Women speaker representation at SAGES annual meetings: a cross-sectional analysis.

BACKGROUND: Gender representation trends at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Annual Meetings and the effect of the 2018 'We R SAGES' initiatives are unknown. We assessed gender trends in oral presentations at the SAGES Annual Meeting between 2012 and 2022 with a focus on assessing the impact of the 2018 initiatives. METHODS: Abstracts selected for oral presentations from 2012 to 2022 were reviewed for presenter and first, second, and senior author gender. Gender was categorized as woman, man, or unknown using public professional profiles. Subsequent publications were identified using search engines. The primary outcome was the temporal trend of proportion of women in each role using interrupted time series analysis. Secondary outcomes included publication rates based on first and senior author genders in 2012-2018 versus 2019-2022. RESULTS: 1605 abstracts were reviewed. The proportion of women increased linearly in all categories: presenter (2.4%/year, R2 = 0.91), first author (2.4%/year, R2 = 0.90), senior author (2%/year, R2 = 0.65), and overall (2.2%, R2 = 0.91), (p < 0.01 for all). Prior to 2018, the proportion of women increased annually for presenters (coefficient: 0.026, 95% CI [0.016, 0.037], p = 0.002) and first authors (coefficient: 0.026, 95% CI [0.016, 0.037], p = 0.002), but there was no significant increase after 2018 (p > 0.05). Female second author proportion increased annually prior to 2018 (coefficient: 0.012, 95% CI [0.003, 0.021], p = 0.042) and increased by 0.139 (95% CI [0.070, 0.208], p = 0.006) in 2018. Annual female senior author proportion did not significantly change after 2018 (p > 0.05). 1198 (75.2%) abstracts led to publications. Women were as likely as men to be first (79% vs 77%, p = 0.284) or senior author (79% vs 77%, p = 0.702) in abstracts culminating in publications. There was no difference in woman first author publication rate before and after 2018 (80% vs 79%, p = 1.000), but woman senior author publication rate increased after 2018 (71% vs 83%, p = 0.032). CONCLUSION: There was an upward trend in women surgeons' presentations and associated publications in the SAGES Annual Meetings over the last decade.

Impact of the ventral hernia working group's publication: a bibliometric analysis.

PURPOSE: The Ventral Hernia Working Group (VHWG) proposed a ventral hernia grading guideline, primarily supported by expert opinion, recommending biologic mesh placement in high-risk patients. We investigated the relationship between this industry-sponsored guideline and discourse around ventral hernia repair (VHR). METHODS: Medline platform from Web of Science's database identified publications "pre-VHWG"(1999-01-01 to 2009-12-31), and "post-VHWG"(2010-01-01 to 2020-12-31) describing VHR and complications or recurrence of VHR with the following comorbidities: COPD, smoking, diabetes, immunosuppression, or obesity. Poisson regression analyzed keyword frequency over time using logarithmically transformed data. RESULTS: Of 1291 VHR publications identified pre-VHWG and 3041 publications identified post-VHWG, 172 (13.3%) and 642 (21.1%) publications respectively included prespecified keywords. The keyword groups "biologic"(IRR 3.39,95%CI1.34-11.4,p = 0.022) and "comorbid"(IRR 1.95, 95%CI1.09-3.74,p = 0.033) significantly increased with frequency after publication of the VHWG. CONCLUSION: The VHWG publication likely contributed to a focus on comorbidities and biologic mesh in the ensuing literature within the field of VHR.

The Role of Neoadjuvant Immunotherapy in the Management of Merkel Cell Carcinoma with Clinically Detected Regional Lymph Node Metastasis.

