Single-port robotic-assisted ureteral reconstruction for management of strictures after renal transplantation.

Ureteral strictures are a common and often challenging complication of renal transplantation. The use of single-port (SP) robotic-assisted laparoscopic surgery is a novel approach in the management of these patients. Here we describe 3 patients with stricture of the transplant ureter causing hydronephrosis and allograft dysfunction, whose ureteral reconstructions were successfully performed using the SP robotic-assisted laparoscopic approach. Two patients underwent transplant-to-native ureteroureterostomy and 1 patient underwent ureteroneocystostomy. We demonstrate that the use of concurrent ureteroscopy and near-infrared fluorescence enables safe and rapid identification of native and transplant ureters. In addition, side-to-side anastomosis of transplant-to-native ureters allows for preservation of ureteral vasculature. In this limited series, the SP robotic platform demonstrates great promise in simplifying and streamlining our approach to ureteral strictures in this patient population.

Second opinion pathologic review in the management of prostate cancer.

INTRODUCTION Inter-institutional re-review of prostate needle biopsy (PNBx) material is required at many institutions before definitive treatment, but adds time and cost and may not significantly alter urologic management. We aim to determine the utility of universal PNBx re-review on influencing the decision to recommend definitive local therapy for patients with prostate cancer. MATERIALS AND METHODS: From 2017-2020, 590 prostate biopsy specimens from outside institutions were re-reviewed at our center for patients considering prostatectomy. Clinical and pathologic characteristics from initial and secondary review were analyzed. Potential for change in treatment candidacy (CTC) was determined by re-diagnosis to non-malignant tissue or change in candidacy for active surveillance (AS) versus definitive treatment (i.e. prostatectomy or radiation therapy). Thus, the following scenarios were considered CTC: downgrading to non-malignant tissue, downgrading ISUP Grade Group (GG) ≥ 2 to GG1, and upgrading GG1 to GG ≥ 2. Any changes between GG2 to GG5 were not considered CTC, as definitive treatment would be offered to all groups. RESULTS: Overall, 55 patients (9.3%) had potential for CTC based on secondary review, all of whom had initial pathologic GG (iGG) ≤ 2. Of the 152 patients with iGG1, 8 were downgraded to no malignancy and 41 were upgraded to GG2 or GG3. Of the 185 patients with iGG2, 6 were downgraded to GG1. No patients with iGG ≥ 3 qualified for a CTC. Features associated with CTC included iGG, number of positive cores, and highest core percentage. Upon multivariable analysis, only iGG1 diagnosis was predictive of CTC (OR 23.66, p < 0.001). CONCLUSION: Second review may be helpful in determining need for definitive treatment in patients with GG1 and GG2 prostate cancer, i.e. those considering AS. This process appears unnecessary in GG3+ patients, as management for patients considering surgery would not change. This may allow for judicious redirection of hospital resources.

Defining the Safety Profile for Performing Pancreatoduodenectomy in the Setting of Hyperbilirubinemia.

BACKGROUND: Hyperbilirubinemia is commonly observed in patients requiring pancreatoduodenectomy (PD). Thus far, literature regarding the danger of operating in the setting of hyperbilirubinemia is equivocal. What remains undefined is at what specific level of bilirubin there is an adverse safety profile for undergoing PD. The aim of this study is to identify the optimal safety profile of patients with hyperbilirubinemia undergoing PD. PATIENTS AND METHODS: The present work analyzed 803 PDs from 2004 to 2018. A generalized additive model was used to determine cutoff values of total serum bilirubin (TB) that were associated with increases in adverse outcomes, including 90-day mortality. Subgroup comparisons and biliary stent-specific analyses were performed for patients with TB below and above the cutoff. RESULTS: TB of 13 mg/dL was associated with an increase in 90-day mortality (P = 0.043) and was the dominant risk factor on multivariate logistic regression [odds ratio (OR) 8.193, P = 0.001]. Increased TB levels were also associated with reoperations, number of complications per patient, and length of stay. Patients with TB greater than or equal to 13 mg/dL (TB ≥ 13) who received successful biliary decompression through stenting had less combined death and serious morbidity (P = 0.048). CONCLUSIONS: Preoperative TB ≥ 13 mg/dL was associated with increased 90-day mortality after PD. Reducing a TB ≥ 13 is generally recommended before proceeding to surgery.

Decoding Grade B Pancreatic Fistula: A Clinical and Economical Analysis and Subclassification Proposal.

