Author: admin

Cystectomy is a major surgery that requires the removal of the bladder and the creation of a urinary diversion. It’s a component of treatment for many patients with bladder cancer and may be an option for patients with other conditions, like neurogenic bladder and fistula repair. Now, surgeons at Cleveland Clinic are increasingly using nerve-sparing techniques for cystectomy that preserve sexual function and quality of life without compromising cancer treatment.

“There’s been a shift in the urologic cancer community in terms of prioritizing quality-of-life outcomes without compromising cancer treatment,” says Nima Almassi, MD. “Historically, cystectomy has been performed with a wide resection to maximize oncologic treatment and avoid positive margins and cancer recurrence.”

Prospective studies have shown that patients generally report positive quality-of-life outcomes across most domains following cystectomy, with a few exceptions. Body image, especially for patients who need a stoma, urinary function, and sexual function tend to be areas where patients report a decreased quality of life. For men undergoing cystectomy, a wide (non-nerve sparing) resection will cause severe erectile dysfunction. Nerve-sparing cystectomy represents one method of potentially improving quality of life outcomes for men undergoing surgery.

Postoperative sexual outcomes in men and women

Urologic oncologists like Dr. Almassi say that many patients don’t need to sacrifice their sexual function because of treatment. For male patients undergoing cystectomy, erectile dysfunction (ED) is a very common side effect, but nerve-sparing cystectomy can help temper it.

The Cleveland Clinic team has also been focused on improving the bladder cancer experience in women, which includes evaluating similar nerve-sparing and organ-sparing techniques to preserve reproductive anatomy and obviate surgical menopause and sexual dysfunction. Prospective studies ongoing at Cleveland Clinic have shown that women who undergo vaginal-sparing cystectomy appear to have less prolapse than women, but the data are still early when it comes to sexual function.

Patient selection is key

Patients eligible for this type of surgery have a good baseline ED and are motivated to preserve it. Additionally, they must be free of specific disease characteristics that could complicate oncologic control, such as cancer abutting or involving the neurovascular bundle. Preoperative MRI imaging can guide patient selection.

Similarly, aggressive subtypes of bladder cancer with high risk of being locally advanced may not be suitable for a nerve-sparing surgical approach. “In this case, we would not recommend nerve-sparing out of concern it could compromise cancer control,” says Dr. Almassi.

A positive institutional experience

Nerve-sparing cystectomy requires the surgeon to dissect the neurovascular bundles off the bladder and prostate. “We have found that this has yielded much better erectile function in patients after surgery without compromising oncologic outcomes. For all patients who we’ve deemed eligible for this, we have not had positive surgical margins,” notes Dr. Almassi.

Using validated questionnaires, patients report their erectile function about every three months for a year. The team is finding that around six months postoperatively, most patients experience only mild ED, and that remains consistent. Even three months following the surgery, he says, patients typically are recovering well but are often not yet sexually active at this time.

“Most patients’ erectile function ends up returning to within three points on a 25-point scale from their preoperative baseline, suggesting erectile function can recover to similar levels to what it was before surgery.”

Part of the center’s protocol is starting patients on tadalafil, and they may still be using it when function is assessed postoperatively, Dr. Almassi remarks.

The Cleveland Clinic team opts for a robotic approach, owing to better visualization and access to the neurovascular bundle. However, performing this technique with open surgery is also achievable in experienced hands. “The way the field has transitioned, fewer surgeons in high volume centers perform open cystectomy,” he explains.

A call for screening candidates

“Optimizing quality of life for our patients is a major focus for our group. Studies show that sexual function declines after cystectomy. We have an opportunity to safely personalize a surgical technique in select patients to help preserve functional outcomes,” says Dr. Almassi. “We certainly encourage our colleagues to consider screening patients who may be good candidates.”

Due to time constraints and surging patient volumes, elderly emergency department patients are not routinely screened for delirium. A Cleveland Clinic geriatrician is making a case for why that should change, however, showing that even a 60-second test can accurately detect confused patients who may otherwise slip through the cracks.

