Readmission-related outcomes of surgical versus transcatheter aortic valve replacement in patients aged 65 or older with bicuspid aortic valve.

BACKGROUND: There continues to be debate regarding the superiority of transcatheter (TAVR) over surgical aortic valve replacement (SAVR) in patients with bicuspid aortic valves (BAV). We aimed to compare outcomes during readmissions in elderly patients with BAV who underwent SAVR or TAVR. METHODS: Patients 65 years or older with BAV who underwent TAVR or isolated SAVR were identified using the National Readmission Database from 2012 through 2018. We compared outcomes during readmissions within 90 days after discharge from the index surgery. Propensity score matching was performed to adjust the baseline differences. RESULTS: During the study period, 8555 and 1081 elderly patients with BAV underwent SAVR and TAVR, respectively. The number of patients who underwent TAVR went up by 179 % from 2012 to 2018. Propensity score matching yielded 573 patients in each group. A total of 111 (19.4 %) in the SAVR group and 125 (21.8 %) in the TAVR group were readmitted within 90 days after the index surgery (p = .31). The mortality during the readmissions within 90 days was equivalent between the two groups (0.9 % in the SAVR group vs. 3.2 % in the TAVR group, p = .22). However, the median hospital cost was approximately doubled in the TAVR group during the readmission (18,250 dollars vs. 9310 dollars in the SAVR group, p < .001). CONCLUSIONS: Readmission within 90 days was common in both groups. While the mortality during the readmissions after the surgery was equivalent between the two groups, hospital cost was significantly more expensive in the TAVR group.

The Effect of COVID-19 on Cardiac Surgical Volume and its Associated Costs.

The COVID-19 pandemic significantly affected health care and in particular surgical volume. However, no data surrounding lost hospital revenue due to decreased cardiac surgical volume have been reported. The National Inpatient Sample database was used with decreases in cardiac surgery at a single center to generate a national estimate of decreased cardiac operative volume. Hospital charges and provided charge to cost ratios were used to create estimates of lost hospital revenue, adjusted for 2020 dollars. The COVID period was defined as January to May of 2020. A Gompertz function was used to model cardiac volume growth to pre-COVID levels. Single center cardiac case demographics were internally compared during January to May for 2019 and 2020 to create an estimate of volume reduction due to COVID. The maximum decrease in cardiac surgical volume was 28.3%. Cumulative case volume and hospital revenue loss during the COVID months as well as the recovery period totaled over 35 thousand cases and 2.5 billion dollars. Institutionally, patients during COVID months were younger, more frequently undergoing a CABG procedure, and had a longer length of stay. The pandemic caused a significant decrease in cardiac surgical volume and a subsequent decrease in hospital revenue. This data can be used to address the accumulated surgical backlog and programmatic changes for future occurrences.

Prospective Assessment of Systemic MicroRNAs as Markers of Response to Neoadjuvant Chemotherapy in Breast Cancer.

Neoadjuvant chemotherapy (NACT) is used in locally advanced breast cancer to reduce tumour burden prior to surgical resection. However, only a subset of NACT treated patients will respond to treatment or achieve a pathologic complete response (pCR). This multicenter, prospective study (CTRIAL-IE (ICORG) 10-11 study) evaluated circulating microRNA as novel non-invasive prognostic biomarkers of NACT response in breast cancer. Selected circulating microRNAs (Let-7a, miR-21, miR-145, miR-155, miR-195) were quantified from patients undergoing standard of care NACT treatment (n = 114) from whole blood at collected at diagnosis, and the association with NACT response and clinicopathological features evaluated. NACT responders had significantly lower levels of miR-21 (p = 0.036) and miR-195 (p = 0.017), compared to non-responders. Evaluating all breast cancer cases miR-21 was found to be an independent predictor of response (OR 0.538, 95% CI 0.308-0.943, p < 0.05). Luminal cancer NACT responders were found to have significantly decreased levels of miR-145 (p = 0.033) and miR-21 (p = 0.048), compared to non-responders. This study demonstrates the prognostic ability of miR-21, miR-195 and miR-145 as circulating biomarkers stratifying breast cancer patients by NACT response, identifying patients that will derive the maximum benefit from chemotherapy.

