Association of Surgical Approach With Treatment Burden, Oncological Effectiveness, and Perioperative Morbidity in Adrenocortical Carcinoma.

MICROABSTRACT: In the National Cancer Database (NCDB), patients treated with minimally invasive adrenalectomy (MIA) for adrenocortical carcinoma (ACC) had similar oncological outcomes and cumulative treatment burden with less morbidity compared with open adrenalectomy (OA). Although OA remains the standard of care for adrenal lesions concerninge for malignancy, MIA in appropriately selected patients may offer equivalent oncological outcomes. INTRODUCTION/BACKGROUND: We investigated the cumulative treatment burden, oncological effectiveness, and perioperative morbidity in patients undergoing MIA compared with (OA) for patients with ACC. PATIENTS AND METHODS: We reviewed the NCDB for patients undergoing surgical resection (MIA vs. OA) for ACC from 2010 to 2017. Inverse probability of treatment weighted logistic regression, negative binomial, and Cox proportional hazards models were fit to assess for an association of surgical approach with cumulative treatment burden (any adjuvant therapy, radiation therapy [RT], and systemic therapy), oncological effectiveness (positive surgical margins [PSM], lymph node yield [LNY], and overall survival [OS]), and perioperative morbidity (length of stay [LOS] and readmission) as appropriate. RESULTS: We identified 776 patients that underwent adrenalectomy for ACC, of which 307 underwent MIA. We noted patients with larger tumors (OR 0.82, 95% CI 0.78-0.86, P < .001) were less likely to have MIA prior to IPTW. We did not appreciate a significant association of MIA with cumulative treatment burden or the use of any adjuvant therapy (OR 0.85, 95% CI 0.60-1.21, P = .375), adjuvant RT (OR 0.94, 95% CI 0.59-1.50, P = .801), or adjuvant systemic therapy (OR 0.84, 95% CI 0.58-1.21, P = .352). Patients undergoing MIA had similar oncological effectiveness of surgery and OS when compared with patients which underwent OA. Patients that underwent MIA had a significantly shorter LOS (IRR: 0.74, 95% CI 0.62-0.88, P = .001) and lower odds of readmission (OR 0.46, 95% CI 0.23-0.91, P = .026). CONCLUSIONS: Although the standard of care for adrenal lesions suspicious for ACC remains OA, in appropriately selected patients, MIA may offer similar oncological effectiveness and cumulative treatment burden, with less morbidity, than OA.

A comparison of healing and complication rates between common flaps utilized in total knee arthroplasty: a review of the literature.

BACKGROUND: Flap reconstruction with perforator, fasciocutaneous, muscular, and/or free microvascular flaps is utilized to cover wound defects and improve vascularization and antibiotic/nutrient delivery. Flap use in revision procedures for total knee arthroplasty has been explored previously; however, current data are limited and studies comparing healing and complication rates between different flap types are lacking. METHODS: A literature review was performed using PubMed on 13 January 2022. Studies were included if they reported healing and complication rates for either gastrocnemius, rectus abdominis, latissimus dorsi, fasciocutaneous, chimeric, or gracilis flaps in the setting of revision total knee arthroplasty (TKA). RESULTS: The final cohort included gastrocnemius (n = 421, healing rate 73.8%, complication rate 59.9%), gracilis (n = 9, healing rate 93%, complication rate 55.6%), latissimus dorsi (n = 41, healing rate 67%, complication rate 46.3%), rectus abdominis (n = 3, healing rate 100%, complication rate 0%), fasciocutaneous (n = 78, healing rate 70%, complication rate 19.2%), and chimeric flaps (n = 4, healing rate 100%, complication rate 25%). There was no significant difference when comparing healing rates across flap types (p = 0.39). There was a significant difference when comparing complication rates across flap types (p < 0.0001), with a significant difference being noted between gastrocnemius and fasciocutaneous complication rates (p < 0.0001). All other comparisons between flap types by complication rate were not significantly different. CONCLUSIONS: Gastrocnemius flaps are the workhorse flap in the setting of revision TKA, as evidenced by this review. Healing rates did not vary significantly across flap types, which suggests that determining the appropriate flap for coverage of soft-tissue defects in revision TKA should be driven by defect size and location as well as physician experience and patient tolerance.

Oncologic Outcomes of cT1 and cT2 Micropapillary Variant Compared with cT1 and cT2 Conventional Urothelial Carcinoma Treated with Radical Cystectomy.