BACKGROUND: Immunotherapy is emerging as a promising option for certain locally advanced and metastatic cutaneous malignancies. However, the role of neoadjuvant immunotherapy (NIO) in Merkel cell carcinoma (MCC) with clinically detected regional lymph node metastasis (CDRLNM) has not been fully elucidated. METHODS: For this study, MCC patients with CDRLNM who underwent surgical excision were selected from the National Cancer Database (NCDB). Those who received NIO were propensity-matched with those who did not, and Kaplan-Meier analysis was used to compare overall survival (OS). RESULTS: Of the 1809 selected patients, 356 (19.7%) received NIO followed by wide excision (n = 352, 98.9%) or amputation (n = 4, 1.1%). The rate of complete pathologic response for the primary tumor (ypT0) was 45.2%. Only 223 patents (63.4%) also underwent lymph node dissection (LND). The complete pathologic nodal response (ypN0) rate for these patients was 17.9%. A pathologic complete response of both the primary tumor and the nodal basin (ypT0 ypN0) was seen in 16 of the 223 patients who underwent both primary tumor surgery and LND. Subsequently, 151 pairs were matched between the NIO and no-NIO groups (including only patients with LND). Kaplan-Meier analysis demonstrated a significant OS improvement with NIO (median not reached vs. 35.0 ± 8.0 months; p = 0.025). The 5-year OS was 57% in the NIO group versus 44% in no-NIO group (p = 0.021). CONCLUSION: The study suggests that NIO in MCC with CDRLNM provides improved OS in addition to promising rates of primary complete response, which could change the profile of surgical resection. This supports ongoing clinical trials exploring the use of NIO in MCC.

The association of permanent versus absorbable fixation on developing chronic post-herniorrhaphy groin pain in patients undergoing laparoscopic inguinal hernia repair.

INTRODUCTION: Fixation of mesh during minimally invasive inguinal hernia repair is thought to contribute to chronic post-herniorrhaphy groin pain (CGP). In contrast to permanent tacks, absorbable tacks are hypothesized to minimize the likelihood of CGP. This study aimed to compare the rates of CGP after laparoscopic inguinal hernia repair between absorbable versus permanent fixation at maximum follow-up. METHODS: This is a post hoc analysis of a randomized controlled trial in patients undergoing laparoscopic inguinal hernia repair (NCT03835351). All patients were contacted at maximum follow-up after surgery to administer EuraHS quality of life (QoL) surveys. The pain and restriction of activity subdomains of the survey were utilized. The primary outcome was rate of CGP, as defined by a EuraHS QoL pain domain score ≥ 4 measured at ≥ 1 year postoperatively. The secondary outcomes were pain and restriction of activity domain scores and hernia recurrence at maximum follow-up. RESULTS: A total of 338 patients were contacted at a mean follow-up of 28 ± 11 months. 181 patients received permanent tacks and 157 patients received absorbable tacks during their repair. At maximum follow-up, the rates of CGP (27 [15%] vs 28 [18%], P = 0.47), average pain scores (1.78 ± 4.38 vs 2.32 ± 5.40, P = 0.22), restriction of activity scores (1.39 ± 4.32 vs 2.48 ± 7.45, P = 0.18), and the number of patients who reported an inguinal bulge (18 [9.9%] vs 15 [9.5%], P = 0.9) were similar between patients with permanent versus absorbable tacks. On multivariable analysis, there was no significant difference in the odds of CGP between the two groups (OR 1.23, 95% CI [0.60, 2.50]). CONCLUSION: Mesh fixation with permanent tacks does not appear to increase the risk of CGP after laparoscopic inguinal hernia repair when compared to fixation with absorbable tacks. Prospective trials are needed to further evaluate this relationship.

Examining the Role for Donor-specific Antibody Testing in Simultaneous Liver-kidney Transplantation: A Single-center Analysis of Outcomes.