Although delirium screenings are routine for older patients being admitted to the hospital or ICU, they are not yet commonplace in emergency departments, explains Saket Saxena, MD, Codirector of the geriatric emergency department at Cleveland Clinic. “Unfortunately, elderly patients who present with acute conditions often wait hours or days to be fully screened for delirium,” he says, “However, we know that recognizing the disorder early can significantly improve patient care.”

Dr. Saxena is the principal author of a recent study that evaluated 4AT, a bedside screening tool for delirium in emergency department patients. The study found that 4AT, which takes around one minute to complete, can detect delirium with a positivity rate of 14%, a number that is consistent with the general population. Interestingly, about 7% of those determined to have delirium did not initially present with a complaint of altered mental status.

Combatting diagnostic challenges

When people imagine delirium, he notes, they often think of patients who are agitated or even aggressive – getting out of bed, struggling or pulling out their lines. However, a significant number of these patients have hypoactive delirium, a condition that prompts a quiet, docile demeanor. Although these patients may not appear obviously confused, they will sleep a lot, eat little and decline to actively participate in conversations or therapies.

“That is the type of delirium that often gets missed when patients are transitioned from emergency to inpatient care,” explains Dr. Saxena.

Although hypoactive delirium can be particularly difficult to identify because it can easily be explained away by simple fatigue or “not being hungry,” the disorder can have a significant impact on patient outcomes.

“Nutritional status cannot be maintained if the patient isn’t eating,” explains Dr. Saxena. “And if the patient isn’t getting out of bed, the chances of debilitation rise; muscular strength is lost, and the risk of blood clots in the legs increases. All of these factors play a role in how these patients perform during hospitalization and beyond.” In fact, studies have found that patients with delirium have a length of stay that’s twice as long as those without, he notes.

Historically, Cleveland Clinic has used the Confusion Assessment Method to screen patients for delirium in the hospital or ICU; however, no method has been used to formally assess delirium in the emergency department. In preparation for the study, Dr. Saxena worked with triage nurses to identify the delirium screening tool they were most comfortable using in an emergency setting. The 4AT method, which was deemed easy to learn and administer, was chosen as the preferred rapid delirium test. Patients were flagged for screening if they were over 65 years old and medically complex, and all patients over age 80 were screened.

Clinical implications

The rapid test begins by asking the person accompanying the patient if they are concerned about or have noticed any changes in the patient’s mental status. If the caregiver answers yes, the assessment is completed by asking the patient “orientation” questions that evaluate their ability to understand today’s date, where they are, and their date of birth and age. Their attention span is measured by asking the patient to name the months of the year backwards.

Any patient who receives a score of four or more is flagged for delirium.

Dr. Saxena said the study demonstrates that while detecting delirium in the acute setting is challenging, it can be done quickly and accurately using a rapid test like the 4AT method. Among Dr. Saxena’s future goals are improving interdepartmental communication about high-risk geriatric patients. “This approach helps ensure continuity of care throughout the hospital stay by making subsequent caregivers aware of any diagnoses – including delirium – that were made in the emergency department.

Despite the rising incidence of rheumatoid arthritis (RA), extra-articular manifestations have become rare in the era of modern treat-to-target therapy. However, they still present clinical challenges — particularly in the case of rheumatoid nodules. In addition to the need to rule out serious differential diagnoses and address potential complications, especially those involving the lungs, these recurrent inflammatory granulomas can affect daily life not only cosmetically but also functionally.

Christopher Edwards, MD, professor of rheumatology at University Hospital Southampton in Southampton, England, discussed the clinical relevance and management of rheumatoid nodules during the 2025 Annual Meeting of the European Alliance of Associations for Rheumatology.

When Edwards began his career in rheumatology, the presence of rheumatoid nodules was considered a key diagnostic criterion for RA. If not found on the hands, clinicians often examined the elbows and Achilles tendons, which are also common sites. Histologically, rheumatoid nodules are granulomatous inflammatory lesions that evolve through multiple stages. While often subcutaneous, they can also be found on the sclera, larynx, heart valves, and — most significantly — in the lungs.

