Robotic partial nephrectomy after pazopanib treatment in a solitary kidney with segmental vein thrombosis.

OBJECTIVE: To demonstrate our surgical technique of robotic partial nephrectomy (RPN) in a patient with a solitary kidney who received neoadjuvant Pazopanib, highlighting the multidisciplinary approach. MATERIALS AND METHODS: In our video, we present the case of 77-year-old male, Caucasian with 6.6cm left renal neoplasm in a solitary kidney. An initial percutaneous biopsy from the mass revealed clear cell RCC ISUP 2. After multidisciplinary tumor board meeting, Pazopanib (800mg once daily) was administered for 8 weeks with repeat imaging at completion of therapy. Post-TKI image study was compared with the pre-TKI CT using the Morphology, Attenuation, Size, and Structure criteria showing a favorable response to the treatment. Thereafter, a RPN was planned3. Perioperative surgical outcomes are presented. RESULTS: Operative time was 224 minutes with a cold ischemia time of 53 minutes. Estimated blood loss was 800ml and the length of hospital stay was 4 days. Pathology demonstrated a specimen of 7.6cm with a tumor size of 6.5cm consistent with clear cell renal carcinoma ISUP 3 with a TNM staging pT1b Nx. Postoperative GFR was maintained at 24 ml / min compared to the preoperative value of 33ml / min. CONCLUSIONS: A multidisciplinary approach is effective for patients in whom nephron preservation is critical, providing na opportunity to select those that may benefi t from TKI therapy. Pazopanib may allow for PN in a highly selective subgroup of patients who would otherwise require radical nephrectomy. Prospective data will be necessary before this strategy can be disseminated into clinical practice. Available at: http://www.intbrazjurol.com.br/video-section/20180240_Garisto_et_al.

Active Surveillance for Prostate Cancer: How to Do It Right.

Prostate cancer is the most common malignancy affecting men. There has been a nearly 70% increase in new prostate cancer cases, mostly classified as low risk, that have been diagnosed in early stages as a consequence of prostate-specific antigen (PSA) screening. Data regarding the natural history of this disease confirm the clinical insignificance of low-grade prostate cancer, which is associated with scant or no metastatic dissemination. Active surveillance is a conservative management approach, conducted for those patients with "low-risk" or "favorable-risk" disease, which avoids long-term adverse effects on the patient's quality of life. It is characterized by a routine protocol of close monitoring with digital rectal examination, periodic biopsy, and serial PSA testing. As defined by D'Amico, active surveillance is broadly appropriate for men with a Gleason score of 6 or less and a PSA level of less than 10 ng/mL. Typically, Gleason pattern 3 disease lacks the common genetic aberrancies of a true cancer. An essential element of the active surveillance approach is early recognition of higher-risk disease, which is diagnosed by systematic biopsy in 30% of patients who initiate active surveillance with low-risk disease. Also, a small group of patients have molecular alterations that can cause progression to more aggressive disease; these men can be switched to immediate treatment if such progression is detected. Oncologic outcomes for active surveillance cohorts have shown the long-term safety of this approach, with a cancer-specific mortality rate of 3% at 10 to 15 years. In this review of active surveillance for favorable-risk prostate cancer, we will discuss the rationality of this approach, the biological evidence for employing active surveillance in Gleason pattern 3 and 4 prostate cancer, patient selection for active surveillance, clinical trial data on active surveillance, and the role of prostate cancer biomarkers and imaging studies (MRI) for clinical decision making in patients with low-risk disease.

Protection from outpatient sudden cardiac death following ICD removal using a wearable cardioverter defibrillator.

