Dr. Francesco Sanguedolce Section editor Barcelona (ES)
fsangue@ hotmail.com
Thus, these reported findings indicate that immunosuppressed kidney transplant recipients admitted to the hospital with acute COVID-19 infection can mount SARS-CoV-2-reactive adaptive immune responses. One conclusion might be that empirical reductions in immunosuppressive therapy for all kidney transplant recipients with active COVID-19 may not be required.
Source: Evidence of potent humoral immune activity in COVID19 infected kidney transplant recipients. Susan Hartzell, Sofia Bin, Claudia Benedetti, Meredith Haverly, Lorenzo Gallon, Gianluigi Zaza, Leonardo V Riella, Madhav C Menon, Sander Florman, Adeeb H Rahman, John M Leech, Peter S Heeger, Paolo Cravedi Am J Transplant, 2020 Aug 12, doi: 10.1111/ajt.16261. Online ahead of print
Synergistic effect of enhanced recovery and prehabilitation pathways in robot-assisted prostatectomy Enhanced recovery after surgery (ERAS) regimens have demonstrated their benefits for improving perioperative outcomes after major oncology surgeries. In the urology field, in which mainly data exist for radical cystectomy, few reports of ERAS in robot-assisted radical prostatectomy have been published and no publication from the ERAS Society gives guidance to urologists performing prostate cancer surgery. In addition to ERAS, prehabilitation by promoting patient education and counselling could also play an important role in improving postoperative recovery and return to normal life. In the present series, the authors have assessed the impact of both ERAS and prehabilitation on per- and postoperative outcomes after robotic radical prostatectomy. They included 507 consecutive patients operated between 2016 and 2019. The implementation of ERAS and prehabilitation pathways was progressive, and 3 patient sub-groups were compared as follows: ERAS-/PreHab-, ERAS+/PreHab-, ERAS+/ PreHab+. The ERAS programme was extrapolated from an existing radical cystectomy programme. The prehabilitation pathway consisted of a 1-day programme 2-3 weeks before surgery including various stakeholders’ interventions such as physiotherapist, specialised nurses (pain, oncology), dietetician, psychologist. The cost of this journey was 250 euros per patient. Main endpoints were the duration of hospital stay, peroperative parameters, readmission rate, and overall costs. The authors found that length of stay was significantly reduced by implementing ERAS and PreHab pathways (1.6 days versus 3.5 days if ERAS only, versus 4.7 days if ERAS-/PreHab).
The authors found that length of stay was significantly reduced by implementing ERAS and PreHab pathways This reduction in hospital stay was obtained without compromising postoperative outcomes as the readmission and morbidity rates were not altered while continuously decreasing length of stay. In a multivariable analysis taking into account age, BMI, ASA score, operative time, and surgeon, both ERAS and PreHab pathways were independently correlated with a lower risk of prolonged length of stay. The odds ratio for prolonged stay was 0.144 in ERAS+/ PreHab- patients and 0.025 in ERAS+/ PreHab+patients (p<0.001). Overall costs significantly decreased when ERAS and PreHab pathways were combined. With the implementation of ERAS, costs Key articles
August/September 2020
were reduced by 10%. Cost saving continued decreasing with the implementation of PreHab despite the added preoperative 1-day programme cost (-11.6%). The cost reduction was mainly achieved by a reduction in the hospital stay without an increase in the readmission rate. ERAS and PreHab did not affect the length of stay at readmission or the delay between surgery and readmission. Although the generalisability of these findings may be limited by the differences in national health care systems and local economic pressures, especially when assessing the perioperative costs, this study report notable improvements in key perioperative outcomes through the use of ERAS and PreHab pathways. There was also a strong suggestion of synergistic improvements after the addition of PreHab to standard ERAS protocol. These findings highlight that the optimisation of perioperative care pathways plays a pivotal role in major oncology surgery, and not only in colorectal and bladder cancer surgery. Prehabilitation might change patients’ interpretation of their surgery by improving their psychological perception of the treatment and by reducing the risk of regret about treatment choice. Standardisation of these perioperative protocols is critically needed, as well as more patient-reported outcomes and satisfaction assessment studies, in order to better define our patients’ definition of quality and to adapt pre- and post-surgery pathways based on patient-centered experience, and not only on quantitative measures.