Utilization and Outcomes of Surgical Castration in Comparison to Medical Castration in Metastatic Prostate Cancer.

BACKGROUND: Androgen deprivation therapy (ADT) is the gold standard for metastatic prostate cancer, which can be achieved either by surgical or medical castration. In this study, we evaluated the trends of utilization of surgical castration and also assess the survival differences of patients who underwent surgical castration when compared with those who underwent medical castration. MATERIALS AND METHODS: The National Cancer Database was used to identify patients with metastatic prostate cancer from 2004 to 2014. Cochran-Armitage tests were used to assess temporal trends in the proportion of patients receiving surgical castration relative to medical castration. Logistic and Cox regression models were utilized to estimate the odds of utilization of surgical castration and the effect of castration on overall survival (OS). RESULTS: A total of 33,585 patients with metastatic prostate cancer were identified; 31,600 (94.1%) had medical castration, and 1985 (5.9%) underwent surgical castration. There was significant decline in the trend of utilization of surgical castration from 8.6% in 2004 to 3.1% in 2014. On multivariable analysis, being of a non-Caucasian race, having lower median income levels, having non-private insurance, and earlier years of diagnosis were found to be associated with increased odds of choosing surgical castration over medical castration. Notably, the odds of surgical castration were lower at academic centers. On univariable analysis, a survival difference between castration modality was evidenced (P < .01); 5-year OS for medical castration and surgical castration were 24.3% and 18.2%, respectively. However, on multivariable analysis, there was no OS difference between surgical castration and medical castration (P = .13). CONCLUSIONS: In this large contemporary analysis, the utilization of surgical castration has declined over time, with no OS difference when compared with medical castration. Increasing the utilization of surgical castration could help reduce health care expenditures. With rising health care costs, patients and physicians need to be aware of treatment options and their financial implications.

Nongenitourinary complications associated with robot-assisted laparoscopic and radical retropubic prostatectomy: A single institution assessment of 1,100 patients over 11 years.

OBJECTIVES: Robot-assisted laparoscopic prostatectomy (RALP) and radical retropubic prostatectomy (RRP) provide similar outcomes in terms of biochemical recurrence, postoperative continence, and erectile function. Little is known about other complications of these procedures. To further address this, we examined patient outcomes at our institution over an 11-year period. METHODS: A retrospective review of 1,113 prostatectomies (646 RALP and 467 RRP) performed over 11 years by 9 different urologists at a single U.S. academic center was undertaken. Preoperative data collected included age, body mass index (BMI), prostate-specific antigen (PSA), biopsy Gleason score, and tumor (T) stage. Postoperative data included pelvic lymph node dissection (PLND), intensive care unit (ICU) admission rate, length of stay (LOS), ileus, wound infection rate, umbilical hernia occurrence, inguinal hernia occurrence, ophthalmic complications, upper and lower extremity complications, postoperative neuropathy, residual cancer, and cancer recurrence. RESULTS: Significant differences between RRP and RALP included performance of PLND (54.1% vs. 35.9%, P < 0.0001 respectively), umbilical hernia rates (2.4% vs. 6.5%, P = 0.0015, respectively), inguinal hernia rates (5.4% vs. 2.5%, P = 0.0101, respectively), and LE complications (9.0% vs. 5.1%, P = 0.016, respectively). No difference was observed regarding ICU admission, LOS, ileus, wound infection, and ophthalmic or upper extremities complications. CONCLUSIONS: RRP patients were more likely to have lower extremity complications and inguinal herniae, whereas RALP patients had an increased umbilical hernia rate and a trend toward more corneal abrasions.

Beyond Infrastructure: Understanding Why Patients Decline Surgery in the Developing World: An Observational Study in Cameroon.