BACKGROUND: An implantable cardioverter defibrillator (ICD) is effective in preventing sudden cardiac death (SCD). Once an ICD is removed and reimplantation is not feasible, a wearable cardioverter defibrillator (WCD) may be an alternative option. We determined the effectiveness of WCD for SCD prevention in patients who were discharged after ICD removal. METHODS: A retrospective study was conducted on all WCD (LifeVest, ZOLL, Pittsburgh, PA, USA) patients who underwent ICD removal due to cardiac device infections (CDIs) at two referral centers between January 1, 2005 and December 31, 2009. Clinical characteristics, device information, and WCD data were analyzed. Sudden cardiac arrest was defined as all sustained ventricular tachycardia (VT) and ventricular fibrillation occurring within a single 24-hour period. RESULTS: Ninety-seven patients (mean age 62.8 ± 13.3, male 80.4%) were included in the study. The median duration of antibiotic use was 14.7 days (interquartile range [IQR] 10-30). The median daily WCD use was 20 hours/day and the median length of use was 21 days (IQR 5-47). A total of three patients were shocked by WCD. Two patients had four episodes of sustained VT, successfully terminated by the WCD. A third patient experienced two inappropriate treatments due to oversensitivity of the signal artifact. Three patients experienced sudden death outside the hospital while not wearing the device. Five patients died while hospitalized. CONCLUSION: WCD can prevent SCD, until ICD reimplantation is feasible in patients who underwent device removals for CDI. However, patient compliance is essential for the effective use of this device.

On-Clamp vs. Off-Clamp Robot-Assisted Partial Nephrectomy for cT2 Renal Tumors: Retrospective Propensity-Score-Matched Multicenter Outcome Analysis.

We compared perioperative outcomes after on-clamp versus off-clamp robot-assisted partial nephrectomy (RAPN) for >7 cm renal masses. A multicenter dataset was queried for patients who had undergone RAPN for a cT2cN0cM0 kidney tumor from July 2007 to February 2022. The Trifecta achievement (negative surgical margins, no severe complications, and ≤ 30% postoperative estimated glomerular filtration rate (eGFR) reduction) was considered a surrogate of surgical quality. Overall, 316 cases were included in the analysis, and 58% achieved the Trifecta. A propensity-score-matched analysis generated two cohorts of 89 patients homogeneous for age, ASA score, preoperative eGFR, and RENAL score (all p > 0.21). Compared to the on-clamp approach, OT was significantly shorter in the off-clamp group (80 vs. 190 min; p < 0.001), the incidence of sRFD was lower (22% vs. 40%; p = 0.01), and the Trifecta rate higher (66% vs. 46%; p = 0.01). In a crude analysis, >20 min of hilar clamping was associated with a significantly higher risk of sRFD (OR: 2.30; 95%CI: 1.13−4.64; p = 0.02) and with reduced probabilities of achieving the Trifecta (OR: 0.46; 95%CI: 0.27−0.79; p = 0.004). Purely off-clamp RAPN seems to be a safe and viable option to treat cT2 renal masses and may outperform the on-clamp approach regarding perioperative surgical outcomes.

Contamination of transvenous pacemaker leads due to tunneled hemodialysis catheter infection: a report of 2 cases.

Catheter-related bacteremia is a frequent complication associated with the use of tunneled hemodialysis catheters. Catheter-related bacteremia can lead to metastasis of infection to other sites. This article presents 2 patients with transvenous pacemakers (placed >2 years ago) who were receiving long-term hemodialysis therapy using tunneled hemodialysis catheters. Both were admitted to the hospital with catheter-related bacteremia. Blood cultures showed methicillin-resistant Staphylococcus aureus (MRSA) in both cases. Transesophageal echocardiography was negative for the presence of valvular endocarditis, but showed lead-associated vegetation in both cases. Intravenous antibiotic therapy was initiated, and both the tunneled hemodialysis catheters and cardiac devices were removed by a cardiothoracic surgeon. The catheter tip and leads cultures showed MRSA in both cases. After resolution of bacteremia, both patients received an epicardial cardiac device. Antibiotic therapy was continued for 6 weeks. Renal physicians providing dialysis therapy should be aware that catheter-related bacteremia could cause contamination of transvenous pacemaker leads. Because catheter-related bacteremia is a frequent complication, epicardial leads might be considered as an alternative route to provide cardiac support to catheter-consigned patients. Epicardial leads do not navigate through the central veins, lie in the path of blood flow, or cause central venous stenosis.

