Holmium Laser Excision of Genitourinary Mesh Exposure Following Anti-Incontinence Surgery: Minimum Six-Month Follow-up.
Embargoed until Sunday, May 17, 2015 1:00 p.m. CT
The polypropylene mesh implants used in some incontinence surgeries for women can erode tissue and sometimes intrude into the bladder or urethra, often causing pain, bleeding and infection. Conventional treatment requires major open surgery.
Mayo Clinic researchers have discovered they can trim mesh with an endoscopic laser and remove it without having to make incisions.
"Removal of mesh with old-fashioned surgery is a big surgery," says lead author Daniel Elliott, M.D., a Mayo Clinic urologist. "We were trying to see if there is a way to get this done easier. With certain types of mesh exposures this is very effective and others it's not. But it presents itself as a potential option for some of these people to avoid a major surgery."
Dr. Elliott and colleagues performed transurethral endoscopic excision using a holmium laser on 10 patients between May 2011 and July 2013. Eight reported an improvement in symptoms with one not reporting. Three of the patients experienced recurring urinary incontinence. One underwent an additional laser treatment.
"In those nine individuals, they have all avoided a major operation," says Dr. Elliott. "That from my perspective is wonderful."
Artificial Urinary Sphincter Outcomes in Octogenarians
Embargoed until Tuesday, May 19, 2015 10:30 a.m. CT
As Americans live longer, operations to provide artificial urinary sphincters to relieve urinary incontinence among men over 80 are expected to increase. Mayo Clinic researchers have discovered that octogenarians undergoing the operation experience more infections and erosion of the device in tissues. But risks are low enough that patients shouldn't be excluded from surgery on the basis of their age alone.
Urinary incontinence is common after prostate surgery. "When it's severe enough the artificial sphincter is the gold standard for dealing with it," says lead author Daniel Elliott, M.D., a Mayo Clinic urologist.
"A lot of men who had their prostates removed 15, 20 years ago when they were in their 60s, are now leaking in their 80s," says Dr. Elliott. "They are otherwise healthy. But they're also 80 years old. So the question is: How do these individuals do?"
Mayo Clinic has the world's largest database on artificial sphincters. Dr. Elliott and colleagues evaluated the outcomes of 1,157 patients, of whom 101 were 80 years of age or older. Results for octogenarians were as good as those of younger patients except the rates of infection and device erosion are about double that of younger men.
"It doesn't mean we don't do the procedure. It just means that the patient has to be warned about that," says Dr. Elliott. "We can help them, but they're going to be very well educated about all the good and bad that can happen. Overwhelmingly, it's going to be a positive outcome."
Sacral Neuromodulation for the Management of Bladder/Bowel Dysfunction in Children with Attention Deficit Hyperactivity Disorder
Embargoed until Saturday, May 16 7:30 a.m. CT
Bed-wetting can be tough to treat, especially when the patients are children with attention deficit hyperactivity disorder (ADHD). Medications and behavioral changes such as voiding on a schedule often don't work.
One treatment that has been shown to work is neuromodulation of the sacral nerves with mild electrical pulses to normalize neural activity between the bladder and the brain. The question is: Does it work for children with ADHD?
"We found that this therapy works equally well in the kids that have ADHD compared to those that don't," says author Derek Lomas, M.D., a Mayo Clinic research fellow. "What we are really trying to find whether this is a viable option in the ADHD kids. And our study shows that it is."
Since 2002, Dr. Lomas worked with a group of researchers who implanted neuromodulation devices in children with bowel and bladder dysfunction, which often is associated with bed-wetting problems. The researchers reviewed records to compare outcomes of 133 patients, some with ADHD and some without. Nearly 80 percent of patients with ADHD experienced reduced problems with bed-wetting -- a higher percentage than children without ADHD.
"Kids with ADHD are harder to treat and more likely to fail medical management, and we have this option available for those kids that have this kind of refractory bladder-bowel dysfunction," says Dr. Lomas. "So the benefit is that there's another tool in the chest for these kids."
Long-Term Patient-Reported Functional Outcomes Following Open, Laparoscopic and Robotic-Assisted Radical Prostatectomy Performed by High-Volume Surgeons
Embargoed until Tuesday, May 19, 2015 10:30 a.m. CT
Men requiring the removal of a prostate cancer have the choice of three kinds of prostatectomy: open surgery, laparoscopic surgery and robotic-assisted surgery. Which provides better results, especially in terms of after-surgery urinary incontinence and sexual dysfunction?
According to researchers at Mayo Clinic and Massachusetts General Hospital, patients at a medical centers, where surgeons perform a large number of operations, can expect virtually identical results with all three types of surgery.
"I think it reaffirms the point that it's not necessarily the surgery that is being done but it's more likely the surgeon that's doing it," says lead author Jeffrey Karnes, M.D., a Mayo urologist. "The outcomes were independent of the technique, whether it was done robotic, laparoscopic or standard open."
