Guinea). There are significant differences in the frequency distribution of clock gene alleles among these populations. Population genetic analyses indicate that these differences are likely to arise from genetic drift rather than from natural selection.

Shift Work in Nurses: Contribution of Phenotypes and Genotypes to Adaptation

Background Daily cycles of sleep/wake, hormones, and physiological processes are often misaligned with behavioral patterns during shift work, leading to an increased risk of developing cardiovascular/metabolic/gastrointestinal disorders, some types of cancer, and mental disorders including depression and anxiety. It is unclear how sleep timing, chronotype, and circadian clock gene variation contribute to adaptation to shift work. Methods Newly defined sleep strategies, chronotype, and genotype for polymorphisms in circadian clock genes were assessed in 388 hospital day- and night-shift nurses. Results Night-shift nurses who used sleep deprivation as a means to switch to and from diurnal sleep on work days (∼25%) were the most poorly adapted to their work schedule. Chronotype also influenced efficacy of adaptation. In addition, polymorphisms in CLOCK, NPAS2, PER2, and PER3 were significantly associated with outcomes such as alcohol/caffeine consumption and sleepiness, as well as sleep phase, inertia and duration in both single- and multi-locus models. Many of these results were specific to shift type suggesting an interaction between genotype and environment (in this case, shift work). Conclusions Sleep strategy, chronotype, and genotype contribute to the adaptation of the circadian system to an environment that switches frequently and/or irregularly between different schedules of the light-dark cycle and social/workplace time. This study of shift work nurses illustrates how an environmental “stress” to the temporal organization of physiology and metabolism can have behavioral and health-related consequences. Because nurses are a key component of health care, these findings could have important implications for health-care policy.

Tumour volume is an independent predictor of prostate‐specific antigen recurrence in patients undergoing radical prostatectomy for clinically localized prostate cancer

Authors from the USA sought to establish the relationship between tumour volume, pathological stage and outcomes after radical prostatectomy. In a large series of patients they found that tumour volume was correlated directly with pathological stage, and that it was independently correlated with PSA recurrence. The authors suggested that tumour volume had a potential use for prognostication in patients undergoing radical prostatectomy.

ESTIMATED BLOOD LOSS AND TRANSFUSION REQUIREMENTS OF RADICAL CYSTECTOMY

PURPOSE Radical cystectomy has been associated with significant blood loss and/or transfusion requirement. We defined and characterized blood loss and transfusion parameters in this population. MATERIALS AND METHODS We reviewed the records of 304 consecutive patients who underwent radical cystectomy and urinary diversion between October 1995 and July 2000. Charts were examined, and univariate and multivariate logistic regression analysis was performed to evaluate estimated blood loss and the transfusion requirement. RESULTS Complete blood loss data were available in 297 cases. Overall 45% of patients had anemia preoperatively. Median estimated blood loss was 600 ml. (range 100 to 3,000). On univariate analysis increased estimated blood loss was related to patient age, American Society of Anesthesiologists score, longer operative time and paralytic ileus. Overall transfusion was done in 88 of 297 cases (30%) with a median requirement of 2 units (range 1 to 10). The transfusion rate in male and female patients was 26% and 40%, respectively (p <0.05). On univariate analysis female gender, ileal conduit diversion and lower preoperative hematocrit correlated with transfusion need (p = 0.04, <0.001 and <0.001, respectively). On multivariate logistic regression analysis lower preoperative hematocrit, increased estimated blood loss, major complications and ileal conduit diversion type correlated with a higher transfusion rate (odds ratio 8.34, 5.88 and 4.60, respectively). CONCLUSIONS Acute blood loss anemia is common in patients undergoing radical cystectomy, and predicting blood loss and transfusion requirements remains difficult. These data indicate the need for continued refinement in surgical techniques to decrease blood loss as well as for strategies designed to decrease the need for blood transfusion.

Single-Center Comparison of Laparoscopic Pyeloplasty, Acucise Endopyelotomy, and Open Pyeloplasty

PURPOSE To compare Acucise endopyelotomy (Applied Medical, Irvine, California), laparoscopic pyeloplasty, and open pyeloplasty in the treatment of ureteropelvic junction (UPJ) obstruction. PATIENTS AND METHODS A retrospective review of all adult patients undergoing surgical correction of UPJ obstruction between December 1999 and August 2001 at Vanderbilt University Medical Center was performed. Patients undergoing UPJ correction with Acucise endopyelotomy (N = 9), laparoscopic pyeloplasty (N = 16), and open pyeloplasty (N = 7) were compared in regard to demographic information, operative data, recovery parameters, cost data, and outcome (as determined by diuretic renography, the Whitaker test, or both). RESULTS Success rates of 56%, 94%, and 86% were obtained for Acucise endopyelotomy, laparoscopic pyeloplasty, and open pyeloplasty, respectively. There were no differences between the Acucise endopyelotomy and laparoscopic pyeloplasty groups in age, American Society of Anesthesiology (ASA) score, length of follow-up, estimated blood loss (EBL), hospital stay, total hospital cost, or analgesic requirement. The Acucise patients demonstrated shorter operating times (1.7 v 3.3 hours; P < 0.001) and time to oral intake (7.9 v 16 hours; P = 0.008) than the laparoscopic pyeloplasty group. When the laparoscopic pyeloplasty patients were compared with the open pyeloplasty patients, there was no difference in operative time, EBL, time to oral intake, or total hospital costs. The laparoscopically treated patients demonstrated significantly lower analgesic requirements (27.2 v 124.2 mg of morphine sulfate equivalent; P = 0.02) and shorter hospital stays (1.4 v 3.0 days; P = 0.03) than the open surgery patients. The Acucise patients demonstrated shorter operative time (1.7 v 3.4 hours; P < 0.001), shorter hospital stay (1.3 v 3.0 days; P = 0.02), and lower analgesic requirement (22.4 v 124.2 mg of morphine sulfate equivalent; P = 0.02) than the open surgery patients. CONCLUSIONS Laparoscopic pyeloplasty achieves a success rate equal to that of open pyeloplasty while providing a recovery similar to that obtained with Acucise endopyelotomy and is gaining popularity as the treatment of choice for UPJ obstruction.

Improving cancer pain management through patient and family education.

The purpose of this study was to determine if continued access to information following a baseline pain education program would increase knowledge and positive beliefs about cancer pain management, thus resulting in improved pain control during a 6-month follow-up period. Patients with cancer-related pain and their primary caregivers received a brief pain education program, and were then randomized into one of three information groups: a) usual care, b) pain hot line, and c) weekly provider-initiated follow-up calls for 1 month post-education. Sixty-four patients and their primary caregivers were recruited. Both patients and caregivers showed an improvement in knowledge and beliefs after the baseline pain education program. Continued access to pain information with either the pain hot line or provider-initiated weekly follow-up calls did not affect long-term outcomes of pain intensity, interference because of pain, adequacy of analgesics used, or pain relief. In addition, long-term outcomes did not differ between patients who had improvement and those who showed decline in knowledge and beliefs pre-post education. These findings suggest that a brief pain education program can improve knowledge and beliefs of both patient and primary caregiver. Continued access to pain related information using either a patient- or provider-initiated format did not affect long-term pain outcomes.