Intraoperative monitoring of the femoral and sciatic nerves in total hip arthroplasty with high-riding developmental dysplasia.

AIMS: This study aimed to explore whether intraoperative nerve monitoring can identify risk factors and reduce the incidence of nerve injury in patients with high-riding developmental dysplasia. PATIENTS AND METHODS: We conducted a historical controlled study of patients with unilateral Crowe IV developmental dysplasia of the hip (DDH). Between October 2016 and October 2017, intraoperative nerve monitoring of the femoral and sciatic nerves was applied in total hip arthroplasty (THA). A neuromonitoring technician was employed to monitor nerve function and inform the surgeon of ongoing changes in a timely manner. Patients who did not have intraoperative nerve monitoring between September 2015 and October 2016 were selected as the control group. All the surgeries were performed by one surgeon. Demographics and clinical data were analyzed. A total of 35 patients in the monitoring group (ten male, 25 female; mean age 37.1 years (20 to 46)) and 56 patients in the control group (13 male, 43 female; mean age 37.9 years (23 to 52)) were enrolled. The mean follow-up of all patients was 13.1 months (10 to 15). RESULTS: The two groups had no significant differences in preoperative data. In the monitoring group, ten nerve alerts occurred intraoperatively, and no neural complications were detected postoperatively. In the control group, six patients had neural complications. The rate of nerve injury was lower in the monitoring group than in the control group, but this did not achieve statistical significance. The degree of leg lengthening was significantly greater in the monitoring group than in the control group. In further analyses, patients who had previous hip surgery were more likely to have intraoperative nerve alerts and postoperative nerve injury. CONCLUSION: Nerve injury usually occurred during the processes of exposure and reduction. The use of intraoperative nerve monitoring showed a trend towards reduced nerve injury in THA for Crowe IV DDH patients. Hence, we recommend its routine use in patients undergoing leg lengthening, especially in those with previous hip surgery. Cite this article: Bone Joint J 2019;101-B:1438-1446.

Traction Time, Force and Postoperative Nerve Block Significantly Influence the Development and Duration of Neuropathy Following Hip Arthroscopy.

PURPOSE: To (1) evaluate the individual and combined effects of traction time and traction force on postoperative neuropathy following hip arthroscopy, (2) determine if perioperative fascia iliaca block has an effect on the risk of this neuropathy, and (3) identify if the these items had a significant association with the presence, location, and/or duration of postoperative numbness. METHODS: Between February 2015 and December 2016, a consecutive cohort of hip arthroscopy patients was prospectively enrolled. Traction time, force, and postoperative nerve block administration were recorded. The location and duration of numbness were assessed at postoperative clinic visits. Numbness location was classified into regions: 1, groin; 2, lateral thigh; 3, medial thigh; 4, dorsal foot; and 5,preoperative thigh or radiculopathic numbness. RESULTS: A total of 156 primary hip arthroscopy patients were analyzed, 99 (63%) women and 57 (37%) men. Mean traction time was 46.5 ± 20.3 minutes. Seventy-four patients (47%) reported numbness with an average duration of 157.5 ± 116.2 days. Postoperative fascia iliaca nerve block was a significant predictor of medial thigh numbness (odds ratio, 3.36; 95% confidence interval, 1.46-7.76; P = .04). Neither traction time nor force were associated with generalized numbness (P = .85 and P = .40, respectively). However, among those who experienced numbness, traction time and force were greater in patients with combined groin and lateral thigh numbness compared with those with isolated lateral thigh or medial thigh numbness (P = .001 and P = .005, respectively). CONCLUSIONS: Postoperative neuropathy is a well-documented complication following hip arthroscopy. Concomitant pudendal and lateral femoral cutaneous nerve palsy may be related to increased traction force and time, even in the setting of low intraoperative traction time (<1 hour). Isolated medial thigh numbness is significantly associated with postoperative fascia iliaca blockade. LEVEL OF EVIDENCE: IV, case series.

Neurophysiological monitoring during neurosurgery: anesthetic considerations based on outcome evidence.

