No abstract

Iatrogenic injury to the urinary tract during colorectal surgery can be a source of significant morbidity. Although most cases of ureteral injury occur in patients without significant risk factors, the incidence of urinary tract injuries increases in patients with prior pelvic operations, inflammatory bowel disease, infection, and in patients with extensive neoplasms causing distortion of normal surgical planes. The most commonly injured locations are the ureter, bladder, and urethra. Mechanisms of injury include ligation, transection, devascularization, and energy induced. Early identification of urinary tract injuries is paramount in minimizing morbidity and preservation of renal function. Anatomic considerations for preventing injuries, diagnostic techniques for localizing and staging injuries, as well as reconstructive techniques and principles of repair are discussed. KEYWORDS: Iatrogenic injury, repair, ureter, bladder, urethraObjectives: Upon completion of this article, the reader should have an understanding of the location of iatrogenic injuries to the urinary tract, anatomic considerations for preventing injuries, diagnostic techniques for localizing and staging injuries, as well as reconstructive techniques for repair.Iatrogenic injury to the urinary tract during operations within the pelvis and retroperitoneum occur most commonly to the ureters followed by injuries to the bladder and urethra. Although most cases of ureteral injury occur in patients without significant risk factors, 1 the incidence of urinary tract injuries increases in patients with prior pelvic operations, inflammatory bowel disease, infection, and in patients with extensive neoplasms causing distortion of normal surgical planes. Unrecognized congenital anomalies such as a duplicated ureter (1/125 persons), retrocaval ureter, horseshoe or pelvic kidneys (1/400 persons) can present unfamiliar anatomy to the surgeon.2 In some cases, resection and reconstruction of a portion of the urinary tract is mandated by disease severity. The rate of urologic complications with the application of minimally invasive technologies (laparoscopy and robotics) for colorectal procedures has been relatively constant when compared with open surgical techniques. Use of the various energy-based tissue devices in close proximity to the urinary tract can cause a delayed presentation of a urinary injury. Early identification of urinary tract injuries is paramount in minimizing morbidity and preservation of renal function. Intraoperative repair of injuries to the urinary tract can be performed through consultation with a urologic surgeon or by the initial operating surgeon. Principles of repair for specific injuries are discussed herein.

Background The early diagnosis and treatment of depression are cancer care priorities. These priorities are critical for prostate cancer survivors because men rarely seek mental health care. However, little is known about the epidemiology of depression in this patient population. The goal of this study was to describe the prevalence and predictors of probable depression in prostate cancer survivors. Methods The data were from a population‐based cohort of North Carolinian prostate cancer survivors who were enrolled from 2004 to 2007 in the North Carolina–Louisiana Prostate Cancer Project (n = 1031) and were prospectively followed annually from 2008 to 2011 in the Health Care Access and Prostate Cancer Treatment in North Carolina study (n = 805). Generalized estimating equations were used to evaluate an indicator of probable depression (Short Form 12 mental composite score ≤48.9; measured at enrollment and during the annual follow‐up) as a function of individual‐level characteristics within the longitudinal data set. Results The prevalence of probable depression fell from 38% in the year of the cancer diagnosis to 20% 6 to 7 years later. Risk factors for probable depression throughout the study were African American race, unemployment, low annual income, younger age, recency of cancer diagnosis, past depression, comorbidities, treatment decisional regret, and nonadherence to exercise recommendations. Conclusions Depression is a major challenge for prostate cancer survivors, particularly in the first 5 years after the cancer diagnosis. To the authors' knowledge, this is the first study to demonstrate an association between treatment decisional regret and probable depression.

PET/CT has emerged as a promising staging modality for both primary and recurrent prostate cancer. Newer tracers have increased detection accuracies for small, incipient metastatic foci. The clinical implications of these occult PET/CT detected disease foci require organized evaluation. Efforts should be aimed at defining their natural history as well as responsiveness and impact of metastasis-directed therapy.

Background In patients with metastatic renal cell carcinoma (mRCC), the timing of systemic targeted therapy in relation to cytoreductive nephrectomy (CN) is under investigation. Objective To evaluate postoperative complications after the use of presurgical targeted therapy prior to CN. Design, setting, and participants A retrospective review of all patients who underwent a CN at The University of Texas M.D. Anderson Cancer Center from 2004 to 2010 was performed. Inclusion in this study required documented evidence of mRCC, with treatment incorporating CN. Interventions Patients receiving presurgical systemic targeted therapy prior to CN were compared to those undergoing immediate CN. Measurements Complications were assessed using the modified Clavien system for a period of 12 mo postoperatively. Results and limitations Presurgical therapy was administered to 70 patients prior to CN (presurgical), while 103 patients had an immediate CN (immediate). A total of 232 complications occurred in 57% of patients (99 of 173). Use of presurgical systemic targeted therapy was predictive of having a complication >90 d postoperatively (p = 0.002) and having multiple complications (p = 0.013), and it was predictive of having a wound complication (p < 0.001). Despite these specific complications, presurgical systemic targeted therapy was not associated with an increased overall complication risk on univariable or multivariate analysis (p = 0.064 and p = 0.237) and was not predictive for severe (Clavien ≥3) complications (p = 0.625). This study is limited by its retrospective nature. As is inherent to any retrospective study reporting on complications, we are limited by reporting bias and the potential for misclassification of specific complications. Conclusions Despite an increased risk for specific wound-related complications, overall surgical complications and the risk of severe complications (Clavien ≥3) are not greater after presurgical targeted therapy in comparison to upfront cytoreductive surgery.