The role of the RAPID score in surgical planning for empyema.

Background: The RAPID [Renal (urea), Age, fluid Purulence, Infection source, Dietary (albumin)] score is a validated scoring system which allows risk stratification in patients with pleural infection at presentation. Surgical intervention plays a key role in managing pleural empyema. Methods: A retrospective study of patients with complicated pleural effusions and/or empyema undergoing thoracoscopic or open decortication admitted to multiple affiliated Texas hospitals from September 1, 2014 to September 30, 2018. The primary outcome was all-cause 90-day mortality. The secondary outcomes were organ failure, length of stay and 30-day readmission rate. The outcomes were compared between early surgery (≤3 days from diagnosis) and late surgery (>3 days from diagnosis) and low [0-3] vs. high [4-7] RAPID scores. Results: We enrolled 182 patients. Late surgery was associated with increased organ failure (64.0% vs. 45.6%, P=0.0197) and longer length of stay (16 vs. 10 days, P<0.0001). High RAPID scores were associated with a higher 90-day mortality (16.3% vs. 2.3%, P=0.0014), and organ failure (81.6% vs. 49.6%, P=0.0001). High RAPID scores with early surgery were associated with higher 90-day mortality (21.4% vs. 0%, P=0.0124), organ failure (78.6% vs. 34.9%, P=0.0044), 30-day readmission (50.0% vs. 16.3%, P=0.027) and length of stay (16 vs. 9 days, P=0.0064). High vs. low RAPID scores with late surgery was associated with a higher rate of organ failure (82.9% vs. 56.7%, P=0.0062), but there was not a significant association with mortality. Conclusions: We found a significant association between RAPID scores and surgical timing with new organ failure. Patients with complicated pleural effusions who had early surgery and low RAPID scores experienced better outcomes including decreased length of stay and organ failure compared with those who had late surgery and low RAPID scores. This suggests that using the RAPID score may help identify those who would benefit from early surgery.

What's in a name? The heterogeneous clinical spectrum and prognostic factors in a cohort of adults with hemophagocytic lymphohistiocytosis.

PURPOSE: Hemophagocytic lymphohistiocytosis (HLH) in adults is rare but frequently fatal. Diagnosis is often delayed and treatment approaches vary significantly in contrast to the protocol-driven approach typically used in pediatric HLH. To improve care of these complex patients, this study retrospectively examined the prevalence, clinical characteristics, therapies and outcomes of adult HLH patients at two large tertiary care centers. METHODS: Adult patients with HLH confirmed by retrospective review of electronic medical records using HLH2004 criteria during admissions to the University of Texas Southwestern and Parkland Memorial Hospitals between June 2007 and June 2017 were studied. RESULTS: Of 31 patients included, 67.7% were male with mean age of 46 years. Average time from admission to diagnosis was 10.5 days. 48% of patients had malignancy, with T-cell lymphoma being most common. Infections were seen in 70%. Autoimmune disorders were found in 9.6%. In total, 13 patients survived (44.8%). Median survival was 8 months with increased mortality in malignancy-associated HLH (median 0.56 months versus 36.5 months, p < 0.001). T-cell lymphoma carried a worse prognosis than other malignancies. Central nervous system disease, hypoalbuminemia, elevated bilirubin, elevated soluble interleukin 2 receptor, and elevated lactate dehydrogenase, were also associated with poor survival. Treatment varied significantly. No individual treatment improved survival. CONCLUSION: This study corroborates prior limited data in adult HLH patients regarding poor survival, particularly in malignancy-associated HLH. Earlier recognition of this disease and a multidisciplinary approach to streamline diagnosis and optimize treatment are needed to improve outcomes in adult HLH patients.

Factors Influencing the Rate of Lost to Followup after Suburethral Synthetic Sling Removal.

INTRODUCTION: We report on variables associated with lost to followup in women undergoing suburethral synthetic sling removal for complications of mid urethral slings. METHODS: Following institutional review board approval a prospectively maintained database of consecutive women with nonneurogenic bladder who underwent 1 synthetic sling removal only was reviewed. Data reviewed by a third party investigator included distance traveled for appointment, marital status, employment status, if the patient received primary care from the institution, if patient's last followup visit was routine or for ongoing urological treatment, type of insurance coverage and UDI-6 (Urogenital Distress Inventory Short Form) questionnaire scores. Patients who did not reach a minimum followup length of 6 months were contacted via phone and interviewed using a standardized script. RESULTS: From 2005 to 2015, 129 patients had a mean followup of 25 months (range 6 to 114). Of the 38 women lost to followup 19 could not be reached and there was 1 nonrecoverable loss due to death. There was a significant increase in patients returning for followup if they had ongoing treatment (p=0.0035). The most commonly reported reasons for lost to followup were distance to the care center and the patient being content with the postoperative outcome. UDI-6 total score decreased significantly after synthetic sling removal in the lost to followup population by an average of 4.2 points (p=0.0337). CONCLUSIONS: Geographical factors and ongoing treatment may explain lost to followup in women referred to a tertiary care center for complications of mid urethral slings.

