Clips Can be Safely Used for Vascular Control of the Renal Vessels During Laparoscopic Donor Nephrectomy.

OBJECTIVE: To review our experience using clips to control the renal vessels during laparoscopic donor nephrectomy (LDN) and determine the safety of this practice. METHODS: We performed a retrospective review of patients who underwent LDN at our centre January 1, 2007-September 17, 2019. The primary outcome was the rate of complication associated with vascular control of the renal vessels, which included (1) conversion to open to manage bleeding, (2) additional procedures for bleeding, and (3) major bleeding requiring blood transfusion. Secondary outcomes included the rate of renal artery/vein clip dislodgement or crossing, change in hemoglobin, warm ischemia time and the incidence of intra-operative complications and postoperative in-hospital complications. RESULTS: We included 503 patients who underwent LDN, of which 497 were left sided. The main renal artery was controlled with 3 titanium clips in 489 (97%) cases. The main renal vein was controlled with 2 polymer-locking clips in 478 (95%) cases. For our primary outcome, there were no conversions to open to manage bleeding, no secondary procedures due to bleeding and no major bleeding requiring blood transfusion. Additionally, there were no donor deaths. Regarding our secondary outcomes, there were 5 intraoperative events related to the titanium clips being placed on the renal artery and 1 intraoperative event related to the polymer-locking clips on the renal vein, none of which resulted in any morbidity. CONCLUSION: Using 3 titanium clips on the renal artery and 2 polymer-locking clips on the renal vein during left LDN is safe and provides excellent vascular control.

Routine Preoperative Electrocardiograms in Patients at Low Risk for Cardiac Complications During Shockwave Lithotripsy: Are They Useful?

INTRODUCTION: Routine preoperative electrocardiogram (ECG) before shockwave lithotripsy (SWL) is frequently performed despite recommendations against its use in asymptomatic patients undergoing low-risk surgical procedures. This study assesses whether routine preoperative ECG before SWL is useful in patients at low risk for cardiac complications. MATERIALS AND METHODS: A retrospective study of SWL at our center (2003-2013) reviewed all cardiac-related preoperative cancellations, intraoperative complications, postoperative admissions, and emergency department presentations in patients at low risk for cardiac complications. Patients received SWL with sedation and continuous five-lead ECG monitoring. RESULTS: Of 30,892 referrals, preoperative ECG triggered 13 (0.04%) cancelations in low-risk patients (1 with new atrial fibrillation and 12 with ischemia/previous infarction). Of these patients, 1 had a subsequent abnormal cardiac work-up and 11 underwent uncomplicated SWL without cardiac intervention (2 had unknown history). Of 27,722 treatments, 5 (0.02%) were stopped prematurely in low-risk patients because of arrhythmia (3 had normal preoperative ECG, 1 had abnormal ECG, and 1 did not complete ECG). Three patients developed an arrhythmia with sedation and 2 patients were admitted postoperatively because of cardiac complications (1 for atrial fibrillation and 1 for hypertension), of whom all had normal preoperative ECG. No patients presented to our emergency department with cardiac complications after SWL. CONCLUSIONS: In patients at low risk for cardiac complications, preoperative ECG triggered very few cancellations and did not predict early termination of treatment or cardiac complications after SWL. These findings suggest that in low-risk patients, routine preoperative ECG has little effect on treatment or complication rate and should be omitted.

Dual usage of a stone basket: Stone capture and retropulsion prevention.

INTRODUCTION: Stone migration during ureteroscopy (URS) for proximal ureteric calculi is a constant challenge. Several retropulsion prevention devices have been developed to optimize URS outcomes. Our technique involves capturing the stone within a four-wire Nitinol stone basket and then performing laser lithotripsy to dust the stone while it is engaged in the basket. The dusted fragments wash out with the irrigation fluid and once small enough, the remaining stone is removed intact. METHODS: A retrospective chart review was performed of all proximal semi-rigid URS procedures for a solitary calculus (2000-2016). We compared our new technique introduced in 2010 to URS control procedures that did not use retropulsion prevention techniques or devices. RESULTS: One hundred and forty patients underwent URS for proximal ureteric calculi. Mean stone diameter was 9.3±3.4 mm, with similar impaction rate between both groups (44.1% vs. 43.1% control; p=n/s). The mean surgical procedure time was 53.3±17.9 minutes for the new technique and 65.2±29.2 minutes for the control group (p=0.005). Compared to the new technique, the control group had a higher rate of retropulsion (33.3% vs. 14.7%; p=0.01) and required flexible URS more often to exclude or remove residual fragments (24.1% vs. 59.1%; p=0.001). Using the new technique, stone-free rates were higher (79.1% vs. 69.4%; p=n/s) and there was a lower likelihood of leaving residual fragments both <3 mm and ≥3 mm (p=0.001). CONCLUSIONS: Our novel technique results in shorter operative times, lower retropulsion rates, and decreases postoperative residual stone fragments.