PURPOSE OF REVIEW: This article reviews the recent outcome studies that investigated intraoperative neurophysiological monitoring (IONM) during spine, neurovascular and brain tumor surgery. RECENT FINDINGS: Several recent studies have focused on identifying which types of neurosurgical procedures might benefit most from IONM use. Despite conflicting literature regarding its efficacy in improving neurological outcomes, many experts have advocated for the use of IONM in neurosurgery. Several themes have emerged from the recent literature: the entire perioperative team must always work together to ensure adequate communication and intervention; systems and checklists, in which each member of the perioperative team has a clearly defined role, can be useful in the event of a sudden intraoperative changes in electrophysiological signals; regardless of the IONM modality used, any sudden change in electrophysiological signal should prompt an immediate and appropriate intervention; a multimodal IONM approach is often, but not always, advantageous over a single IONM approach. SUMMARY: For neurosurgical procedures that can be complicated by neural injury, the use of IONM should be considered according to specific patient and surgical factors. Future studies should focus on improving IONM technology and optimizing sensitivity and specificity for detecting any impending neural damage.

Multimodal intraoperative monitoring during surgical correction of scoliosis to avoid neurologic damage.

The purpose of this study was to evaluate the application of multimodal intraoperative monitoring (MIOM) system in patients with congenital scoliosis (CS) and adolescent idiopathic scoliosis (AIS).Twelve patients who underwent posterior surgical correction of scoliosis for CS and AIS from June 2014 to July 2018 were enrolled in this study. During the operation, we monitored the functional status of the spinal cord by MIOM. An abnormal somatosensory evoked potential was defined as a prolonged latency of more than 10% or a peak-to-peak amplitude decline of more than 50% when compared to baseline. An abnormal transcranial motor evoked potential (TcMEP) was defined as a TcMEP amplitude decrease of more than 50%. A normal triggered electromyography response, which presented with the absence of an electrical response on stimulation at 8.2 mA, indicated that the pedicle screw was not in contact with the spinal cord or nerve root.A total of 12 patients underwent MIOM surgery, of which 9 patients with negative MIOM had no significant deterioration of neurological function postoperatively, and exhibited satisfactory surgical correction of scoliosis during follow-ups. However, the remaining 3 patients suffered from MIOM events, 2 patients had normal neurological function, and 1 patient had deteriorated neurological function postoperatively.Using MIOM in CS and AIS surgery could promptly detect iatrogenic neurological injury at the early stage. Therefore, rapid response by appropriate intraoperative interventions can be taken to minimize the injury. Besides, stable MIOM recordings encourage surgeons to correct scoliosis even when the Cobb angle of scoliosis was extremely large.

Intraoperative Neuromonitoring (IONM): Is There a Role in Metastatic Spine Tumor Surgery?

STUDY DESIGN: A retrospective design. OBJECTIVE: We aim to report our experience with multimodal intraoperative neuromonitoring (IONM) in metastatic spine tumor surgery (MSTS). SUMMARY OF BACKGROUND DATA: IONM is considered as standard of care in spinal deformity surgeries. However, limited data exist about its role in MSTS. METHODS: A total of 135 patients from 2010 to 2017, who underwent MSTS with IONM at our institute, were studied retrospectively. After excluding seven with no baseline signals, 128 patients were analyzed. The data collected comprised of demographics, pre and postoperative American Spinal Injury Association (ASIA) grades and neurological status, indications for surgery, type of surgical approach. Multimodal IONM included somatosensory-evoked potentials (SSEPs), transcranial electric motor-evoked potentials (tcMEP), and free running electromyography (EMG). RESULTS: The 128 patients included 61 males and 67 females with a mean age of 61 years. One hundred sixteen underwent posterior procedures; nine anterior and three both. The frequency of preoperative ASIA Grades were A = 0, B = 0, C = 10, D = 44, and E = 74 patients. In total, 54 underwent MSTS for neurological deficit, 66 for instability pain, and 8 for intractable pain.Of 128 patients, 13 (10.2%) had significant IONM alerts, representing true positives; 114 true negatives, one false negative, and no false positives. Among the 13 true positives, four (30%) underwent minimally invasive and nine (70%) open procedures. Eight (69.2%) patients had posterior approach. Seven (53.84%) true positive alerts were during decompression, which resolved to baseline upon completion of decompression, while five (38.46%) were during instrumentation, which recovered to baseline after adjusting/downsizing the instrumentation, and one (8.3%) during lateral approach, which reversed after changing the plane of dissection. Of the seven patients without baseline, five were ASIA-A and two were ASIA-C. The sensitivity, specificity, positive, and negative predictive values were 99.1%, 100%, 100%, and 92.9%, respectively. CONCLUSION: Multimodal IONM in MSTS helped in preventing postoperative neurological deficit in 9.4% of patients. Its high sensitivity and specificity to detect intraoperative neurological events envisage its use in ASIA-grade D/E patients requiring instrumented decompression. LEVEL OF EVIDENCE: 3.