Cost Analysis of Vaginal Mid Urethral Sling Suburethral Removal.

INTRODUCTION: For cost analysis of mid urethral sling surgery there is a lack of data on costs associated with long-term complications. Therefore, we studied the costs related to a vaginal suburethral synthetic sling removal procedure over 2 consecutive years. METHODS: From a prospectively maintained database of consecutive women who underwent 1 vaginal suburethral synthetic sling removal only, we analyzed the cost of suburethral synthetic sling removal for 2013 and 2014. Costing data were obtained for operating room expenses, medical and surgical supplies, pharmacy, anesthesia supplies, and room and bed. Professional fees for the suburethral synthetic sling removal procedure were obtained from the Medicare fee-for-service schedule. Costs for 2013 were adjusted by 3% to match 2014 costs. RESULTS: From 2013 to 2014 a total of 46 women underwent suburethral synthetic sling removal. Mean ± SD length of surgery was 62 ± 22 minutes and median length of stay was 1 day (range 0 to 2). Costs for medical and surgical supplies decreased significantly from 2013 to 2014 while operating room and total cost increased during that time. No significant differences were found among payer types. With the 3% inflation adjustment for 2013 the mean total cost based on these factors was $3,714 ± $941, with a median cost of $3,556. Of the 46 women 13 were treated on an outpatient basis and the median cost was reduced at $3,030. CONCLUSIONS: At our tertiary care center the mean total cost of suburethral synthetic sling removal was $3,714, with a slight total cost increase from 2013 to 2014 but a cost saving for those treated as outpatients. This information will be useful for inclusion in the overall cost of mid urethral sling procedures.

Management of Urinary Incontinence Following Suburethral Sling Removal.

PURPOSE: We evaluated urinary incontinence outcomes following synthetic suburethral sling removal in women. MATERIALS AND METHODS: We reviewed a prospectively maintained database of 360 consecutive women who underwent transvaginal suburethral sling removal from 2005 to 2015. We excluded patients with neurogenic bladder, nonsynthetic or multiple slings, prior mesh for prolapse, concomitant surgery during sling excision, urethral erosion or fistula, postoperative retention or less than 6-month followup. Demographics, sling type, indications for removal, time to removal and patient reported outcomes were recorded. Outcomes were stratified by incontinence type, including stress predominant, urge predominant and mixed urinary incontinence. Subsequent management was evaluated, including observation, minimally invasive outpatient interventions (bulking agents, neuromodulation or onabotulinumtoxinA) or more invasive surgery (autologous fascial sling or bladder suspension). No patients elected to receive a subsequent synthetic sling. Success was defined by responses to UDI-6 (Urogenital Distress Inventory) questions 2 and 3, self-reported satisfaction with continence at the last visit and no further intervention. RESULTS: Of the 99 patients who met inclusion criteria 27 denied any subjective leakage after suburethral sling removal alone while 72 experienced some degree of incontinence after removal. Stress predominant urinary incontinence occurred in 26 patients, which was persistent in 7 and de novo in 19, urge predominant incontinence was noted in 14, which was persistent in 6 and de novo in 8, and mixed urinary incontinence occurred in 32, which was persistent in 13 and de novo in 19. Mean followup was 23 months (range 6 to 114). The success rate following a single minimally invasive intervention after suburethral sling removal was 81%, 86% and 75% in patients with stress predominant, urge predominant and mixed urinary incontinence, respectively. CONCLUSIONS: Patients who undergo suburethral sling removal may show urinary control, or de novo or persistent incontinence with a higher predilection for stress predominant or mixed urinary incontinence. However, after a single minimally invasive intervention following suburethral sling removal the success rate reached 75% to 86%.

Skene's gland cyst excision.

INTRODUCTION AND HYPOTHESIS: We review our experience with long-term outcome after Skene's gland cyst excision. MATERIALS AND METHODS: After receiving institutional review board approval, we reviewed a surgical database of all procedures performed by two surgeons at one institution for Skene's gland cyst excision. Parameters evaluated include presenting symptoms, preoperative evaluation, excision site, perioperative complications, and clinical outcomes. The technique of surgical excision is presented in the accompanying video, and includes cystoscopy, dissection of cyst wall from the floor of the urethra, complete removal of the cyst wall, and primary vaginal-wall closure. RESULTS: From 2001 to 2013, ten women underwent Skene's gland cyst excision. Mean follow-up was 3.5 years (range 3-96 months). Presenting symptoms were dyspareunia (4), urinary tract infections (4), vaginal mass (1), and voiding dysfunction (1). Five patients had more than one presenting symptom. To exclude urethral diverticulum, magnetic resonance imaging (MRI) was done in all patients and a voiding cystourethrogram in five. No perioperative complications were reported. A distal meatoplasty was done in two women. No recurrence occurred. Eight of ten women who were sexually active remained sexually active postoperatively. CONCLUSIONS: Excision of Skene's gland cyst is a safe procedure with acceptable long-term functional outcomes.