OBJECTIVE: The aim of this study was to describe characteristics and management approaches for grade B pancreatic fistula (B-POPF) and investigate whether it segregates into distinct subclasses. BACKGROUND: The 2016 ISGPS refined definition of B-POPF is predicated on various postoperative management approaches, ranging from prolonged drainage to interventional procedures, but the spectrum of clinical severity within this entity is yet undefined. METHODS: Pancreatectomies performed at 2 institutions from 2007 to 2016 were reviewed to identify B-POPFs and their treatment strategies. Subclassification of B-POPFs into 3 classes was modeled after the Fistula Accordion Severity Grading System (B1: prolonged drainage only; B2: pharmacologic management; B3: interventional procedures). Clinical and economic outcomes, unique from the ISGPS definition qualifiers, were analyzed across subclasses. RESULTS: B-POPF developed in 320 of 1949 patients (16.4%), and commonly required antibiotics (70.3%), prolonged drainage (67.8%), and enteral/parenteral nutrition (54.7%). Percutaneous drainage occurred in 79 patients (24.7%), always in combination with other strategies. Management of B-POPFs was widely heterogeneous with a median of 2 approaches/patient (range 1 to 6) and 38 various strategy combinations used. Subclasses B1-3 comprised 19.1%, 52.2%, and 28.8% of B-POPFs, respectively, and were associated with progressively worse clinical and economic outcomes. These results were confirmed by multivariable analysis adjusted for clinical and operative factors. Notably, distribution of the B-POPF subclasses was influenced by institution and type of resection (P < 0.001), while clinical/demographic predictors proved elusive. CONCLUSION: B-POPF is a heterogeneous entity, where 3 distinct subclasses with increasing clinical and economic burden can be identified. This classification framework has potential implications for accurate reporting, comparative research, and performance evaluation.

Identification of an Optimal Cut-off for Drain Fluid Amylase on Postoperative Day 1 for Predicting Clinically Relevant Fistula After Distal Pancreatectomy: A Multi-institutional Analysis and External Validation.

OBJECTIVE: The aim of this study was to investigate the relationship between drain fluid amylase value on the first postoperative day (DFA1) and clinically relevant fistula (CR-POPF) after distal pancreatectomy (DP), and to identify the cut-off of DFA1 that optimizes CR-POPF prediction. BACKGROUND: DFA1 is a well-recognized predictor of CR-POPF after pancreatoduodenectomy, but its role in DP is largely unexplored. METHODS: DFA1 levels were correlated with CR-POPF in 2 independent multi-institutional sets of DP patients: developmental (n = 338; years 2012 to 2017) and validation cohort (n = 166; years 2006 to 2016). Cut-off choice was based on Youden index calculation, and its ability to predict CR-POPF occurrence was tested in a multivariable regression model adjusted for clinical, demographic, operative, and pathological variables. RESULTS: In the developmental set, median DFA1 was 1745 U/L and the CR-POPF rate was 21.9%. DFA1 correlated with CR-POPF with an area under the curve of 0.737 (P < 0.001). A DFA1 of 2000 U/L had the highest Youden index, with 74.3% sensitivity and 62.1% specificity. Patients in the validation cohort displayed different demographic and operative characteristics, lower values of DFA1 (784.5 U/L, P < 0.001), and reduced CR-POPF rate (10.2%, P < 0.001). However, a DFA1 of 2000 U/L had the highest Youden index in this cohort as well, with 64.7% sensitivity and 75.8% specificity. At multivariable analysis, DFA1 ≥2000 U/L was the only factor significantly associated with CR-POPF in both cohorts. CONCLUSION: A DFA1 of 2000 U/L optimizes CR-POPF prediction after DP. These results provide the substrate to define best practices and improve outcomes for patients receiving DP.

Ultra-stable dendrite-free Na and Li metal anodes enabled by tin selenide host material.

Lithium/sodium metal anodes are considered promising candidates to realize high-energy-density batteries because of their high theoretical specific capacity and low potential. However, their cycling stability are hindered by uncontrolled dendrites growth. Herein, SnSe nanoparticles are tightly anchored on the fiber of carbon cloth (CC) to construct SnSe@CC host material in order to control Li/Na nucleation behavior and restrain dendrites growth. It is demonstrated that the alloying product of Li15Sn4/Na15Sn4 with strong metal affinity can provide abundant active nucleation sites, and three-dimensional structure of CC host can significantly decrease the local electric current, thereby guiding homogeneous metal deposition without Li and Na dendrites. Meanwhile, the conversion product of Li2Se/Na2Se will uniformly cover on the surface of metal to serve as ultra-stable solid state interface film. As a result, high-capacity Li metal anode (20 mAh·cm-2) and Na metal anode (10 mAh·cm-2) can work steadily with ultra-long lifespans over 5000 and 6000 h with low overpotentials of 7 mV and 141 mV, respectively. Moreover, the assembled Li and Na metal full batteries exhibit superior electrochemical performances, confirming the practicability of metal anode confined in composite host. Such a strategy of conversion-alloying-type materials as hosts opens up a new path for dendrite-free metal anode electrode.

