EURURO Vol. 72 No. 6

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Re: The Use of Apnea During Ureteroscopy
Emiliani E, Talso M, Baghdadi M, et al
Urology 2016;97:266–8
Expert’s summary:
In this “surgeon’ s workshop” paper, the authors describe their
technique for perioperative apnea during retrograde intrare-
nal surgery (RIRS) for laser treatment of stones and various
other diseases. Ventilation was interrupted for a few minutes
to limit renal movements due to diaphragmatic displace-
ments, and consequently facilitate the surgeon’s work. Gen-
eral anesthesia was always achieved, with administration of
intravenous propofol and remifentanil associated with inser-
tion of a supraglottic airway device. A few minutes before the
initiation of apnea, the patient was ventilated with 100%
oxygen (preoxygenation). Inhalational anesthetics were pro-
hibited to [1_TD$DIFF]prevent the risk of the patient awakening during the
procedure. Interruption of ventilation allowed maintenance of
apnea for approximately 3–5 min. Apnea could be repeated
during the procedure, alternating with periods of preoxygena-
tion. No postoperative complications were observed. The clin-
ical results of this strategy were not assessed.
Expert’s comments:
RIRS with laser fragmentation is currently the technique
most frequently used for[2_TD$DIFF] the treatment of renal stones of
<2 cm in diameter [1]. Other conditions such as upper
urinary tract tumors and strictures are also managed via
RIRS, usually under general anesthesia However, kidney
movements along the psoas axis can make laser treatments
difficult and increase the operative time. The technique of
perioperative apnea during RIRS has rarely been described
and has not been evaluated. Emiliani et al described their
collaborative work with anesthesiologists for perioperative
apnea. This strategy seems to be easy to apply and should be
considered in well-selected cases. Undoubtedly the absence
or the limitation of kidney movements induced by apnea
could be helpful during RIRS. Use of a laser is somewhat
easier under such conditions, especially for complex cases.
Nevertheless, many surgeons and anesthesiologists might
hesitate to induce perioperative apnea because of various
concerns regarding the potential consequences of the result-
ing hypercapnea. Preoperative verbal communication with
the anesthesiologist is the first step when a [3_TD$DIFF]urologist wishes
to use an apnea strategy. In light of such information, the
anesthesiologist will be able to evaluate the procedure safety
and choose suitable drugs such as propofol and remifentanil
. Further prospective studies comparing RIRS with and
without apnea would be of great interest to determine
whether better laser precision and improved results can
be obtained without increasing the rate of medical compli-
cations related to the procedure.
Conflicts of interest: The author has nothing to disclose.
References
[1] .
[2] .
[3]
Paul Meri
Department of Urology, St. Louis Hospital, Paris, France
*Department of Urology, St. Louis Hospital, 1 Avenue Claude Vellefaux,
Paris 75475, France.
E-mail address:
© 2017 European Association of Urology.
Published by Elsevier B.V. All rights reserved.
Re: Validation of the 2015 Prostate Cancer Grade Groups
for Predicting Long-term Oncologic Outcomes in a
Shared Equal-access Health System
[2_TD$DIFF]Schulman [4_TD$DIFF]AA, [5_TD$DIFF]Howard [6_TD$DIFF]LE, Tay[7_TD$DIFF] KJ, et al
Cancer. In press.
Expert’s summary:
Recently, a new grading system for prostate cancer has been
suggested [1]. It incorporates the Gleason scoring system into
five distinct prognostic grade groups: Prognostic Grade Group
1 (GG) equals Gleason score 6, GG 2 Gleason score 3 + 4 = 7,
GG 3 includes Gleason score 4 + 3 = 7, GG 4 Gleason score 4
+ 4 = 8, and GG 5 Gleason scores 9 and 10. In a retrospective
multicenter analysis, data of 2509 men who underwent a
radical prostatectomy between 2005 and 2015 were reviewed
as to the utility of the GGs. Median follow-up was 60 mo.
There were 36.2% patients in GG1, 32.4% in GG2, 15.9%in GG3,
11.1% in GG4, and 4.4% in GG5. Biochemical recurrence free
rates were 83%, 74%, 67%, 66%, and 47% in the respective GGs
1–5. Higher GG was associated with more advanced clinical
stage, age, more recent surgery, higher prostate-specific
antigen, higher number of positive cores, and a higher per-
centage of positive cores. Interestingly, race had no influence
on measured outcomes. The authors concluded that “the five-
tier GG system predicted multiple long-term endpoints after
radical prostatectomy in an equal-access health system. The
predictive value was consistent across races.”
Expert’s comments:
The grading system developed by Dr. Donald Gleason in the
1960 is widely used to predict prostate cancer prognosis .
Over time, limitations of the Gleason system became apparent
and it was revised by a consensus committee . In 2013, a
new grading system was suggested to both incorporate the
Gleason system and better predict prognosis of prostate can-
cer [1] . Compared with this study, Epstein and colleagues
reported similar, yet slightly higher 5-yr biochemical risk-free
survival rates: 97.5% for GG 1, 93.1% for GG 2, 78.1% for GG 3,
63.6% for GG 4, and 48.9% for GG 5. The new system has been
accepted by the World Health Organization in 2016 . The
current study was tested under real-life conditions in a Veter-
ans Administration population. It adds to the growing
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