Perioperative outcomes of open vs. robotic radical cystectomy: a nationwide comparative analysis (2008-2014).

INTRODUCTION: Radical cystectomy (RC) is a complex procedure with high perioperative morbidity. In an effort to reduce complications, robotic-assisted RC (RARC) has been adopted as a minimally invasive alternative to the open approach (ORC). Herein, we examine post-operative outcomes of the two surgical approaches in the United States (US) using a large all-payer database. MATERIAL AND METHODS: Using International Classification of Disease, ninth revision (ICD-9) codes, patient who underwent RC were captured from National Inpatient Sample (2008-2014). ICD-9 diagnosis and procedure codes were used to identify post-operative complications. Trends in the utilization of RARC were analyzed. Logistic and log-linear regression accounting for hospital sample weights and sampling years were performed to analyze outcomes after adjustment of pertinent covariates. RESULTS: Of 11,189 patients, 14% underwent RARC. RARC was performed in more teaching hospitals, male patients, those with private insurance, and lower comorbidity score. Performance of RARC steadily increased over the study period (p <0.01). In the last year of the study, 22.8% of cases performed robotically. The weighted average length-of-stay were 10.4 and 8.79 days for ORC and RARC, respectively (p <0.01). In multivariable analyses, RARC was associated with decreased blood transfusion, parenteral nutrition, pneumonia, surgical-site infection, wound and respiratory complications (all, p <0.05). No significant differences were found for in-hospital mortality, cardiac, genitourinary, and vascular complications. CONCLUSIONS: Performance of RARC has significantly increased in recent years. RARC appears safe and feasible for select patients. Earlier discharge and lower complications were noted for those undergoing RARC across different hospital systems nationwide.

Important surgical concepts and techniques in inguinal lymph node dissection.

PURPOSE OF REVIEW: Penile cancer is a rare disease with significant physical and psychosocial morbidity. It has a propensity to spread to the inguinal lymph nodes where it can progress to the pelvis and beyond. Here, we present a contemporary review on the surgical management of the lymph nodes. RECENT FINDINGS: Appropriate management of the lymph nodes is critical, and has been shown to impact survival for these patients. Those with lower stage disease can achieve cure with inguinal lymph node dissection (ILND), whereas a multidisciplinary approach is required in those with more extensive disease. Tertiary referral center should be strongly considered. Advances in surgical techniques have allowed for improved outcomes and lower morbidity postoperatively. Modified ILND can be safely performed for those with nonpalpable nodes, whereas diagnostic sentinel node biopsy is a good alternative in centers of experience. Minimally invasive ILND has recently gained popularity with favorable results at short-term follow-up. For those with more advanced disease, the literature remains scarce with no high-level evidence as of yet. SUMMARY: Early upfront surgery appears the best way to approach men with early involvement of the inguinal lymph nodes, whereas systemic therapy is typically reserved for higher volume disease. Clinical trial enrollment continues to be a priority to garner more evidence-based recommendations for this aggressive malignancy.

Penile ulceration caused by a foreign body reaction in a crew member on board a cruise ship.

A crew member had a foreign body implanted subcutaneously on his dorsum penis stealthily 6 years earlier by a fellow crew member without any medical training. He presented to the ship's medical centre after a week of pain, erythema and oedema over the foreign body, which was eventually removed by the patient, leaving behind a penile ulceration. He was treated conservatively initially with intravenous and then with oral antibiotics until complete secondary wound closure was achieved.

Medevac from a cruise ship of a patient with spontaneous coronary artery dissection who presented with epigastralgia.

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome that has been associated with peripartum and postpartum periods. It results from the separation of the layers of the arterial wall of the coronary artery with the subsequent formation of a false lumen. We report a case of a 54-year-old female who presented to the cruise ship's medical facility complaining of epigastralgia and dizziness. Work up including an electrocardiography and cardiac profile was ordered. Results yielded a diagnosis of non-ST segment elevation myocardial infarction (NSTEMI). Treatment following American Heart Association recommendations including nitrates, clopidogrel and enoxaparin was given. After debarkation at sea and referral to a reference hospital, the patient was diagnosed with SCAD. Patient's outcome was favorable and she was discharged home a few days after, despite being managed as a NSTEMI.