Case Report: Blinatumomab as upfront consolidation and maintenance therapy in a pediatric patient with high-risk B-cell acute lymphoblastic leukemia.

Introduction: B-cell acute lymphoblastic leukemia (B-ALL) is the most common malignancy in children. The current conventional chemotherapy regimens have high overall survival but with significant short- and long-term toxicities, sometimes requiring delay and termination of chemotherapy. Bispecific T-cell engager antibody blinatumomab has been successful in achieving bone marrow remission and acting as bridging therapy in minimal residual disease (MRD)-positive relapsed adult and pediatric B-ALL patients. Its role as upfront therapy is being explored. Here, we report the first case to our knowledge showing the feasibility, tolerability, and sustained remission using blinatumomab upfront as consolidation and maintenance therapy for 2 years in a pediatric patient with high-risk B-ALL who had significant toxicities with conventional chemotherapy. 'Case presentation: An 11-year-old Hispanic girl presented with complaints of fever, abdominal pain, and fatigue. On further evaluation, she had tachycardia, pallor, cervical lymphadenopathy, and pancytopenia. Bone marrow studies confirmed high-risk B-ALL. The patient was started on induction chemotherapy per AALL1131. Her induction course was complicated by syncope, febrile neutropenia, and invasive cryptococcal fungal infection. End-of-induction bone marrow results were MRD negative. Further chemotherapy was withheld due to cardiopulmonary and renal failure, along with ventricular arrhythmias requiring intensive care. The patient received two cycles of blinatumomab as consolidation therapy and then transitioned back to conventional consolidation therapy; however, it was terminated mid-consolidation due to Pseudomonas and Aspergillus sepsis. She was then given blinatumomab maintenance therapy for 2 years and tolerated it well without any irreversible toxicity. She had an episode of Staphylococcus epidermidis sepsis and pneumonia treated by antibiotics and a single episode of a seizure while on blinatumomab therapy. At the time of publication, she is 25 months off treatment and in sustained remission without any further transplant or chemotherapy. She received monthly intravenous immunoglobulin G during the blinatumomab maintenance. Conclusion: Blinatumomab given upfront as consolidation and maintenance therapy for 2 years in a pediatric high-risk B-ALL patient with significant toxicities to conventional chemotherapy was feasible and very well tolerated without any irreversible toxicity and led to sustained remission without any bridging transplant or further chemotherapy.

Use of retrograde pyelogram to plan for miniature open incision in pediatric pyeloplasty.

INTRODUCTION: As robotic-assisted surgery becomes increasingly utilized for pediatric ureteropelvic junction (UPJ) obstruction, open surgeons have countered by using muscle-splitting, miniature (≤2 cm) incisions. To prepare for this type of incision during pyeloplasty, it is necessary to define the exact location of the UPJ. The use of retrograde pyelogram (RPG) at the time of pyeloplasty helps the surgeon to identify the exact location of UPJ, and thus be able to use a muscle-splitting, miniature incision for open pyeloplasty. OBJECTIVE: We hypothesize that when performing a muscle-splitting, miniature incision open approach; preoperative RPG frequently changes the traditional pyeloplasty flank incision at the tip of the 11th or 12th rib. MATERIALS & METHODS: A retrospective review of open pyeloplasties performed by a single surgeon at our institution from 7/1/2010 to 12/31/2018 was performed to determine rate of use of RPG, open pyeloplasty incision location and to determine what factors are predictive of incisional site. RESULTS: 114 of 122 (93.4%) patients with 115 renal units had pyeloplasties with preoperative RPG performed. Of the 8 procedures without RPG, two had a pelvic kidney diagnosed prior to surgery, two had narrow ureteric orifices that were difficult to cannulate, and four had associated reflux. In 31/115 (27%) pyeloplasties the incision was changed from a standard incision position at the 11th or 12th rib to an alternative incision (i.e. extended muscle-transecting incision at the tip of the 11th or 12th rib, or to an alternate incision site including Gibson, McBurney's incision, or low anterior abdominal incision). 84/115 (73.0%) had a miniature (<2 cm) incision at the tip of the 11th or 12th rib. Grade IV hydronephrosis was a significant predictor for changing the traditional incision site (p = 0.02). Preoperative nephrostomy tube insertion was also associated with an increased likelihood of having an alternate incision (p = 0.04). Incision site was not significantly affected by age of the patient at surgery, patient sex, size of the affected kidney, T1/2 times of <30 min, split function of <30%, kidney length differential, or laterality. CONCLUSION: The consistent use of RPG prior to pyeloplasty helps surgeons to plan for a small muscle-splitting, miniature open incisions. In our experience, 27% of pyeloplasties required alternative incision sites based on the results of pre-operative RPG.