INTRODUCTION: Our objective was to estimate the difference in outcomes for patients with clinical T stage 1 (cT1) and 2 (cT2) micropapillary (MPBC) and urothelial carcinoma (UCBC) bladder cancer treated with radical cystectomy (RC). METHODS: We reviewed the National Cancer Database for patients with cT1/2N0M0 MPBC and UCBC treated with RC from 2004-2016. Patients were classified by cT stage and histology. Outcomes of interest included upstaging to advanced pathological stage (pT3/4), pathologically node positive disease (pN+), and overall survival (OS). The Kaplan-Meier method was used to estimate 5-year OS probability. Multivariable logistic regression models were fit to test for an association between cT stage and histology with outcomes. RESULTS: We identified 23,871 patients, of whom 384 had MPBC and 23,487 had UCBC. More patients with cT1 and cT2 MPBC had advanced pathological stage and pN+ (cT1: 31% and 34%; cT2: 44% and 60%, respectively) compared with cT1 and cT2 UCBC (cT1: 18% and 14%; cT2: 27% and 24%, respectively). Compared with cT2 UCBC, patients with cT1 MPBC had similar odds of advanced pathological stage (OR: 0.96, 95% CI: 0.63-1.45, p=0.837) and increased odds of pN+ (OR: 1.62, 95% CI: 1.03-2.56, p=0.038). Five-year OS estimates for cT1 MPBC and UCBC were similar (58% and 60%, respectively) while cT2 MPBC had worse OS than cT2 UCBC (33% and 45%, respectively). CONCLUSIONS: In a cohort of patients undergoing RC, cT1/2 MPBC had worse outcomes than cT1/2 UCBC. Patients and surgeons should consider aggressive therapies for patients with cT1 MPBC due to the risk of inferior outcomes associated with cT2 MPBC disease.

Arthroscopic Versus Open Management of Diffuse-Type Tenosynovial Giant Cell Tumor of the Knee: A Meta-analysis of Retrospective Cohort Studies.

BACKGROUND: Whether arthroscopic or open surgical management for diffuse-type tenosynovial giant cell tumor (D-TGCT) of the knee is associated with a lower rate of recurrence is unknown. METHODS: PubMed, Scopus, Web of Science, Cochrane, and EMBASE were searched on December 3, 2020. Retrospective studies that reported on recurrence rates for arthroscopic versus open management of D-TGCT were included. A total of 16 studies evaluating 1143 patients with D-TGCT of the knee were included (nopen = 551, narthroscopic = 350 patients, and narthroscopic/open = 23 patients). Random-effects meta-analyses were used to summarize and compare the reported recurrence rates, stratified by approach and overall recurrence. The meta-analysis was registered with PROSPERO. RESULTS: The recurrence rate per year (incidence) for arthroscopic procedures was 0.11 (95% CI 0.08 to 0.16, P < 0.0001) and for open procedures was 0.07 (95% CI 0.04 to 0.13, P < 0.0001). There was a 1.56 times (95% CI 1.04 to 2.34, P = 0.0332) increased risk of recurrence when treating D-TGCT of the knee with an arthroscopic approach. When evaluating only the subset of studies that had data for both arthroscopic and open approaches, the incidence rate per year for arthroscopic procedures was 0.17 (95% CI 0.11 to 0.27, P < 0.0001) and for open procedures was 0.11 (95% CI 0.06 to 0.19, P < 0.0001). The rate of overall complications was 0.04 (95% CI 0.01 to 0.08, P < 0.0001). CONCLUSION: Arthroscopic surgical management of D-TGCT of the knee in our study resulted in a 1.56 times risk of recurrence as compared with the open approach. The percent of overall complications was minimal.

Assessing the recognition of female orthopaedic surgeons in Castle Connolly's "America's Top Doctors" from 2000 to 2020.

BACKGROUND: The field of orthopaedic surgery has one of the lowest percentages of practicing female physicians. Studies have shown disparities in various academic societies' award recipients by sex. Given the recent increased use of physician rating platforms by patients and focus on consumer-driven healthcare, our aim was to assess the recognition of female orthopaedic surgeons. METHODS: A twenty-year quantitative analysis was performed comparing the rate of top female orthopaedic surgeons listed on Castle Connolly's "America's Top Doctors" to the percentage of practicing female orthopaedic surgeons as reported by the American Academy of Orthopaedic Surgeons. RESULTS: From 2000 to 2020, there was a statistically significant increase in the percentage of top female orthopaedic surgeons listed on Castle Connolly (1.3%-5.3%), as well as an increase in overall practicing AAOS female members (2.7%-5.8%). When comparing the rate of top female orthopaedic surgeons listed on Castle Connolly to the proportion of practicing female AAOS members from 2000 to 2020, there were no statistically significant differences. CONCLUSIONS: The increase in the rate of top female orthopaedic surgeons recognized by Castle Connolly was proportionate to the increase in percentage of practicing female AAOS members over the past 20 years. This study highlights the persistence of a gender discrepancy in the academic sector of orthopaedic surgery.

