First Comparison of Retroperitoneal Versus Transperitoneal Robot-Assisted Nephroureterectomy with Bladder Cuff: A Single Center Study.

INTRODUCTION: After recent presentation of the first complete robot-assisted retroperitoneal nephroureterectomy with bladder cuff (RRNU) for patients with upper tract urothelial cancer (UTUC), we aimed to compare this new surgical technique with robot-assisted transperitoneal nephroureterectomy (TRNU) representing the current standard of care. METHODS: Robot-assisted nephroureterectomies (NUs) were retrospectively analyzed and compared based on two groups: transperitoneal versus retroperitoneal approach. Baseline data were collected for patient demographics, tumor characteristics, intra- (EAUiaiC) and postoperative (Clavien-Dindo) complications, and perioperative variables. Tumor characteristics included grade of malignancy, clinical stage, and surgical margin status. Short-term follow-up data including 30-day readmission rates were collected. Statistical analyses were performed assuming a significant p-value of < 0.05. RESULTS: The analysis includes perioperative patient data after proven UTUC of 24 TRNU versus 12 RRNU (mean age: 70 versus 71 years; BMI: 25.9 versus 26.1 kg/m2; CCI score ≥ 4: 83% versus 75%; ASA score ≥ 3: 37% vs 33%). Intraoperative (16.4% vs 0%, p = 0.35) and postoperative (25% vs 12.5%, p = 0.64) complications demonstrated no significant discrepancy. Notably, RRNU demonstrated significantly shorter surgery time (p < 0.05) and length of stay (p < 0.05). There was no significant difference in histopathological tumor characteristics, whereas significantly more lymph nodes were removed through RRNU (11.0±3.3 vs. 6.4±5.1, p < 0.05). Finally, no statistical difference was shown in short-term follow-up. CONCLUSION: We report the first head-to-head comparison between RRNU and TRNU. RRNU proves to be a safe and feasible approach which appears to be non-inferior to TRNU. RRNU expands the spectrum of minimally invasive treatment options, particularly for patients with major previous abdominal surgery.

[Implementation of Enhanced Recovery after Surgery (ERAS®) protocol in radical cystectomy at the University Medical Center Mainz]. / Implementierung des ERAS®-Protokolls (Enhanced Recovery After Surgery) nach radikaler Zystektomie an der Universitätsmedizin Mainz.

BACKGROUND: In surgical fields there has been a perceivable paradigm shift during the last decade concerning patient pre- and rehabilitation. Current literature suggests close interdisciplinary collaboration after complex procedures such as radical cystectomy in order to optimize perioperative patient care for the benefit of "fast-track" surgery. OBJECTIVES: To compose a catalogue of standardized measures after radical cystectomy based on guidelines set by the ERAS®-Society. RESULTS: The protocol commences with preoperative education in order to improve the physical and psychological condition of the patient. Crucial aspects in peri- and postoperative patient care are gentle surgical technique, adequate pain management, early mobilization and oral food intake, early removal of drains and foreign material and a seamless return to normal, daily life. CONCLUSIONS: Prospective data analysis will be the next step in order to establish the effectiveness of the protocol especially regarding postoperative complications and median duration of hospital stay.

Long-Term Effectiveness of Direct CT-Guided Aspiration and Fenestration of Symptomatic Lumbar Facet Synovial Cysts.

BACKGROUND AND PURPOSE: Lumbar facet synovial cysts are commonly seen in facet degenerative arthropathy and may be symptomatic when narrowing the spinal canal or compressing nerve roots. The purpose of this study was to analyze the safety, effectiveness, and long-term outcomes of direct CT-guided lumbar facet synovial cyst aspiration and fenestration for symptom relief and for obviating an operation. MATERIALS AND METHODS: We retrospectively reviewed the medical records and imaging studies of 64 consecutive patients between 2006 and 2016 who underwent 85 CT-guided lumbar facet synovial cyst fenestration procedures in our department. We recorded patient demographics, lumbar facet synovial cyst imaging characteristics, presenting symptoms, change in symptoms after the procedure, and whether they underwent a subsequent operation. We also assessed long-term outcomes from the medical records and via follow-up telephone surveys with patients. RESULTS: Direct CT-guided lumbar facet synovial cyst puncture was technically successful in 98% of procedures. At first postprocedural follow-up, 86% of patients had a complete or partial symptomatic response. During a mean follow-up of 49 months, 56% of patients had partial or complete long-term relief without the need for an operation; 44% of patients underwent an operation. Patients with calcified, thick-rimmed, or low T2 signal intensity cysts were less likely to respond to the procedure and more likely to need an operation. CONCLUSIONS: CT-guided direct lumbar facet synovial cyst aspiration and fenestration procedures are safe, effective, and minimally invasive for symptomatic treatment of lumbar synovial facet cysts. This procedure obviates an operation in a substantial number of patients, even at long-term follow-up, and should be considered before surgical intervention.

