Comparison of valve-less and standard insufflation on pneumoperitoneum-related complications in robotic partial nephrectomy: a prospective randomized trial.

To prospectively compare standard and valve-less insufflation systems on pneumoperitoneum-related complications in robotic-assisted laparoscopic partial nephrectomy. A prospective randomized controlled trial was conducted during a 1.5-year period to compare insufflation-related complications in partial nephrectomy surgery by a single surgeon. Thirty-one patients were recruited for each group: AirSeal insufflation system at 12 mmHg (AIS12), AirSeal at 15 mmHg (AIS15), and conventional insufflation system at 15 mmHg (CIS). Primary outcome assessed was rate of subcutaneous emphysema. Secondary outcomes included rates of pneumothorax, pneumomediastinum, shoulder pain scores, overall pain scores, pain medication usage, insufflation time, recovery room time, length of hospital stay and impact of surgical approach. Predictors for subcutaneous emphysema were assessed with univariate and multivariate logistic models. 93 patients with similar baseline characteristics were randomized into the three insufflation groups. Incidence of subcutaneous emphysema was lower in the AIS12 group compared to CIS (19% vs 48%, p = 0.03,). Mean pain score was less for AIS12 compared to CIS at 12 h (3.1 vs 4.4, p = 0.03). Shoulder pain was less in AIS12 and AIS15 groups compared to CIS at 8 h (AIS12 vs CIS: 0.6 vs 1.6, p = 0.01, AIS15 vs CIS: 0.6 vs 1.6, p = 0.02), and between AIS12 as compared to CIS at 12 h (0.4 vs 1.4, p = 0.003) postoperatively. There was no difference between morphine equivalent use, insufflation time, recovery room time, and length of hospital stay. Multivariable regression analysis showed AirSeal at 12 mmHg and the transperitoneal approach to be the only significant predictors for lower risk of developing subcutaneous emphysema (p < 0.001). Compared to standard insufflation, AirSeal insufflation at 12 mmHg was associated with reduced risk of developing subcutaneous emphysema in robotic partial nephrectomy. Furthermore, shoulder pain was reduced in both AirSeal groups compared to standard insufflation. The retroperitoneal approach increases the risk of developing subcutaneous emphysema.

Prospective Pilot Trial to Evaluate a High Resolution Diffusion-Weighted MRI in Prostate Cancer Patients.

OBJECTIVES: High-resolution prostate imaging may allow for detection of subtle changes in tumor size, decrease the reliance on biopsies, and help define tumor boundaries during ablation. This pilot clinical trial evaluates a novel high-resolution prostate MRI for detection of small, biopsy-proven prostate tumors. METHODS: Our team developed a software that can be loaded on any modern MRI to generate high resolution diffusion-weighted imaging sequences (HR-DWI), which were compared to standard diffusion-weighted imaging sequence (S-DWI) in a prospective pilot trial in active surveillance patients. HR-DWI captures the entire volume of the prostate rather than sections, reducing streaking artifacts and geometric distortions. Multiple shots, rather than single shots, are used to differentiate signal and noise, enhancing resolution. All images were read by two radiologists. The primary outcome was the percent of biopsy-proven zones seen in 17 patients. The trial was powered to detect discordant proportions of 0.04 and 0.40 at one-sided alpha=0.05. RESULTS: The resolution was defined using standard phantoms. HR-DWI produced a 5-fold improvement in spatial resolution when compared to S-DWI. Multiparametric (MP)-MRI incorporating S-DWI was useful for predicting biopsy results (AUC 0.72, Fisher's exact p<0.001); however, using HR-DWI allowed MP-MRI to be more highly predictive of biopsy results (AUC 0.88, Fisher's exact p<0.001). AUC for MP-MRI incorporating HR-DWI was significantly larger than MP-MRI incorporating S-DWI (p=0.002). MP-MRI with HR-DWI had a sensitivity of 95.7% and identified tumor in 22 of 23 zones proven to have cancer on biopsy. In contrast, MP-MRI with S-DWI had a sensitivity of 60.9% and only identified 14 of 23 biopsy-positive zones (p=0.004). CONCLUSION: We developed a novel DWI and evaluated its improved resolution in a clinical setting. This technology has many potential applications and should be evaluated in future clinical trials as a patient management tool.

Appendicovesical Fistula Following Transurethral Resection of Bladder Tumor With Mitomycin C.

Appendicovesical fistula is a rare entity, with only 116 cases reported to date. It is an uncommon form of enterovesical fistula and often associated with a history of appendicitis. It can present as pneumaturia, fecaluria, and recurrent urinary tract infections, not unlike symptoms of enterovesical fistulas. We present a novel case of appendicovesical fistula developing after transurethral resection of bladder tumor and instillation of mitomycin C. Treatment included laparoscopic appendectomy and bladder repair.

Sacral Osteomyelitis After Robotic Sacrocolpopexy.

BACKGROUND: Robotic-assisted abdominal sacrocolpopexy (RASC) is an effective procedure for the surgical treatment of vaginal vault prolapse associated with a rare, but serious, risk of sacral osteomyelitis. CASE: We report a case of Bacteroides fragilis sacral osteomyelitis after RASC that presented only as back pain. Treatment included intravenous antibiotics and abdominal exploration with removal of sacral mesh. CONCLUSIONS: Sacral osteomyelitis is a rare complication following RASC and may present only as back pain without constitutional symptoms. Intravenous antibiotics and surgical excision of sacral mesh are routinely performed, but preservation of vaginal mesh is a viable option. The clinician should have a high index of suspicion for osteomyelitis in any patient who presents with back pain after RASC, regardless of absence of other presenting symptoms.