Characteristics of Female Genital Restoration Surgery for Congenital Adrenal Hyperplasia Using a Large-scale Administrative Database.

OBJECTIVE: To analyze nationwide information on the timing of surgical procedures, cost of surgery, hospital length of stay following surgery, and surgical complications of female genital restoration surgery (FGRS) in females with congenital adrenal hyperplasia (CAH). MATERIALS AND METHODS: We used the Pediatric Health Information System database to identify patients with CAH who underwent their initial FGRS in 2004-2014. These patients were identified by an International Classification of Diseases, Ninth Revision (ICD-9) diagnosis code for adrenogenital disorders (255.2) in addition to a vaginal ICD-9 procedure code (70.x, excluding vaginoscopy only) or perineal ICD-9 procedure code (71.x), which includes clitoral operations (71.4). RESULTS: A total of 544 (11.8%) females underwent FGRS between 2004 and 2014. Median age at initial surgery was 9.9 months (interquartile range 6.8-19.1 months). Ninety-two percent underwent a vaginal procedure, 48% underwent a clitoral procedure, and 85% underwent a perineal procedure (non-clitoral). The mean length of stay was 2.5 days (standard deviation 2.5 days). The mean cost of care was $12,258 (median $9,558). Thirty-day readmission rate was 13.8%. Two percent underwent reoperation before discharge, and 1 (0.2%) was readmitted for a reoperation within 30 days. Four percent had a perioperative surgical complication. CONCLUSION: Overall, 12% of girls with CAH underwent FGRS at one of a national collaborative of freestanding children's hospitals. The majority underwent a vaginoplasty as a part of their initial FGRS for CAH. Clitoroplasty was performed on less than half the patients. Overall, FGRS for CAH is performed at a median age of 10 months and has low 30-day complication and immediate reoperation rates.

Parental decisional regret and views about optimal timing of female genital restoration surgery in congenital adrenal hyperplasia.

PURPOSE: The role of female genital restoration surgery (FGRS) in girls with congenital adrenal hyperplasia (CAH) is controversial, with no long-term parent-reported outcomes available. Decisional regret (DR) affects most parents after their children's treatment of pediatric conditions, including hypospadias. We aimed to assess parental DR after FGRS in infancy or toddlerhood and explore optimal timing for surgery. MATERIALS AND METHODS: One-hundred and six parents of females with CAH undergoing FGRS before 3 years old and followed at our institution (1999-2017) were invited to enroll online. Higher Decision Regret Scale (DRS) scores indicated greater DR (range 0-100). Participants also reported preferred FGRS timing relative to their surgery (earlier, same, later/delayed). Non-parametric statistical tests were used. RESULTS: Thirty-nine parents (median 4.4 years after FGRS) participated (36.8% response rate). Median age at FGRS was 9 months. Median DRS score was 0 (mean: 5.0). Overall, 20.5% of parents reported some regret (all mild-moderate) (Figure). Fewer parents reported DR after FGRS compared with published DR after hypospadias repair (50-92%, p ≤ 0.001) or adenotonsillectomy (41-45%, p ≤ 0.03). No parent preferred delayed FGRS. Seven parents (18.1%) preferred earlier surgery, especially when performed after birthday (80.0% vs. 8.8%, p = 0.004). DISCUSSION: We present the first report of validated long-term parent-reported outcomes after FGRS in infant and toddler girls with CAH. One limitation is that this is largely a single surgeon series. Reasons for the observed low levels of DR are likely multifactorial. Far from a definitive study, we aimed to provide parents willing to share about their experience an opportunity to do so. For that reason, selection bias may exist in our study. While parents with higher DR were potentially less likely to participate because of mistrust of the medical establishment, those with a negative experience may in fact be more likely to voice their opinions. A low participation rate was likely a result of the sensitive nature of FGRS, a desire for privacy, and inability to locate parents. A larger study will be required to assess how DR is affected by sexual function, genital appearance and complications, and DR among women with CAH. CONCLUSIONS: Parents of females with CAH report low levels of DR after FGRS in infancy and toddlerhood. This appears to be lower than after other genital and non-genital pediatric procedures. When present, parental DR is usually mild. No parents preferred delayed surgery, even among those with DR. Some preferred earlier surgery.