Outpatient Extraperitoneal Single-Port Robotic Radical Prostatectomy.

OBJECTIVE: To assess the safety and feasibility of extraperitoneal single-port robotic assisted laparoscopic radical prostatectomy using the da Vinci SP robotic platform for same-day surgery. METHODS: Extraperitoneal single-port robotic prostatectomy (ESRP) using the da Vinci SP platform was performed on 60 patients with clinically localized prostate cancer and no prior definitive therapy. An enhanced recovery protocol was used in the perioperative period and minimal to no opiates were used in these patients. Preoperative, perioperative, and postoperative data were collected in a prospectively maintained institutional review board approved database and evaluated in a retrospective fashion. RESULTS: Mean operative time was 198 minutes and mean estimated blood loss was 179 mL. No patients required blood transfusion and there were no intraoperative complications. Pain at discharge was 0-1 in 37% of patients. Forty-five patients (75%) were discharged home the day of surgery, including patients with all surgical start times. When excluding patients that were planned for an overnight stay preoperatively or patients whose surgery finished after 6 PM, 88% of patients were discharged home the day of surgery and 96% were discharged within 24 hours of surgery. Median length of stay was 4.2 hours. Fourty-eight percent of patients required 0-1 pads at 30 days postoperatively in patients with 30 day follow data (n = 58) and 76% of patients reported requiring 0-1 pads per day by 90 days postoperatively (n = 37). CONCLUSION: ESRP using the da Vinci SP platform can be performed safely and reproducibly as a same-day outpatient surgery with minimal to no opiate use, excellent pain control, and acceptable short term functional and oncological outcomes.

A novel technique for tethered dialysis catheter removal using the laser sheath.

Traction and cutdown techniques can successfully remove a tunneled dialysis catheter (TDC) in a great majority of patients. However, these methods may not be successful in patients with catheters that are tethered or attached to the central veins or the atrium. A forceful application of traction can lead to catheter breakage with subsequent retention of the broken piece and carries a potential risk of vascular and atrial wall avulsion. Open thoracotomy has been employed to remove an attached TDC. However, this procedure is invasive and bears a significant morbidity. This report presents three cases of tethered TDCs that underwent laser sheath extraction. The TDCs had been in place for an average of 26 months. The patients underwent initial unsuccessful removal attempt using the traction method with surgical exploration all the way to the venotomy site. The laser technique that is used to remove pacemaker/implantable cardioverter defibrillator leads was then applied to these stuck catheters. All three catheters were successfully removed without any damage to the catheter, central veins, or the right atrium. There were no retained catheter fragments left in the central veins or the atrium. One patient demonstrated a significant thrombus that extended from the tip of the catheter all the way to the right ventricle. The external sheath of the laser device successfully aspirated the thrombus. There were no procedure-related complications. In this small series, a laser sheath successfully extracted tethered dialysis catheters. The study found the procedure to be effective, easy to perform, and minimally invasive. We suggest that this approach be considered for the removal of tethered catheters that cannot be removed using traditional approaches.

Patency rates for angioplasty in the treatment of pacemaker-induced central venous stenosis in hemodialysis patients: results of a multi-center study.

