Shared decision-making in urology and female pelvic floor medicine and reconstructive surgery.

Shared decision-making (SDM) is a hallmark of patient-centred care that uses informed consent to help guide patients with making complex health-care decisions. In SDM, patients and providers work together to determine the best course of action based on both the current available evidence and the patient's values and preferences. SDM not only provides a framework for the legal and ethical obligations providers need to fulfil for informed consent, but also leads to improved knowledge of treatment options and satisfaction of decision-making for patients. Tools such as decision aids have been developed to support SDM for complex decisions. Several decision aids are available for use in the field of urology and female pelvic medicine and reconstructive surgery, but these decision aids are also associated with barriers to SDM implementation including patient, provider and systematic challenges. However, solutions to such barriers to SDM include continued development of SDM tools to improve patient engagement, expand training of providers in SDM communication models and a process to encourage implementation of SDM.

Robotic Rectus Abdominis Muscle Flap following Robotic Extirpative Surgery.

SUMMARY: Vascularized tissue for obliteration of large pelvic dead spaces created by extirpative surgery has been shown to reduce complication rates. As more extensive resections are performed robotically, plastic surgeons have been challenged to reconstruct the resulting defects using a minimally invasive approach. The goal of this study was to report the authors' experience with robotic harvest of the rectus abdominis muscle for reconstruction of pelvic defects. The authors conducted a retrospective case series of patients who underwent robotic flap harvest following robotic extirpative surgery at their institution. Patient demographics, surgical characteristics, and postoperative outcomes were collected. These were compared to a retrospective cohort of patients who underwent open rectus abdominis muscle harvest. The authors identified seven male patients who underwent robotic flap harvest for pelvic reconstruction between 2013 and 2019. Their mean age was 66 ± 6 years and mean body mass index was 31 ± 5 kg/m2. Six patients (86 percent) had a history of radiation therapy and five patients (71 percent) received hormone therapy or chemotherapy. Surgical-site complications occurred in two patients. One patient developed ventral hernia. The donor-site complication rate was 19 percent (n = 18) in patients who underwent open rectus abdominis muscle harvest (n = 95). This study demonstrates the safety, efficacy, and reproducibility of robotic harvest of the rectus abdominis muscle in complex, multidisciplinary, minimally invasive pelvic surgery. The technique avoids violation of the anterior rectus sheath and wound complications related to open flap harvest, and early experience suggests reduced donor-site morbidity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Living With Urinary Diversions: Patient Insights to Improve the Perioperative Experience.

OBJECTIVE: To evaluate the perioperative decision-making process, post-operative decision regret and reflection on the peri-operative experience of patients undergoing radical cystectomy and urinary diversion through patient interviews. METHODS: Patients identified as having undergone radical cystectomy for malignancy were interviewed 6-24 months from the time of surgery and stratified by diversion type. Following written consent, interviews were conducted either in person or over the phone using a semi-structured script. Patients were asked 9 open-ended questions, with additional unscripted follow-up questions based on themes raised by the patient. The interviews were reviewed for common themes, preferences, and recommendations. RESULTS: A total of 13 interviews were conducted. No patient expressed decision regret about their choice of urinary diversion. Ten out of 13 interviewees specifically stated that they had adequate information about diversion options pre-operatively, none felt they did not have adequate pre-operative counseling. One area identified as improvable was postoperative counseling- specifically, for ostomy appliances, catheters, or irrigation. The most striking recurrent theme was the desire for a "buddy system" in which patients could contact and maintain discussion about their surgical experience with an experienced patient. The overall impression was that this system would be most useful in the recovery/maintenance phase rather than in the pre-operative decision-making process. CONCLUSION: This data furnishes a basis to develop more accessible and effective counseling and highlights the need to concentrate on post-surgical maintenance care, including management of urostomy appliances, catheters, and reinforcing irrigation technique.

Analyzing National Incidences and Predictors of Open Conversion During Minimally Invasive Partial Nephrectomy for cT1 Renal Masses.

Objectives: To analyze predictors of open conversion during minimally invasive partial nephrectomy (MIPN) for cT1 renal masses. Methods: The National Cancer Database (NCDB) was investigated for kidney cancer patients who underwent partial nephrectomy (PN) between 2010 and 2015. Patients who underwent MIPN were stratified into converted and nonconverted groups. Sociodemographics, facility characteristics, and surgical outcomes were compared between the two groups, and multivariate logistic regression model was fitted to identify independent predictors of open conversion. Results: In total, 54,246 patients underwent PN for kidney cancer during the 6-year period. Of those, 18,994 (35%) were open partial nephrectomies (OPNs) and 35,252 (64%) were MIPN. Overall, 1010 (2.87%) of MIPNs were converted to OPN. There was an increasing utilization of MIPN from 50.35% in 2010 to 74.73% in 2015. Patients who had open conversion had more 30-day readmissions (5.95% vs 3.31%, p < 0.01). On multivariate analysis; high-volume facility (>30 MIPNs/year), year of surgery (2015 vs 2010), and robotic approach predicted a lower likelihood of conversion (odds ratio [OR] 0.52, confidence interval [CI] 0.44-0.62; OR 0.59, CI 0.47-0.73; and OR 0.31, CI 0.27-0.35; respectively, p < 0.001 for all). Conversely, Medicaid (vs private insurance; OR 1.75, CI 1.39-2.19, p < 0.001) and male sex (OR 1.26, CI 1.11-1.44, p < 0.001) were independent predictors of conversion. Conclusions: Open conversion in MIPN occurred in 2.87% of cases. There was an increasing utilization of MIPN associated with decreased conversion rates. Higher volume hospitals and progressing year of surgery were associated with less likelihood of conversion.