3D Reconstruction of Carotid Artery from Ultrasound Images.

3D reconstruction is an important area in computer vision, which can be applied to assist in medical diagnosis. Compared to observing 2D ultrasound images, 3D models are more suitable for diagnostic interpretation. In this paper, we describe an approach for 3D reconstruction of the carotid artery utilizing ultrasound images from the transverse and longitudinal views. We implement a human-computer interface to ensure the accuracy of the segmentation results by involving superpixels and ellipse fitting techniques. This approach is expected to achieve better accuracy to assist diagnostics in the future.

Graphene/Silver Nanowires/Graphene Sandwich Composite for Stretchable Transparent Electrodes and Its Fracture Mechanism.

Polycrystalline graphene grown by chemical vapor deposition (CVD) is characterized by line defects and disruptions at the grain boundaries and nucleation sites. This adversely affects the stretchability and conductivity of graphene, which limits its applications in the field of flexible, stretchable, and transparent electrodes. We demonstrate a composite electrode comprised of a graphene/silver nanowires (AgNWs)/graphene sandwich structure on a polydimethylsiloxane substrate to overcome this limitation. The sandwich structure exhibits high transparency (>90%) and excellent conductivity improvement of the graphene layers. The use of AgNWs significantly suppresses the conductivity loss resulting from stretching. The mechanism of the suppression of the conductivity loss was investigated using scanning electron microscopy, atomic force microscopy, and lateral force microscopy. The results suggest that the high surface friction of the sandwich structure causes a sliding effect between the graphene layers would produce low crack or hole formation to maintain the conductivity. In addition to acting as conductive layers, the top and bottom graphene layers can also protect the AgNWs from oxidation, thereby enabling maintenance of the electrical performance of the electrodes over a prolonged period. We also confirmed the applicability of the sandwich structure electrode to the human body, such as on the wrist, finger, and elbow.

Contemporary National Trends and Variations of Pelvic Lymph Node Dissection in Patients Undergoing Robot-Assisted Radical Prostatectomy.

INTRODUCTION: Previous studies showed suboptimal adherence to clinical practice guidelines for pelvic lymph node dissection (PLND) during radical prostatectomy (RP). Robot-assisted RP (RARP) has become the predominant surgical management for localized prostate cancer in the United States but contemporary national data on PLND adherence during RARP are still lacking. METHODS: RARPs for clinically localized (cT1-2N0M0) intermediate-risk and high-risk prostate cancer diagnosed between 2010 and 2016 in National Cancer Database were identified. Outcome of interest was PLND and multivariable logistic regressions were used to identify whether patient demographics and facility characteristics were associated with the outcome. RESULTS: We included 115,355 patients in the final cohort (intermediate-risk = 86,314, high-risk = 29,041). From 2010 to 2016, there was an increasing trend of PLND in the overall, intermediate-risk, and high-risk cohorts. In 2016, PLND was performed in 79.7% of the intermediate-risk and 93.5% of the high-risk patients. Multivariable logistic regressions showed Hispanic race/ethnicity (vs. white) (odds ratio [OR] = 0.90, P = .010), lowest socioeconomic status (vs. highest) (OR = 0.85, P < .001), rural area (vs. metro area) (OR=0.61, P < .001), and community facility (vs. academic) (OR = 0.56, P < .001) were some of the factors associated with lower PLND rate. Variations of PLND rate among reporting facility's locations were also identified. CONCLUSION: Contemporary national data showed significantly increased PLND rate in patients who underwent RARP for intermediate-risk and high-risk prostate cancer in recent years. However, there were still some variations in PLND rate among different patient populations and facilities. Continued efforts need to be made to further increase PLND rate and narrow or eliminate disparities we identified.

Long-term Functional, Psychological, Emotional, and Social Outcomes in Survivors of Firearm Injuries.