While hemodialysis access ligation has been used to manage pacemaker (PM) and implantable cardioverter-defibrillator (ICD) lead-induced central venous stenosis (CVS), percutaneous transluminal balloon angioplasty (PTA) has also been employed to manage this complication. The advantages of PTA include minimal invasiveness and preservation of arteriovenous access for hemodialysis therapy. In this multi-center study we report the patency rates for PTA to manage lead-induced CVS. Consecutive PM/ICD chronic hemodialysis patients with an arteriovenous access referred for signs and symptoms of CVS due to lead-induced CVS were included in this analysis. PTA was performed using the standard technique. Technical and clinical success was examined. Technical success was defined as the ability to successfully perform the procedure. Clinical success was defined as the ability to achieve amelioration of the signs and symptoms of CVS. Both primary and secondary patency rates were also analyzed. Twenty-eight consecutive patients underwent PTA procedure. Technical success was 95%. Postprocedure clinical success was achieved in 100% of the cases where the procedure was successful. The primary patency rates were 18% and 9% at 6 and 12 months, respectively. The secondary patency rates were 95%, 86%, and 73% at 6, 12, and 24 months, respectively. On average, 2.1 procedures/year were required to maintain secondary patency. There were no procedure-related complications. This study finds PTA to be a viable option in the management of PM/ICD lead-induced CVS. Additional studies with appropriate design and sample size are required to conclusively establish the role of PTA in the management of this problem.

Technique for Docking and Port Placement Using a Purpose-built Robotic System (SP1098) in Human Cadaver.

OBJECTIVES: To describe step-by-step the port placement and the robot docking of the new purpose-built robotic platform for R-LESS. The feasibility of different approaches to the pelvic fossa and the retroperitoneum was reported in cadaver models. METHODS: This was a preclinical study on human cadavers to assess the feasibility of the da Vinci SP1098 surgical system for R-LESS pelvic fossa and retroperitoneal urological surgeries. We used the SP1098 to perform R-LESS prostatectomies and cystoprostatectomies with transperineal and transvesical approaches, and nephrectomies (radical or partial) with retroperitoneal approach. The primary outcome was to report the port placement and docking. The technical feasibility of the procedures was then demonstrated as measured by the need for adjunctive ports or the occurrence of intraoperative complications. Operative times were recorded. RESULTS: A total of 14 procedures were performed on 12 human cadavers. Namely 4 prostatectomies and 2 cystoprostatectomies with transperineal approach, 3 transvesical prostatectomies, 1 retroperitoneal radical, and 4 retroperitoneal partial nephrectomies. Operative times were in line with those of standard multiport robotic surgery. Neither additional ports nor percutaneous instruments were required. No intraoperative complications occurred. Limitations include the preclinical model, the small sample size, and the lack of a control group. CONCLUSION: In this preclinical model, the port placement and robot docking using the SP1098 robotic platform is reproducible and feasible for pelvic fossa and retroperitoneal urological surgeries.

Trifecta Outcomes in Renal Hilar Tumors: A Comparison Between Robotic and Open Partial Nephrectomy.

OBJECTIVES: To report a comparative analysis of outcomes in patients who underwent excisions of renal hilar tumors using both open and robotic approaches. MATERIALS AND METHODS: We retrospectively reviewed robotic and open patients who underwent partial nephrectomy of renal hilar tumors between 2011 and 2016. "Trifecta" was defined as negative surgical margins, no complications, and a glomerular filtration rate (GFR) preservation of ≥90% at last follow-up. Inverse probability of treatment weighting (IPTW) was applied to equilibrate treatment groups, minimize selection bias, and optimize inference on the basis of each patient's clinicodemographic characteristics. RESULTS: One hundred robotic and 64 open patients had sufficient data for IPTW. After weighting, there were no statistical differences in baseline characteristics between the two groups (p < 0.05). On adjusted analyses, robotic partial nephrectomy (RPN) achieved equivalent rates of trifecta to open surgery (21.1% vs 13.9%, respectively, p = 0.387). There were no differences between robotic and open cohorts for negative margin rates (72.8% vs 90.4%, p = 0.124), absence of complications (68.6% vs 75.2%, p = 0.587), or GFR ≥90% (39.4% vs 21.6%, p = 0.111). The robotic cohort had a shorter mean length of stay (3.8 vs 5.0 days, p = 0.012), and no difference in estimated blood loss (253.3 vs 357.1, p = 0.091) or operating time (199.8 vs 200.4, p = 0.961). CONCLUSIONS: In our analysis both open and RPN for hilar tumors were equally likely to achieve a low "trifecta" outcome with a shorter mean length of stay in the robotic cohort.