Complications and Outcomes of Pregnancy and Cesarean Delivery in Women With Neuropathic Bladder and Lower Urinary Tract Reconstruction.

OBJECTIVE: To determine the outcomes of pregnancy and cesarean delivery (CD) in women with neuropathic bladder (NB) and pediatric lower urinary tract reconstruction (LUTR) as these women often have normal fertility and may become pregnant. METHODS: We reviewed consecutive patients with NB due to spinal dysraphism who underwent LUTR, became pregnant, and had a CD at our institution from July 2001 to June 2016. We collected data on demographics, hydronephrosis, symptomatic urinary tract infection, continence, and catheterization during pregnancy. CD data included gestational age, abdominal or uterine incisions, and complications. RESULTS: We identified 18 pregnancies in 11 women. Fifteen live newborns were delivered via CD (53.3% term births). Thirteen of 15 patients (86.7%) developed new (10) or worsening (3) hydronephrosis. Six of 13 patients (46.2%) underwent nephrostomy tube placement. Eight of 15 patients (53.3%) developed difficulty catheterizing (66.7% via native urethra, 44.4% via catheterizable channel); 50.0% of patients required an indwelling catheter. Five of 15 patients (33.3%) developed urinary incontinence during pregnancy. Ten of 15 patients (66.7%) had a urinary tract infection (30.0% febrile). A urologist was present for all CDs: 5 were scheduled, 10 occurred emergently. Complications occurred in 40.0% (5 cystotomies, 1 bowel deserosalization, 1 vaginal laceration). All cystotomies occurred during emergent CD. Three patients (20.0%) developed urinary fistulae after emergent CD. CONCLUSIONS: Women with NB and LUTR have high rates of complications during pregnancy and CD, despite routine involvement of urologists. Women with prolonged labor, previous CD, or those with a history of noncompliance developed the worst complications. Based on our experience, a urologist should always be present and participate in the CD.

Does endoscopy of difficult to catheterize channels spare some patients from formal open revision?

INTRODUCTION: Patients with continent catheterizable channels (CCC) may develop difficulty catheterizing postoperatively. In complex cases, endoscopic evaluation with indwelling catheter placement may be indicated, but the risk factors for subsequent formal channel revision are not well defined. The purpose of this study was to determine the risk factors for formal channel revision after attempted endoscopic management of difficulty catheterizing. MATERIALS AND METHODS: We performed an IRB-approved retrospective review of pediatric (<21 years old) patients undergoing CCC construction at our institution from 1999 to 2014 to identify patients who underwent endoscopy for difficulty catheterizing. Fisher's Exact test was used for categorical data and Mann-Whitney U test for continuous variables to examine the association between endoscopic intervention and subsequent formal revision. RESULTS: Sixty-three of 434 patients (14.5%) underwent at least one endoscopy for reported difficulty catheterizing their CCC, with 77.8% of these requiring additional intervention during endoscopy (catheter placement, dilation, etc.). Of these, almost half with functioning channels (43.5%, 27/62) were managed successfully with endoscopy without formal revision; six (22.2%) of whom underwent more than one endoscopy. These 27 patients continued to catheterize well at a median follow-up of 3.2 years (interquartile range 2.0-6.0). Patients requiring revision had a median of 1.7 years between CCC creation and first endoscopy, versus 1.6 years in those who were not revised (p = 0.60). There was no statistically significant difference between revised and non-revised channels in terms of patient age at CCC creation, underlying patient diagnosis, status of bladder neck, stomal location, or channel type (p ≥ 0.05) (see Table). CONCLUSION: Approximately half of our patients did not require a formal channel revision after endoscopic management. We did not identify any specific risk factors for subsequent formal revision of a CCC. We recommend performing at least one endoscopic evaluation for those with difficulty catheterizing prior to proceeding with formal open revision.