A correlation of the effects of normoxia, hyperoxia and anoxia on PO2 of endolymph and cochlear potentials.

Change in PO2 in endolymph, endocochlear potentials and cochlear microphonics have been tested in normoxia, hyperoxia and anoxia on 24 guinea pigs. The polarographic method and construction of oxygen-sensitive microelectrodes is described in detail. The normal level of PO2 in endolymph vaires between 20 and 30 mm Hg. One-minute anoxia induced by breathing 100% N2 caused a decline in PO2, EP and CM, but during recovery only PO2 returned with over-correction to the preexposure level. Hyperoxia evoked by breathing 100% oxygen failed to increase the cochlear potentials and the PO2 in the endolymph. This suggests that vasoconstriction most likely occurs proximal to the capillaries bed of the stria vascularis.

Tracheal reconstruction with pedicled thyroid cartilage.

Limited areas of tracheal stenosis have been repaired with a variety of techniques. More extensive upper tracheal defects present a greater challenge with less predictable success. The following is the description of yet another technique for reconstruction of extensive upper tracheal defects. We report on the use of a muscle-pedicled thyroid alar graft which carries its own blood supply and perichondrial covering, supplies a large, conveniently shaped graft, requires one operative site and one operative sitting, and has proven advantageous even in the comprised patient.

Evaluation of otic drops on infection and healing of traumatic tympanic membrane perforations.

Guinea pigs were used to compare the efficacy of three commercially available otic preparations in treating traumatic tympanic membrane perforations. The results suggest that a clear, viscous solution of low pH will significantly reduce the incidence of infection and will not retard subsequent membrane healing.

Avoidance of early complications following radical neck dissection.

Multiple factors are associated with the increased risk of postoperative complications following radical neck dissection. Most significant of these are preoperative radiation and entry into the pharynx. The most common of these complications are discussed, and following is a description of preoperative, intraoperative, and postoperative methods to reduce them. Changes in operative methods and antibiotic coverage were associated with a decrease in wound infection and fistula formation. It is suggested that patients in high risk categories be covered with preoperative, prophylactic gram positive antibiotic coverage, along with Tobramycin.

Frontal sinus trephination: a new technique for office procedure.

A new office technique for frontal sinus trephination is described. The procedure is simple, expedient, and inexpensive. Our experience with 16 patients suggests that this procedure is reasonably safe and, in addition, avoids the often-seen complications of supratrochlear nerve injury and persistent noticeable scar.

Ototoxicity of tobramycin sulfate.

Fifty-four healthy guinea pigs were studied histologically for evaluation of Tobramycin sulfate ototoxicity. They were treated with 50, 100, 150 and 200 mg/kg/day under different schedules. Loss of hair cells occurred when dosage of 1,200 mg/kg was reached. Animals receiving 700 mg/kg were without damage to the inner ear. Outer hair cell loss occurred first in the basal turn, spreading upward. Inner hair cell loss began in the apical turn, progressing downward. When a total dose of 1,400 mg/kg was reached by (two) different schedules the higher daily dose produced about twice the hair cell loss; therefore, the ototoxic effect depends on the total dose but even more on the increased blood concentration.

The bookend nasal septal splint.

A malleable nasal septal splint is presented. Its purpose is to hold the septum in the midline, and to depress the floor of the inlet over the premaxillary wings. Blunting of the nasal valves is avoided. This appliance can be both firmly seated and well tolerated, since its pedestals can be curved up laterally within the lateral crura. Additional splints can be threaded onto the first one to reach high posterior synechiae. A useful modification is provided to support nasal bones when nasal packing must be avoided.

