Safety and feasibility of outpatient robot-assisted radical prostatectomy.

Since its inception, robot-assisted radical prostatectomy (RARP) has developed into a familiar surgical modality with improved perioperative outcomes including decreased hospital stay for localized prostate cancer patients. Experience with outpatient RARP has been reported as early as 2010. In this study, we evaluate the safety and feasibility of outpatient RARP by comparing perioperative outcomes between patients undergoing outpatient RARP to patients discharged on the day following surgery. This is a single-institution retrospective cohort study. Patients with localized disease who underwent RARP without pelvic lymph node dissection from September 2017 to January 2018 were included. T tests and Chi-squared analysis were used to compare demographic and perioperative characteristics of patients who were discharged on the same day of surgery (outpatient RARP) to patients discharged on the day after surgery (inpatient RARP). Of the 51 patients included in the study, 26 underwent outpatient RARP while 25 underwent inpatient RARP. There was no significant difference in mean age (61.4 vs 65.8 years, p = 0.05), BMI (27.1 vs 28.3 kg/m2, p = 0.35), ethnicity, tobacco use (8 vs 15%, p = 0.41), PSA (8.7 vs 8.4 ng/dL, p = 0.77), biopsy Gleason score distribution, prostate size (51.8 vs 57.7 cc, p = 0.26) or preoperative hemoglobin (14.3 vs 13.4 g/dL, p = 0.06), respectively. There was no significant difference between operative time (95.3 vs 101 min, p = 0.16), EBL (52.8 vs 66.5 cc, p = 0.08), postoperative change in hemoglobin (- 1 vs - 1.1 g/dL, p = 0.62), pathologic stage distribution or complication rate (4 vs 8%, p = 0.58) between patients who underwent outpatient vs inpatient RARP, respectively. Outpatient RARP offers similar or improved perioperative outcomes when compared to inpatient RARP. We advocate outpatient RARP as a safe and feasible alternative to inpatient RARP for appropriately selected prostate cancer patients. Furthermore, we introduce an outpatient model that can be applied to other institutions seeking to implement outpatient RARP.

Refractory anemia leading to renal hemosiderosis and renal failure.

Renal hemosiderosis is a rare cause of renal failure and, as a result, may not be diagnosed unless a detailed history, careful interpretation of blood parameters and renal biopsy with special staining is done. Here, we present a rare case of renal hemosiderosis presenting with renal failure.

IL-6 does not predict current urolithiasis in stone formers.

INTRODUCTION: Interleukin-6 (IL-6), an inflammatory marker, has previously been found to be elevated in the urine of patients with urolithiasis. Oxalate and other stone precursors have been shown to increase IL-6 production in proximal tubular epithelial cells in vitro. We examined whether urinary IL-6 could be used as a screening test to determine current urolithiasis in individuals who are known to form urinary stones. METHODS: Thirty-five adult patients with current urolithiasis demonstrated on imaging were enrolled in the study. Exclusion criteria included disease known to elevate IL-6. Each patient provided a pre-treatment urine specimen and one month after proven to be stone-free an additional urine specimen was obtained. The urinary IL-6/creatinine ratio was determined for both specimens and compared. RESULTS: Ten patients provided both specimens. The mean pre-operative urinary IL-6/creatinine ratio before the procedure was 1.63 pg/mL. The mean post procedure urinary IL-6/creatinine ratio after the patient was confirmed to be stone-free was 1.81 pg/mL. These were not significantly different (p=0.38). Preoperative urinary IL-6/creatinine ratio did not correlate to stone size (r=0.15) and no correlation was seen between time from treatment and stone free IL-6/creatinine ratio (r=0.48). CONCLUSION: Urinary IL-6 is not a good screening test for current urolithiasis in stone-forming individuals. It is elevated whether the stone is present or not.

Tubeless percutaneous nephrolithotomy with antegrade stent tether: clinical experience.