A snapshot of the adult spina bifida patient - high incidence of urologic procedures.

INTRODUCTION: To describe the urologic outcomes of contemporary adult spina bifida patients managed in a multidisciplinary clinic. MATERIAL AND METHODS: A retrospective chart review of patients seen in our adult spina bifida clinic from January 2004 to November 2011 was performed to identify urologic management, urologic surgeries, and co-morbidities. RESULTS: 225 patients were identified (57.8% female, 42.2% male). Current median age was 30 years (IQR 27, 36) with a median age at first visit of 25 years (IQR 22, 30). The majority (70.7%) utilized clean intermittent catheterization, and 111 patients (49.3%) were prescribed anticholinergic medications. 65.8% had urodynamics performed at least once, and 56% obtained appropriate upper tract imaging at least every other year while under our care. 101 patients (44.9%) underwent at least one urologic surgical procedure during their lifetime, with a total of 191 procedures being performed, of which stone procedures (n = 51, 26.7%) were the most common. Other common procedures included continence procedures (n = 35, 18.3%) and augmentation cystoplasty (n = 29, 15.2%). Only 3.6% had a documented diagnosis of chronic kidney disease and 0.9% with end-stage renal disease. CONCLUSIONS: Most adult spina bifida patient continue on anticholinergic medications and clean intermittent catheterization. A large percentage of patients required urologic procedures in adulthood. Patients should be encouraged to utilize conservative and effective bladder management strategies to reduce their risk of renal compromise.

Robotic-assisted laparoscopic transplant-to-native ureteroureterostomy in a pediatric patient.

OBJECTIVE: Management of late-occurring or long (>3 cm) post-transplant ureteral strictures usually requires open surgery, which includes ureteroureterostomy (UU) as an option. Recently, robotic-assisted laparoscopic UU for ectopic ureters in a duplicated system has been described. We report a case of a robotic-assisted laparoscopic transplant-to-native side-to-side UU in a 14-year-old girl with a stricture of nearly two-thirds of her transplant ureter 5 years after a cadaveric renal transplant. RESULTS: Robotic-assisted laparoscopic native-to-transplant UU was performed with resultant durable improvement in the patient's hydronephrosis and kidney function. CONCLUSION: Based on our case and review of the literature, robotic-assisted laparoscopic UU should be part of the armamentarium for long or late-occurring transplant ureteral strictures.

Contemporary national comparison of open, laparoscopic, and robotic-assisted laparoscopic pediatric pyeloplasty.

OBJECTIVE: We sought to determine current and longitudinal trends in the usage of open (OP), laparoscopic (LP), and robotic pyeloplasties. (RALP) Furthermore, we aimed to describe patient and hospital level characteristics associated with the use of minimally invasive pyeloplasties (MIP) and to compare basic utilization metrics for each approach. MATERIALS/METHODS: The 2000, 2003, 2006, and 2009 Kid's Inpatient Databases (KID) were used to determine current and longitudinal trends. As a result of a specific billing code for robotic surgery introduced in 2008, the 2009 KID database was used for analysis of RALP. Patient and hospital characteristics examined included: age, gender, race, insurance status, hospital location, and academic status. Utilization metrics of length of stay (LOS) and cost were determined from each modality. RESULTS: In 2009, there were 3354 pediatric pyeloplasties performed in the USA (85% OP, 3% LP, 12% RP). Compared with 2000, this represents an 11.7% decrease in the overall number of pyeloplasties but a progressive increase in MIP from 0.34% in 2000 to 11.7%. Mean patient age was 3.7 years for OP, 9.3 years for LP and 9.9 years for RALP. MIP was more commonly performed in females, Caucasians, patients with private insurance, at urban hospitals and at teaching hospitals. Although length of stay (LOS) in days was statistically lower for MIP (3.46 OP, 2.86 LP, 1.96 RP, p < 0.001), total cost between the groups was not statistically different. On multivariable logistic regression analysis, age (OR 1.17, p < 0.001) increased the odds of MIP whereas lack of private insurance decreased the odds of MIP (OR 0.62, p = 0.002). CONCLUSION: Although utilization of MIP is increasing in the USA, especially in older children, OP remains predominant. MIP was associated with a decrease in LOS. The odds of MIP were higher in older children, whereas the lack of private insurance decreased the odds of MIP.