Source : A combination of enhanced recovery after surgery and prehabilitation pathways improves perioperative outcomes and costs for robotic radical prostatectomy. Ploussard G, et al. Cancer 2020
Kidney transplant recipients with COVID-19 carry higher risk of AKI Kidney transplant recipients (KTR) share unique characteristics, including disease vintage, immunosuppression and single functioning kidneys. The authors of this study reviewed the literature in a preliminary analysis to assess the impact of the coronavirus disease 2019 (COVID-19) on outcomes in KTR compared to non-transplant patients. Published information in peer-reviewed journals from 1 January 2020 to 24 April 2020 was evaluated with available data on acute kidney injury (AKI), renal replacement therapy (RRT), and intensive care unit (ICU) stay and death rate. The study compared clinical outcomes for KTRs vs non-transplant recipients with COVID-19.
The risk of death may not be significantly different between kidney transplant recipients and the general population A total of 19 published articles on studies were reviewed, studies which included a total of 88 KTR and 5342 non-transplant patients. The sample size varied between 2 and 2634. Mean age was 58.6 years vs 58.9 years in KTR vs non-transplant patients. Patient-level incidence of acute kidney injury (27.5% vs 13.3%, p< .001), RRT (15.4% vs 3.3%, p < .001), ICU stay (34.1% vs 15.1%, p< 0.001) and death (22.7% vs 16.2%, p= .10) was higher in kidney transplant recipients, representing relative risks of 2.06 (1.44, 2.96), 4.72 (2.62, 8.51), 2.25 (1.67, 3.03), and 1.41 (0.95, 2.08), respectively. These early results suggest that kidney transplant recipients are at a significantly higher risk of AKI, RRT and ICU stay from SARS-CoV-19 infection compared to the general population. However, the risk of death may not be significantly different.
Source: Early Report on Published Outcomes in Kidney Transplant Recipients Compared to Nontransplant Patients Infected With Coronavirus Disease 2019. Fahad Aziz, Didier Mandelbrot, Tripti Singh, Sandesh Parajuli, Neetika Garg, Maha Mohamed, Brad C Astor, Arjang Djamalict. Transplant Proc 2020 Jul 13; S0041-1345(20)32626-9, doi: 10.1016/ j.transproceed 2020. Online ahead of print.
Pentafecta after robotassisted radical cystectomy The global use of robot-assisted radical cystectomy (RARC) for muscle-invasive bladder cancer treatment has steadily increased during the last two decades. Several studies have demonstrated that the robotic approach could improve some perioperative outcomes such as blood loss and complication rates. However, high level of evidence is missing. In this multi-institutional Korean series, the authors have defined the success of RARC by a revised version of pentafecta. Five criteria were used as follows: negative soft tissue surgical margins, more than 15 lymph nodes retrieved, no major grade 3-5 Clavien complications at 3-month, no clinical recurrence, no uretero-enteric strictures. They included consecutive patients from 11 institutions who underwent RARC between April 2007 and May 2019. The KORARC database is a planned web-based electronic database originating from the Korean Society of Endourology and Robotics. Overall, 730 patients were included in the present analysis. Mean follow-up was 30 months. Only 16.7% of patients received neoadjuvant chemotherapy.
