Effect of active versus passive void trials on time to patient discharge, urinary tract infection, and urinary retention: a randomized clinical trial.

PURPOSE: We sought to determine the effect of active versus passive voiding trials on time to hospital discharge and rates of urinary tract infection (UTI) and urinary retention (UR). METHODS: We performed a prospective, randomized trial comparing active (AVT) versus passive (PVT) void trials of inpatients requiring urethral catheter removal. Of 329 eligible patients, 274 were randomized to AVT (bladder filled with saline before catheter removal) or PVT (spontaneous bladder filling after catheter removal). Primary outcome was time to hospital discharge. Secondary outcomes were UTI (NSQIP criteria) and UR (requiring repeat catheterization) within 2 weeks of void trial. RESULTS: The median time to void was 18 (5-115) versus 236 (136-360) min in the AVT and PVT groups, respectively (p < 0.0001). However, no difference was seen in comparison of the median time to hospital discharge between AVT [28.4 (13.6-69.3) h] and PVT [30.0 (10.4-75.6) h] cohorts, respectively (p = 0.93). Six (4.8%) and 13 (12.9%) patients developed UTI in the AVT and PVT groups, respectively (p = 0.03). Eleven (8.8%) and 12 (11.9%) patients developed UR in the AVT and PVT groups, respectively (p = 0.36). CONCLUSION: Our study comparing AVT versus PVT demonstrated no difference in time to discharge despite a 3.6 h reduction in time to void associated with AVT. AVT was associated with a 63% reduction in UTI, with no difference seen in UR rates across cohorts. Given the reduction in UTI and technical advantages, our data suggest that AVT should be considered as a recommended technique for void trial protocol. TRIAL REGISTRATION: NCT02886143 (clinicaltrials.gov).

Positioning injuries associated with robotic assisted urological surgery.

PURPOSE: Nerve injury associated with patient positioning during surgery is well documented. With the development of robotic surgery, surgeons are faced with new surgical positioning, requiring attention to ensure patient safety. Published reports that address positioning injury during robotic surgery are sparse and none address the overall incidence. In this study we determine the incidence of positioning injury during robotic assisted urological surgery, identify risk factors and describe the time to resolution of the neurological injury. MATERIALS AND METHODS: We reviewed all adult urological cases at our institution that used the da Vinci® Si and da Vinci Standard® Surgical System from January 2010 to December 2011. We characterized risk factors into the 4 domains of positioning, operative, patient specific and anesthesia related. Within these 4 categories we collected data on 13 specific aspects of patient care to determine their association with positioning injury. RESULTS: Of 334 operations 22 positioning injuries (6.6%) were documented. Of these injuries 13 (59.1%) resolved within 1 month, 4 (18.2%) resolved between 1 and 6 months, and 5 (22.7%) persisted beyond 6 months. We found operative time (p <0.0001), in-room time (p <0.0001) and ASA (American Society of Anesthesiologists) class (p = 0.0033) were significantly associated with injury. CONCLUSIONS: Positioning injuries are under recognized in robotic assisted urological surgery and may persist beyond 6 months. Consideration must be given to counseling patients about the risks of positioning injuries, especially for long operations. Patients with multiple medical comorbidities (ASA class 4) are particularly at risk for these injuries.

Effect of body mass index on recurrence following urethroplasty.

BACKGROUND: Limited investigation exists to understand whether obesity affects outcomes of urethral reconstruction. We sought to assess whether body mass index (BMI) is an independent predictor for stricture recurrence following urethroplasty. METHODS: We performed a retrospective review of patients undergoing urethroplasty between 2007-2014, identifying 137 patients for study inclusion. Data collected included BMI and patient demographic and surgical characteristics, including age, stricture length and location, etiology, and urethroplasty technique. Stricture-free survival analysis was performed using Kaplan-Meier method. Logistic regression was performed to assess predictors for stricture recurrence using both univariate and multivariate models. RESULTS: Mean patient age and follow-up was 46.7 (±16.4) years and 91.8 (±30.5) months, respectively. A recurrence rate of 17% was identified, with a mean time to recurrence of 29 months. There was no difference when comparing the mean BMI in patients with and without recurrence (28.9 vs. 30.4 kg/m2, respectively) (P=0.4). A higher rate of stricture recurrence was seen when comparing the cohort with a BMI <25 kg/m2 versus remaining cohorts (BMI: 25-30 kg/m2; BMI >30 kg/m2). However, in univariate and multivariate analysis, BMI failed to demonstrate statistical significance as a predictor for urethroplasty outcome. On multivariate analysis, fasciocutaneous repair type was predictive of stricture recurrence. No additional potential predictors assessed were found to be significant. CONCLUSIONS: In the present study, BMI did not independently predict for stricture recurrence following urethroplasty.