OBJECTIVE: The aim of this study was to quantify and describe a population of patients in rural Cameroon who present with a surgically treatable illness but ultimately decline surgery, and to understand the patient decision-making process and identify key socioeconomic factors that result in barriers to care. BACKGROUND: An estimated 5 billion people lack access to safe, affordable surgical care and anesthesia when needed, and this unmet need resides disproportionally in low-income countries (LICs). An understanding of the socioeconomic factors underlying decision-making is key to future efforts to expand surgical care delivery in this population. We assessed patient decision-making in a LIC with a cash-based health care economy. METHODS: Standardized interviews were conducted of a random sample of adult patients with treatable surgical conditions over a 7-week period in a tertiary referral hospital in rural Cameroon. Main outcome measures included participant's decision to accept or decline surgery, source of funding, and the relative importance of various factors in the decision-making process. RESULTS: Thirty-four of 175 participants (19.4%) declined surgery recommended by their physician. Twenty-six of 34 participants declining surgery (76.4%) cited procedure cost, which on average equaled 6.4 months' income, as their primary decision factor. Multivariate analysis revealed female gender [odds ratio (OR) 3.35, 95% confidence interval (95% CI) 2.14-5.25], monthly earnings (OR 0.83, 95% CI, 0.77-0.89), supporting children in school (OR 1.22, 95% CI 1.13-1.31), and inability to borrow funds from family or the community (OR 6.49, 95% CI 4.10-10.28) as factors associated with declining surgery. CONCLUSION: Nearly one-fifth of patients presenting to a surgical clinic with a treatable condition did not ultimately receive needed surgery. Both financial and sociocultural factors contribute to the decision to decline care.

Novel use of the capio urethral anastomotic suturing device: a 50-case assessment.

OBJECTIVE: Robotic laparoscopic assisted prostatectomy (RALP) has become the predominant technique for prostatectomy despite significant expense and no robust evidence supporting better cancer control, erectile function, or continence. Several studies have demonstrated lower bladder neck contracture (BNC) rates with RALP, believed to be related to improved visualization and control of the urethrovesical anastomosis. We evaluated the Capio™ radical prostatectomy (RP) suture capturing device for improving anastomotic precision during urethrovesical anastomosis in open radical prostatectomy. MATERIALS AND METHODS: We performed a retrospective review on a single-surgeon series of 50 consecutive patients undergoing radical retropubic prostatectomy (RRP) with utilization of the Capio™ RP device at an academic hospital (February 2010 to May 2012). Patient demographics, pathology, and outcomes data including rates of anastomotic leak, BNC, erectile function, and continence were collected. RESULTS: Mean age of patients at the time of procedure was 60.4 ± 6.43 years. Patients were stratifed by D'Amico criteria into low (14.3%), intermediate (67.4%), and high (18.4%) risk groups. Mean follow-up for all patients was 13.1 ± 7.29 months. No patients were diagnosed with BNC within 90 days after surgery. Two patients (4%) were subsequently diagnosed and treated for BNC, one of whom was asymptomatic prior to diagnosis. CONCLUSION: Utilizing the Capio™ RP device during RRP, we were able to achieve a BNC rate equivalent to rates reported for RALP. Use of the Capio™ RP device appears to be a cost-effective method for improving RRP urethrovesical anastomotic results.

Ureteroileal anastomotic strictures after a Bricker ileal conduit: 50 case assessment of the impact of conversion from a slit incision to a "shield shaped" ileotomy.

PURPOSE: Ureteroileal anastomotic stricture is a late complication of Bricker ileal conduits. We report our utilization of a "shield shaped" rather than a standard slit ileotomy. MATERIALS AND METHODS: We retrospectively reviewed a single surgeon's experience performing Bricker ileal conduits, initially using a slit incision, then a shield shaped ileotomy. Patient demographics, type of ileotomy, indication, history of prior radiation or chemotherapy, development of postoperative ureteroileal anastomotic stricture, date of stricture diagnosis, imaging modality, stricture treatment, outcome, and length of follow up were recorded. RESULTS: A total of 50 ileal conduit patients were identified between 2001-2009. A traditional slit incision ileotomy was performed in 25 patients (Group 1) and a shield shaped ileotomy was performed in the following 25 (Group 2). After excluding 1 patient in each group that died within 90 days postoperatively, a total of 95 renal units were anastomosed, (Group 1: 24 patients, 48 renal units, 2001-2005; and Group 2: 24 patients, 47 renal units, 2006-2009). A total of 8 (8.3%) ureteroileal anastomotic strictures were identified: 6 (12.5%) in Group 1, including 1 with bilateral strictures, and 2 (4.3%) in Group 2. Stricture diagnosis occurred at 1, 4, 4, 5, 14 and 42 months in Group 1, and at 6 and 10 months in Group 2. Mean follow up was 24.2 (2-85) months and 12.3 (2-26) months for each cohort, respectively. No increase in postoperative anastomotic leakage was identified. CONCLUSIONS: Modifying the standard ileotomy slit to a shield shaped incision does not eliminate postoperative anastomotic strictures. This technique provides greater visualization of the suture line, making it technically easier to perform.