Diagnosis of varicoceles in men undergoing vasectomy may lead to earlier detection of hypogonadism.

OBJECTIVE: To determine the temporal relationship between vasectomy, varicocele, and hypogonadism diagnosis. Many young men undergo their first thorough genitourinary examination in their adult lives at the time of vasectomy consultation, providing a unique opportunity for diagnosis of asymptomatic varicoceles. Varicoceles have recently been implicated as a possible reversible contributor to hypogonadism. Hypogonadism may be associated with significant adverse effect, including decreased libido, impaired cognitive function, and increased cardiovascular events. Early diagnosis and treatment of hypogonadism may prevent these adverse sequelae. METHODS: Data were collected from the Truven Health Analytics MarketScan database, a large outpatient claims database. We reviewed records between 2003 and 2010 for male patients between the ages of 25 and 50 years with International Classification of Diseases, Ninth Revision codes for hypogonadism, vasectomy, and varicocele, and queried dates of first claim. RESULTS: A total of 15,679 men undergoing vasectomies were matched with 156,790 men with nonvasectomy claims in the same year. Vasectomy patients were diagnosed with varicocele at an earlier age (40.9 vs 42.5 years; P=.009). We identified 224,817 men between the ages of 25 and 50 years with a claim of hypogonadism, of which 5883 (2.6%) also had a claim of varicocele. Men with hypogonadism alone were older at presentation compared with men with an accompanying varicocele (41.3 [standard deviation±6.5] vs 34.9 [standard deviation±6.1]; P<.001). CONCLUSION: Men undergoing vasectomies are diagnosed with varicoceles at a younger age than age-matched controls. Men with varicoceles present with hypogonadism earlier than men without varicoceles. Earlier diagnosis of varicocele at the time of vasectomy allows for earlier detection of hypogonadism.

Risk of bladder cancer in patients with spina bifida: case reports and review of the literature.

PURPOSE: This article presents four cases of patients with spina bifida who developed bladder cancer while under our care and provides a literature review on the incidence, initial presentation, possible etiologies, and role for screening for bladder cancer in the neurogenic bladder population. METHODS: Case reports of four patients are presented followed by a literature review of the current available studies. RESULTS: Patients with spina bifida present with bladder cancer at an atypically young age with very advanced disease. The dire prognosis associated with bladder cancer in these patients demands that we provide better treatment, diagnosis, and prevention modalities. However, the potential morbidity, financial burden, and lack of proven benefit discourage cystoscopic screening in this patient population. Until we have more data on how to best serve spina bifida patients, this population should receive careful and regular urologic follow-up. CONCLUSION: Given the atypical young age of presentation and very advanced nature of bladder cancer in the spina bifida population, the authors strongly recommend that any new bladder changes, such as including increased urinary leakage, pain, recurrent infections, or increased gross hematuria, prompt immediate urologic referral for endoscopic evaluation and biopsy as indicated.

A protocol based, electronic medical record enabled care coordination system improves the timeliness and efficiency of care for patients with hematuria.

PURPOSE: We determined whether including a care coordination system to manage the referral process for hematuria would lead to improved quality of care. MATERIALS AND METHODS: Inflection Navigator, a protocol based, electronic medical record enabled care coordination system, was developed to support primary care physicians evaluating newly discovered hematuria. We studied the system for patients referred for microscopic and gross hematuria from May 2009 to May 2010. We compared outcomes in these 106 patients and in 105 referred to our urology department for hematuria during the same period who did not use the system. RESULTS: Patients in the care coordination group completed the evaluation in a significantly shorter time with more than a 1-month difference in time between referral and the completion of the imaging and cystoscopy components of the assessment (mean 40.9 vs 74.1 days, p <0.05). This system potentially lowered health care costs by decreasing the mean ± SD number of urology visits needed to complete an evaluation from 2.1 ± 1.5 in the standard referral group to 1.6 ± 1.4 in the care coordination group (p <0.05). CONCLUSIONS: A protocol based care coordination system for hematuria decreased the time needed to complete an evaluation and decreased the number of overall visits required to make a final diagnosis. Thus, the Inflection Navigator system is an example of an electronic medical record enabled process innovation that can improve the efficiency of care while potentially lowering health care costs.