Preoperative Testing for Urethral Sling Surgery for Stress Urinary Incontinence: Overuse, Underuse and Cost Implications.

PURPOSE: We identify areas of overuse and underuse in the preoperative evaluation of patients undergoing mid urethral sling surgery. We also estimate the effect of overuse of preoperative testing on health care costs. MATERIALS AND METHODS: We conducted a retrospective review of women who underwent sling surgery with or without concomitant prolapse repair between 2012 and 2013. Physician orders for preoperative electrocardiogram, chest x-ray, basic metabolic panel, complete blood count, coagulation studies and urinalysis were classified as appropriate or inappropriate based on summary guidelines from the American Academy of Family Physicians. The additional costs of inappropriate tests were estimated using the 2014 Medicare clinical laboratory and physician fee schedules. RESULTS: A total of 101 women who underwent mid urethral sling surgery were identified and 346 preoperative tests were ordered. Overall 76% of coagulation profiles, 73% of complete blood counts, 47% of basic metabolic panels, 39% of chest x-rays and 21% of electrocardiograms ordered did not have an appropriate clinical indication. In addition, 6% of electrocardiograms, 22% of chest x-rays and 10% of urinalyses were not ordered despite an appropriate indication. The estimated charges of overused tests were $1,844.15 for the cohort, or $18 per patient. CONCLUSIONS: Preoperative testing is overused as well as underused in patients undergoing sling surgery. The greatest variation occurred with the use of electrocardiograms, chest x-rays and urinalysis. Poor adherence to national guidelines leads to increased health care costs and warrants increased awareness in following evidence-based guidelines.

Multiparametric MRI Improves Accuracy of Clinical Nomograms for Predicting Extracapsular Extension of Prostate Cancer.

OBJECTIVE: To compare the accuracy of multiparametric magnetic resonance imaging (MP-MRI) with the Partin tables and Memorial Sloan-Kettering (MSK) nomogram for predicting extracapsular extension (ECE) in prostate cancer and to create a tool for clinicians to estimate pathologic ECE risk. METHODS: A retrospective review of 112 patients who underwent 3T MP-MRI of the prostate and radical prostatectomy was performed. Regression analyses were carried out to identify predictors of ECE. Predictive accuracy of models based on nomogram and MP-MRI were compared. RESULTS: A total of 33 of patients (29%) had ECE on MP-MRI whereas 26 patients (23%) had ECE on final pathology. Mean age was 62.8 years and mean prostate-specific antigen was 8.2 ng/dL. MRI was a significant predictor of ECE that was independent of age, prostate-specific antigen, Gleason score, clinical stage, and percent positive cores on biopsy. Sensitivity, specificity, positive predictive value, and negative predictive value of MP-MRI for ECE were 84.6%, 87.2%, 66.7%, and 94.9%, respectively. Areas under the curve for Partin and MSK nomograms for predicting ECE were 0.85 and 0.86, respectively. Area under the curve increased to 0.92 and 0.94, respectively, when MP-MRI was added to each nomogram. We provide an online tool that integrates Partin or MSK nomogram results with ECE status determined from MRI to predict pathologic ECE. Within the typical range of risks for ECE provided by the clinical nomograms (ie, 15%-40%), MRI was useful for predicting pathologic ECE. CONCLUSION: MP-MRI may be a useful adjunct for clinically staging prostate cancer. MP-MRI improved accuracy of existing clinical nomograms for prediction of pathologic ECE.

Multiparametric magnetic resonance imaging localizes established extracapsular extension of prostate cancer.

OBJECTIVE: To define the accuracy of multiparametric magnetic resonance imaging (MP-MRI) for identifying focal and established extracapsular extension (ECE) in various zones of the prostate. METHODS: Between 2010 and 2013, 342 patients underwent MP-MRI of the prostate (3T, no endorectal coil with axial perfusion and diffusion images). The findings of the images were reported as negative, suspicious, or positive for ECE by a single expert radiologist. Radical prostatectomy specimens were reviewed to confirm the size and the location of ECE and further defined as focal or established ECE. Established ECE included extension that was multifocal or involving more than 5 glands. The accuracy of MRI in localizing focal and established ECE to each zone of the prostate was determined. Regression analyses were performed to identify predictors of ECE. RESULTS: We identified 112 patients who underwent prostate MP-MRI and radical prostatectomy. MRI findings considered suspicious or definite for ECE accurately predicted pathologic ECE (P<0.001). MP-MRI identified established ECE but not focal ECE. Sensitivity, specificity, positive predictive value, and negative predictive value of MP-MRI for established ECE were 70.7%, 90.6%, 57.1%, and 95.1%, respectively. MRI identified ECE to the left vs. right side as well as each zone of the prostate; however, sensitivity was lowest at the apex. On multivariate analysis, MRI was a significant predictor of ECE that was independent of prostate-specific antigen level, Gleason score, and clinical stage. CONCLUSION: MP-MRI is useful for identifying established but not focal ECE in all zones of the prostate. MRI was a significant independent predictor of established ECE and may be a useful adjunct in staging prostate cancer.

Bladder perforation secondary to primary systemic amyloidosis.

Amyloidosis is a disorder of protein folding characterized by extracellular aggregation and deposition of amyloid protein fibrils. Light-chain amyloidosis, also known as primary systemic amyloidosis, is the most common form of the disease. We present a case of an 84-year-old male with a history of systemic primary amyloidosis causing genitourinary, cardiac, and autonomic dysfunction who presented with hematuria and hypotension secondary to bladder perforation. He underwent open repair of a large extraperitoneal bladder defect. He ultimately died as a result of medical complications from his disease.