Laparoscopic radical prostatectomy: six months of fellowship training doesn't prevent the learning curve when incorporating into a lower volume practice.

INTRODUCTION: To assess whether 6 months of standard laparoscopic radical prostatectomy (LRP) training reduces the learning curve. METHODS: A single urologist (JAB) performed two 3-month fellowships at medical centers with high-volume LRP surgeons (Thomas Jefferson University, 2002 and Massachusetts General Hospital, 2003). He participated in 29 transperitoneal and 23 extraperitoneal LRPs, performing part or all (2) of 28 cases. He subsequently initiated a LRP program at our institution in July 2003, performing 32 procedures between July 2003 and June 2006 (excluding a 3-month 2004 robotic surgery sabbatical). Six residents served as assistant. RESULTS: Median patient age, BMI, and preoperative PSA were 58 (46-71) years, 30 (21-37), and 5.4 (3.2-13.6) ng/ml, respectively. Median estimated blood loss (EBL) and operative time were 400 (50-1700) ml and 411 (282-652) minutes. Median hospital stay, catheterization, and follow-up were 2 (1-12) days, 15 (8-52) days, and 10 (1-30) months, respectively. Ten (31%) and 6 (19%) underwent pelvic lymphadenectomy and open conversion. Five patients (16%) received transfusion. Twenty-three (72%) were pathologic stage pT2 and 9 (28%) pT3. Thirteen, 15, and 3 specimens were Gleason 6, 7, and > or =8, respectively. Fifteen (47%) had positive surgical margins (14 apical and 7 other sites). Nineteen (59%) had complications and 4 (12.5%) salvage radiation therapy. Of 20 patients followed 12 months, 12 (60%) are continent (pad free) and 4 (27%) potent patients remain so with or without PDE5 inhibitor. CONCLUSION: Six months of training (52 cases, 28 as surgeon for part or all) did not alleviate the LRP learning curve.

Delayed orchiectomy at postchemotherapy retroperitoneal lymph node dissection due to laterality of retroperitoneal metastatic pattern consistent with testicular primary: assessment of pathologic findings.

OBJECTIVES: It has been estimated that extragonadal germ cell tumors (EGCTs) constitute 3% to 5% of germ cell neoplasms. An interesting clinical scenario occurs when a patient with a presumed EGCT and normal testicular examination and ultrasound findings has a retroperitoneal metastatic pattern consistent with either a right or left-sided testicular primary. We reviewed the pathologic data of patients presenting with these clinical findings after delayed orchiectomy at postchemotherapy retroperitoneal lymph node dissection (PC-RPLND). METHODS: We identified 14 patients with apparent EGCT who had undergone simultaneous orchiectomy at PC-RPLND at our institution from July 1979 to July 2002 because of a lateralizing pattern of retroperitoneal metastases concerning for a testicular primary. Of the 14 patients, 3 had completely normal testicular ultrasound findings after chemotherapy and 11 had minimal ultrasound findings not consistent with a testicular tumor. RESULTS: Two (14%) of the PC orchiectomy specimens contained mature teratoma and eight (57%) contained necrosis and/or focal fibrosis. Thus, 10 (71%) of 14 patients undergoing PC orchiectomy at PC-RPLND because of metastatic disease laterality had evidence of a testicular primary. CONCLUSIONS: Most (71%) patients with a presumed EGCT who underwent PC orchiectomy because of lateralizing retroperitoneal metastases had histologic evidence of a testicular primary (20% teratoma, 80% focal necrosis or fibrosis). If the retroperitoneal pattern of metastatic tumor spread is consistent with a primary testicular tumor, we offer PC orchiectomy to patients with apparent EGCT at PC-RPLND, even if the PC testicular examination and ultrasound findings are normal.