Extracorporeal shockwave lithotripsy versus ureteroscopy: a comparison of intraoperative radiation exposure during the management of nephrolithiasis.

BACKGROUND AND PURPOSE: Both shockwave lithotripsy (SWL) and ureteroscopy (URS) may be used in the treatment of similar stones and both need fluoroscopic imaging to achieve this. Fluoroscopy, however, is a source of ionizing radiation. The purpose of this study is to compare the effective radiation dose (ERD) between patients undergoing SWL vs URS. PATIENTS AND METHODS: The ERD was measured among consecutive patients who were undergoing either SWL or URS between January 2010 and February 2011. For SWL, ERD was calculated using fluoroscopic exposure time, current, voltage, skin-to-source distance, and field size. For URS, it was calculated from the measured dose-area product. We measured several patient and stone factors. Univariate and multivariate analyses were performed. RESULTS: A total of 190 patients were included (87 SWL and 103 URS). In the univariate analyses, no differences were found in ERD (7.32 vs 6.00 mSv, P=0.262 and 7.23 vs 6.07 mSv, P=0.198, for renal and ureteral stones, respectively). In the multivariate analyses, among renal stones, SWL was associated with a higher ERD than URS (ß=2.06, P=0.026), and body mass index and stone size were also significant predictors (ß=0.212, P=0.045 and ß=0.452, P=0.004, respectively). Among ureteral stones, no differences were found (ß=0.425, P=0.674), and only the presence of a stent was related to ERD (ß=2.53, P=0.013). CONCLUSIONS: Among patients with renal stones, SWL was associated with a modest increase in ERD compared with URS, but for ureteral stones, both modalities were associated with similar levels of radiation. This information may be relevant for frequent stone formers needing treatments for which cumulative exposures may become significant.

Simple modifications in operating room processes to reduce the times and costs associated with robot-assisted laparoscopic radical prostatectomy.

BACKGROUND AND PURPOSE: Robot-assisted laparoscopic radical prostatectomy (RALRP) is the most expensive, yet most common, surgical treatment for patients with prostate cancer. Furthermore, its popularity continues to grow despite the lack of evidence for functional and oncologic superiority over other treatments. As a result, we modified operating room (OR) processes to determine if the times and costs that are associated with RALRP in an academic setting could be reduced. PATIENTS AND METHODS: Four modifications in OR processes were implemented: Trainee adherence to time-oriented surgical goals; use of a dedicated anesthesia team; simultaneous processing by nursing and urology house staff during case turnover; and identification and elimination of unused disposable instruments. Total surgical, anesthesia, and OR turnover times were measured. Payroll, surgical supply, OR time, and anesthesia costs were also measured. One hundred RALRP cases before and after the modifications were implemented were compared. RESULTS: Patients undergoing RALRP were similar both before and after the modifications were implemented. Total surgical, anesthesia, and turnover times were reduced by 17.4 (6.8%, P=0.041), 4.5 (19.1%, P=0.006), and 12.1 (28.1%, P=0.005) minutes, respectively. Payroll, surgical supply, and OR costs were reduced by $330 (25%), $609 (15.7%), and $1638 (27.7%), respectively. There was no fiscally significant change in anesthesia costs. CONCLUSIONS: Using simple modifications, it is possible that RALRP efficiency can be improved by decreasing its associated times and costs. These modifications were implemented in an academic setting but may be used in any institution. These modifications represent an initial attempt to improve RALRP cost-competitiveness with other treatment modalities.

Delay of surgery in men with low risk prostate cancer.

