Functional penile replantation after traumatic avulsion amputation below the pubis: A case report.

Penile amputation is a rare injury with significant posttraumatic ramifications. We present a case of successful immediate replantation after traumatic penile avulsion in a 52-year-old male patient. The patient reported his penis was caught in machinery during a boating accident, and avulsed at the level of the pubis. Immediate replantation of this proximal avulsion injury with no suitable proximal arterial stumps required transfer of the superficial inferior epigastric artery for arterial inflow. One artery and two veins were repaired. The urethral injury was found to be immediately distal to the urethral sphincter in the membranous portion, and repaired primarily. Urinary diversion was performed with a suprapubic catheter until the repair had healed. The postoperative course was complicated by less than 10% skin necrosis requiring skin grafting. At three years follow up, the patient has a penis with normal urinary function and is able to obtain erections with pharmacologic aids. Avulsion should not preclude penile replantation, which may have acceptable functional and esthetic results.

Preoperative multivariable prognostic models for prediction of survival and major complications following surgical resection of renal cell carcinoma with suprahepatic caval tumor thrombus.

OBJECTIVE: Surgical resection for renal cell carcinoma (RCC) with suprahepatic inferior vena cava tumor thrombus is associated with significant morbidity, yet there are currently no tools for preoperative prognostic evaluation. Our goal was to develop a preoperative multivariable model for prediction of survival and risk of major complications in patients with suprahepatic thrombi. METHODS: We identified patients who underwent surgery for RCC with suprahepatic tumor thrombus extension from 2000 to 2013 at 4 tertiary centers. A Cox proportional hazard model was used for analysis of overall survival (OS) and logistic regression was used for major complications within 90 days of surgery (Clavien ≥ 3A). Nomograms were internally calibrated by bootstrap resampling method. RESULTS: A total of 49 patients with level III thrombus and 83 patients with level IV thrombus were identified. During median follow-up of 24.5 months, 80 patients (60.6%) died and 46 patients (34.8%) experienced major complication. Independent prognostic factors for OS included distant metastases at presentation (hazard ratio = 2.52, P = 0.002) and Eastern Cooperative Oncology Group (ECOG) performance status (hazard ratio = 1.84, P<0.0001). Variables associated with increased risk of major complications on univariate analysis included preoperative systemic symptoms, level IV thrombus, and elevated preoperative alkaline phosphatase and aspartate transaminase levels; however, only systemic symptoms (odds ratio = 8.45, P<0.0001) was an independent prognostic factor. Preoperative nomograms achieved a concordance index of 0.72 for OS and 0.83 for major complications. CONCLUSIONS: We have developed and internally validated multivariable preoperative models for the prediction of survival and major complications in patients with RCC who have a suprahepatic inferior vena cava thrombus. If externally validated, these tools may aid in patient selection for surgical intervention.

Multi-Quadrant Biopsy Technique Improves Diagnostic Ability in Large Heterogeneous Renal Masses.

PURPOSE: Percutaneous biopsy obtained from a single location is prone to sampling error in large heterogeneous renal masses, leading to nondiagnostic results or failure to detect poor prognostic features. We evaluated the accuracy of percutaneous biopsy for large renal masses using a modified multi-quadrant technique vs a standard biopsy technique. MATERIALS AND METHODS: Clinical and pathological data for all patients with cT2 or greater renal masses who underwent percutaneous biopsy from 2009 to 2014 were reviewed. The multi-quadrant technique was defined as multiple core biopsies from at least 4 separate solid enhancing areas in the tumor. The incidence of nondiagnostic findings, sarcomatoid features and procedural complications was recorded, and concordance between biopsy specimens and nephrectomy pathology was compared. RESULTS: A total of 122 biopsies were performed for 117 tumors in 116 patients (46 using the standard biopsy technique and 76 using the multi-quadrant technique). Median tumor size was 10 cm (IQR 8-12). Biopsy was nondiagnostic in 5 of 46 (10.9%) standard and 0 of 76 (0%) multi-quadrant biopsies (p=0.007). Renal cell carcinoma was identified in 96 of 115 (82.0%) tumors and nonrenal cell carcinoma tumors were identified in 21 (18.0%). One complication occurred using the standard biopsy technique and no complications were reported using the multi-quadrant technique. Sarcomatoid features were present in 23 of 96 (23.9%) large renal cell carcinomas studied. Sensitivity for identifying sarcomatoid features was higher using the multi-quadrant technique compared to the standard biopsy technique at 13 of 15 (86.7%) vs 2 of 8 (25.0%) (p=0.0062). CONCLUSIONS: The multi-quadrant percutaneous biopsy technique increases the ability to identify aggressive pathological features in large renal tumors and decreases nondiagnostic biopsy rates.