BACKGROUND AND PURPOSE: A limitation of tubeless percutaneous nephrolithotomy (PCNL) is the need for post-operative office cystoscopy to remove the ureteral stent. We developed a novel technique of intraoperative stent placement that allows removal via the flank. Herein, we report on our initial clinical experience. PATIENTS AND METHODS: Thirty consecutive patients (36 renal moieties) undergoing tubeless PCNL had ureteral stents placed at the end of the procedure with a stent tether exiting the flank incision. Patients were discharged home with the tether protected by a clear occlusive bandage. The stents were removed in the office between 3 and 12 days postoperatively by gently pulling on the tether. Patients were assessed for difficulty in removing the stent, leakage of urine from the flank, and any other postoperative complications. RESULTS: All stents could be removed from the flank using the tether. No urine leakage was noted in any patient, nor did any patient develop any complication related to stent placement or removal. Stents from several manufacturers were employed, with no difference noted. Patients reported no additional discomfort from the presence of the flank tether, and no significant pain was noted during stent removal. CONCLUSION: Utilization of the tether to remove the ureteral stent via the flank after tubeless PCNL is a feasible, safe, and cost-effective improvement on the standard tubeless PCNL technique. This modification obviates postoperative office cystoscopy, allowing easy removal of a stent.

Need for ancillary procedures among patients undergoing tubeless percutaneous renal surgery for nephrolithiasis.

PURPOSE: We routinely perform percutaneous nephrolithotomy (PCNL) without the use of nephrostomy tubes. We examined the need for secondary surgery for the treatment of residual stones in patients who underwent both tubeless surgery and PCNL with tube placement. PATIENTS AND METHODS: We retrospectively reviewed the charts of 180 patients who underwent 186 percutaneous nephrolithotomies. Among them, 125 patients had tubeless surgery, and 61 had nephrostomy tubes. We compared the need for ancillary surgical procedures for residual stone disease in the two groups. RESULTS: A total of 99 patients (79%) without tubes and 25 (41%) of those with tubes were stone free after surgery. A total of 45 ancillary procedures were performed for residual stone disease, with 15% of the tubeless and 43% of the patients with tubes requiring a second procedure. Extracorporeal shockwave lithotripsy (SWL) was the most common ancillary procedure. CONCLUSIONS: Patients who are eligible for tubeless PCNL are unlikely to need a secondary procedure, and residual stones can most often be treated with SWL. Patients who required nephrostomy tubes had more complicated disease and a greater need for subsequent surgery.

Dispensing errors in community pharmacy: perceived influence of sociotechnical factors.

OBJECTIVE: This study examined the impact of pharmacists' perceptions of errors in dispensing, errors in communication, delays in prescription processing, efficiency and physical mobility in the pharmacy by practice setting and sociotechnical factors (i.e. pharmacy design, drive through pick-up window services and automated dispensing systems). SETTING: Community pharmacy practice in the USA. DESIGN: A two-page survey was mailed to a geographically stratified random sample of 1047 community pharmacies. One-way analysis of variance was used to determine the impact of attitudinal items with respect to pharmacy practice setting (e.g. mass merchant, supermarket, chain and independent) and sociotechnical factors. Pharmacy characteristics, pharmacist experience and total dispensing errors were also addressed. RESULTS: The response rate was 45.0% (n = 429). Pharmacists perceived that pharmacy design significantly (P < 0.05) contributed to dispensing errors, errors in communication, problems with efficiency and those similar problems were observed for all items relating to drive through window pick-up services. Automated dispensing systems were perceived as less likely (P < 0.05) to contribute to dispensing errors, errors in communication, efficiency problems and extra physical movement. Perceived dispensing error rate was 0.057%, and the number of dispensing errors was positively and significantly (P < 0.001) correlated with prescription volume. Cognitive errors accounted for approximately 80% of the dispensing errors. CONCLUSIONS: Perceptions of dispensing errors by pharmacists are influenced by design, drive through pick-up window services, and automated dispensing systems. However, more effort is needed to determine how cognitive processes relate to sociotechnical variables in pharmacy practice and other environments.

Modification of tubeless percutaneous nephrolithotomy: anterograde stent with flank tether.