Biopsy When Malignancy Is Suspected

Pulmonary nodules can present diagnostic difficulties. “I’ve seen patients who were initially told they had lung metastases,” Edwards recalled. Waiting for further imaging and biopsy can be highly distressing for patients. Granulomatosis with polyangiitis can also resemble rheumatoid nodules, further complicating the diagnosis.

It is especially important to distinguish these nodules from infections such as tuberculosis. Patients with RA are at increased risk for infection due to both the underlying disease and immunosuppressive treatment. Like tuberculomas, pulmonary rheumatoid nodules can undergo central necrosis when exposed to tumor necrosis factor-alpha inhibitors, leading to cavitation or even pneumothorax. “Any cavity in the lung can become infected,” Edwards cautioned.

Diagnosing Peripheral Nodules

Diagnosing peripheral rheumatoid nodules is usually straightforward. These nodules typically feel rubbery on palpation and are movable relative to the underlying tissue. Important differential diagnoses include gouty tophi, lipomas, epidermoid cysts, infectious granulomas, sarcoidosis, and neoplastic lesions.

Imaging tools such as ultrasound or fine-needle aspiration can help clarify the diagnosis, particularly when gout is suspected. “Biopsy is rarely required — only if there’s concern about a neoplastic or malignant process,” Edwards explained.

Better Disease Control, Fewer Nodules

“In my practice, I see very few nodules these days,” said Edwards. Epidemiological data support this trend: The 10-year cumulative incidence of subcutaneous nodules in RA patients decreased from 30.9% between 1985 and 1999 to 15.8% between 2000 and 2014.

Multiple factors likely contributed to this decline, including the earlier initiation of more effective therapies and a reduction in smoking rates. Smoking remains a major risk factor for nodule development, along with long-standing, severe RA, male sex, and seropositivity for rheumatoid factor or anti-cyclic citrullinated peptide antibodies. “Patients with nodules are almost always seropositive,” Edwards noted.

These findings suggest that maintaining tight control of disease activity is more critical for preventing nodules than concerns about drug-induced nodulosis.

Little Reason to Discontinue Methotrexate

“There was a time when we worried that methotrexate might be causing nodules,” Edwards said, referring to anecdotal reports of increased nodulosis after initiating methotrexate (MTX). “But now we’re using more MTX and seeing fewer nodules.”

He emphasized that the presence of nodules alone should not prompt discontinuation of MTX. “It wasn’t a reason to stop methotrexate back then, and it’s not a reason now — though in some cases, it may justify a more aggressive treatment approach.”

Other medications — particularly tumor necrosis factor inhibitors like etanercept — have also been linked to nodule development, though Edwards suggested this may reflect reporting bias. “It might not be causal,” he said.

Often, treatment isn’t necessary. “Sometimes it’s just a matter of observation,” Edwards noted. Painful or functionally limiting nodules may be managed with local glucocorticoid injections to reduce discomfort and soften the nodules. However, he admitted he had never personally injected a rheumatoid nodule.

He also cautioned against injections over the elbow. “There’s something about the skin and the olecranon bursa that makes infections more likely in that area. I saw one patient who needed plastic surgery after an infection left a significant wound.”

Rheumatoid nodules also have a tendency to recur.

When to Consider Surgery

“Surgery can benefit some patients,” Edwards said. Surgical removal may be warranted for nodules that ulcerate, become infected, or impair function — such as large nodules on the thumb or fingertip that interfere with gripping. “Patients are usually happy to regain function, even if the nodule comes back a couple of years later.” Nodules that are consistently irritated by shoes or clothing straps may also merit removal.

Pulmonary rheumatoid nodules — unlike subcutaneous ones — often contain B cells and typically respond well to rituximab or abatacept. “These lung nodules tend to shrink or stabilize with rituximab, and certainly, no new ones seem to develop,” Edwards noted. Case reports and small series have also documented improvement with Janus kinase inhibitors.