Importance: The outcomes of firearm injuries in the United States are devastating. Although firearm mortality and costs have been investigated, the long-term outcomes after surviving a gunshot wound (GSW) remain unstudied. Objective: To determine the long-term functional, psychological, emotional, and social outcomes among survivors of firearm injuries. Design, Setting, and Participants: This prospective cohort study assessed patient-reported outcomes among GSW survivors from January 1, 2008, through December 31, 2017, at a single urban level I trauma center. Attempts were made to contact all adult patients (aged ≥18 years) discharged alive during the study period. A total of 3088 patients were identified; 516 (16.7%) who died during hospitalization and 45 (1.5%) who died after discharge were excluded. Telephone contact was made with 263 (10.4%) of the remaining patients, and 80 (30.4%) declined study participation. The final study sample consisted of 183 participants. Data were analyzed from June 1, 2018, through June 20, 2019. Exposures: A GSW sustained from January 1, 2008, through December 31, 2017. Main Outcomes and Measures: Scores on 8 Patient-Reported Outcomes Measurement Information System (PROMIS) instruments (Global Physical Health, Global Mental Health, Physical Function, Emotional Support, Ability to Participate in Social Roles and Activities, Pain Intensity, Alcohol Use, and Severity of Substance Use) and the Primary Care PTSD (posttraumatic stress disorder) Screen for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Results: Of the 263 patients who survived a GSW and were contacted, 183 (69.6%) participated. Participants were more likely to be admitted to the hospital compared with those who declined (150 [82.0%] vs 54 [67.5%]; P = .01). Participants had a median time from GSW of 5.9 years (range, 4.7-8.1 years) and were primarily young (median age, 27 years [range, 21-36 years]), black (168 [91.8%]), male (169 [92.3%]), and employed before GSW (pre-GSW, 139 [76.0%]; post-GSW, 113 [62.1%]; decrease, 14.3%; P = .004). Combined alcohol and substance use increased by 13.2% (pre-GSW use, 56 [30.8%]; post-GSW use, 80 [44.0%]). Participants had mean (SD) scores below population norms (50 [10]) for Global Physical Health (45 [11]; P < .001), Global Mental Health (48 [11]; P = .03), and Physical Function (45 [12]; P < .001) PROMIS metrics. Eighty-nine participants (48.6%) had a positive screen for probable PTSD. Patients who required intensive care unit admission (n = 64) had worse mean (SD) Physical Function scores (42 [13] vs 46 [11]; P = .045) than those not requiring the intensive care unit. Survivors no more than 5 years after injury had greater PTSD risk (38 of 63 [60.3%] vs 51 of 119 [42.9%]; P = .03) but better mean (SD) Global Physical Health scores (47 [11] vs 43 [11]; P = .04) than those more than 5 years after injury. Conclusions and Relevance: This study's results suggest that the lasting effects of firearm injury reach far beyond mortality and economic burden. Survivors of GSWs may have negative outcomes for years after injury. These findings suggest that early identification and initiation of long-term longitudinal care is paramount.

Extended Experience with a Dynamic, Data-Driven Selective Drain Management Protocol in Pancreaticoduodenectomy: Progressive Risk Stratification for Better Practice.

BACKGROUND: Intraoperative drain use for pancreaticoduodenectomy has been practiced in an unconditional, binary manner (placement/no placement). Alternatively, dynamic drain management has been introduced, incorporating the Fistula Risk Score (FRS) and drain fluid amylase (DFA) analysis, to mitigate clinically relevant postoperative pancreatic fistula (CR-POPF). STUDY DESIGN: An extended experience with dynamic drain management was used at a single institution for 400 consecutive pancreaticoduodenectomies (2014 to 2019). This protocol consists of the following: drains omitted for negligible/low-risk FRS (0 to 2) and drains placed for moderate/high-risk FRS (3 to 10) with early (postoperative day [POD] 3) removal if POD1 DFA ≤5,000 U/L. Adherence to this protocol was prospectively annotated and outcomes were retrospectively analyzed. RESULTS: The overall CR-POPF rate was 8.7%, with none occurring in the negligible/low-risk cases. Moderate/high-risk patients manifested an 11.9% CR-POPF rate (n = 35 of 293), which was lower on-protocol (9.5% vs 21%; p = 0.014). After drain placement, POD1 DFA ≥5,000 U/L was a better predictor of CR-POPF than FRS (odds ratio 14.7; 95% CI, 4.3 to 50.3). For POD1 DFA ≤5,000 U/L, early drain removal was associated with fewer CR-POPFs (2.8% vs 23.5%; p < 0.001), and substantiated by multivariable analysis (odds ratio 0.09; 95% CI, 0.03 to 0.28). Surgeon adherence was inversely related to CR-POPF rate (R = 0.846). CONCLUSIONS: This extended experience validates a dynamic drain management protocol, providing a model for better drain management and individualized patient care after pancreaticoduodenectomy. This study confirms that drains can be safely omitted from negligible/low-risk patients, and moderate/high-risk patients benefit from early drain removal.