Concurrent Robotic Pyelolithotomy and Partial Nephrectomy: Tips and Tricks.

OBJECTIVE: With the evolution of robot-assisted surgery in the urology field, this technology is being applied to treat many genitourinary conditions.1 Although incidence of urolithiasis and renal neoplasm has increased, encountering both entities in a single kidney is noteworthy. Our video exhibits the concurrent management of a renal calculus and an ipsilateral renal neoplasm using a robotic platform. MATERIALS AND METHODS: A 53-year-old man was diagnosed with a 1.7-cm left renal pelvis calculus and a 4.7-cm enhancing ipsilateral upper pole renal mass (R.E.N.A.L score 8a) after an episode of flank pain. After reviewing preoperative imaging, a single-setting approach using a robotic platform was planned. Main steps of our robotic technique on the case included (1) kidney defatting and mobilization, (2) hilum and ureter dissection up to the renal pelvis, (3) intraoperative ultrasound for tumor demarcation and stone localization, (4) anterior robotic pyelolithotomy,2 (5) double J stent placement and pyelotomy closure, (6) excision of renal mass, and (7) renorrhaphy. Perioperative outcomes were recorded. RESULTS: The operative time was 180 minutes and the estimated blood loss was 100 mL. Warm ischemia time was 17 minutes. There were no intra- or postoperative complications. The patient was discharged home on postoperative day 3. Final pathology reported a 3.4-cm mass consistent with a clear cell renal carcinoma, with a tumor, nodes, metastases (TNM) staging pT1aNx and negative surgical margin. The double J stent was removed after 4 weeks, and the patient remained asymptomatic at 1 month postoperatively. CONCLUSION: Pyelolithotomy and robotic partial nephrectomy can be performed effectively when treating patients with concurrent kidney mass and renal stone using the same surgical access. This minimally invasive approach should be contemplated as an option when managing patients with both conditions in an ipsilateral kidney. Furthermore, it will diminish the necessity of various surgeries while preserving renal function and maintaining oncological outcomes. We underline that the association of both procedures increases the likelihood of technical complications and risk for clot-related or stone-related ureteral obstruction, infection, and urine leak.

Precise Clamping of Renal Artery With Endovascular Stents During Robotic Partial Nephrectomy: Technical Hints to Optimize Outcomes.

OBJECTIVE: To describe our surgical technique for robotic partial nephrectomy,1 focusing on specific technical hints for vascular clamping on patients with renal masses and endovascular stent (ES) in the renal artery. METHODS: We reviewed the records of 3 patients that underwent robotic partial nephrectomy in our institution with precise clamping of renal arteries due to previous placement of ES. Perioperative outcomes were recorded. In our video, we present the case of 73-year-old Caucasian with a 10-cm left renal neoplasm and associated fenestrated endograft due to endovascular aorta repair. After preoperative imaging was reviewed, a robotic approach was planned. RESULTS: Key hints for outcomes optimization during nephron sparing surgery on patients with ES on the renal arteries: (1) preoperative computed tomography scan is crucial for surgical planning on dissection of the renal pedicle,2 (2) an additional multiplanar volume rendering of the computed tomography scan may allow better 3-dimensional visualization and orientation of the renal vasculature and anatomy, (3) precise renal artery clamping distal from the renal artery stent is required to avoid renal stent occlusion, (4) extensive and meticulous dissection of the renal pedicle is mandatory to dictate correct clamping, and (5) an intraoperative Doppler ultrasound after clamping release confirms the blood flow through the renal arteries.3 From the patients analyzed, median age was 69.6 years, median body mass index was 31.3, and mean estimated glomerular filtration rate was 36.6 mL/min. No cases were converted to open procedures. Perioperative outcomes are described in Table 1. CONCLUSION: Partial nephrectomy in patients with renal artery stents requires distal dissection of the renal artery beyond the stent. Our described technique provides feasible, reproducible, and valuable surgical suggestions for outcomes optimization during nephron-sparing surgery on patients with endovascular graft stents.

