Pediatric sutureless circumcision: an effective and cost efficient alternative.

INTRODUCTION: Circumcision is the most commonly performed surgical procedures in male children. Maine is one of 18 states in the United States which does not pay for neonatal circumcisions. The aim of this study was to perform outcomes and cost analysis of a sutureless circumcision technique versus circumcision using sutures. Specifically, we evaluated Dermaflex (2-octyl cyanoacrylate, 2-OCA) surgical glue circumcision as a cost effective, faster, and safe alternative to traditional suture circumcision. MATERIALS AND METHODS: Our study was a non-randomized series. We collected the operative details prospectively, abstracted clinical outcomes retrospectively, and performed data analysis retrospectively. One hundred and twenty-six circumcisions were performed by two pediatric urologists over a 1 year period. Suture circumcisions were performed exclusively during the first 6 months, and 2-OCA glue circumcisions were performed during the second 6 months. Billing charges were analyzed to extrapolate variable costs between the two surgical procedures. The technique used to perform the sutureless circumcision was a modification of the standard sleeve technique, with the use of monopolar diathermy instead of scalpel, and application of 2-OCA glue to approximate tissue edges. RESULTS: From Jan 2013 to Jan 2014, 72 patients underwent circumcision with suture, and 54 patients underwent circumcision with 2-OCA glue. Mean age in the glue group was 61 months (range 8-202 months), and 50 months in the suture group (range 5-215 months), p = 0.19. All cases were performed under general anesthesia, as outpatient surgery. Mean operative cut time was 18.4 min for the glue group, and 28.6 min for the suture group (p < 0.01). The 10.2 min operative time difference translated to a $378 cost savings per glue circumcision case. Complication rates were not statistically significant between the two groups. CONCLUSION: The use of 2-OCA tissue adhesive for sutureless circumcision is an alternative to the standard technique. It results in faster operative times, with a significant cost savings, while maintaining comparable complication rates to the standard suture technique. This is a viable, less expensive surgical option for patients whose circumcisions are not covered by Medicaid.

Robot-assisted radical prostatectomy: learning rate analysis as an objective measure of the acquisition of surgical skill.

OBJECTIVE: To adapt an industrial definition of learning-curve analysis to surgical learning, and elucidate the rate at which experienced open surgeons acquire skills specific to robot-assisted radical prostatectomy (RARP) at a community-based medical centre. PATIENTS, SUBJECTS AND METHODS: The total procedure time (TPT) of the first 75 RARPs, performed by three surgeons experienced with retropubic RP, was analysed to determine the point at which their learning rate stabilised. Operative characteristics were compared before and after this point to isolate the plateau of learning rate as a mark of acquiring surgical skill. The operative characteristics examined were TPT, estimated blood loss (EBL), bladder neck contractures (BNC), positive margins (PM) and length of hospital stay (LOS). RESULTS: The mean rate of TPT decrease, for procedures 1-75, was 13.4% per doubling of RARPs performed. After the first 25 procedures the TPT decreased at a rate of 1.8% per doubling, not significantly different from 0 (P > 0.05). There was no significant difference between procedures 1-25 and 26-75 in rates of EBL, BNC and PM. There was a significant change for all surgeons in TPT, with a mean of 303.1 min (RARPs 1-25) vs 213.6 min (26-75) (P < 0.001), and LOS, of 2.1 days (1-25) vs 1.4 days (26-75) (P < 0.001). CONCLUSIONS: An industrial definition of learning-curve analysis can be adapted to provide an objective measure of learning RARP. The average learning rate for RARP was found to plateau by the 25th procedure. Also, the learning rate plateau can serve as an objective measure of the acquisition of surgical skill.

Spontaneous rectus sheath hematoma: an unusual cause of gross hematuria.

The diagnosis of a spontaneous rectus sheath hematoma, even in anticoagulated patients, requires a high index of suspicion. Gross hematuria is also not infrequent in anticoagulated patients. Although urinary symptoms from a rectus sheath hematoma have been described, generally it would not be considered a common cause of gross hematuria in this population. We report here on 2 cases of spontaneous rectus sheath hematoma spontaneously fistulizing into the bladder and causing gross hematuria.