A Rare Ureteral Injury Following Posterior Approach Lumbar Discectomy.

Iatrogenic ureteral injuries account for ∼75% of all ureteral injuries and occur primarily during urologic, gynecologic, general, and vascular surgery procedures. Ureteral injury during spine surgery is a rare complication with only occasional reports in the literature. In this case report, we present a case of unrecognized left ureteral injury during an open right lumbar discectomy with a delayed presentation, and discuss the steps required for diagnosis and management. This report highlights a rare complication during laminectomy and serves to better inform patients and surgeons about this potential complication and the management options.

Intraoperative Radiographic Determination of Ureteral Length as a Method of Determining Ideal Stent Length.

INTRODUCTION: Accurate determination of ureteral length (UL) and appropriate stent length remains a challenge. The objective of this study was to describe an intraoperative technique to measure UL and determine appropriate stent length, and to compare this technique with other methods of determining appropriate stent length. METHODS: Patients undergoing ureteroscopy requiring postoperative stenting and who had a preoperative CT were prospectively identified. Gender, age, height, body mass index, L1 to L5 lumbar height on CT, and surgeon's estimate of UL were recorded. UL was measured using four methods: direct measurement with a ureteral catheter, ureteropelvic junction (UPJ) to ureterovesical junction distance on axial and coronal CT, and using a novel intraoperative radiographic technique. Radiographic measurement was performed using a radiographic nipple marker affixed to the skin over the ureteral orifice (UO) and an angiographic catheter with radiopaque markings at 1 cm intervals. UL was the distance from the UPJ to the marker at the UO measured using the catheter markers. Correlation between direct measurement and the recorded variables and methods of ureteral measurement were calculated. Stent length was chosen based on radiographic measurement. Stents were deemed of appropriate length if they showed a proximal coil in the renal pelvis and a distal coil in the bladder without crossing midline. RESULTS: Twenty-five ureters from 23 patients were included. Radiographically measured UL was strongly correlated with direct measurement. (r = 0.873, p < 0.01). Coronal and axial CT ULs were significantly associated with direct measurement (p < 0.05). Height, lumbar height, and surgeon's estimate of UL were not. Stents were deemed of appropriate length in 23/25 cases (92%). CONCLUSIONS: This new method for radiographic UL measurement is strongly correlated with directly measured UL. A length of stent chosen based on radiographic UL resulted in an appropriate stent length.

Preliminary report on a new surgical technique for the management of bothersome scrotomegaly in selected adolescent males.

Idiopathic scrotomegaly in adolescent boys can be a bothersome and distressing complaint. The challenge lies in accepting its potential impact on the patient's body image, offering a simple solution with minimal morbidity. Herein, we present a novel approach to reduction scrotoplasty, which adds to the limited published strategies available, and provides surgeons with a safe and effective procedure to correct this condition. Our report also calls attention to a potentially under-recognized medical problem in adolescents and young adults.

Long-term complications in men who have early or late radiotherapy after radical prostatectomy.

INTRODUCTION: Choosing adjuvant radiotherapy (RT) or salvage RT after radical prostatectomy (RP) for locally advanced prostate cancer is controversial. Performing RT early after RP may increase the risk of urinary complications compared to RT performed later. We evaluated the urinary complication rates of men treated with surgery followed by early or late RT. METHODS: Using a retrospective chart review, we compared rates of urinary incontinence (UI), bladder neck contracture (BNC), or urethral stricture in men with prostate cancer treated with early RT (<6 months after RP) or late RT (≥6 months after RP), 3 years after RT. RESULTS: In total, 652 patients (between 2000 and 2007) underwent early RT (162, 24.8%) or late RT (490, 75.2%) after RP. The mean time to early RT was 3.6 months (range: 1-5 months) and to late RT was 30.1 months (range: 6-171 months). At 3 years post-RT, UI rates were similar in the early RT and the late RT groups (24.5% vs. 23.3%, respectively, p = 0.79). Prior to RT, 27/652 (4%) patients had a BNC and 11/652 (1.7%) had a urethral stricture, of which only 1 BNC persisted at 3 years post-RT. After RT, 17/652 (2.6%) BNC and 4/652 (0.6%) urethral stricture developed; of these, 6 BNC and 2 urethral strictures persisted at 3 years. CONCLUSION: Rates of UI, BNC, and urethral stricture were similar with early and late RT at 3 years post-RT. These findings suggest that the timing of RT after RP does not alter the incidences of these urinary complications and can aid in the decision-making process regarding adjuvant RT versus salvage RT.

