Thromboembolic risk in patients with lung cancer receiving systemic therapy.

In this retrospective study, we investigated the influence of chemotherapy and immunotherapy on thromboembolic risk among United States Veterans with lung cancer during their first 6 months (180 days) following initiation of systemic therapy. Included patients received treatment with common front-line agents that were divided into four groups: chemotherapy alone, immunotherapy alone, combination of chemo- and immunotherapies, and molecularly targeted therapies (control group). The cohort experienced a 7·4% overall incidence of thrombosis, but the analysis demonstrated significantly different rates among the different groups. We explored models incorporating multiple confounding variables as well as the competing risk of death, and these results indicated that both chemo- and immunotherapies were associated with an increased incidence of thrombosis, either alone or combined, compared with the control group (7·56%, P = 2.2 × 10-16 ; 10·2%, P = 2.2 × 10-16 ; and 7·87%, P = 2.4 × 10-14 respectively vs. 4·10%). The Khorana score was found to be associated with increased risk, as were vascular disease and metastases. We found an association between risk of thrombosis and the use of anticoagulation, accounting for several confounders, including history of thrombosis. Further study is warranted to better determine the drivers of thromboembolic risk and to identify ways to mitigate this risk for patients.

Ureteroscopic evaluation and treatment of benign essential hematuria: a systematic review.

INTRODUCTION The advent of ureteroscopy has revolutionized the treatment many urologic diseases, including benign essential hematuria. This systematic review examines the treatment of benign essential hematuria (BEH) with ureteroscopic interventions. MATERIALS AND METHODS: We performed a systematic review of the literature from 1977 to May 2020. We included studies that evaluated the use of ureteroscopy to diagnose or treat BEH. Demographics, follow up, findings, treatment method and success rate were extracted from each identified paper. Quality analysis was performed independently by both authors. RESULTS: Our search resulted in 587 articles. Fifteen of these studies met inclusion criteria and were included in the final analysis. No randomized controlled trials were found. All 15 studies were case series. Nine studies were graded as good, five as fair, and one as poor. Follow up ranged from 2 to 108 months. A total of 307 patients underwent ureteroscopy for suspected BEH; 223 (73%) were diagnosed with a discrete lesion, 33 (11%) with a diffuse lesion, and 44 (14%) had no lesions seen on ureteroscopy. Of those diagnosed with discrete lesions, the most common was minute venous ruptures (35%), followed by hemangiomas (26%). Ureteroscopic treatment successfully relieved the hematuria and symptoms in most patients, and was more successful in those treated for discrete lesion (115/120, 96%) than diffuse (10/19, 53%). CONCLUSIONS: Ureteroscopic treatment of BEH yields excellent outcomes. In this systematic review, 96% of patients with discrete lesions and 53% of patients with diffuse lesions had resolution of their hematuria after ureteroscopic interventions.

Higher outcomes of vasectomy reversal in men with the same female partner as before vasectomy.

PURPOSE: We reviewed fertility outcomes of vasectomy reversal at a high surgical volume center in men with the same female partner as before vasectomy. MATERIALS AND METHODS: We retrospectively studied a prospective database. All vasectomy reversals were performed by a single surgeon (EFF). Patients who underwent microsurgical vasectomy reversal and had the same female partner as before vasectomy were identified from 1978 to 2011. Pregnancy and live birth rates, procedure type (bilateral vasovasostomy, bilateral vasoepididymostomy, unilateral vasovasostomy or unilateral vasoepididymostomy), patency rate, time from reversal and spouse age were evaluated. RESULTS: We reviewed the records of 3,135 consecutive microsurgical vasectomy reversals. Of these patients 524 (17%) who underwent vasectomy reversal had the same female partner as before vasectomy. Complete information was available on 258 patients (49%), who had a 94% vas patency rate. The clinical pregnancy rate was 83% by natural means compared to 60% in our general vasectomy reversal population (p <0.0001). On logistic regression analysis controlling for female partner and patient ages, years from vasectomy and vasectomy reversal with the same female partner the OR was 2 (p <0.007). Average time from vasectomy was 5.7 years. Average patient and female partner age at reversal was 38.9 and 33.2 years, respectively. CONCLUSIONS: Outcomes of clinical pregnancy and live birth rates are higher in men who undergo microsurgical vasectomy reversal with the same female partner. These outcomes may be related to a shorter interval from vasectomy, previous fertility and couple motivation.