BACKGROUND: Simultaneous liver-kidney transplantation (SLKT) is increasingly used for patients with concurrent end-stage liver and renal disease. Emerging evidence suggests that simultaneous liver transplant can provide a tolerogenic benefit to multiorgan transplant recipients. Posttransplant donor-specific antibody (DSA) may be associated with worse outcomes; however, the role for testing DSA in SLKT is unclear. METHODS: This study retrospectively assessed the impact of DSA on outcomes following primary SLKT at a large-volume center between 2008 and 2018. Patients were grouped by positive DSA, negative DSA, and DSA not tested, and data were obtained from our institutional database and chart review. RESULTS: The cohort included 138 SLKT recipients with a mean age of 56.1 ± 9.7 y; 61.6% were male, and 55.8% were Hispanic. Overall, 62 patients were tested for DSA posttransplant, and 33 patients (23.9%) had at least 1 DSA detected. A total of 34 patients (24.6%) experienced at least 1 episode of liver rejection, and 23 patients (16.7%) experienced kidney rejection. Over 50% of patients with de novo DSA changed status during their posttransplant course. Rates of both liver and kidney rejection were slightly higher in the DSA + group, but liver allograft, kidney allograft, and patient survival did not differ when grouped by whether DSA testing was performed or DSA positivity. CONCLUSIONS: These data demonstrate that SLKT is associated with excellent long-term patient and allograft survival with a relatively low rate of rejection. In our experience, testing for DSA does not impact SLKT outcomes' and further multicenter analyses are needed to establish standard of care.

Contemporary strategies to assess and manage liver donor steatosis: a review.

PURPOSE OF REVIEW: Due to a persistent shortage of donor livers, attention has turned toward ways of utilizing marginal grafts, particularly those with steatosis, without incurring inferior outcomes. Here we review the evaluation and utilization of steatotic liver allografts, highlight recently published data, and discuss novel methods of graft rehabilitation. RECENT FINDINGS: Although severe liver allograft (>60%) steatosis has been associated with inferior graft and recipient outcomes, mild (<30%) steatosis has not. There is ongoing debate regarding safe utilization of grafts with moderate (30-60%) steatosis. Presently, no established protocols for evaluating steatosis in donor candidates or utilizing such grafts exist. Liver biopsy is accepted as the gold standard technique, though noninvasive methods have shown promise in accurately predicting steatosis. More recently, machine perfusion has been shown to enhance ex situ liver function and reduce steatosis, emerging as a potential means of optimizing steatotic grafts prior to transplantation. SUMMARY: Steatotic liver allografts constitute a large proportion of deceased donor organs. Further work is necessary to define safe upper limits for the acceptable degree of steatosis, develop standardized evaluation protocols, and establish utilization guidelines that prioritize safety. Machine perfusion has shown promise in rehabilitating steatotic grafts and offers the possibility of expanding the deceased donor pool.

Effect of COVID-19 on Surgical Training Across the United States: A National Survey of General Surgery Residents.

INTRODUCTION: COVID-19 emerged as a global pandemic in 2020 and has affected millions of lives. Surgical training has also been significantly affected by this pandemic, but the exact effect remains unknown. We sought to perform a national survey of general surgery residents in the United States to assess the effect of COVID-19 on surgical resident training, education, and burnout. METHODS: An anonymous online survey was created and distributed to general surgery residents across the United States. The survey aimed to assess changes to surgical residents' clinical schedules, operative volume, and educational curricula as a result of the COVID-19 pandemic. Additionally, we sought to assess the impact of COVID-19 on resident burnout. RESULTS: One thousand one hundred and two general surgery residents completed the survey. Residents reported a significant decline in the number of cases performed during the pandemic. Educational curricula were largely shifted toward online didactics. The majority of residents reported spending more time on educational didactics than before the pandemic. The majority of residents feared contracting COVID-19 or transmitting it to their family during the pandemic. CONCLUSIONS: COVID-19 has had significant impact on surgical training and education. One positive consequence of the pandemic is increased educational didactics. Online didactics should continue to be a part of surgical education in the post-COVID-19 era. Steps need to be taken to ensure that graduating surgical residents are adequately prepared for fellowship and independent practice despite the significantly decreased case volumes during this pandemic. Surgery training programs should focus on providing nontechnical clinical training and professional development during this time.

Grade IV Renal Laceration in a 13-Year-Old Boy With Cross-fused Renal Ectopia.