Does Robotic Surgical Simulator Performance Correlate With Surgical Skill?

OBJECTIVE: To assess the relationship between robotic surgical simulation performance and the real-life surgical skill of attending surgeons. We hypothesized that simulation performance would not correlate with real-life robotic surgical skill in attending surgeons. DESIGN: In 2013, Birkmeyer et al. demonstrated an association between laparoscopic surgical performance as determined by expert review of video clips and surgical outcomes. Using that model of expert review, we studied the relationship between robotic simulator performance and real-life surgical skill. Ten attending robotic surgeons performed 4 tasks on the da Vinci Skills Simulator (Camera Targeting 1, Ring Walk 3, Suture Sponge 3, and Energy Dissection 3). Two video clips of a robotic-assisted operation were then recorded for each surgeon. Three expert robotic surgeons reviewed the recordings and rated surgical technique using the Global Evaluative Assessment of Robotic Skills. SETTING: University of Virginia; Charlottesville, VA; tertiary hospital PARTICIPANTS: All attending surgeons who perform robotic-assisted surgery at our institution were enrolled and completed the study. RESULTS: The surgeons had a median of 7.25 years of robotic surgical experience with a median of 91 cases (ranging: 20-346 cases) in the last 4 years. Median scores for each simulator task were 87.5%, 39.0%, 77.5%, and 81.5%. Using Pearson's correlation, scores for each of the individual tasks correlated poorly with expert review of intraoperative performance. There was also no correlation (r = -0.0304) between overall simulation score (mean: 70.7 ± 9.6%) and expert video ratings (mean: 3.66 ± 0.32 points). CONCLUSIONS: There was no correlation between attending surgeons' simulator performance and expert ratings of intraoperative videos based on the Global Evaluative Assessment of Robotic Skills scale. Although novice surgeons may put considerable effort into training on robotic simulators, performance on a simulator may not correlate with attending robotic surgical performance. Development of simulation exercises that guide novice surgeons toward expert performance is needed.

11 Years Later-Isolated Testicular Relapse of ALL After Stem Cell Transplantation Treated With Surgery Only: A Case Report and Review of the Literature.

Despite advances in therapy for childhood acute lymphoblastic leukemia (ALL), relapses continue to occur and are associated with significant morbidity and mortality. Individuals who relapse after stem cell transplantation (SCT) have an especially poor prognosis and typically require intensive systemic therapy to provide any chance of cure. The majority of relapses occur within 2 years following SCT; relapses later than 4 years post SCT are rare. Here we describe an isolated testicular relapse of ALL 11 years after SCT, treated with local control measures only, and review the literature for other cases of very late ALL relapse following SCT.

Diagnosing suprascapular neuropathy in patients with shoulder dysfunction: a report of 5 cases.

BACKGROUND AND PURPOSE: Suprascapular neuropathy, resulting in shoulder pain and weakness, is frequently misdiagnosed. The consequences of misdiagnosis can include inappropriate physical rehabilitation or surgical procedures. The purpose of this case report is to describe the differential diagnosis of suprascapular neuropathy. CASE DESCRIPTIONS: Five patients were initially diagnosed with subacromial impingement syndrome and referred for physical therapy. Physical therapist examination findings were consistent with subacromial impingement syndrome and suprascapular neuropathy. Subsequent electrophysiologic testing confirmed the diagnosis of suprascapular neuropathy in all 5 patients. DISCUSSION: The differential diagnosis of patients with suprascapular neuropathy includes subacromial impingement syndrome, rotator cuff pathology, C5-6 radiculopathy, and upper trunk brachial plexopathy. The diagnostic process and a table with key findings based on evidence and clinical experience is presented for differential diagnosis.