Posterior Nerve-Sparing Multilevel Cervical Corpectomy and Reconstruction for Metastatic Cervical Spine Tumors: Case Report and Literature Review.

BACKGROUND: Cervical spine metastases with circumferential spinal cord compression often are treated with combined anteroposterior decompression and stabilization. In patients with large anterior neck masses, previous radiotherapy to the neck, or previous anterior neck surgery, however, anterior approaches may pose additional risk. In such cases, posterior-only approaches that allow for circumferential decompression and anterior column reconstruction may be beneficial. CASE DESCRIPTION: We present the case of a 70-year-old man with follicular thyroid carcinoma metastatic to the cervical spine causing spinal cord compression. We used a posterior-only approach for a C6-C7 partial corpectomy and posterior decompression and fusion from C2 to T2. Our technique involved preoperative embolization of the right vertebral artery to safely gain access to the ventral surface of the spinal cord and vertebral bodies. Anterior column support was provided by a chest tube/polymethylmethacrylate construct, allowing the implant to be placed within the anterior column from a posterior approach without nerve root sacrifice. The patient tolerated the procedure well. He had no postoperative neurologic deficits. Two months later, he underwent a total thyroidectomy followed by stereotactic radiotherapy to the tumor bed (2700 cGy total, 3 fractions). At 1-year follow-up, he was active and without significant pain or focal neurologic deficits. CONCLUSIONS: We propose a novel approach to ventral/circumferential cervical spine tumors that combines epidural decompression and cervical stabilization via a posterior-only approach. By using a chest tube/polymethylmethacrylate construct, anterior column support can be achieved through a posterior approach without nerve root sacrifice.

A safe technique for insertion of heel wires for hindfoot external fixation frames: an anatomical study.

Aims: Anatomical atlases document classical safe corridors for the placement of transosseous fine wires through the calcaneum during circular frame external fixation. During this process, the posterior tibial neurovascular bundle (PTNVB) is placed at risk, though this has not been previously quantified. We describe a cadaveric study to investigate a safe technique for posterolateral to anteromedial fine wire insertion through the body of the calcaneum. Materials and Methods: A total of 20 embalmed cadaveric lower limbs were divided into two groups. Wires were inserted using two possible insertion points and at varying angles. In Group A, wires were inserted one-third along a line between the point of the heel and the tip of the lateral malleolus while in Group B, wires were inserted halfway along this line. Standard dissection techniques identified the structures at risk and the distance of wires from neurovascular structures was measured. The results from 19 limbs were subject to analysis. Results: In Group A, no wires pierced the PTNVB. Wires were inserted a median 22.3 mm (range 4.7 to 39.6) from the PTNVB; two wires (4%) passed within 5 mm. In Group B, 24 (46%) wires passed within 5 mm of the PTNVB, with 11 wires piercing it. The median distance of wires from the PTNVB was 5.5 mm (range 0 to 30). A Mann-Whitney U test showed that this was significantly closer than in Group A (Hodges-Lehmann shift, 14.06 mm; 95% confidence interval (CI) 10.52 to 16.88; p < 0.0001). In Group B, with an increased angle of insertion there was greater risk to the PTNVB (rs = -0.80; p < 0.01). Conclusion: Insertion of wires using an entry point one-third along a line from the point of the heel to the tip of the lateral malleolus (Group A) appears to be the safer technique. An insertion angle of up to 30° to the coronal plane can be used without significant risk to the PTNVB. Insertion of wires halfway along a line from the point of the heel to the tip of the lateral malleolus (Group B) carried a significantly higher risk of injury to neurovascular structures and, if necessary, an angle of insertion parallel to the coronal plane should be used. Cite this article: Bone Joint J 2018;100-B:1054-9.