Ethical considerations of physician career involvement in global health work: a framework.

Examining the ethics of long-term, career involvement by physicians in global health work is vital, given growing professional interest and potential health implications for communities abroad. However, current literature remains heavily focused on ethical considerations of short-term global health training experiences. A literature review informed our development of an ethics framework centered on two perspectives: the practitioner perspective, further subdivided into extrinsic and intrinsic factors, and community perspectives, specifically that of the host community and the physician's home community. Some physician factors included cultural/linguistic differences, power imbalances, and sustainable skills/competencies. Receiving community factors included resource limitations, standard of care disparities, and community autonomy. Home community factors focused on the opportunity cost of an unavailable physician who was trained and supported by the local community. Descriptive review permitted comparison with existing short-term literature, noting similarities and differences. Our framework provides a basis for further research and critical analysis of ethical implications of career-long physician global health work.

Comparative analysis: potential barriers to career participation by north american physicians in global health.

Physician interest in global health, particularly among family physicians, is reflected by an increasing proliferation of field training and service experiences. However, translating initial training involvement into a defined and sustainable global health career remains difficult and beset by numerous barriers. Existing global health literature has largely examined training experiences and related ethical considerations while neglecting the role of career development in global health. To explore this, this paper extrapolates potential barriers to global health career involvement from existing literature and compares these to salary and skills requirements for archetypal physician positions in global health, presenting a framework of possible barriers to sustained physician participation in global health work. Notable barriers identified include financial limitations, scheduling conflicts, security/family concerns, skills limitations, limited awareness of opportunities, and specialty choice, with family practice often closely aligned with global health experience. Proposed solutions include financial support, protected time, family relocation support, and additional training. This framework delineates barriers to career involvement in global health by physicians. Further research regarding these barriers as well as potential solutions may help direct policy and initiatives to better utilize physicians, particularly family physicians, as a valuable global health human resource.

Oncologic outcomes following surgical resection of renal cell carcinoma with inferior vena caval thrombus extending above the hepatic veins: a contemporary multicenter cohort.

PURPOSE: Suprahepatic inferior vena caval tumor thrombus in renal cell carcinoma cases has historically portended a poor prognosis. With advances in perioperative treatment of patients with high level thrombus contemporary outcomes are hypothesized to be improved. We evaluated long-term oncologic outcomes of contemporary surgical treatment of patients with renal cell carcinoma in whom level III-IV inferior vena caval thrombus was managed at high volume centers. MATERIALS AND METHODS: We examined clinical and pathological data on patients with renal cell carcinoma and level III-IV thrombus treated with surgery from January 2000 to June 2013 at 4 tertiary referral centers. Survival outcomes and associated prognostic variables were assessed by Kaplan-Meier and multivariate Cox regression analyses. RESULTS: We identified 166 patients, including 69 with level III and 97 with level IV thrombus. Median postoperative followup was 27.8 months. Patients with no evidence of nodal or distant metastasis (pN0/X, M0) had 5-year 49.0% cancer specific survival and 42.2% overall survival. There was no difference in survival based on tumor thrombus level or pathological tumor stage. Variables associated with an increased risk of death from kidney cancer on multivariate analysis were regional nodal metastases (HR 3.94, p <0.0001), systemic metastases (HR 2.39, p = 0.01), tumor grade 4 (HR 2.25, p = 0.02), histological tissue necrosis (HR 3.11, p = 0.004) and increased preoperative serum alkaline phosphatase (HR 2.30, p = 0.006). CONCLUSIONS: Contemporary surgical management achieves almost 50% 5-year survival in patients without metastasis who have renal cell carcinoma thrombus above the hepatic veins. Factors associated with increased mortality included nodal/distant metastases, advanced grade, histological necrosis and increased preoperative serum alkaline phosphatase. These findings support an aggressive surgical approach to the treatment of patients with renal cell carcinoma who have advanced tumor thrombus.

