Peri-operative SARS-CoV-2 infection increases postoperative mortality. The aim of this study was to determine the optimal duration of planned delay before surgery in patients who have had SARS-CoV-2 infection. This international, multicentre, prospective cohort study included patients undergoing elective or emergency surgery during October 2020. Surgical patients with pre-operative SARS-CoV-2 infection were compared with those without previous SARS-CoV-2 infection. The primary outcome measure was 30-day postoperative mortality. Logistic regression models were used to calculate adjusted 30-day mortality rates stratified by time from diagnosis of SARS-CoV-2 infection to surgery. Among 140,231 patients (116 countries), 3127 patients (2.2%) had a pre-operative SARS-CoV-2 diagnosis. Adjusted 30-day mortality in patients without SARS-CoV-2 infection was 1.5% (95%CI 1.4-1.5). In patients with a pre-operative SARS-CoV-2 diagnosis, mortality was increased in patients having surgery within 0-2 weeks, 3-4 weeks and 5-6 weeks of the diagnosis (odds ratio (95%CI) 4.1 (3.3-4.8), 3.9 (2.6-5.1) and 3.6 (2.0-5.2), respectively). Surgery performed ≥ 7 weeks after SARS-CoV-2 diagnosis was associated with a similar mortality risk to baseline (odds ratio (95%CI) 1.5 (0.9-2.1)). After a ≥ 7 week delay in undertaking surgery following SARS-CoV-2 infection, patients with ongoing symptoms had a higher mortality than patients whose symptoms had resolved or who had been asymptomatic (6.0% (95%CI 3.2-8.7) vs. 2.4% (95%CI 1.4-3.4) vs. 1.3% (95%CI 0.6-2.0), respectively). Where possible, surgery should be delayed for at least 7 weeks following SARS-CoV-2 infection. Patients with ongoing symptoms ≥ 7 weeks from diagnosis may benefit from further delay.
SARS-CoV-2 has been associated with an increased rate of venous thromboembolism in critically ill patients. Since surgical patients are already at higher risk of venous thromboembolism than general populations, this study aimed to determine if patients with peri-operative or prior SARS-CoV-2 were at further increased risk of venous thromboembolism. We conducted a planned sub-study and analysis from an international, multicentre, prospective cohort study of elective and emergency patients undergoing surgery during October 2020. Patients from all surgical specialties were included. The primary outcome measure was venous thromboembolism (pulmonary embolism or deep vein thrombosis) within 30 days of surgery. SARS-CoV-2 diagnosis was defined as peri-operative (7 days before to 30 days after surgery); recent (1-6 weeks before surgery); previous (≥7 weeks before surgery); or none. Information on prophylaxis regimens or pre-operative anti-coagulation for baseline comorbidities was not available. Postoperative venous thromboembolism rate was 0.5% (666/123,591) in patients without SARS-CoV-2; 2.2% (50/2317) in patients with peri-operative SARS-CoV-2; 1.6% (15/953) in patients with recent SARS-CoV-2; and 1.0% (11/1148) in patients with previous SARS-CoV-2. After adjustment for confounding factors, patients with peri-operative (adjusted odds ratio 1.5 (95%CI 1.1-2.0)) and recent SARS-CoV-2 (1.9 (95%CI 1.2-3.3)) remained at higher risk of venous thromboembolism, with a borderline finding in previous SARS-CoV-2 (1.7 (95%CI 0.9-3.0)). Overall, venous thromboembolism was independently associated with 30-day mortality ). In patients with SARS-CoV-2, mortality without venous thromboembolism was 7.4% (319/4342) and with venous thromboembolism was 40.8% (31/76). Patients undergoing surgery with peri-operative or recent SARS-CoV-2 appear to be at increased risk of postoperative venous thromboembolism compared with patients with no history of SARS-CoV-2 infection. Optimal venous thromboembolism prophylaxis and treatment are unknown in this cohort of patients, and these data should be interpreted accordingly.
Introduction Radical cystectomy (RC) is the current standard of care for treating muscle-invasive bladder cancer (MIBC), however bladder preservation by offering radical radiotherapy (RT) is gaining interest for improving the quality of life while maintaining a reasonable oncological outcome. In this study, we have compared outcomes of the two treatment options. Materials and methods This is a 10-year retrospective cohort study that included all patients who were treated for histologically proven muscle-invasive bladder cancer in the department of uro-oncology at Shaukat Khanum Memorial Cancer Hospital and Research Centre from January 2005 to January 2015. Data was analysed using Statistical Product and Service Solutions (SPSS), version 21 (IBM Corp., Armonk, NY). The primary end point of our study was to calculate the three-and five-year disease-free survival (DFS) and overall survival (OS). Results A total of 230 patients were included in the study with male gender predominating (88%). The mean and standard deviation for age was 58.32+11.128. Radical cystectomy was performed in 119 patients while 111 received RT. Clinically, 34% had stage 2 disease, while 66 % had stage 3 cancer. The median follow-up duration was 41 months (range: 2-155). During follow-up 57.4% of patients showed no recurrence. Local recurrence was found in 9.6% patients and distant metastasis in 32.2%. The three-year DFS of RC was 63% and that of RT was 57% while the five-year DFS for RC and RT were 60% and 49%, respectively (p=0.196). The three-year OS of RC was 64% and that for RT was 58%. On further analysis the five-year OS of RC was 53% and that for RT was 50% (p=0.98). Upon stage-based comparisons, we found no statistically significant difference between the three-and five-year DFS and OS of stage 2 and stage 3 when treated with either modality. Conclusion Most studies favor RC and consider it as the gold standard treatment for muscle-invasive bladder tumor treatment. The current study reveals that bladder preservation approach by chemo radiotherapy is a viable treatment option, having comparable oncological outcomes with patients receiving radical cystectomy, and can be offered to patients having muscle-invasive urothelial bladder cancer.
Background and objective In this study, we aimed to analyze the association of ureteral wall thickness (UWT) measured on non-contrast CT (NCCT) with stone impaction as found in ureteroscopy (URS). Materials and methods We analyzed 43 patients who underwent URS and pneumatic/laser lithotripsy for ureteric stones from May to November 2022. The UWT was measured by an experienced radiologist on NCCT. Clinical predictors of the impacted stone were calculated by univariate and multivariate regression analysis. The receiver operating characteristic (ROC) curve was calculated for the UWT cutoff to apply it for impaction with different parameters. We also evaluated the association of intra- and postoperative parameters of the two groups with UWT. Results Out of the 43 patients with stones, 26 (60.46%) patients had impacted stones. Univariate analysis was used to analyze the site (left-sided stone impacted more commonly), stone size, stone density [Hounsfield unit (HU)], hydronephrosis, UWT, and duration between initial presentation and surgery, and multivariate analysis was utilized to assess stone density, as well as UWT's association with impacted stones. The ROC curve showed a cutoff of 3.5 mm for UWT with an accuracy of 0.83. High UWT (≥3.5 mm) was associated with a significantly lower stone-free rate, more complications, and mean operative time as compared to low UWT (<3.5 mm) (p<0.05). Conclusion Based on our findings, high UWT is associated with high rates of impacted stones and a lower stone-free rate when compared to low UWT.
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