Identification of oncological characteristics associated with improved overall survival in patients with adrenocortical carcinoma treated with adjuvant radiation therapy: Insights from the National Cancer Database.

OBJECTIVES: To test for an association between oncological risk factors and overall survival in patients with non-metastatic adrenocortical carcinoma treated with adjuvant radiation therapy at high-risk for recurrence per NCCN guidelines. MATERIALS AND METHODS: We analyzed data from patients undergoing surgical resection with or without aRT in the NCDB from 2004 to 2017. A multivariable Cox proportional hazards model was fit to assess for an association of aRT and OS. To determine whether aRT was associated with improved OS in patients with specific NCCN risk factors, we fit three multivariable Cox proportional hazard models with an interaction term between NCCN risk factors and the use of aRT. RESULTS: We identified 1,433 patients treated surgically for adrenocortical carcinoma with at least one risk factor. 259 patients received adjuvant radiation therapy (18%) while 1,174 (82%) patients did not. After adjustment, we noted a significant association between adjuvant radiation therapy and overall survival in the entire cohort in the multivariable Cox proportional hazards model (HR 0.68, 95% CI 0.55-0.85, P = 0.001). Adjuvant radiation therapy was associated with increased overall survival in patients with positive surgical margins (HR 0.47, 95% CI 0.35-0.65, P < 0.001), large tumor size ≥6 cm (HR 0.69, 95% CI 0.55-0.87, P = 0.002), and high-grade disease (HR 0.61, 95% CI 0.37-0.99, P = 0.046). CONCLUSIONS: Patients with ACC at high-risk for recurrence were associated with improved overall survival when treated with adjuvant radiation therapy. These data may help identify which patients should consider aRT after resection of clinically localized ACC.

Endoscopic Removal of an Intrauterine Device in the Left Distal Ureter.

Background: Intrauterine device (IUD) migration to the ureter is rare. Symptoms can vary, but often mimic renal colic. Radiographic imaging may aid the diagnosis of a foreign body in the ureter. Reports on endoscopic managements of a migrated IUD are not well described. Case Presentation: We present a 36-year-old woman with a history of IUD insertion. Her symptoms included hematuria, dysuria, and suprapubic/abdominal pressure. After the removal of her IUD by her gynecologist, her hematuria eventually stopped, but she presented again with persistent pain. CT revealed a radiopaque foreign body in the distal left ureter protruding into the bladder. A careful resection with a resectoscope uncovered a long cylindrical shaped foreign body, suspicious of a broken piece of the IUD. Conclusion: Although not always feasible and long-term results remain to be determined, endoscopic management is a safe and effective method of identifying and removing a retained IUD in the ureter. When evaluating a woman with abdominal pain who has an indwelling IUD, a spontaneous migration of the IUD should be considered in the differential diagnosis.

Intraoperative transradial angiography augments safe hysterectomy for uterine fibroids in the setting of ambiguous arterial anatomy: a case report.

BACKGROUND: Transfemoral access is the traditional gold standard for uterine artery angiography; however, transradial access is gaining in popularity because of its decreased complication profile and patient preference. We present a case of a patient who underwent successful total abdominal hysterectomy for symptomatic uterine fibroids with ambiguous pelvic vasculature that would have been otherwise aborted if it were not for intraoperative transradial access angiography. CASE PRESENTATION: A 52-year-old Caucasian woman presented to her gynecologist for an elective total abdominal hysterectomy and bilateral salpingo-oophorectomy. During preoperative imaging, a 15-cm mass consistent with a uterine fibroid was identified, and the patient's gynecologist decided to treat her with surgical resection, given the fibroid's size. The procedure was halted upon discovery of a complicated vascular plexus at the fundus of the uterus, and an intraoperative vascular consult was requested. The vascular operator used a transradial access to perform pelvic angiography in real time to identify the complicated pelvic vasculature, which allowed the gynecologist to surgically resect the uterine fibroid. The patient was discharged on postoperative day 4 without any complications. CONCLUSIONS: Intraoperative imaging is a useful technique for the identification of complicated anatomical structures during surgical procedures. The successful outcome of this case demonstrates an additional unique benefit of transradial access and highlights an opportunity for interdisciplinary collaboration for management of complicated surgical interventions.