Hand-assisted laparoscopic nephroureterectomy (HALNU): an assessment of the impact of obesity in 50 procedures.

OBJECTIVE: The aims of this study was to review our experience with hand-assisted laparoscopic nephroureterectomy (HALNU) and to evaluate the impact of body-mass index (BMI) on outcomes. METHODS: We retrospectively analyzed 50 HALNU patients. Twenty had body mass indices (BMIs) <25 (normal cohort), 18 had BMIs between 25 and 29.9 (overweight cohort), and 12 had BMIs >/=30 (obese cohort). RESULTS: The cohorts had similar operative times: 349, 326, and 320 minutes, respectively. Most patients (38) underwent a total HAL distal ureterectomy, but 9 underwent an initial transurethral ureteral dissection (5 [25%], 2 [11%], and 2 [17%]). Five patients were converted to open and 1 had a planned open ureterectomy. The cystotomy was sutured closed in most but left open in 6 (3 [15%], 2 [11%], and 1 [8%]), and a stapled ureteral division was performed in 7 (3 [15%], 2 [11%], and 2 [17%]). Increased BMI was associated with delayed oral intake (P = 0.034). No significant cohort differences were observed for estimated blood loss (EBL), transfusion rate, complication rate, surgical margin status, distant metastases, or death rate. The obese cohort demonstrated trends toward increased hospitalization and bladder cancer recurrence (P = 0.083, P = 0.097). Patients with prior open surgery had longer hospitalizations (P = 0.024). Patients without prior surgery were more commonly alive with persistent disease (P = 0.027). EBL was greater for patients who had transurethral ureteral dissection (P = 0.030). Patients undergoing a stapled ureteral division had delayed oral intake, bowel function, and discharge (P = <0.001, P = 0.034, and P = 0.034). CONCLUSIONS: HALNU is an effective surgical treatment for patients with BMIs as great as 45.

Impact of fellowship training in initiating a laparoscopic donor nephrectomy program.

OBJECTIVES: Laparoscopic donor nephrectomy (LDN) is the current standard of care, but remains a challenging procedure. A urologist at our center performed 6 months of standard and hand-assisted laparoscopic nephrectomy (HALN) fellowship (46 cases, 30 as surgeon). He subsequently performed 30 HAL renal surgeries prior to initiating our hand-assisted laparoscopic donor nephrectomy (HALDN) program. METHODS: We reviewed the intra- and postoperative outcomes of the first 20 HALDNs performed at our center. We examined demographics, estimated blood loss (EBL), operative time, complications, change in hemoglobin and creatinine, length of hospital stay, warm ischemic time, and recipient outcome. RESULTS: Twenty (20) patients underwent HALDN between November 2003 and December 2005. The mean operative time was 277 minutes. EBL averaged 176 mL. An expected rise in creatinine of 0.1-0.8 mg/dL occurred in all patients. One (1) patient had a splenic abrasion and was transfused intraoperatively. Two (2) patients' courses were complicated by ileus. The remaining patients were discharged on postoperative days 2-6. There were no other complications. Warm ischemia time averaged 3.7 minutes. Two (2) recipients experienced acute or delayed rejection episodes, requiring increased immunosuppression. One (1) recipient had good renal function until he developed sepsis 3 months later and died. All recipients were discharged with functioning grafts, and there have been no ureteral strictures. CONCLUSIONS: Six (6) months of laparoscopic nephrectomy training plus a 30-case HAL/LRN surgical experience sufficiently prepares a surgeon to initiate a HALDN program. Even at a lower volume transplant center, positive operative results and long-term graft outcomes can be achieved.

Incorporation of hand-assisted laparoscopic nephrectomy into an academic training program: an assessment of the utility of a 3-month minifellowship.