PURPOSE: Treatment options for patients with low risk prostate cancer include radical prostatectomy, radiation therapy, and active surveillance. Among patients treated with radical prostatectomy, prior studies have demonstrated significantly higher biochemical progression rates with surgical delays of 6 months or greater. We determined the impact of surgical delay on radical prostatectomy outcomes specifically in low risk patients. MATERIALS AND METHODS: From our radical prostatectomy database we identified men who fulfilled the D'Amico low risk criteria (clinical stage T1c/T2a, prostate specific antigen less than 10 ng/ml, and biopsy Gleason 6 or less). Pathological tumor features and biochemical progression rates were compared between men with and without surgical delay. We used Cox proportional hazards models to examine predictors of biochemical progression. RESULTS: Of 1,111 men who fulfilled the D'Amico low risk criteria, those with a surgical delay of 6 months or more were significantly older, had a higher proportion of African American men, and a lower proportion of clinical stage T2a (vs T1). A surgical delay of 6 months or more was associated with a greater risk of high grade disease at prostatectomy (p = 0.001) and biochemical progression (p = 0.04). The progression-free survival rate was significantly lower among men with a surgical delay. On multivariate analysis with prostate specific antigen and clinical stage, surgical delays of 6 months or more were significantly and independently associated with time to biochemical progression. CONCLUSIONS: In men who met the D'Amico low risk criteria, a surgical delay of 6 months or more was associated with significantly worse radical prostatectomy outcomes, including more pathology upgrading and a higher rate of biochemical progression. Low risk patients choosing to defer initial definitive therapy should be counseled regarding the possibility of worse treatment outcomes at a later date.

Communication failure in the operating room.

BACKGROUND: Communication errors contribute to the occurrence of adverse events in various domains of health care. Recent studies surveying perceptions of communication in the operating room have found disparities in the perceived quality of communication among members of the operating room team. Our aim was to characterize the nature of communication failures observed in the operating room and to assess whether a Team Training curriculum had any impact on observed communication errors. METHODS: Intraoperative observation was performed and communication errors were identified according to predetermined criteria. Observed errors were classified according to the type of error, subject matter, and observed effect. RESULTS: Seventy-six communication failures were observed over 150 hours of observation. Overall, communication errors relating to equipment and keeping team members informed of the progress of an operation comprised 36% and 24% of all observed communication errors, respectively. Prior to the introduction of a Team Training curriculum, 56 errors were observed over 76 hours (rate,737 errors per hour; standard error, 0.098). After Team Training, 20 errors over 74 hours were observed (rate .270 errors per hour; standard error, 0.060; P < .001). CONCLUSION: Communication failures related most frequently to equipment and keeping team members updated as to the progress of an operation. These failures can lead to procedural delay and inefficiencies. A program that teaches teamwork and communication skills is one strategy that may improve communication among members of the operating room team.

Surgical reconstruction of the male urethral diverticulum.

OBJECTIVES: To describe the outcomes and reconstructive techniques used for men with symptomatic urethral diverticula in an attempt to standardize treatment based on the length of the urethral defect after diverticulum excision and the type of repair used. Urethral diverticula are rare in men and may be either congenital or acquired. METHODS: Between 2003 and 2008, 13 men were treated surgically for symptomatic urethral diverticula at a single institution by a single surgeon (C.M.G.). A total of 6 (46.2%) patients had urethral defects of < 4 cm and underwent excision of the diverticulum with primary anastomosis. Substitution urethroplasty using either penile skin or buccal mucosa was used in 7 (53.8%) patients with urethral defects of >or= 4 cm. Demographic and preoperative characteristics were compared among patients according to the length of the urethral defect. RESULTS: The mean age of men at the time of surgery was 38.4 years (+/- 13.0; range, 20.4-63.7), with a median follow-up time of 21.7 (+/- 29.0; range, 0.9-84.0) months. Neither age at the time of surgery, length of follow-up, or diverticulum volume was significantly different between men who underwent primary repair vs substitution urethroplasty. The overall success rate was 92% (12/13) with an overall complication rate of 42% at intermediate follow-up. CONCLUSIONS: Outcomes after excision and primary anastomosis for diverticula associated with defects of < 4 cm were similar to outcomes after diverticulum excision and substitution urethroplasty for defect of >or= 4 cm.

Is the transition from open to robotic prostatectomy fair to your patients? A single-surgeon comparison with 2-year follow-up.