A limitation of tubeless percutaneous nephrolithotomy is the need for postoperative office cystoscopy for removal of the ureteral stent. We have developed a novel technique of intraoperative ureteral stent placement that allows for outpatient removal of the stent through the flank using the stent tether.

Rapid, noninvasive diagnosis of visceral leishmaniasis in India: comparison of two immunochromatographic strip tests for detection of anti-K39 antibody.

Used with blood or serum, a new anti-K39 antibody immunochromatographic strip test (IT-Leish; DiaMed AG) proved sensitive (range, 99 to 100%) and specific (range, 95 to 100%) for the noninvasive serodiagnosis of visceral leishmaniasis in India. Used with serum, the IT-Leish test and the existing Kalazar Detect test (InBios International, Inc.) yielded comparable results for symptomatic infection and identified apparent subclinical infection in 15 to 32% of healthy residents in a region where visceral leishmaniasis is highly endemic.

Use of rectus fascia graft for corporeal reconstruction during placement of penile implant.

OBJECTIVES: To report on the technique of using autologous rectus fascia graft for corporeal and tunica reconstruction during placement of an inflatable penile prosthesis. Reconstructing the corpora cavernosa and closing the tunica albuginea over an inflatable penile prosthesis can be challenging when severe fibrosis is encountered. METHODS: Fifteen patients with severe fibrosis of the corpora or tunica were included in this study. Eight patients had severe corporeal fibrosis secondary to an infected or malfunctioned penile prosthesis that had been previously removed, and seven had severe penile curvature secondary to tunical fibrosis with concomitant erectile dysfunction. All patients underwent corporeal or tunica reconstruction using autologous rectus fascia after placement of an inflatable penile prosthesis. Postoperatively, patients were evaluated at 1, 6, 12, and 24 months. Data on patient satisfaction, graft function, and complications were recorded. RESULTS: At a mean follow-up of 18 months (range 12 to 64), augmentation of the tunica or corporeal defect using autologous rectus fascia graft was successful in all patients. The penile prostheses were functioning properly with no evidence of graft infection, erosion, or abdominal wall hematoma. Patients demonstrated good results, with return to sexual intercourse at a mean of 9 weeks postoperatively (range 8 to 10). CONCLUSIONS: Use of an autologous rectus fascia graft for coverage of a tunical or corporeal defect during penile prosthesis placement in patients with corporeal or tunica fibrosis is surgically feasible, safe, and efficacious. Long-term follow-up of this reconstructive technique has demonstrated excellent clinical results with no morbidity related to the rectus fascia graft harvesting.

Impact of urinary incontinence on self-concept in children with spina bifida.

PURPOSE: Low self-concept and self-esteem are thought to be the main predictors of psychological problems in children and adolescents. Children with spina bifida are thought to be at an increased risk for low self-concept and self-esteem given their disabilities. We examined the impact of urinary continence on self-concept in children with myelomeningocele. MATERIALS AND METHODS: A total of 50 patients 7 to 19 years old with spina bifida were evaluated using the Hartner self-perception profile. Each patient was asked to self-rate on a scale of 1 to 4 using specific domains of self-concept, including scholastic competence, social acceptance, athletic competence, physical appearance, behavioral conduct and global self-worth. Continence and several other factors, namely ambulatory status, family situation and insurance status, were reviewed simultaneously. RESULTS: There were no statistically significant differences between continent patients with spina bifida and controls. Overall children with spina bifida rated lower in scholastic competence, social acceptance and behavioral conduct than controls. Girls with spina bifida scored lower in perceived athleticism, physical appearance and global self-worth than boys with spina bifida. Continent girls were self-rated higher in social acceptance and global self-worth than incontinent girls. Continent boys were self-rated higher in scholastic competence, social acceptance, physical appearance and behavior compared to incontinent boys. CONCLUSIONS: Continence is associated with better self-concept in children with spina bifida and incontinent girls are at particularly high risk for poor self-esteem. Urologists' efforts to promote continence are likely to have a positive effect on self-concept in boys and girls with spina bifida.