Outcomes of Robot-assisted Partial Nephrectomy for Clinical T2 Renal Tumors: A Multicenter Analysis (ROSULA Collaborative Group).

BACKGROUND: While partial nephrectomy (PN) represents the standard surgical management for cT1 renal masses, its role for cT2 tumors is controversial. Robot-assisted PN (RAPN) is being increasingly implemented worldwide. OBJECTIVE: To analyze perioperative, functional, and oncological outcomes of RAPN for cT2 tumors. DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of a large multicenter, multinational dataset of patients with nonmetastatic cT2 masses treated with robotic surgery (ROSULA: RObotic SUrgery for LArge renal mass). INTERVENTION: Robotic-assisted PN. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Patients' demographics, lesion characteristics, perioperative variables, renal functional data, pathology, and oncological data were analyzed. Univariable and multivariable regression analyses assessed the relationships with the risk of intra-/postoperative complications, recurrence, and survival. RESULTS AND LIMITATIONS: A total of 298 patients were analyzed. Median tumor size was 7.6 (7-8.5) cm. Median RENAL score was 9 (8-10). Median ischemia time was 25 (20-32) min. Median estimated blood loss was 150 (100-300) ml. Sixteen patients had intraoperative complications (5.4%), whereas 66 (22%) had postoperative complications (5% were Clavien grade ≥3). Multivariable analysis revealed that a lower RENAL score (odds ratio [OR] 0.46, 95% confidence interval [CI] 0.21-0.65, p=0.02) and pathological pT2 stage (OR 0.51, 95% CI 0.12-0.86, p=0.001) were protective against postoperative complications. A total of 243 lesions (82%) were malignant. Twenty patients (8%) had positive surgical margins. Ten deaths and 25 recurrences/metastases occurred at a median follow-up of 12 (5-35) mo. At univariable analysis, higher pT stage was predictive of a likelihood of recurrences/metastases (p=0.048). While there was a significant deterioration of renal function at discharge, this remained stable over time at 1-yr follow-up. The main limitation of this study is its retrospective design. CONCLUSIONS: RAPN in the setting of select cT2 renal masses can safely be performed with acceptable outcomes. Further studies are warranted to corroborate our findings and to better define the role of robotic nephron sparing for this challenging indication. PATIENT SUMMARY: This report shows that robotic surgery can be used for safe removal of a large renal tumor in a minimally invasive fashion, maximizing preservation of renal function, and without compromising cancer control.

Single-Incision Laparoscopy Surgery Excision of an Infected Urachal Cyst: Description of the Technique.

Background: Urachal cysts (UCs) are secondary to incomplete obliteration of the embryonic urachal duct and may become symptomatic when infected. Treatment is primarily surgical to excise the infected cyst. Surgical approaches include a lower midline laparotomy or minimally invasive (MI) techniques. Case: We present a case of a young male with an infected UC that was treated with a single-incision laparoscopy surgery. The operative technique is described. Conclusion: This approach is a safe and feasible option for the MI management of UCs.

Multicenter experience with extraction of the Riata/Riata ST ICD lead.

