EURURO Vol. 72 No. 5

855 860

incidence of device infection, but appears to have altered the
organisms most commonly causing infection [3]. Historically,
most wound infections for penile prostheses have been caused
by coagulase-negative Staphylococcus, which tends to cause a
local infection and is generally amenable to a salvage proce-
dure [4] . In the era of coated devices, we now witness organ-
isms that tend to present with earlier infections and systemic
symptoms and are less amenable to salvage. This manuscript
highlights the increasing prevalence of atypical organisms
that cause systemic symptoms and purulent infections.
Patients with systemic symptoms and purulent drainage are
not well served by a salvage operation, and should undergo
explantation of all device components. The question is what
antibiotics should be used perioperatively for prosthetic sur-
gery. We contend that patients with risk factors for infection
should have broader perioperative coverage than those
recommended by current guidelines. Vancomycin [2_TD$DIFF]and [3_TD$DIFF]ami-
noglycosides, both commonly used[4_TD$DIFF] for prosthetic cases in the
United States, [5_TD$DIFF]provide [6_TD$DIFF]coverage for MRSA and [7_TD$DIFF]gram [8_TD$DIFF]negative [9_TD$DIFF]
organisms, [10_TD$DIFF]respectively. The real lesson from this article is the
need to consider adding antifungals (eg, fluconazole) both
locally and systemically in men with any increase in the risk
of penile prosthesis infection. Although the vast majority of
implantation surgeons use postoperative antibiotics, compar-
ative data are needed to evaluate the utility of this practice [5].
Conflicts of interest: The authors have nothing to disclose.
References
[1]
.
[2]
.
[3]
.
[4]
[5]
.
Wayne J.G. Hellstrom*, Kenneth J. DeLay
Department of Urology, Tulane University School of Medicine, New Orleans,
LA, USA
*Corresponding author. Department of Urology, Tulane University School
of Medicine, 1430 Tulane Avenue 86-42, New Orleans, LA 70112, USA.
E-mail addresses: , (W.
J. Hellstrom).
© 2017 European Association of Urology.
Published by Elsevier B.V. All rights reserved.
Re: Critical Analysis of Early Recurrence After Laparo-
scopic Radical Cystectomy in a Large Cohort by the ESUT
Albisinni S, Fossion L, Oderda M, et al
J Urol 2016;195:1710–7
Experts’ summary:
This study characterizes unusual early disease recurrence
patterns among patients with favorable disease characteristics
undergoing laparoscopic radical cystectomy (RC). Of patients
with pT2 N0 R0 disease or less, 8.7% experienced recurrence
within 2 yr including many with disseminated disease or
bulky metastases. The authors conclude that technical factors
of minimally invasive surgery may have contributed to these
unexpected recurrences.
Experts’ comments:
Although the explanation for the above findings is unclear,
they are thought provoking and cannot be ignored as a signal.
Similar questions were raised in a retrospective reviewof open
and robot-assisted RC, which observed a higher frequency of
extrapelvic nodal metastases and peritoneal carcinomatosis in
the latter group even though overall relapse rates were com-
parable [1] . These observations are not limited to urological
surgery and have been noted in gynecological and colorectal
malignancies.
Theoretical explanations proposed for observed higher
rates and distinct pattern of early recurrence include a
“funnel” effect of the ports, lower intraperitoneal immune
response due to pneumoperitoneum, lower pH due to CO2
insufflation that aids cell implantation, and pulsatile
pneumoperitoneum potentiating migration of vascular
tumor emboli. The use of the AirSeal device, which
maintains constant insufflation as opposed to the cyclic
insufflation typical of conventional systems, can theoreti-
cally obviate the former and latter effects but requires
further research.
Another concern is the Trendelenburg position
employed during minimally invasive RC (MIRC), which is
hypothesized to aid disease dissemination by potentiating
the flow of potentially malignant-cell containing irrigation
cranially. Reassuringly, a small study of pelvic irrigation
during robotic cystectomy did not find any malignant cells
on cytology [2]. However, it should be noted that the
majority of the cohort had favorable disease character-
istics, and therefore, this mechanism of tumor spread
cannot be confidently ruled out, especially in advanced
disease.
Strategies to prevent local recurrence after open RC have
included preoperative radiation and intravesical chemo-
therapy. Contemporary techniques include urethral cathe-
terization followed by clamping and clipping of ureters,
and/or suture ligation of urethra to prevent spillage
[3]. Intraoperative instillation of mitomycin has been
employed during nephroureterectomy and could theoreti-
cally decrease relapse after RC [4]. Furthermore, intraperi-
toneal chemotherapy is administered during surgical
resection of other abdominopelvic malignancies to mini-
mize seeding and could be adopted in the MIRC setting.
Many of these safeguards have associated morbidity, and
thus patient selection is paramount. In those with carcino-
ma in situ (CIS), where a field change in the urothelium has
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