Impact on Pregnancy of Gross and Microscopic Vasal Fluid during Vasectomy Reversal.

PURPOSE: We compared fertility outcomes with gross and microscopic fluid findings at vasectomy reversal at a high volume vasectomy reversal center. MATERIALS AND METHODS: A retrospective study of a prospective database was performed. All vasectomy reversals were performed by a single surgeon (EFF) between 1978 and 2011. The clinical pregnancy rate was self-reported or determined via patient mailers. Patient and operative findings were determined through database review. We classified vasal fluid as opalescent, creamy, pasty or clear. Intraoperative light microscopy was used to determine if sperm or sperm parts were present and if they were motile. Multivariate analysis was performed evaluating patient age, partner age, years after vasectomy, type of surgery, and gross and microscopic fluid analysis. RESULTS: A total of 2,947 microsurgical vasectomy reversals were reviewed after we excluded reversals performed for post-vasectomy pain. We determined the pregnancy status of 902 (31%) cases. On univariate analysis with respect to pregnancy the presence of motile sperm at vasovasostomy neared statistical significance (p=0.075) and there was no difference between bilateral vs unilateral motile sperm. Gross fluid appearance was not statistically significant but we found the order of pregnancy success to be opalescent, creamy, clear then pasty fluid. On multivariate analysis only female partner age and sperm heads only or no sperm seen on light microscopy had statistical significance (p <0.05). CONCLUSIONS: The presence of motile sperm at vasectomy reversal approaches statistical significance on univariate analysis as a factor that affects clinical pregnancy rates. On multivariate analysis female partner age and microscopic findings of sperm heads only or no sperm are inversely related to pregnancy rates. These data will help counsel couples after vasectomy reversal and reinforce the importance of female partner age.

Timing, incidence and risk factors for venous thromboembolism in patients undergoing radical cystectomy for malignancy: a case for extended duration pharmacological prophylaxis.

PURPOSE: Patients undergoing radical cystectomy for bladder cancer are at high risk for venous thromboembolism. Recent data have demonstrated that the risk of venous thromboembolism often extends beyond hospital discharge in nonurological surgical populations. To our knowledge the timing of venous thromboembolism in patients who have undergone radical cystectomy during a 30-day postoperative period has not been assessed. Therefore, we evaluated the timing, incidence and risk factors for venous thromboembolism for patients undergoing radical cystectomy for malignancy. MATERIALS AND METHODS: In this descriptive, observational, retrospective study data from 1,307 patients who underwent radical cystectomy for malignancy from 2005 to 2011 were collected using the American College of Surgeons NSQIP (National Surgical Quality Improvement Program) database. Venous thromboembolism occurrences were evaluated by postoperative day and whether they occurred while an inpatient or after discharge home. Univariate and multivariate Cox regression and logistic regression models were used to evaluate risk factors associated with venous thromboembolism. RESULTS: Of 1,307 patients 78 (6%) were diagnosed with venous thromboembolism. The mean time to venous thromboembolism diagnosis was 15.2 days postoperatively. Of all venous thromboembolism events 55% were diagnosed after patient discharge home. The 30-day mortality rate from venous thromboembolism was 6.4%. Risk factors for the development of venous thromboembolism on multivariate analysis were age (p = 0.024), operative time (p = 0.004) and sepsis or septic shock (p = 0.0001). CONCLUSIONS: More than half of all venous thromboembolisms (55%) in patients undergoing radical cystectomy for malignancy occurred after discharge home and the mean time to venous thromboembolism diagnosis was 15.2 days postoperatively. It is reasonable to consider extended duration pharmacological prophylaxis (4 weeks) in this high risk surgical population.

A single dose of a non-steroidal anti-inflammatory drug (NSAID) prevents severe pain after ureteric stent removal: a prospective, randomised, double-blind, placebo-controlled trial.