Impact of 5α-reductase inhibitors on men followed by active surveillance for prostate cancer.

BACKGROUND: In two large randomized controlled trials, 5α-reductase inhibitors (5-ARIs) were shown to prevent prostate cancer. No prior work had shown the effect of 5-ARIs on those already diagnosed with low-risk prostate cancer. OBJECTIVE: Our aim was to determine the effect of 5-ARIs on pathologic progression in men on active surveillance. DESIGN, SETTING, AND PARTICIPANTS: We conducted a single-institution retrospective cohort study comparing men taking a 5-ARI versus no 5-ARI while on active surveillance for prostate cancer. MEASUREMENTS: Pathologic progression was evaluated and defined as Gleason score >6, maximum core involvement >50%, or more than three cores positive on a follow-up prostate biopsy. Kaplan-Meier analyses were conducted along with multivariable Cox proportional hazard regression modeling for predictors of pathologic progression. RESULTS AND LIMITATIONS: A total of 288 men on active surveillance met the inclusion criteria. The median follow-up was 38.5 mo (interquartile range: 23.6-59.4) with 93 men (32%) experiencing pathologic progression and 96 men (33%) abandoning active surveillance. Men taking a 5-ARI experienced a lower rate of pathologic progression (18.6% vs 36.7%; p=0.004) and were less likely to abandon active surveillance (20% vs 37.6%; p=0.006). On multivariable Cox proportional hazards analysis, lack of 5-ARI use was most strongly associated with pathologic progression (hazard ratio: 2.91; 95% confidence interval, 1.5-5.6). The main study limitation was the retrospective design and variable duration of 5-ARI therapy. CONCLUSIONS: The 5-ARIs were associated with a significantly lower rate of pathologic progression and abandonment of active surveillance.

A sticky situation: management of spray polyurethane foam insulation in body orifices.

Spray polyurethane foam insulation is commonly used in the construction industry to fill gaps, seal, and insulate. We present three cases of intentional spray foam insertion in body orifices and discuss the management of such situations in the emergency department. This series includes a case of oral foam insertion used in a suicide attempt by suffocation and two cases of rectal insertion. All of these cases had potential long-term consequences; one was life-threatening. To our knowledge, this is the first published report on the medical management and removal of foam insulation from body orifices. In all three cases, the foam insulation material was successfully removed after allowing the material to harden.

Perceptions of emergency medicine residents and fellows regarding competence, adverse events and reporting to supervisors: a national survey.

OBJECTIVE: We sought to characterize the perceptions of emergency medicine (EM) residents and fellows of their clinical and procedural competence, as well as their attitudes, practices and perceived barriers to reporting these perceptions to their supervisors. METHODS: A Web-based survey was distributed to residents and fellows, via their residency directors, in all Canadian EM residency programs outside of Quebec. RESULTS: Of 220 residents and fellows contacted in 9 of 10 EM programs of the Royal College of Physicians and Surgeons of Canada and 12 of 13 EM programs of The College of Family Physicians of Canada, 82 (37.3%) completed all or part of the survey. Response rates varied slightly by question; 25 of 82 re-spondents (30.5% [95% confidence interval (CI) 19.9%-41.1%]) agreed with the statement, "I sometimes feel unsafe or un-qualified with undertaking unsupervised responsibilities or procedures, but I do not report this to my senior physician" and 32 of 81 (39.5% [95% CI 28.2%-50.8%]) had felt this within the past 6 months. Moreover, 34 of 82 (41.5% [95% CI 30.2%-52.7%]) reported their lack of competence to a supervisor half the time or less. Trainees reported worry about loss of trust, autonomy or respect (38/80, 47.5% [95% CI 35.9%-59.1%]) or reputation (32/80, 40.0% [95% CI 28.6%-51.4%]). Nights on-call (30/79, 38% [95% CI 26.6%-49.3%]), admission decisions (13/79, 16.5% [7.6%-25.3%]) and central line insertion (13/79, 16.5% [95% CI 7.6%-25.3%]) were reported to be frequently undertaken despite not feeling competent. Suggestions to improve reporting included encouragement to report without penalty (41/82, 50.0% [95% CI 38.6%-61.4%]) and a less judgmental environment (32/82, 39.0% [95% CI 27.9%-50.2%]). CONCLUSION: Emergency medicine trainees report that they frequently do not feel competent when undertaking responsibilities without supervision. Barriers to reporting these feelings or reporting adverse events appear to relate to social pressures and authority gradients. Modifications to the training culture are encouraged to improve patient safety.