Perioperative outcomes following surgical resection of renal cell carcinoma with inferior vena cava thrombus extending above the hepatic veins: a contemporary multicenter experience.

BACKGROUND: Surgery for renal cell carcinoma (RCC) patients with inferior vena cava (IVC) thrombus above the hepatic veins is technically complex and associated with an increased risk of perioperative morbidity and mortality. However, minimal data exist that describe contemporary perioperative outcomes at major referral centers or the prognostic factors associated with poor outcomes. OBJECTIVE: To determine the preoperative predictors of major complications and 90-d mortality after surgery in RCC patients who have IVC thrombus above the hepatic veins. DESIGN, SETTING, AND PARTICIPANTS: We reviewed medical records of all RCC patients who had IVC tumor thrombus above hepatic veins and had had surgery between January 2000 and December 2012 at the Mayo Clinic, M.D. Anderson Cancer Center, University of Texas Southwestern Medical Center, and the University of Wisconsin Hospital. OUTCOME MEASUREMENT AND STATISTICAL ANALYSIS: Major complications recorded were defined as ≥ 3A according to the Clavien-Dindo system within 90 d of surgery. Univariate and multivariate analyses were used to evaluate associations of preoperative variables with risk of major complications or 90-d mortality. RESULTS AND LIMITATIONS: A total of 162 patients were identified for study (level 3, 4 in 69, 93 patients, respectively, according to the Neves classification). Cardiopulmonary bypass was used in 60 of 162 patients (37.5%), and 40 patients (24.7%) had preoperative angioembolization. Major complications were reported in 55 patients (34.0%), with the most common being respiratory, cardiac, and hematologic issues. After multivariate analysis, preoperative systemic symptoms and level 4 thrombus were independently associated with increased risk of major complications. Mortality was reported in 17 patients (10.5%) within 90 d after surgery. After multivariate analysis, Eastern Cooperative Oncology Group (ECOG) performance status (PS) and low serum albumin were preoperative factors independently associated with increased risk of 90-d mortality. CONCLUSIONS: Contemporary perioperative mortality and major complication rates for RCC patients who have upper-level thrombus are 10% and 34%, respectively. Patients who have ECOG PS >1 or low serum albumin have increased risk for perioperative mortality.

Minimally invasive radical prostatectomy: transition from pure laparoscopic to robotic-assisted radical prostatectomy.