INTRODUCTION: The aim of this study was to assess the amount of training necessary for a midcareer urologic surgeon to incorporate hand-assisted laparoscopic (HAL) renal surgery into an academic practice. MATERIALS AND METHODS: A urologist (JAB) without laparoscopic surgical experience in his fifth year of practice completed a 3-month minifellowship at a high-volume center primarily to learn HAL nephrectomy (HALN), during which he performed 15 HALNs (and 2 HAL nephroureterectomies) and assisted during 5 HALNs. Surgical outcomes and resident surgical participation on nephrectomy cases at the home medical center during the 6 months prior to (phase 1) and after (phase 2) the fellowship were evaluated. RESULTS: During phase 1, 12 open nephrectomies were performed in a mean operative time of 265 (10-387) minutes. During phase 2, 16 HALNs were initiated and 2 (13%) combined cases were converted to open at the discretion of general surgeon. The mean operative time was 288 (226-355) minutes. Ten (10) and 5 patients from each cohort had concomitant procedures performed. The mean tumor size was 8.7 (2-15) and 7.1 (2.5-15) cm. Three (3) patients from each cohort were anemic preoperatively (hemoglobin < or =10 mg/dL). Ten (10) (83%) and 4 (25%) patients from each cohort received transfusions. There were 3 and 2 intraoperative and postoperative cohort complications, respectively. Residents were the operative surgeon on all cohort 1 and two thirds of cohort 2 cases. Chief residents completed the entirety of their third and fourth HALNs, respectively. CONCLUSIONS: A 3-month fellowship is an effective tool for a midcareer urologist to rapidly gain significant HALN experience. Twenty-two (22) cases (17 as surgeon) allowed for the immediate incorporation of this procedure into a complex academic practice without any interruption of residency training.

A multi-institution, minimally invasive urological oncology fellowship: a critical assessment of the clinical training and academic benefits.

PURPOSE: We evaluated the clinical training and academic productivity of a unique minimally invasive urological oncology fellowship performed in 3-month rotations at 4 institutions. MATERIAL AND METHODS: With Georgia Cancer Coalition grant funding and institutional support a faculty urologist (JAB) completed 3-month fellowships at Thomas Jefferson University, Philadelphia in 2002, Indiana University, Indianapolis in 2003, Massachusetts General Hospital, Boston in 2003 and Henry Ford Hospital, Detroit in 2004. RESULTS: The trainee operated under the direction of 8 surgeons and assisted/observed another 5. Total operative experience was 355 cases, including 53 standard laparoscopic radical prostatectomies, 100 robotic assisted laparoscopic radical prostatectomies, 30 standard (including 13 donor) and 22 hand assisted laparoscopic nephrectomies, 6 nephroureterectomies, 14 partial nephrectomies, 3 renal cyst decortications, 12 pyeloplasties, 5 adrenalectomies, 2 hand assisted laparoscopic ureterolysis procedures, 1 laparoscopic partial and 1 radical cystectomy, hand assisted laparoscopic cystectomy, robotic cystectomy, 26 open and 2 laparoscopic retroperitoneal lymph node dissections, 5 complex open bladder surgeries, 6 complex open renal surgeries and approximately 24 endoscopic laser upper tract tumor cases. Post-fellowship sequential initiation of laparoscopic renal cancer (April 2002), prostatectomy (July 2003) and donor nephrectomy (November 2003) programs was accomplished at the home institution. Academic projects were completed during each fellowship phase with 43 presented abstracts and 2 book chapters, 2 non-peer reviewed articles and 12 peer reviewed articles published to date. CONCLUSIONS: A multi-institution fellowship allows serial acquisition and incorporation of a wide variety of cutting edge, minimally invasive and oncological procedures into an academic practice. It allows greater exposure to more high volume experts in varying oncological subspecialties. Clinical research and academic productivity are possible.

Hand-assisted laparoscopic ureterolysis to treat ureteral obstruction secondary to idiopathic retroperitoneal fibrosis: assessment of a novel technique and initial series.

