Canadian Update on Surgical Procedures (CUSP) Urology Group consensus for intraoperative hemostasis during minimally invasive partial nephrectomy.

INTRODUCTION: Partial nephrectomy remains the gold standard in the management of small renal masses. However, minimally invasive partial nephrectomy (MIPN) is associated with a steep learning curve, and optimal, standardized techniques for time-efficient hemostasis are poorly described. Given the relative lack of evidence, the goal was to describe a set of actionable guiding principles, through an expert working panel, for urologists to approach hemostasis without compromising warm ischemia or oncological outcomes. METHODS: A three-step modified Delphi method was used to achieve expert agreement on the best practices for hemostasis in MIPN. Panelists were recruited from the Canadian Update on Surgical Procedures (CUSP) Urology Group, which represent all provinces, academic and community practices, and fellowship-and non-fellowship-trained surgeons. Thirty-two (round 1) and 46 (round 2) panellists participated in survey questionnaires, and 22 attended the in-person consensus meeting. RESULTS: An initial literature search of 945 articles (230 abstracts) underwent screening and yielded 24 preliminary techniques. Through sequential survey assessment and in-person discussion, a total of 11 strategies were approved. These are temporally distributed prior to tumor resection (five principles), during tumor resection (two principles), and during renorrhaphy (four principles). CONCLUSIONS: Given the variability in tumor size, depth, location, and vascularity, coupled with limitations of laparoscopic equipment, achieving consistent hemostasis in MIPN may be challenging. Despite over two decades of MIPN experience, limited evidence exists to guide clinicians. Through a three-step Delphi method and rigorous iterative review with a panel of experts, we ascertained a guiding checklist of principles for newly beginning and practicing urologists to reference.

Routine Preoperative Electrocardiograms in Patients at Low Risk for Cardiac Complications During Shockwave Lithotripsy: Are They Useful?

INTRODUCTION: Routine preoperative electrocardiogram (ECG) before shockwave lithotripsy (SWL) is frequently performed despite recommendations against its use in asymptomatic patients undergoing low-risk surgical procedures. This study assesses whether routine preoperative ECG before SWL is useful in patients at low risk for cardiac complications. MATERIALS AND METHODS: A retrospective study of SWL at our center (2003-2013) reviewed all cardiac-related preoperative cancellations, intraoperative complications, postoperative admissions, and emergency department presentations in patients at low risk for cardiac complications. Patients received SWL with sedation and continuous five-lead ECG monitoring. RESULTS: Of 30,892 referrals, preoperative ECG triggered 13 (0.04%) cancelations in low-risk patients (1 with new atrial fibrillation and 12 with ischemia/previous infarction). Of these patients, 1 had a subsequent abnormal cardiac work-up and 11 underwent uncomplicated SWL without cardiac intervention (2 had unknown history). Of 27,722 treatments, 5 (0.02%) were stopped prematurely in low-risk patients because of arrhythmia (3 had normal preoperative ECG, 1 had abnormal ECG, and 1 did not complete ECG). Three patients developed an arrhythmia with sedation and 2 patients were admitted postoperatively because of cardiac complications (1 for atrial fibrillation and 1 for hypertension), of whom all had normal preoperative ECG. No patients presented to our emergency department with cardiac complications after SWL. CONCLUSIONS: In patients at low risk for cardiac complications, preoperative ECG triggered very few cancellations and did not predict early termination of treatment or cardiac complications after SWL. These findings suggest that in low-risk patients, routine preoperative ECG has little effect on treatment or complication rate and should be omitted.

Intraoperative Radiographic Determination of Ureteral Length as a Method of Determining Ideal Stent Length.