BACKGROUND: In November 2011, the Food and Drug Administration issued a class I recall of Riata and Riata ST implantable cardioverter-defibrillator leads. Management recommendations regarding the recall have remained controversial. OBJECTIVE: Data regarding the safety and feasibility of extraction of Riata implantable cardioverter-defibrillator leads are limited. METHODS: We performed a retrospective study of patients undergoing extraction of Riata/Riata ST leads at 11 centers. RESULTS: Between July 2003 and April 2013, 577 Riata/Riata ST leads were extracted from 577 patients (Riata 467, [84%]; Riata ST 89, [16%]). Complete procedural success achieved in 99.1%. The cohort was 78% men, with a mean age of 60 years and a mean left ventricular ejection fraction of 34% ± 14%. The mean implant duration was 44.7 months (range 0-124.6 months). The majority of leads extracted were for infection (305 [53.0%]) and 220 (35.7%) for lead malfunction. Evaluation for lead integrity was performed in 295 cases. Of these, 34.9% were found to have externalized cables. Implant duration was significantly longer in leads with externalized cables (P < .0001). No difference in lead integrity was noted between Riata and Riata ST leads (11.7% vs. 17.7% failure; P = .23). Among leads in which cable externalization was noted, laser sheaths were used more frequently (P = .01). Major complications included 3 superior vena cava/right ventricular perforations requiring surgical intervention with 1 death 12 days after the procedure and 1 pericardial effusion requiring percutaneous drainage (0.87%). CONCLUSION: Extraction of the Riata/Riata ST leads can be challenging, and leads with externalized cables may require specific extraction techniques. Extraction of the Riata/Riata ST leads can be performed safely by experienced operators at high-volume centers with a complication rate comparable to published data.

Laser lead extraction in the octogenarian patient.

BACKGROUND: In the United States, patients aged >75 years are the most rapidly growing segment in the population, with an expected increase of 126% by 2050. These patients account for >70% of the pacemakers and up to two thirds of the implantable cardioverter-defibrillators implanted annually. Our aim was to explore the clinical outcomes of device complications in the octogenarian population. METHODS AND RESULTS: We performed a retrospective chart review of 506 patients undergoing laser lead extraction from January 2004 to September 2009. This population was divided into the following 2 groups based solely on age: octogenarians and nonoctogenarians. These 2 groups were compared on the basis of several characteristics and clinical outcomes. There were 118 patients in the octogenarian group (78 men) and 388 in the nonoctogenarians group (301 men) aged 85±3.8 and 64.2±12.4 years, respectively. A total of 253 leads (atrial, 99; ventricular, 145; coronary sinus, 9) were removed from the patients in the octogenarian group, and 814 leads (atrial, 295; ventricular, 442; coronary sinus, 77) were removed from the patients in the nonoctogenarian group. The main indication for extraction for both groups was infection. The lead implant duration was 59.6±52.8 and 38.6±43.9 months for octogenarians and nonoctogenarians, respectively. There was no significant difference with respect to the proportion of minor (P=0.65), major (P=0.56), and total (P=0.50) complications. CONCLUSIONS: Laser lead extraction is demonstrated to be a safe and effective treatment method in octogenarian patients with multiple comorbidities.

A novel retrograde laser extraction technique using a transatrial approach: an alternative for complex lead extractions.

BACKGROUND: The use of percutaneous lead extraction techniques in a patient with extracardiac or protruding atrial leads could have disastrous consequences. Traditionally, the management of these patients has included a median sternotomy. We describe a minimally invasive technique that involves a transatrial, retrograde laser lead extraction using a video-assisted thoracoscopic approach. METHODS AND RESULTS: Between January 2004 and June 2009, 14 patients with severed leads at the clavicle and extracardiac leads or lead-caused erosions of the atrial wall were identified through chest radiograph and CT scan. There were 9 men and 5 women aged 19 to 91 years (mean age, 69.71 ± 20.67 years). Ten devices were pacemakers, and 4 were defibrillators. Indications for extraction were 12 infections and 2 malfunctions. Mean ejection fraction was 42 ± 17.67% (range, 10% to 65%). Time of implanted leads was 93.69 ± 51.88 months (range, 33 to 213 months). Laser sheaths size were 12 F (7.1%), 14 F (85.7%), and 16 F (7.1%). A right-side thoracoscopy was performed under general anesthesia. A retrograde laser sheath maneuver was performed, freeing the lead from any adhesions. The lead was removed and the incision closed. One patient experienced a pleural effusion. There was no mortality, and all patients were alive and well at 1-month follow-up. CONCLUSIONS: - Transatrial, retrograde laser lead extraction is a safe and effective procedure. This procedure may provide an excellent alternative to open sternotomy.