OBJECTIVES: To determine the incidence of severe pain after ureteric stent removal. To evaluate the efficacy of a single dose of a non-steroidal anti-inflammatory drug (NSAID) in preventing this complication. PATIENTS AND METHODS: A prospective, randomised, double-blind, placebo-controlled trial was performed at our institution. Adults with an indwelling ureteric stent after ureteroscopy were randomised to receive either a single dose of placebo or an NSAID (rofecoxib 50 mg) before ureteric stent removal. Pain was measured using a visual analogue scale (VAS) just before and 24 h after stent removal Pain medication use after ureteric stent removal was measured using morphine equivalents. RESULTS: In all, 22 patients were enrolled and randomised into the study before ending the study after interim analysis showed significant decrease in pain level in the NSAID group. The most common indication for ureteroscopy was urolithiasis (14 patients). The proportion of patients with severe pain (VAS score of ≥7) during the 24 h after ureteric stent removal was six of 11 (55%) in the placebo group and it was zero of 10 in the NSAID group (P < 0.01). There were no complications related to the use of rofecoxib. CONCLUSIONS: We found a 55% incidence of severe pain after ureteric stent removal. A single dose of a NSAID before stent removal prevents severe pain after ureteric stent removal.

Elevated incidence of head and neck cancer in solid organ transplant recipients.

BACKGROUND: Solid organ transplant recipients are known to be at an increased risk of cancer development, but research on head and neck cancer in transplant recipients has been limited and prior risk assessments may not be accurate. METHODS: A retrospective review using a national Veterans Administration database to query outpatient problem lists for ICD codes indicating solid organ transplant and subsequent diagnosis of head and neck cancer. RESULTS: In a study of 30 939 656 patients (37 969 solid organ transplants and 113 995 head and neck cancers), history of transplant significantly predicted head and neck cancer, with relative risks ranging from 1.85 (thyroid) to 2.91 (salivary gland). Worse overall survival (OS) was seen for head and neck cancer patients with prior transplants. CONCLUSIONS: In a large case-control study, prior transplant was a risk factor for head and neck cancer development and worse OS for head and neck cancer patients.

The safety and efficacy of transurethral microwave therapy in high-risk catheter-dependent men.

OBJECTIVE: Previous studies have demonstrated the efficacy of transurethral microwave therapy (TUMT) in the management of high-risk catheter-dependent men, although few have assessed safety in high-risk patients, including those continuing anticoagulation therapy during treatment. Our goal was to assess the safety and effectiveness of TUMT in a population of high-risk catheter-dependent men. MATERIAL AND METHODS: A retrospective analysis of patients who underwent TUMT at a single Veterans Affairs facility for the treatment of benign prostatic hyperplasia was completed. The primary outcome was 30-day postprocedural complications by Clavien-Dindo grade, including bleeding events. The secondary outcome was success in catheter removal. RESULTS: We performed TUMT in 157 men, 105 of whom had urinary retention-requiring an indwelling urethral catheter or clean intermittent catheterization. Overall, 86% of patients underwent TUMT while on anticoagulant therapy and 25% were treated while taking warfarin. The median age of the patients was 76.9 years (95% CI 74.9-78.8) median ASA-score was 3, and median follow-up was 26 months (range 1-65). Only two men experienced hematuria requiring treatment postoperatively and no transfusions were required. Only two patients (1.9%) required readmission within 30 days after treatment. There were 24 (22.9%) Clavien-Dindo grade I-II complications without grade III or higher complications. Urinary retention resolved in 63.7% of men after treatment. CONCLUSION: Our results suggest that TUMT is a safe and reasonably effective treatment for high-risk catheter-dependent men. Furthermore, the low incidence of adverse bleeding events suggests that TUMT is a safe treatment modality for men requiring uninterrupted anticoagulation.

The estimated prevalence of missed positive lymph nodes based on extent of lymphadenectomy at radical prostatectomy.

PURPOSE: To determine practice patterns for the extent of lymphadenectomy at radical prostatectomy and associations with detection of pN1 prostate cancer, as well as the impact of lymphadenectomy extent on underdetection of pN1 disease and overall survival. MATERIALS AND METHODS: Prostatectomy cases in the NCDB from 2004 to 2013 were included. Lymphadenectomy extent was defined by the number of nodes examined. Logistic regression was used to identify risk factors for the top quartile of lymph node count and pN1 disease. This model was created to estimate the expected prevalence of pN1, and generated observed over expected ratios. A Cox regression model was used to evaluate the effect of lymph node count on overall survival. RESULTS: Lymphadenectomy was performed in 209,789 (60%) of 358,522 surgeries, with pN1 in 6,428 (3.08%). Increasing quartiles for lymph node count was associated with pN1 (3-5 nodes OR 2.11; 6-8 nodes OR 3.12; ≥9 nodes OR 5.91, all P< 0.001). The logistic regression model suggested that 59% of pN1 cases are missed due to low lymph node count. Increased lymph node count was associated with increasing pN1 detection (O/E: 1-2 nodes = 0.18; 3-5 nodes = 0.37; 6-8 nodes = 0.56; ≥9 nodes = 1.01). Cox proportional hazards modeling demonstrated that the top quartile for lymph node count had improved overall survival (HR 0.93, CI 0.87-0.99, P= 0.03). CONCLUSIONS: Increasing lymphadenectomy extent was associated with pN1 disease on multivariate analysis, and logistic regression modeling suggested a substantial proportion of pN1 were missed due to low lymphadenectomy extent across all risk groups.