INTRODUCTION: Accurate determination of ureteral length (UL) and appropriate stent length remains a challenge. The objective of this study was to describe an intraoperative technique to measure UL and determine appropriate stent length, and to compare this technique with other methods of determining appropriate stent length. METHODS: Patients undergoing ureteroscopy requiring postoperative stenting and who had a preoperative CT were prospectively identified. Gender, age, height, body mass index, L1 to L5 lumbar height on CT, and surgeon's estimate of UL were recorded. UL was measured using four methods: direct measurement with a ureteral catheter, ureteropelvic junction (UPJ) to ureterovesical junction distance on axial and coronal CT, and using a novel intraoperative radiographic technique. Radiographic measurement was performed using a radiographic nipple marker affixed to the skin over the ureteral orifice (UO) and an angiographic catheter with radiopaque markings at 1 cm intervals. UL was the distance from the UPJ to the marker at the UO measured using the catheter markers. Correlation between direct measurement and the recorded variables and methods of ureteral measurement were calculated. Stent length was chosen based on radiographic measurement. Stents were deemed of appropriate length if they showed a proximal coil in the renal pelvis and a distal coil in the bladder without crossing midline. RESULTS: Twenty-five ureters from 23 patients were included. Radiographically measured UL was strongly correlated with direct measurement. (r = 0.873, p < 0.01). Coronal and axial CT ULs were significantly associated with direct measurement (p < 0.05). Height, lumbar height, and surgeon's estimate of UL were not. Stents were deemed of appropriate length in 23/25 cases (92%). CONCLUSIONS: This new method for radiographic UL measurement is strongly correlated with directly measured UL. A length of stent chosen based on radiographic UL resulted in an appropriate stent length.

Best Stent Length Predicted by Simple CT Measurement Rather than Patient Height.

INTRODUCTION AND OBJECTIVES: Ureteral stent length is important, as stents that are too long might worsen symptoms and too short are at higher risk of migration. The purpose of this study was to determine if patient or radiologic parameters correlate with directly measured ureteral length and if directly measured ureteral length predicts proper stent positioning. METHODS: During stent placement, ureteral length (ureteropelvic junction to ureterovesical junction distance) was directly measured by endoscopically viewing a ureteral catheter (with 1-cm marking) emanating from the ureteral orifice. A 22, 24, or 26 cm stent was chosen to be closest to the measured ureteral length. For ureters >26 cm, a 26 cm stent was chosen. Ends of an "ideally positioned" stent were fully curled in the renal pelvis and bladder, without crossing the bladder midline. Rates of ideal stent position were compared between patients with matching stent and ureteral lengths and those with stent lengths differing by ≥1 cm (mismatched). The measured ureteral length was correlated with patient height, L1-L5 height, and length measured on CT. RESULTS: Fifty-nine ureters from 57 patients were included. Height was reasonably correlated with L1-L5 height (Spearman correlation coefficient [rho] = 0.79), although both were poorly correlated with directly measured ureteral length (rho = 0.18 for height and 0.32 for lumbar height). Ureteral lengths measured on CT correlated well with direct measurement (rho = 0.63 for axial cuts and rho = 0.64 for coronal cuts). Matched stent length was associated with higher rates of ideal stent position than mismatched (100% vs 70.9%, p = 0.006). CONCLUSIONS: CT measurements, rather than height, correlate well with measured length and could be used to choose the appropriate stent length. Stents matching directly measured ureteral lengths are associated with high rates of ideal stent position.

Primary realignment vs suprapubic cystostomy for the management of pelvic fracture-associated urethral injuries: a systematic review and meta-analysis.

OBJECTIVE: To compare primary urethral realignment (PR) with suprapubic cystostomy (SPC) for the management of pelvic fracture-associated posterior urethral injuries with regards to rates of stricture, erectile dysfunction, and urinary incontinence. METHODS: Two electronic databases (MEDLINE and EMBASE) were searched with the assistance of a librarian. Title, abstract, and full text screening was carried out by 2 independent reviewers, with discrepancies resolved by consensus. Narrative reviews, surveys, and historical articles were excluded. Only studies reporting a direct comparison of PR vs SPC for the management of posterior urethral injuries associated with blunt trauma in adults were included. Quality assessment of the included articles was performed in duplicate. Stricture incidence was evaluated for all included studies, as were erectile dysfunction and incontinence rates when reported. All outcomes were treated as dichotomous data with calculation of odds ratio and were pooled using a random effects model with Review Manager 5.1. RESULTS: Our comprehensive search yielded 161 unique articles. Nine articles were included in the final meta-analysis. Stricture rate was significantly lower in the PR group (odds ratio [OR] = 0.12, 95% confidence interval [CI] 0.04-0.41, P <.001). There was no significant difference between the 2 interventions with regards to erectile dysfunction (OR = 1.19, 95% CI 0.73-1.92, P = .49) or incontinence (OR = 0.75, 95% CI 0.38-1.48, P = .41). CONCLUSION: PR appears to reduce the incidence of stricture formation after pelvic fracture-associated posterior urethral injuries as compared with SPC.