National Trends and Impact of Regionalization of Radical Cystectomy on Survival Outcomes in Patients with Muscle Invasive Bladder Cancer.

OBJECTIVE: To evaluate national trends and the effect of surgical volume on perioperative mortality and overall survival (OS)in patients undergoing radical cystectomy (RC) for muscle invasive bladder cancer (MIBC). METHODS: We investigated the National Cancer Database to identify patients with localized MIBC (cT2a-T4, M0) who underwent RC from 2004 to 2014. Demographics, 30- and 90-day mortality rates, as well as OS were analyzed. Hospitals were stratified into low-, medium-, and high-volume centers according to median number of RCs performed per year. Multivariate logistic regression models were fitted to identify independent predictors of perioperative mortality. Kaplan-Meier survival curves were generated to evaluate OS. Cox proportional hazard modeling was performed to identify independent predictors of OS. RESULTS: A total of 24,763 patients with localized MIBC who underwent RC from 2004 to 2014 were included in the study. Overall, most (70.85%) RCs occurred at low-volume hospitals, whereas only 15.83% were performed at high-volume hospitals. Thirty-day mortality rates were 2.87%, 2.19%, and 1.83% (P < .01); and 90-day mortality rates were 8.25%, 6.9%, and 5.9% (P < .01) at low-, medium-, and high-volume hospitals, respectively. Multivariate analyses identified RC volume as an independent predictor of 30- and 90-day mortality. RC in high-volume hospitals was associated with a 35% risk reduction in 30-day mortality (odds ratio 0.65, 95% confidence interval [CI] 0.49-0.85; P < .01), and a 26% risk reduction in 90-day mortality (0.74, 95% CI, 0.63-0.87; P < .01). CONCLUSIONS: Treatment at high-volume centers offers improved outcomes and OS benefit. However, in the United States, only 16% of RCs are performed in high-volume hospitals.

Protein Corona Composition of Silica Nanoparticles in Complex Media: Nanoparticle Size does not Matter.

Biomolecules, and particularly proteins, bind on nanoparticle (NP) surfaces to form the so-called protein corona. It is accepted that the corona drives the biological distribution and toxicity of NPs. Here, the corona composition and structure were studied using silica nanoparticles (SiNPs) of different sizes interacting with soluble yeast protein extracts. Adsorption isotherms showed that the amount of adsorbed proteins varied greatly upon NP size with large NPs having more adsorbed proteins per surface unit. The protein corona composition was studied using a large-scale label-free proteomic approach, combined with statistical and regression analyses. Most of the proteins adsorbed on the NPs were the same, regardless of the size of the NPs. To go beyond, the protein physicochemical parameters relevant for the adsorption were studied: electrostatic interactions and disordered regions are the main driving forces for the adsorption on SiNPs but polypeptide sequence length seems to be an important factor as well. This article demonstrates that curvature effects exhibited using model proteins are not determining factors for the corona composition on SiNPs, when dealing with complex biological media.

Inverse Gas Chromatography with Film Cell Unit: An Attractive Alternative Method to Characterize Surface Properties of Thin Films.

Inverse gas chromatography (IGC) is widely used for the characterization of surfaces. The present work describes a novel IGC tool, the recently developed film cell module, which measures monolithic thin solid film surface properties, whereas only samples in powder or fiber state or polymer-coated supports can be studied by classic IGC. The surface energy of four different solid supports was measured using both classic IGC with columns packed with samples in the powder state, and IGC with the new film cell module or the sessile drop technique, using samples in the film state. The total surface energy and its dispersive and specific components were measured for glass, polyethylene, polyamide and polytetrafluoroethylene. Similar results were obtained for the four materials using the three different techniques. The main conclusion is that the new film cell module for IGC is an attractive alternative to the sessile drop technique as it gives very accurate and reproducible results for surface energy components, with significant savings in time and the possible control of sample humidity and temperature. This film cell module for IGC extends the application field of IGC to any thin solid film and can be used to study the effect of any surface treatment on surface energy.