Effects of laser, scalpel, and electrosurgical excision on wound contracture and graft "take".

Current literature recommends the use of a carbon dioxide laser for excision of lesions where minimal damage and wound contracture are desirable. The extent of tissue damage is evaluated as a correlate of percentage of split-thickness skin graft "take" following excision of full-thickness skin with scalpel, electrocutting current, or carbon dioxide laser. The poorest overall percentage "take" is apparent following laser excision, while the highest overall percentage "take" occurs following scalpel excision. Wound contracture, an inherent part of wound healing, is reportedly minimal or clinically inapparent with laser excision. On the contrary, this experimental evaluation suggests that wound contracture following laser excision is at least as great if not greater than that following other methods of excision when a split-thickness skin graft is applied to the wound bed.

Otoscopy and photography: a new method.

A new hand-held otoscope photographic system, convenient and suitable for clinical application, is introduced. This instrument allows clear otoscopic examination in stenotic or tortuous ear canals, and photographs the subject in one procedure. The instrument consists of a rod-lens optical system, a fiberoptic light source, a camera, and exchangeable speculum and a strobe light. Color photographs of tympanic membranes and middle ear pathology are presented.

Variation of endocochlear PO2 and cochlear potentials by breathing carbon dioxide.

The effect of carbon dioxide on oxygen dioxide tension in the endolymph was determined by the micropolarographic technique. Different concentrations (5% and 10% CO2) and different exposure times (3, 5, and 20 minutes) were investigated. The highest levels of PO2 in the endolymph (101.7, 93.9 and 69.5 mm Hg) were accomplished by respiration of 10% CO2, 90% O2, for 20, 5 and 3 minutes consecutively. The lowest PO2 increase, 50.7 mm Hg was observed after breathing 5% CO2, 90% O2 for 20 minutes. Extreme hypercapnia caused an increase of endocochlear potentials (EP) in all groups. In the second group EP increased from +79.3 to +84.9 and in all groups they had returned to the pretreatment level after CO2 discontinuation. These results support the theory that carbonic anhydrase participates in the generation of EP. At the same time that EP increased, cochlear microphonics declined and opposite after the breathing mixture was discontinued. The results permit the conclusion that high levels of PO2 in endolymph is achievable even with short periods of respiration with high CO2 mixture, and suggest the role of carbonic anhydrase during EP generation.

Frequency dependence of effective nasal resistance.

Forced random noise techniques were used to characterize the effective resistance of the nasal passages in normal subjects and subjects who were candidates for surgical correction of nasal obstruction. The slope of the effective resistance curve was characterized by the average resistances over 3 to 5 Hz and 13 to 15 Hz. Subjects with nasal obstruction had effective nasal resistance curves which were more frequency-dependent than those of normal subjects (p less than 0.05). A mathematical model consisting of two series resistance-inertance elements in parallel was used to simulate the nasal passages. With this model we were able to generate effective resistance curves similar to those measured in both normal and obstructed subjects. The forced random noise technique may be a convenient, noninvasive technique for studying the fluid mechanical properties of airflow in the nasal passages and the effects of pharmacological and surgical interventions on nasal resistance.

Comparisons of tracheostomy incisions in a pediatric model.

Tracheostomy in children causes approximately twice the mortality and morbidity as in the adult. The occurrence of complications correlates closely with the severity of the preoperative tracheal disease, the length of time the tracheostomy is needed, and the age of the patient. Morbidity documented in the postoperative period includes tracheal stenosis and collapsible anterior tracheal wall. The increased incidence of these problems in the pediatric patient may be related to the less rigid nature of the younger cartilage or to partial arrest of the normal tracheal growth rate, and may be aggravated by the style of tracheal incision used. Our study utilized weanling male ferrets in an effort to evaluate the possibly different response of growing, less resilient cartilage to different types of tracheal incision. Animals were randomized into three groups based on the type of incision used: inferiorly based trapdoor, vertical slit, or horizontal H. Endoscopic, radiographic, and airflow studies, as well as cross-sectional areas, were compared on all animals surviving tracheal cannulation for eight days and subsequent decannulation for seven days. Recommendations for pediatric tracheal incision are made on the basis of these studies.