Surgical management of a giant ascending aortic pseudoaneurysm.

Aortic pseudoaneurysm is a rare, life-threatening complication after cardiac or aortic root surgery. When a pseudoaneurysm has eroded bony structures in the chest, the surgeon's challenge is to choose the safest approach for sternotomy. Herein, we report the case of a 74-year-old woman who presented with a giant pseudoaneurysm of the ascending aorta, 8 years after undergoing aortic valve replacement. The 8.9×5.8-cm formation arose in the anterior aortic sinus, extended to the retrosternal region, exerted mass effect on the main pulmonary artery, and eroded the bony structures of the sternum and medial upper chest. A new aortic valved tissue conduit was placed, and the coronary arteries were reimplanted. The patient recovered without neurologic sequelae. We discuss the characteristics of this case and explain our surgical decisions.

Human trypanosomiasis in the eastern region of the Panama Province: new endemic areas for Chagas disease.

The epidemiology of Chagas disease was studied in five rural communities located in the eastern region of the Panama Province. Serological tests for Trypanosoma cruzi infection revealed a prevalence of 5.88% (12/204). Hemocultures coupled with polymerase chain reaction (PCR) analysis showed a Trypanosoma rangeli infection rate of 5.88% (12/204). An overall trypanosome infection index of 11.76% (24/204) was detected in this population. A total of 121 triatomine specimens were collected in domestic and peridomestic habitats. Rhodnius pallescens was confirmed as the predominant species. Molecular analysis showed that 17.8% (13/73) of the examined insects were positive for T. cruzi, 17.8% (13/73) for T. rangeli, and 35.6% (26/73) presented mixed infections. Among 73 R. pallescens evaluated, 16.4% (12/73) contained opossum blood meals. The epidemiological implications of these findings are discussed.

Multicenter experience with extraction of the Sprint Fidelis implantable cardioverter-defibrillator lead.

OBJECTIVES: This study was undertaken to determine the safety and feasibility of extraction of the Sprint Fidelis (Medtronic, Minneapolis, Minnesota) lead. BACKGROUND: The reported failure rate of the Sprint Fidelis defibrillator lead has increased to a range greater than initially appreciated with emerging evidence of an accelerating rate of fracture. At present, consensus guidelines continue to recommend against prophylactic extraction of the lead, citing major complication rates between 1.4% and 7.3%. However, data regarding the safety and feasibility of extraction of small-diameter, backfilled implantable cardioverter-defibrillator leads such as the Sprint Fidelis are limited. METHODS: We performed a retrospective cohort study of consecutive patients undergoing extraction of Sprint Fidelis (models 6930, 6931, 6948, 6949) leads at 5 high-volume centers. Patient characteristics, indications for extraction, and use of countertraction sheath (CTS) assistance are reported. The risk of major and minor complications was determined. A multivariable logistic regression model was developed to predict factors associated with the use of CTS assistance. RESULTS: Between May 2005 and August 2009, 349 Sprint Fidelis leads were extracted from 348 patients. All leads were removed completely. The average duration of the implanted lead was 27.5 months (range 0.03 to 58.8 months). Approximately one-half of the extracted leads were fractured (49.4%), and 26.5% were extracted prophylactically. The other major indication for extraction was infection (22.8%). Extraction was achieved with simple traction in 49.4% leads; CTS assistance was required in 174 cases (50.6%). In multivariable models, length of time since implantation was directly related to the need for CTS assistance (odds ratio per month since implantation: 1.035; 95% confidence interval: 1.010 to 1.061; p=0.006). There were no major procedural complications or deaths. CONCLUSIONS: Extraction of the Sprint Fidelis lead can be performed safely by experienced operators at high-volume centers with a complication rate lower than that reported for older generation leads. However, leads with longer implant durations are associated with the use of CTS assistance. Recommendations regarding prophylactic Sprint Fidelis lead extraction may warrant reconsideration.