Laser resection of the prostate: implications for anesthesia.

Holmium:yttrium-aluminum-garnet and potassium-titanyl-phosphate lasers make it possible to perform transurethral prostate resection with almost no absorption of irrigant and minimal blood loss. Subarachnoid block is usually administered for classical transurethral resection of the prostate, so that the patient can be monitored for the onset of transurethral resection of the prostate syndrome secondary to irrigant absorption. New laser resection techniques may allow the patient and anesthesiologist to choose options most appropriate for the patient's medical conditions and preference. In this study, we review the urologic literature to provide an overview of current laser technology for prostate reduction surgery. We also screened this literature for evidence of potential effects on anesthesia care for special patient groups as well as for overall perioperative management. Our findings suggest that the anesthesiologist may now safely offer general anesthesia for endourologic laser surgery, even on an ambulatory basis. This includes patients with cardiovascular disease or receiving continuous anticoagulation therapy. We found no studies specifically aimed at evaluating best anesthetic practices for patients undergoing laser procedures. Therefore, clinical research is needed to better define the risks and benefits of the various anesthetic alternatives.

Clipless management of the renal vein during hand-assist laparoscopic donor nephrectomy.

BACKGROUND: Laparoscopic live donor nephrectomy has become the preferred method of donor nephrectomy at many transplant centers. The laparoscopic stapling device is commonly used for division of the renal vessels. Malfunction of the stapling device can occur, and is often due to interference from previously placed clips. We report our experience with a clipless technique in which no vascular clips are placed on tributaries of the renal vein at or near the renal hilum in order to avoid laparoscopic stapling device misfires. METHODS: From December 20, 2002 to April 12, 2005, 50 patients underwent hand-assisted laparoscopic left donor nephrectomy (LDN) at our institution. Clipless management of the renal vein tributaries was used in all patients, and these vessels were divided using either a laparoscopic stapling device or the LigaSureTM device (Valleylab, Boulder, CO). The medical and operative records of the donors and recipients were reviewed to evaluate patient outcomes. RESULTS: The mean follow-up time was 14 months. Of the 50 LDN procedures, there were no laparoscopic stapling device malfunctions and no vascular complications. All renal allografts were functioning at the time of follow-up. CONCLUSION: Laparoscopic stapling device failure due to deployment across previously placed surgical clips during laparoscopic live donor nephrectomy can be prevented by not placing clips on the tributaries of the renal vein. In our series, there were no vascular complications and no device misfires. We believe this clipless technique improves the safety of laparoscopic donor nephrectomy.

Exacerbation of occult femoral hernia during laparoscopic prostatectomy.

Laparoscopic prostatectomy has been accepted as an appropriate treatment for prostate cancer because of the shorter hospital stay and quicker recovery. We present a rare complication of groin hernia with incarceration and necrosis of small bowel following laparoscopic prostatectomy. Occult hernias and small fascia defects may not always be apparent pre-operatively, but extension of pneumoperitoneal insufflation to extraperitoneal compartments should alert the surgeon to the possible presence of such a defect.

Vasectomy Reversal for Postvasectomy Pain Syndrome: A Study and Literature Review.

