Variability in perioperative management of pheochromocytoma in Canada.

INTRODUCTION: Despite recent consensus guidelines, there is substantial variability in the management of pheochromocytomas. Our study aimed to characterize the current state of perioperative pheochromocytoma management by Canadian surgeons. METHODS: A 23-item online survey was sent to Canadian surgeons who perform adrenalectomies for pheochromocytoma. We assessed personal and institutional practices, including preoperative and postoperative management. RESULTS: National response rate was 51.8%. Surgeons from nine provinces responded; the majority were general surgeons (70.4%). Reviewing pheochromocytoma patients at a multidisciplinary tumor board was not routine practice (12%) and only 42.3% consistently referred patients for genetic testing. Preoperative α- and ß-blockade at half of the respondent institutions were performed by endocrinology alone (53.8%), with the other half employing a multidisciplinary approach. Half of respondents admitted their pheochromocytoma patients to hospital prior to the day of surgery. Postoperatively, 11.5% of respondents routinely admitted their patients to the intensive care unit (ICU) for monitoring based on personal preference or institutional convention. Multivariate analyses found no significant relationships between demographics or preoperative factors and perioperative management. CONCLUSIONS: Perioperative surgical management of patients undergoing adrenalectomy for pheochromocytoma was highly variable across Canada. Less than half of respondents routinely refer patients for genetic testing, despite recent practice guidelines. Surgeon preference and institutional convention are the main drivers behind preoperative admission and routine postoperative ICU admission, despite a lack of evidence to support this practice.

An update on urethral diverticula: Results from a large case series.

INTRODUCTION: We aimed to describe the presentation, investigations, and management of patients with urethral diverticula and to review the importance of magnetic resonance imaging (MRI) in the diagnosis and surgical management of urethral diverticula. METHODS: This was a retrospective review of female patients who underwent urethral diverticulectomies. This study was approved by the research ethics review board. Data was collected on patient demographics, presenting symptoms, investigations performed, operative technique, and minimum of two-year followup. RESULTS: A total of 17 patients were included in this study, with a median age of 43 years. Most patients (70%) presented with a palpable vaginal lump; 64% presented with either lower urinary tract symptoms (LUTS) or recurrent urinary tract infections (UTIs). Patients underwent a preoperative MRI, which demonstrated that 59% of diverticula were distal and 53% were locally round. These imaging findings were consistent with the operative findings. MRI also demonstrated communication between the urethral diverticulum and the urethral lumen in 80% of cases, compared to only 47% endoscopically. CONCLUSIONS: The most common presentation of a woman with a urethral diverticulum is with either a palpable vaginal lump, LUTS, or recurrent UTIs. A high index of suspicion is required. Pelvic MRI appears to be an ideal imaging modality for the diagnosis of urethral diverticulum. A preoperative MRI is important to exclude alternative pathologies, appropriately counsel the patient, and assist with the surgical planning.

No decrease in incidence of arthroscopic meniscectomy in a Canadian province.

PURPOSE: Arthroscopic meniscectomy (APM) is the most common procedure in orthopedic surgery, despite increasing evidence questioning its benefit over conservative management for treatment of degenerative meniscal tears. The purpose of this study is to determine the epidemiology and trends of APM in Saskatchewan, a Canadian province, over a 20 year period. METHODS: Physician billing codes were used to identify patients who underwent APM in Saskatchewan between January 1, 1998 and December 31, 2017. Records were obtained from eHealth Saskatchewan, a provincial health database. Data was analyzed for overall incidence and age-specific trends of APM. RESULTS: A total of 35,099 APMs were performed during the study period. The population of Saskatchewan ranged from 992,314 to 1,150,782 (median 1,017,368) during this time interval, with 81 orthopedic surgeons performing APM. Overall incidence rate of APM did not change significantly over time. No decrease was observed in patients presumed to have degenerative tears (≥ 50 years). The number of meniscectomies in patients ≥ 50 years was significantly greater during the second decade of study compared to the first (OR 1.48, p < 0.01). Conversely, the increase in incidence rate among older patients was not statistically significant (R2 = 0.125, n.s.). CONCLUSION: Overall incidence rate of APM in Saskatchewan has not decreased during the last 20 years. Furthermore, APM frequency increased over time for individuals ≥ 50 years. Several regional factors may have contributed to these findings, including the large proportion of Saskatchewan residents engaged in physically demanding work and barriers to accessing physiotherapy services. Given recent evidence disputing the benefit of APM over conservative measures, this study highlights the need for improved dissemination of evidence, as well as the importance of an individualized treatment plan to address patient-specific factors. LEVEL OF EVIDENCE: Level IV.