This story was translated from Medscape’s German edition.

Challenges in space exploration are driving new approaches to delivering eye care in the most inaccessible environments, according to Steven Laurie, PhD, senior scientist and technical lead with the Cardiovascular and Vision Laboratory at NASA’s Johnson Space Center in Houston, Texas.

His talk at the Heidelberg 2025 International SPECTRALIS Symposium – And Beyond (ISS) spotlighted how technologies originally designed for spaceflight, like the Heidelberg Spectralis OCT2 and portable Mini OCT, are setting the stage for autonomous medical diagnostics in deep space—and potentially in the most remote regions here on Earth.

Sheryl Stevenson, executive editor with the Eye Care Network, caught up with Laurie to learn how spaceflight is driving innovations in extreme telemedicine—on orbit and beyond.

Sheryl Stevenson: What are the key takeaways from your presentation?

Steven Laurie, PhD: Astronauts onboard the International Space Station (ISS) use the Heidelberg Spectralis OCT2 to image their eyes, and these images have revealed structural changes in the retina and optic nerve head. I will discuss the unique approach NASA has developed to support these data collection activities, including use of remote guidance from Earth. I will end by sharing our experience with a new device Heidelberg Engineering is developing, the Mini OCT, that is smaller in mass and volume than the Spectralis, and that will not require the remote guidance from Earth.

SS: What are the unique ophthalmic challenges that astronauts face during extended space missions, and how is telemedicine being adapted to address them?

SL: In 2011, the first reports were published documenting the development of optic disc edema and choroidal folds in astronauts flying ~6 month missions to the ISS. Soon after, NASA began using the Spectralis OCT2 to track the development of these findings throughout the mission, and this requires real-time video and communication support from experts on the ground to guide crewmembers in the collection of the OCT images. Over the last 10+ years NASA has used telemedicine to support astronauts in collecting OCT images throughout their spaceflight missions, revealing ophthalmic changes in 60% to 70% of crewmembers.

SS: Can you describe the technologies or protocols that enable effective diagnosis and intervention when specialists are millions of miles away?

SL: The ISS orbits ~250 miles above the surface of the Earth, allowing for only ~1-2 second communication delays between experts in mission control, and crewmembers onboard the ISS. We utilize a video feed from within the ISS cabin, 2-way audio, and screen-sharing of the Heidelberg software to collect the OCT images. Images are downlinked and can be reviewed by experts within hours of data collection. Crewmembers receive two 1-hour long training classes on how to use the hardware before their mission. This training utilizes very specific wording and directions to guide crew through acquisition of OCT images.

SS: How might innovations developed for spaceflight telemedicine translate to patient care in remote or underserved areas here on Earth?

SL: The experience that NASA has developed in using remote guidance to collect OCT images on the ISS highlights that remote telemedicine for collecting OCT images is possible and can be utilized to generate high-quality data. While this represents a great opportunity for remote or underserved populations, it still requires the hardware to be in the remote location, and for real-time audio, video, and screen-sharing communication with experts at a different location. The advancements with the new Mini OCT device represents the next frontier for patients to access medical devices in remote locations without requiring the communication pathways or additional technicians to support data collection. This expands the opportunity from telemedicine supported in real-time by clinicians, to autonomous data collection that only requires transmission of the final images to clinicians.

SS: Anything else to add that you feel would be helpful for our audience to know?

SL: As NASA looks toward sending astronauts back to the Moon and on to Mars, the distance from Earth will limit the real-time communication that we enjoy when crew members are on the ISS. Thus, our ability to utilize remote guidance and real-time communication with experts on the ground will no longer be possible. Technology such as the Mini OCT represents one possible solution to this problem, where astronauts can autonomously collect OCT images on themselves, and then have those images sent back to Earth for assessments by clinical experts. We are excited to see the progression of this technology that may benefit astronauts, as well as patients on Earth.