OBJECTIVES: To describe a novel technique and assess an initial series of hand-assisted laparoscopic ureterolysis for the treatment of retroperitoneal fibrosis. METHODS: Five patients (3 women and 2 men, mean age 56.4 years) with ureteral obstruction secondary to retroperitoneal fibrosis underwent bilateral hand-assisted laparoscopic ureterolysis with biopsy. These patients had undergone an imaging evaluation with excretory urography, computed tomography, furosemide washout nucleotide scan, and/or magnetic resonance imaging. All had ureteral stents placed before or at surgery. A periumbilical hand port, bilateral 10-mm perirectal camera ports, and bilateral 5-mm or 10-mm working ports were placed. The ureters were completely mobilized and placed intraperitoneally. The patient demographic, operative, and early and late postoperative data were collected. RESULTS: The average operating room time was 259 minutes (range 215 to 300), and the estimated blood loss was 80 mL (range 50 to 200). The mean hospital stay was 4.20 days (range 3 to 5). One minor intraoperative ureteral injury and no postoperative complications occurred. The mean analgesic requirement was 45.6 mg morphine sulfate (range 20 to 88). Three patients also received 120 mg of parenteral ketorolac. All indwelling ureteral stents were removed by 2 to 4 weeks postoperatively. At 22.4 months (range 12 to 29) postoperatively, 90% of the renal units were unobstructed. CONCLUSIONS: Hand-assisted laparoscopic ureterolysis is an effective minimally invasive technique with less morbidity than open ureterolysis. It offers a shorter operative time and is less technically challenging than conventional laparoscopy. It is our preferred surgical approach for obstructive retroperitoneal fibrosis.

Optical-access visual obturator trocar entry into desufflated abdomen during laparoscopy: assessment after 96 cases.

BACKGROUND: The introduction of optical-access laparoscopic trocars was met with enthusiasm and the impression that these devices provide safer access with decreased complication rates. However, serious complications have been reported. PATIENTS AND METHODS: We retrospectively reviewed our first 96 consecutive cases (17 radical prostatectomies, 2 sacrocolpopexies, 6 adrenalectomies, and 71 renal procedures), performed between October 2001 and April 2003, of optical-access laparoscopic trocar placement as initial entry into the desufflated abdomen. After creating a 12-mm periumbilical or lateral-rectus incision, the 12-mm Endopath Bladeless visual obturator trocar (Ethicon Endosurgery, Cincinnati, OH) was inserted into the peritoneum while carefully observing the separation of the layers of fascia, muscle, and peritoneum. RESULTS: There were no vascular injuries. However, we observed 2 (2.1%) large-bowel injuries: a seromuscular injury and a through-and-through enterotomy of the mid-descending colon. In both cases, the visual obturator was placed lateral to the left rectus muscle, and the large colon was noted to be adherent to the anterior abdominal wall. The bowel injuries were repaired in two layers (running 3-0 Vicryl for the mucosa and 3-0 silk for the seromuscular layer). The operations were completed without open conversion and with uneventful recovery. CONCLUSIONS: Direct placement of an optical-access visual obturator trocar into the desufflated abdomen carries the potential for significant injury. Our current practice is to place the visual trocar after Veress-needle peritoneal insufflation.

Tracheobronchoscopic assessment of exercise-induced pulmonary hemorrhage in horses.

OBJECTIVE: To determine the interobserver variability of assessment of exercise-induced pulmonary hemorrhage (EIPH) during tracheobronchoscopic examination in horses. ANIMALS: 747 Thoroughbred racehorses. Procedures-850 tracheobronchoscopic examinations were performed within 2 hours of racing for the horses. Examinations were recorded on videotape, and EIPH and its severity were assessed independently by 3 veterinarians. Concordance was determined by calculation of the Cohen weighted kappa statistic and tabulation of scores assigned by each observer. RESULTS: Weighted kappa statistics ranged from 0.75 to 0.80. In 99.4% of observations, all observers agreed or 2 of 3 agreed and the third differed by < or = 1 grade. CONCLUSIONS AND CLINICAL RELEVANCE: Results indicated that interobserver reliability of tracheobronchoscopic assessment of EIPH in Thoroughbred racehorses is high when the examination is conducted by experienced veterinarians. Concordance among investigators is sufficient to justify use of this grading system for further studies and clinical descriptions of EIPH.

Transperitoneal versus extraperitoneal approach to laparoscopic radical prostatectomy: an assessment of 156 cases.