Robot-assisted radical prostatectomy (RARP) is a procedure thought to require experience with a significant number of cases before mastering. Most RARP series examine outcomes after the learning curve or by combining results from multiple surgeons. We review a single surgeon's experience during the transition from open radical retropubic prostatectomy (RRP) to RARP using a matched case-control model. We prospectively analyzed 50 RARP cases and made comparison with the last 50 consecutive RRP cases. Operative time was longer for RARP than RRP (341 versus 235 min, p < 0.01), and mean estimated blood loss was less for RARP than RRP (533 versus 1,540 ml, p < 0.01). There was a trend towards fewer positive surgical margins (PSM) for RARP (10%) than RRP (24%; p = 0.06). High-risk patients were found to have a greater percentage of PSM following RRP (70%) in comparison with RARP (17%; p = 0.04). The number of patients who experienced complications was no different between groups (16 versus 12, p = 0.37). Erectile function at 12, 18, and 24 months showed no difference between groups (p = 0.15, 0.92, and 0.23, respectively). There was no difference in continence at 1 year (88.6% versus 89.1%; p = 0.94). During 27.1 months of follow-up for the RARP group and 30.4 months for the RRP group, 92% and 94% of patients had an undetectable prostate-specific antigen (PSA) (defined as ≤0.1), respectively (p = 0.38). We report similar outcomes in patients undergoing RARP by a surgeon transitioning from RRP to RARP, confirming that the learning curve does not affect patient outcomes over a 2-year follow-up.

Infectious complications in patients with chronic bacteriuria undergoing major urologic surgery.

OBJECTIVES: To review our perioperative antibiotic management of patients with chronic bacteriuria who underwent urological procedures, and the relationship to postoperative infectious complications. METHODS: Between January 2002 and January 2007, 77 patients with chronic bacteriuria underwent 94 major open procedures, including ileocystoplasty (n = 53), ileal conduit (n = 19), and pubovaginal sling placement (n = 18). Admission urine cultures were classified as "sensitive" (sensitive to admission antibiotics or no growth), "resistant" (resistant to admission antibiotics), and "unknown" (multiple unspeciated organisms present or no admission culture data available). RESULTS: Our rate of multidrug resistance bacteriuria was 46.3%. There were 7 febrile urinary tract infections, 12 wound infections, 1 episode of sepsis, and no intra-abdominal abscesses, yielding an infectious complication rate of 20.2%. There was no statistical relationship between urine culture status and the rate of febrile urinary tract infections or sepsis, but wound infections were less common in patients with "sensitive" urine cultures. Of the patients who had urine cultures that demonstrated multiple unspeciated organisms, 32% were complicated by wound infections. On multivariate analysis, gender, age, and body mass index were associated with the development of infectious complications. CONCLUSIONS: In a medically complex population of patients, those with neurogenic bladder and frequent catheterization undergoing major abdominal surgery, we demonstrate an infectious complication rate of 20.2%. Wound infections were as common in patients whose urine cultures revealed multiple unspeciated organisms as those that were resistant to the perioperative antibiotics, and in this population, further characterization may allow for more appropriate perioperative coverage and a decreased rate of wound infections.

Outcomes of locally advanced (T3 or greater) prostate cancer in men undergoing robot-assisted laparoscopic prostatectomy.

OBJECTIVES: Despite nearly equivalent outcomes between open and robot-assisted laparoscopic prostatectomy (RALP) for organ-confined prostate cancer (PCa), the role of primary treatment with RALP in men with locally advanced (T3 or greater) PCa has not been described in detail. We report our experience with RALP for pathologically advanced disease. PATIENTS AND METHODS: From October 2005 to November 2008, 220 RALPs were performed by a single surgeon (R.B.N.). Outcomes were assessed prospectively in an institutional review board-approved database. RESULTS: Of 220 RALPs, 35 (15.9%) were performed for pT3 PCa; none of them were identified preoperatively. There was no difference in operative time compared with patients with pT2 disease (271 vs. 295 minutes, p = 0.09). The positive surgical margin (PSM) rate was 20% compared with 4.9% for pT2 (p = 0.004). Sural nerve grafts were performed in 20%, and 57% had bilateral nerve sparing. The use of bilateral or unilateral nerve sparing was not associated with increased PSM (p = 0.85). Biochemical recurrence occurred in 28.6% of men with pT3 disease over an average of 13 months of follow-up time, 30% of which occurred in men with a PSM. At 6 months, an 85% continence rate was achieved, and at 1 year continence was 100% for pT3. Compared with pT2, men with advanced disease had similar recovery after RALP based on postsurgery questionnaires. CONCLUSIONS: RALP is a feasible approach to patients with pathologically advanced PCa as 71% were without evidence of disease at 13 months postoperatively. PSM rate (20%) is comparable to previously reported open PSM rates (24-66%).