OBJECTIVE: To review our institution's experience and success with vasectomy reversal to treat postvasectomy pain syndrome (PVPS) over the last 20 years. MATERIALS AND METHODS: A single surgeon (E.F.F.) performed all the vasectomy reversals. We identified 123 procedures done for PVPS treatment and were able to contact 76 patients. We sent surveys or conducted phone interviews inquiring about satisfaction, levels of pain preoperatively and postoperatively, and the need for additional procedures for pain. Thirty-one patients completed phone or written surveys. In addition, we compared the location of vasectomy among patients presenting for pain to that of fertile patients. RESULTS: Thirty-one men had vasectomy reversal for postvasectomy pain, with median age of 38 years (range, 31-55 years), of which 26 underwent vasovasostomy (VV). Seven patients required epididymovasostomy (EV) on at least 1 side based on intraoperative findings. Eighty-two percent of patients reported improvement in their pain at 3.2 months (±3.4 months) after vasectomy reversal. Thirty-four percent patients had complete resolution of all pain. Mean pain score before procedure was 6.4 (±2.4), decreasing to a median of 2.7 (±2.7) afterward. There was a 59% improvement in pain scores (P <.001). Two patients required additional procedures for continued pain, one orchiectomy and one epididymectomy. Four patients required an additional reversal procedure, one a repeat VV at 1 year and 3 an EV at 1, 5, and 9 years, respectively. Follow-up ranged from 1 to 19 years, with a mean follow-up of 8.4 years. We found no relationship between vasectomy location and pain. CONCLUSION: Vasectomy reversal, through the use of both VV and EV, can provide long-term relief from PVPS.

Results of selective management of ureteropelvic junction obstruction.

BACKGROUND AND PURPOSE: Controversy continues over the need to image the ureteropelvic junction (UPJ) before endopyelotomy to detect crossing vessels. We evaluated a selective management model for UPJ obstruction. PATIENTS AND METHODS: Intraoperative ultrasonography was performed before endopyelotomy in 19 men and 16 women. Patients with large (>4-mm) crossing vessels underwent open or laparoscopic pyeloplasty; the others had ureteroscopic or percutaneous endopyelotomy with electrocautery or the holmium laser. RESULTS: Crossing vessels were found in 25 of the 35 patients and a high-inserting ureter in 4. The vessels were >4 mm in nine patients, seven of whom had successful pyeloplasty and two of whom were managed expectantly with good results. Endopyelotomy was successful in 94% without a crossing vessel and 70% of those with a crossing vessel. The overall success rate (absence of symptom and resolution of obstruction on renal scintigraphy) was 89%. CONCLUSION: Selective management of UPJ obstruction, avoiding endopyelotomy in the presence of a large crossing vessel, appears to improve the success rate.

The current role of endourologic management of renal transplantation complications.

Introduction. Complications following renal transplantation include ureteral obstruction, urinary leak and fistula, urinary retention, urolithiasis, and vesicoureteral reflux. These complications have traditionally been managed with open surgical correction, but minimally invasive techniques are being utilized frequently. Materials and Methods. A literature review was performed on the use of endourologic techniques for the management of urologic transplant complications. Results. Ureterovesical anastomotic stricture is the most common long-term urologic complication following renal transplantation. Direct vision endoureterotomy is successful in up to 79% of cases. Urinary leak is the most frequent renal transplant complication early in the postoperative period. Up to 62% of patients have been successfully treated with maximal decompression (nephrostomy tube, ureteral stent, and Foley catheter). Excellent outcomes have been reported following transurethral resection of the prostate shortly after transplantation for patients with urinary retention. Vesicoureteral reflux after renal transplant is common. Deflux injection has been shown to resolve reflux in up to 90% of patients with low-grade disease in the absence of high pressure voiding. Donor-gifted and de novo transplant calculi may be managed with shock wave, ureteroscopic, or percutaneous lithotripsy. Conclusions. Recent advances in equipment and technique have allowed many transplant patients with complications to be effectively managed endoscopically.

Colocalycostomy for repair of ureterojejunal fistula.

Calycostomy is a procedure used for an inaccessible renal pelvis during pyeloplasty. We report the first case of using an anterior calycostomy to repair a ureterojejeunal fistula in a transverse colon conduit in which the ureter and pelvis were not accessible because of intense fibrosis.

Poly-IC preconditioning protects against cerebral and renal ischemia-reperfusion injury.

Preconditioning induces ischemic tolerance, which confers robust protection against ischemic damage. We show marked protection with polyinosinic polycytidylic acid (poly-IC) preconditioning in three models of murine ischemia-reperfusion injury. Poly-IC preconditioning induced protection against ischemia modeled in vitro in brain cortical cells and in vivo in models of brain ischemia and renal ischemia. Further, unlike other Toll-like receptor (TLR) ligands, which generally induce significant inflammatory responses, poly-IC elicits only modest systemic inflammation. Results show that poly-IC is a new powerful prophylactic treatment that offers promise as a clinical therapeutic strategy to minimize damage in patient populations at risk of ischemic injury.