A 13-year-old boy presented with gross hematuria following a skateboarding accident and was found to have cross-fused renal ectopia of the left kidney with a grade IV right renal laceration and urinary extravasation. Despite a double-J ureteral stent, urinoma drain, and indwelling bladder catheter, his urinoma drain maintained high output. He underwent a ureteral stent exchange and upsizing. A percutaneous nephrostomy tube was subsequently placed for maximal urinary diversion, which ultimately led to the resolution in his urinary leak. This case highlights our endourologic approach to manage a severe urinary leak despite conservative measures in a pediatric patient with a renal anomaly.

Leiomyoma of the testis: case report, review of literature, and discussing the role of contrast-enhanced ultrasound.

Leiomyomas are benign mesenchymal neoplasms that originate from smooth muscle cells. Leiomyoma of the testis is exceedlingly rare. We present a case demonstrating a 1.3 cm hypoehoic mass of the left testis but with significant enhancement on contrast-enhanced scrotal ultrasonography concerning for a malignant neoplasm in a 33-year-old Hispanic male. However, his final pathology revealed a benign disease, specifically intratesticular leiomyoma. We discuss the role of contrast-enhanced scrotal ultrasound in this disease process.

Current status of artificial intelligence applications in urology and their potential to influence clinical practice.

OBJECTIVE: To investigate the applications of artificial intelligence (AI) in diagnosis, treatment and outcome predictionin urologic diseases and evaluate its advantages over traditional models and methods. MATERIALS AND METHODS: A literature search was performed after PROSPERO registration (CRD42018103701) and in compliance with Preferred Reported Items for Systematic Reviews and Meta-Analyses (PRISMA) methods. Articles between 1994 and 2018 using the search terms "urology", "artificial intelligence", "machine learning" were included and categorized by the application of AI in urology. Review articles, editorial comments, articles with no full-text access, and nonurologic studies were excluded. RESULTS: Initial search yielded 231 articles, but after excluding duplicates and following full-text review and examination of article references, only 111 articles were included in the final analysis. AI applications in urology include: utilizing radiomic imaging or ultrasonic echo data to improve or automate cancer detection or outcome prediction, utilizing digitized tissue specimen images to automate detection of cancer on pathology slides, and combining patient clinical data, biomarkers, or gene expression to assist disease diagnosis or outcome prediction. Some studies employed AI to plan brachytherapy and radiation treatments while others used video based or robotic automated performance metrics to objectively evaluate surgical skill. Compared to conventional statistical analysis, 71.8% of studies concluded that AI is superior in diagnosis and outcome prediction. CONCLUSION: AI has been widely adopted in urology. Compared to conventional statistics AI approaches are more accurate in prediction and more explorative for analyzing large data cohorts. With an increasing library of patient data accessible to clinicians, AI may help facilitate evidence-based and individualized patient care.

Objective Assessment of Robotic Surgical Technical Skill: A Systematic Review.

PURPOSE: Robotic surgeries, especially in urology, have grown exponentially during the last decade. Various skills assessment tools have been developed. We reviewed the current status, the current challenges and the future needs of robotic evaluations with a focus on urological applications. MATERIALS AND METHODS: According to PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) criteria 2 paired investigators screened the PubMed®, Scopus® and Web of Science® databases for all full text, English language articles published between 2006 and 2018 using the query (evaluation OR assessment) AND (robot-assisted surgery OR robotic surgery) AND (surgical performance OR surgical skill) AND training. The research design, validity and reliability of each study were ascertained and analyzed. RESULTS: A total of 259 studies were identified, of which 109 were included in the final analysis. We grouped the studies into 2 categories, including manual and automated assessments. Manual evaluation included global skill, procedure specific and error based assessments. For automated assessment we summarized evaluations derived from robotic instrument kinematic tracking data, systems events and surgical video data, and we explored those associations with various domains by manual evaluation. We further reviewed the current progress in automated surgical segmentation and skill evaluation with machine learning and deep learning. Concerns remain regarding efficient and effective surgeon training and credentialing. CONCLUSIONS: No universally accepted robotic skills assessment currently exists. The purpose of assessment (training or credentialing) may dictate whether manual or automated surgeon assessment is more suitable. Moving forward, assessment tools must be objective and efficient to facilitate the training and credentialing of competent surgeons.