OBJECTIVES: The robotic-assisted laparoscopic approach to radical prostatectomy is increasingly utilized and has become well documented as an effective oncologic treatment modality. In this study, we report the initial experience of a single surgeon at a single institution with robotic-assisted laparoscopic prostatectomy (RALP) drawing a comparison to his prior experience with pure laparoscopic prostatectomy (LRP) METHODS: This is a retrospective review of surgical results from a single surgeon performing LRP and transitioning to RALP. Baseline characteristics and outcomes of two hundred seventy five patients undergoing RALP by a single, fellowship-trained, urologic oncologist were analyzed and compared to 45 patients undergoing LRP by the same surgeon. Patient, tumor, and operative characteristics as well as functional outcomes were evaluated. Validated questionnaires, including the International Prostate Symptom Score (IPSS) and International Index of Erectile Function (IIEF), were utilized in the assessment of urinary and sexual parameters. RESULTS: Preoperative patient and tumor characteristics (age, PSA, Gleason score) were similar in both the LRP and RALP groups. Mean operative time (195 vs. 299 minutes), estimated blood loss (223 vs. 299 mL), need for blood transfusion (1.5% vs. 4.4%) and mean length of stay (1.95 vs. 2.63 days) were significantly reduced among patients undergoing RALP as compared to those undergoing LRP. In terms of functional outcomes, continence at 12 months was better among patients undergoing RALP as compared to LRP (94% vs. 82%). In preoperatively potent men undergoing bilateral nerve sparing procedures, RALP conferred 82% potency at 24 months as opposed to only 62% following LRP. CONCLUSIONS: The combination of adjustment in surgical technique from LRP to RALP along with a concurrent institutional commitment to a successful robotic surgery program, has yielded superior operative, oncologic, and functional results.

Congestive heart failure and chronic obstructive pulmonary disease predict poor surgical outcomes in older adults undergoing elective diverticulitis surgery.

BACKGROUND: Diverticulitis is a common medical condition that disproportionately affects older adults. The ideal management of recurrent diverticulitis, including the role of prophylactic colectomy, remains uncertain. OBJECTIVE: This study aimed to investigate the outcomes among older patients undergoing elective surgery for diverticulitis and examine subgroups of patients with comorbid congestive heart failure and chronic obstructive pulmonary disease to determine whether outcomes in these patients are worse than in other groups. DESIGN: This article reports a retrospective cohort study of patients undergoing elective surgery for diverticulitis. SETTING: Data were derived from the 100% Medicare Provider Analysis and Review inpatient files from 2004 to 2007. PATIENTS: Included were 22,752 patients, age 65 years and older, with a primary diagnosis of diverticulitis that underwent elective left-colon resection, colostomy, or ileostomy. MAIN OUTCOME MEASURE: The primary outcome measure was in-hospital mortality. The secondary outcome measures were intestinal diversion rates (colostomy and ileostomy) and postoperative complications. RESULTS: Overall mortality, intestinal diversion (colostomy and ileostomy), and postoperative complication rate were 1.2%, 11.3%, and 22.1%. Patients with congestive heart failure had increased odds of in-hospital mortality (OR 3.5, 95% CI 2.59-4.63), colostomy (OR 1.9, 95% CI 1.69-2.27), and all postoperative complications, including hemorrhagic (OR 1.5, 95% CI 1.01-2.11), wound (OR 1.9, 95% CI 1.50-2.39), pulmonary (OR 4.2, 95% CI 3.59-4.85), cardiac (OR 4.6, 95% CI 3.68-5.74), postoperative shock/sepsis (OR 3.2, 95% CI 2.53-4.35), renal (OR 4.1, 95% CI 3.22-5.12), and thromboembolic (OR 1.6, 95% CI 1.00-2.43) complications. Patients with chronic obstructive pulmonary disease had significantly increased odds of wound (OR 1.4, 95% CI 1.19-1.67) and pulmonary (OR 2.2, 95% CI 1.94-2.50) complications. Advancing age, congestive heart failure, and chronic obstructive pulmonary disease were significantly associated with increased morbidity and mortality. LIMITATIONS: Medicare data are limited by the potential for lack of generalizability to patients <65 years and the potential for coding errors. CONCLUSIONS: Elective diverticular surgery in older patients carries substantial morbidity, especially in those patients with comorbid congestive heart failure and chronic obstructive pulmonary disease. The rate of perioperative complications that we document in this patient population may attenuate some of the expected benefit of surgery.