Five criteria were used as follows: negative soft tissue surgical margins, more than 15 lymph nodes retrieved, no major grade 3-5 Clavien complications at 3-month, no clinical recurrence, no uretero-enteric strictures The pentafecta was achieved in only 28.5% of patients. Patients with RARC-pentafecta attained had a lower ASA score and a lower rate of diabetes mellitus compared with patients who did not achieve RARC-pentafecta. Mean console time was 310 minutes and an orthotopic neobladder was chosen as urinary diversion in 37.7% of the cases. Mean blood loss was 516 cc (transfusion rate: 15%). Major complications were noted in 21.1% of patients including gastrointestinal (26%), infectious (25%), and urinary (23%) complications. Ureterointestinal strictures (8.1%) occurred mainly between 3 and 9 months after the surgery. Neobladder, intracorporeal reconstruction, a lower transfusion rate, a nerve-sparing technique, were correlated with the achievement of pentafecta. Fewer complications and readmissions were reported in the pentafecta sub-group. The most frequent reason for readmission was febrile urinary tract infection. A positive soft tissue margin was noted in 3% of cases. Mean lymph node yield was 19. Pathological grades and stages did not differ between patients who attained pentafecta and those who did not. The 5- and 10-year overall survival rates were 78.6% and 61.1%, respectively. ASA score, diabetes mellitus, diversion type, pathological T and N stages, and pentafecta attainment were significant predictors for overall death. This series confirmed the high risk of complications after radical cystectomy, even after a minimally invasive surgical approach, and the difficulty to achieve perfect oncologic and functional outcomes in a large proportion of patients. The present cohort involved 21 surgeons and therefore, represents an interesting source of real-world clinical data in the emerging field of RARC. The use of validated easy-to-use criteria such as this pentafecta may help to compare different series and to improve patient counseling and information before surgery.
Source: Oncological outcome according to attainment of pentafecta after robot assisted radical cystectomy among bladder cancer patients using KORARC database (730 multicenter robot radical cystectomy database).Oh JJ, Lee S, Ku JH, et al. Published online ahead of print, 2020 Jul 18]. BJU Int. 2020;10.1111/bju.15178. doi:10.1111/bju.15178
Dr. Guillaume Ploussard Section editor Toulouse (FR)
g.ploussard@ gmail.com
Retzius-sparing robotassisted radical prostatectomy: Confirmed durable improvement in urinary function Retzius-sparing surgery has been suggested to improve early continence recovery after robotassisted radical prostatectomy (RARP). Main comments limiting this technique adoption were the concerns about the risk of increased surgical margins and the lack of long-term differences in urinary function. In the present series, the authors reported the comparison between 70 standard RARP (S-RARP) and the subsequent 70 Retziussparing RARP (RS-RARP) cases operated on by a single surgeon. The RS-RARP technique has been standardised and described. For this study, 140 consecutive patients were included, the aim was to mitigate the potential impact of learning curve and surgeon experience on outcomes. The 70 RS-RARP were compared with the 70 preceding S-RARP.
The regression analysis confirmed that RS-RARP was an independent predictor for better 12-month continence results All outcomes were prospectively collected, and long-term functional outcomes were assessed using the EPIC-CP questionnaire. Time to continence and standard oncological outcomes were also reported. Median follow-up was 12 months for RS-RARP versus 46 months for S-RARP. No significant differences were seen in pre-operative features except for PIRADS and Gleason grade which were higher in the S-RARP cohort. Console time, length of stay and complication rates were comparable in both cohorts. Blood loss was lower in RS-RARP (-150 cc, mean). Nerve-sparing procedures were performed in 84.3% and 74.3% of RS-RARP and S-RARP, respectively. No difference was reported in pathological parameters on surgical specimens. However, RS-RARP had fewer nonfocal positive surgical margins (7.1% versus 8.6%, p = 0.016) compared with S-RARP. Most positive margins were anterior in RS-RARP (54%) and posterior for S-RARP. Biochemical follow-up did not differ among groups. There was no benefit from RS-RARP when considering the 12-month continence rates defined by zero pad. However, when continence was defined as zero to one safety pad, RS-RARP was associated with improved outcomes (95.7% versus 85.7%, p = 0.042). Total EPIC-CP scores were better for RS-RARP at 9 and 12 months. Potency rates were comparable in both cohorts (63-65%). The regression analysis confirmed that RS-RARP was an independent predictor for better 12-month continence results (hazard ratio 0.18, 95% CI: 0.05-0.67). The other factors independently correlated with continence were the pre-operative EPIC-CP score and the nerve-sparing procedures. Pentafecta was achieved in half the patients without difference between the two groups. Mean time to continence was 59 and 182 days in the RS-RARP and S-RARP groups (p < 0.001). The rate of positive margins was high (one third) in a population of patients having a pT2 disease in two thirds of the cases. Although no difference was seen regarding the overall surgical margin rates in both cohorts, it would have been interesting to look at potential differences between surgical approaches according to the pathological stage of the disease (surgical margin rates in pT2 and pT3-4 cases).
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