OBJECTIVES: To compare the results of 122 transperitoneal laparoscopic radical prostatectomy (TP-LRP) procedures with those of 34 extraperitoneal LRP (EP-LRP) procedures to assess for differences in outcomes and complications. Both TP-LRP and EP-LRP have been touted as effective techniques for performing LRP. METHODS: We retrospectively reviewed 156 LRPs performed by a single surgeon (D.M.D.) at a single institution between October 2001 and June 2003. EP-LRP was introduced in February 2003. RESULTS: The cohorts were similar in terms of mean patient age, height, weight, body mass index, and American Society of Anesthesiologists Physical Status Classification. Of the total cohort, 19 TP-LRP (16%) and 11 EP-LRP (32%) patients had clinical Stage T2; the remainder had clinical Stage T1c. Similarly, 18 TP-LRP (15%) and 9 EP-LRP (26%) patients had a biopsy Gleason grade of 7 or greater. About one third of patients underwent concomitant pelvic lymphadenectomy (all negative), and 15 TP-LRP (12%) and 2 EP-LRP (6%) patients underwent simultaneous inguinal or umbilical herniorrhaphy. Six TP-LRP patients (5%) required significant lysis of bowel adhesions. The patients in both groups had similar mean operative times (197 minutes and 191 minutes for the TP-LRP and EP-LRP group, respectively; P = 0.29). Clinically significant anastomotic leaks were documented in 7 (6%) TP-LRP and 4 (12%) EP-LRP patients (P = 0.22). The two groups had similar mean hemoglobin decreases (3.0 g/dL) and transfusion rates. The mean time of drainage and hospitalization was 0.5 day longer for the TP-LRP cohort. A mean pathologic Gleason grade of 6.3 was noted for each cohort. Twenty-one TP-LRP (17%) and eight EP-LRP (24%) specimens were pathologic Stage T3, and 29 (24%) of the former and 7 (21%) of the latter (P = 0.81) specimens were margin positive. The complication rates were similar (11% and 12% in TP-LRP and EP-LRP groups, respectively; P = 1.0), except for a greater rate of ileus in the TP-LRP cohort (3 patients). CONCLUSIONS: Extraperitoneal LRP appears to offer similar results to TP-LRP. TP-LRP was associated with a slightly greater ileus rate and EP-LRP with a slightly greater anastomotic leak rate (P = 0.22). However, the latter may have been the result of improved detection. Also, it was easier to manage using the EP-LRP approach.

Laparoscopic radical prostatectomy and body mass index: an assessment of 151 sequential cases.

PURPOSE: Little objective data are available regarding obesity and the performance of laparoscopic radical prostatectomy (LRP). We reviewed our LRP series to determine the effect of body mass index (BMI) on operative time, blood loss, anastomotic leakage, positive margins, length of stay, complications, urinary continence and erectile function. MATERIALS AND METHODS: A single institution retrospective review was performed of 151 sequential LRPs performed by a single surgeon. Patients were separated into those who were nonobese (BMI less than 30), and those with classes I (BMI 30 to 34.9), II (BMI 35 to 39.9) and III (BMI 40 or greater) obesity according to WHO criteria. RESULTS: There were 97 patients in the nonobese and 54 in the obese cohort, including 35, 14 and 5 with classes I to III obesity, respectively. A trend toward greater preoperative prostate specific antigen (p = 0.14), Gleason score (p = 0.06) and American Society of Anesthesiologists classification (p = 0.07) was noted in the obese (BMI 30 or greater) group. The cohorts had similar prostate size (p = 0.11), pathological grade (p = 0.57), pathological stage (p = 0.50), postoperative hemoglobin decrease (p = 0.77) and hospital stay (p = 0.90). The rates of positive margins (p = 1.0), anastomotic leakage (p = 0.49), prostate specific antigen recurrence (p = 1.0) and complication (p = 0.14) were also similar. Early postoperative urinary continence (p = 1.0) and erectile function (p = 0.19) appeared equivalent. Mean operative time +/- SD was greater in obese than in nonobese patients (208 +/- 43 vs 192 +/- 34 minutes, p = 0.02). Mean operative time was longer in patients with classes II and III obesity (220 +/- 47 minutes, p <0.05 and 249 +/- 32, p <0.01, respectively). The class III group had a longer mean operative time than the class I obesity group (198 +/- 34 minutes, p <0.05). Obese patients underwent a greater number of additional procedures at the time of LRP (p = 0.01). CONCLUSIONS: While obesity significantly increased LRP operative time, it did not significantly impact other intraoperative and postoperative surgical parameters. LRP should be offered to obese patients as a feasible and effective treatment option for prostate cancer.