Prostatectomia radical minimamente invasiva: transición de laparoscopia pura a laparoscopia asistida por robot / Minimally invasive radical prostatectomy: transition from pure laparoscopic to robotic-assisted radical prostatectomy

OBJETIVO: El abordaje laparoscópico asistido por robot en la prostatectomía radical es cada vez más utilizado y se ha convertido en una modalidad de tratamiento oncológico efectivo bien documentado. En este estudio, presentamos la experiencia inicial de un solo cirujano en una sola institución con prostatectomía laparoscópica asistida por robot (PRAR) estableciendo una comparación con su experiencia previa en la prostatectomía laparoscópica pura (PRL).MÉTODOS: Se trata de una revisión retrospectiva de los resultados quirúrgicos de un solo cirujano realizando la PRL y la transición a la PRAR. Las características básicas y los resultados obtenidos de doscientos setenta y cinco pacientes sometidos a PRR por un único y entrenado, urólogo oncológico, se analizaron y se compararon con 45 pacientes sometidos a prostatectomía radical laparoscópica por el mismo cirujano. Se evaluaron las características de los pacientes, de los tumores y de la técnica operatoria, así como los resultados funcionales. Se utilizaron cuestionarios validados, incluyendo el International Prostate Symptom Score (IPSS) y el Índice Internacional de Función Eréctil (IIEF), en la evaluación de los parámetros urinarios y sexuales(AU)

RESULTADOS: Las características preoperatorias de los pacientes y de los tumores incluidos (edad, PSA, índice de Gleason) fueron similares en ambos grupos, PRL y PRAR. El tiempo quirúrgico promedio (195 vs 299 minutos), la pérdida estimada de sangre (223 vs 299 ml), la necesidad de transfusión de sangre (1,5% vs 4,4%) y la estancia media (1,95 vs 2,63 días) se redujeron significativamente entre pacientes sometidos a PRAR en comparación con aquellos sometidos a prostatectomía radical laparoscópica. En cuanto a los resultados funcionales, la continencia a los 12 meses fue superior en los pacientes sometidos PRAR con respecto a la PRL (94% vs 82%). Entre aquellos sujetos potentes preoperatoriamente sometidos a procedimientos de preservación neurovascular bilateral, el 82% de los tratados con PRAR mantienen la potencia a los 24 meses en comparación con sólo el 62% de los sometidos a PRL.CONCLUSIONES: La combinación de ajustes en la técnica quirúrgica entre la PRLy la PRAR, junto con un compromiso institucional concurrentes a un exitoso programa de cirugía robótica, ha generado unos resultados funcionales, oncológicos y quirúrgicos superiores(AU)

OBJECTIVES: The robotic-assisted laparoscopic approach to radical prostatectomy is increasingly utilized and has become well documented as an effective oncologic treatment modality. In this study, we report the initial experience of a single surgeon at a single institution with robotic-assisted laparoscopic prostatectomy (RALP) drawing a comparison to his prior experience with pure laparoscopic prostatectomy (LRP).METHODS: This is a retrospective review of surgical results from a single surgeon performing LRP and transitioning to RALP. Baseline characteristics and outcomes of two hundred seventy five patients undergoing RALP by a single, fellowship-trained, urologic oncologist were analyzed and compared to 45 patients undergoing LRP by the same surgeon. Patient, tumor, and operative characteristics as well as functional outcomes were evaluated. Validated questionnaires, including the International Prostate Symptom Score (IPSS) and International Index of Erectile Function (IIEF), were utilized in the assessment of urinary and sexual parameters. RESULTS: Preoperative patient and tumor characteristics (age, PSA, Gleason score) were similar in both the LRP and RALP groups. Mean operative time (195 vs. 299 minutes), estimated blood loss (223 vs. 299 mL), need for blood transfusion (1.5% vs. 4.4%) and mean length of stay (1.95 vs. 2.63 days) were significantly reduced among patients undergoing RALP as compared to those undergoing LRP. In terms of functional outcomes, continence at 12 months was better among patients undergoing RALP as compared to LRP (94% vs. 82%). In preoperatively potent men undergoing bilateral nerve sparing procedures, RALP conferred 82% potency at 24 months as opposed to only 62% following LRP.CONCLUSIONS: The combination of adjustment in surgical technique from LRP to RALP along with a concurrent institutional commitment to a successful robotic surgery program, has yielded superior operative, oncologic, and functional results(AU)

The role of self-efficacy in quality of life for disadvantaged men with prostate cancer.