Researchers reviewed the results of patient self-reported surveys of 1,686 men who received one of the three types of radical prostatectomy at one of the two academic centers between 2009 and 2012. Surveys were collected an average of 30.5 months after surgery. Slightly more than 6 percent of patients reported a moderate to major problem with urinary function. Just over 37 percent complained of a moderate to major problem with sexual dysfunction.
"It shows fairly good consistent outcomes directly from our patients," says Dr. Karnes. "It's probably more important to have a high-volume surgeon that does one technique than a low-volume surgeon that's just starting in that technique. If you're going to have somebody build a house, you'd probably want to know how many houses they've built rather than what kind of tools they have in their toolkit."
Very Long-Term Oncological Outcomes of Patients Treated with Radical Prostatectomy for Node-Positive Prostate Cancer: A Multi-Institutional, Conditional Survival Analysis
Embargoed until Sunday, May 17, 2015 3:30 p.m. CT
Long-term survival rates of men who have had cancerous prostates and nodes removed -- even those who have had biochemical recurrence (an elevated prostate specific antigen (PSA) level of more than 0.2 ng/mL) -- are often better than expected, says Marco Moschini, M.D., lead author and Mayo Clinic research fellow.
In the largest series of papers ever published on this topic with the longest follow-up, researchers at Mayo Clinic and San Raffaele Hospital (Milan) evaluated 1,947 patients whose prostates had been removed with associated lymph node spread. Median follow-up was more than 14 years.
In patients with a biochemical recurrence, the rates for remaining metastasis free (no evidence of spread) for 10, 15 and 20 years were approximately 55, 50 and 45 percent, respectively.
If a patient doesn't have a biochemical recurrence (PSA greater than 0.2 ng/mL) in the first five, 10 or 15 years, he is not likely to die from the cancer, says Dr. Moschini. But follow-up and continued monitoring of PSA are important, says Dr. Moschini, because "your recurrence rate is never zero."
The Impact of Excess Fat Mass on Mortality after Radical Nephrectomy for Renal Cell Carcinoma: Beyond Body Mass Index.
Embargoed until Sunday, May 17, 2015 8:00 a.m. CT
Obesity is a risk factor for all kinds of diseases and mortality. But being overweight has often shown to be an advantage in surviving surgery. "People with a higher body mass index may actually do better after surgery," says Matthew Tollefson, M.D., Mayo Clinic associate professor of urology. "That's called the obesity paradox."
But does fat offer the protection? Or does something else? That's the question Dr. Tollefson attempted to answer in a study of 390 patients who underwent radical nephrectormy for renal cell carcinoma. Overweight patients were imaged by CT scan to determine total body fat mass as well as skeletal muscle index. "In the past people have looked at body mass index, but no one looked at it in greater detail to try to distinguish the fatty components from the muscular components," says Dr. Tollefson.
Heavier patients did better during an average 7.2 years after surgery because their greater fat mass accompanied greater muscle mass. "Essentially it showed that the more muscle mass that you have, the better people do," says Dr. Tollefson. "The fatty tissue was more of an innocent bystander and didn't seem to have much of an effect on prognosis."
Dr. Tollefson will also discuss three other studies he conducted that correlate nutrition and fitness with surgery outcomes:
"Sarcopenia Is Independently Associated with Increased Mortality Following Radical Nephrectomy for Localized Renal Cell " Sarcopenia, the degenerative loss of skeletal muscle mass that accompanies aging, is a risk factor in radical nephrectomy surgery. Among 390 patients, overall survival declined with increased sarcopenia, Dr. Tollefson says.
"Nutritional Predictors of Perioperative Complications and Mortality Following Radical Nephrectomy: A Population-Based Analysis." Extreme obesity and poor nutrition (measured by low serum albumin and significant preoperative weight loss) are both risk factors for increased mortality within 30 days of radical nephrectomy surgery. The study was based on a review of 8,618 patient cases in the American College of Surgeons National Surgical Quality Improvement Program.
"Nutritional Predictors of Perioperative Complications and Mortality Following Radical Cystectomy: A Population-Based Analysis." A review of 2,055 patient cases from the National Surgical Quality Improvement Program showed that low serum albumin, morbid obesity and extreme underweight were all risk factors increasing mortality within 30 days after radical cystectomy (urinary bladder removal). All four of these studies will help doctors identify patients who have a higher degree of risk from surgery. "I think it adds to the argument of 'prehabilitation' before surgery -- getting patients to exercise and to have good nutrition both before and then shortly after surgery as well," says Dr. Tollefson. "In people who are very malnourished, a lot of times we would even consider delaying surgery for a couple of weeks to try to improve nutrition before we would dive into a major surgery." Says Dr. Tollefson, "Being fit is really the important part of it."
INFORMATION:
About Mayo Clinic
Mayo Clinic is a nonprofit organization committed to medical research and education, and providing expert, whole-person care to everyone who needs healing. For more information,visit http://mayocl.in/1ohJTMS or http://newsnetwork.mayoclinic.org/.