Mitochondrial correlation microscopy and nanolaser spectroscopy - new tools for biophotonic detection of cancer in single cells.

Currently, pathologists rely on labor-intensive microscopic examination of tumor cells using century-old staining methods that can give false readings. Emerging BioMicroNano-technologies have the potential to provide accurate, realtime, high-throughput screening of tumor cells without the need for time-consuming sample preparation. These rapid, nano-optical techniques may play an important role in advancing early detection, diagnosis, and treatment of disease. In this report, we show that laser scanning confocal microscopy can be used to identify a previously unknown property of certain cancer cells that distinguishes them, with single-cell resolution, from closely related normal cells. This property is the correlation of light scattering and the spatial organization of mitochondria. In normal liver cells, mitochondria are highly organized within the cytoplasm and highly scattering, yielding a highly correlated signal. In cancer cells, mitochondria are more chaotically organized and poorly scattering. These differences correlate with important bioenergetic disturbances that are hallmarks of many types of cancer. In addition, we review recent work that exploits the new technology of nanolaser spectroscopy using the biocavity laser to characterize the unique spectral signatures of normal and transformed cells. These optical methods represent powerful new tools that hold promise for detecting cancer at an early stage and may help to limit delays in diagnosis and treatment.

Ultrafast nanolaser flow device for detecting cancer in single cells.

Currently, pathologists rely on labor-intensive microscopic examination of tumor cells using staining techniques originally devised in the 1880s that depend heavily on specimen preparation and that can give false readings. Emerging BioMicroNanotechnologies (Gourley, 2005) have the potential to provide accurate, realtime, high throughput screening of tumor cells without invasive chemical reagents. These techniques are critical to advancing early detection, diagnosis, and treatment of disease. Using a new technique to rapidly assess the properties of cells flown through a nanolaser semiconductor device, we discovered a method to rapidly assess the respiratory health of a single mammalian cell. The key discovery was the elucidation of biophotonic differences in normal and transformed (cancer) mouse liver cells by using intracellular mitochondria as biomarkers for disease. This technique holds promise for detecting cancer at a very early stage and could nearly eliminate delays in diagnosis and treatment.

The shape of the force-elbow angle relationship for maximal voluntary contractions and sub-maximal electrically induced contractions in human elbow flexors.

The force-length relationship is a basic property of skeletal muscle. Knowledge of this relationship is necessary for most analyses of human movement, and in simulation models predicting movement control strategies. Studies on animal muscles have shown that force-length relationships for sub-maximal contractions are not related through a simple scaling procedure to the relationship for maximal contractions. Furthermore, potentiation might produce a shift of sub-maximal relative to maximal force-length relationships. In this study, we tested the hypothesis that human force-elbow angle relationships for sub-maximal unpotentiated contractions are shifted to larger elbow angles (i.e. larger muscle lengths) compared to the relationship for maximal voluntary contractions (MVC), and that this shift is reduced, or even abolished, for sub-maximal potentiated contractions. Force-elbow angle relationships (48-160 degrees) were obtained from healthy subjects (n=13). At each of nine tested elbow angles, the test set consisted of a single twitch (ST(pre)) and a doublet twitch (DT(pre)) stimulation of m. biceps brachii, followed by an MVC, followed by another single twitch (ST(post)) and a doublet twitch (DT(post)) stimulation. The single and doublet twitches induced sub-maximal contractions. The force-elbow angle relationships for the pre-MVC (unpotentiated) twitch contractions were shifted to larger angles compared to those obtained for MVC. The force-elbow angle relationships for the post-MVC (potentiated) twitch contractions were shifted to smaller angles compared to those obtained for the unpotentiated twitch contractions. These results support the idea that the shift to larger muscle lengths for the sub-maximal, unpotentiated force-length relationships relative to the relationship for maximal contractions may be caused by a length-dependent Ca(2+) sensitivity that may be offset, at least in part, by potentiation.