PURPOSE: Self-efficacy is associated with increased participation in treatment decision making and improved health related quality of life. We examined the influence of perceived efficacy in patient-physician interactions on health related quality of life among low income, uninsured men with prostate cancer during a 2-year period. MATERIALS AND METHODS: We analyzed data derived on participants enrolled in a state funded program providing free prostate cancer treatment and care to indigent men. We used validated instruments to measure patient self-efficacy (confidence in interacting with physicians), and the general and prostate specific health related quality of life outcomes of urinary, sexual and bowel bother, symptom distress, psychological well-being and vitality. We performed repeated measures analysis with general linear mixed modeling to estimate the association of sociodemographic and clinical covariates with health related quality of life. RESULTS: Our cohort included a total of 472 observations in 99 men. Self-efficacy had a measurable effect on subjective measurements of general and disease specific health related quality of life. Men with the lowest self-efficacy had inferior mean health related quality of life scores across all outcomes. Low self-efficacy was significantly associated with worse bowel bother and general symptom distress during the 2-year study period. Similar health related quality of life outcomes trajectories were observed across self-efficacy categories. CONCLUSIONS: Of disadvantaged men with clinically localized prostate cancer those with the lowest self-efficacy in physician interactions fared worst across all measured domains of health related quality of life. Interventions to improve patient-physician communication in this population may provide physicians with a supplemental method by which to address health perceptions, mitigate symptom experience and improve health outcomes.

Shifting trends in liver-directed management of patients with colorectal liver metastasis: a population-based analysis.

BACKGROUND: We sought to evaluate population-based temporal trends in perioperative management, as well as short- and long-term outcomes associated with the operative management of colorectal liver metastasis (CRLM). METHODS: Using Surveillance, Epidemiology and End Results-Medicare linked data, we identified 2,121 patients with operatively managed CRLM between 1991 and 2006. Clinicopathologic data, trends in operative management, and survival were examined. RESULTS: Preoperative evaluation included computed tomography (CT; 66%), magnetic resonance imaging (MRI; 5%), and positron emission tomography (PET; 2%) with a temporal increase in the use of all 3 modalities over time (all P < .05). Patients undergoing hepatectomy only (n = 1,267; 60%) decreased over time, whereas the use of ablation alone (n = 668; 32%) and combined resection plus ablation (n = 186; 9%) increased (all P < .05). The use of both preoperative (10% to 16%) and adjuvant chemotherapy (35% to 47%) increased over time (P < .05). There was a marked temporal increase in patient comorbidities (>3 comorbidities: 1991-1995, 3%; 2003-2006, 12%; P < .001); however, perioperative complications (63%) and 30-day mortality (3%) did not change over time (both P > .05); 90-day mortality decreased from 9% to 7% over the study period (P = .007). Overall the 1-, 3-, and 5-year survivals were 74%, 42%, and 28% with no improvement over time (P = .19). On multivariate analysis, synchronous disease (hazard ratio [HR], 1.7) and use of ablation alone (HR, 1.2) were associated independently with a worse survival (both P < .05). CONCLUSION: Most patients were evaluated with CT; PET was employed rarely. Although there was a temporal increase in chemotherapy utilization, only one half of patients received perioperative chemotherapy. Mortality associated with hepatic operations was low, but morbidity remained high with no temporal change despite an increased number of patient medical comorbidities.