Complications and Prevention Strategies of Oblique Lateral Interbody Fusion Technique.

OBJECTIVE: To analyze the early complications and causes of oblique lateral interbody fusion, and put forward preventive measures. METHODS: There were 235 patients (79 males and 156 females) analyzed in our study from October 2014 to May 2017. The average age was 61.9 ± 0.21 years (from 32 to 83 years). Ninety-one cases were treated with oblique lateral interbody fusion (OLIF) alone (OLIF alone group) and 144 with OLIF combined with posterior pedicle screw fixation through the intermuscular space approach (OLIF combined group). In addition, 137/144 cases in the combined group were primarily treated by posterior pedicle screw fixation, while the treatments were postponed in 7 cases. There were 190 cases of single fusion segments, 11 of 2 segments, 21 of 3 segments, and 13 of 4 segments. Intraoperative and postoperative complications were observed. RESULTS: Average follow-up time was 15.6 ± 7.5 months (ranged from 6 to 36 months). Five cases were lost to follow-up (2 cases from the OLIF alone group and 3 cases from the OLIF combined group). There were 7 cases of vascular injury, 22 cases of endplate damage, 2 cases of vertebral body fracture, 11 cases of nerve injury, 18 cases of cage sedimentation or cage transverse shifting, 3 cases of iliac crest pain, 1 case of right psoas major hematoma, 2 cases of incomplete ileus, 1 case of acute heart failure, 1 case of cerebral infarction, 3 case of left lower abdominal pain, 9 cases of transient psoas weakness, 3 cases of transient quadriceps weakness, and 8 cases of reoperation. The complication incidence was 32.34%. Thirty-three cases occurred in the OLIF alone group, with a rate of 36.26%, and 43 cases in the group of OLIF combined posterior pedicle screw fixation, with a rate of 29.86%. Fifty-seven cases occurred in single-segment fusion, with a rate of 30.0% (57/190), 4 cases occurred in two-segment fusion, with a rate of 36.36% (4/11), 9 cases occurred in three-segment fusion, with a rate of 42.86% (9/21), and 6 cases occurred in four-segment fusion, with a rate of 46.15% (6/13). CONCLUSION: In summary, OLIF is a relatively safe and very effective technique for minimally invasive lumbar fusion. Nonetheless, it should be noted that OLIF carries the risk of complications, especially in the early stage of development.

Predictive modelling of 2-year potency outcomes using a novel 90-day erection fullness scale after robot-assisted radical prostatectomy.

OBJECTIVE: To introduce a patient-reported erection fullness scale (%fullness) after robot-assisted radical prostatectomy (RARP) as a qualitative adjunct to the five-item version of the International Index of Erectile Function (IIEF-5) and as a 90-day predictor of 2-year potency outcomes. PATIENTS AND METHODS: Prospective data were collected from 540 men with preoperative IIEF-5 scores of 22-25 who underwent RARP by a single surgeon, and of whom 299 had complete data at all time points up to 2 years. In addition to standard assessment tools (IIEF-5 and erections sufficient for intercourse [ESI]), the men were asked to 'indicate the fullness you are able to achieve in erections compared to before surgery?' (range: 0-100%). The primary outcome was prediction of potency (defined as ESI) at 24 months, based on 90-day %fullness tertile (0-24%, 25-74% and 75-100%). RESULTS: A total of 299 men with complete follow-up were included in the study. Significant predictors of 24-month potency included age, body mass index, pathological stage, nerve-sparing status and %fullness tertiles. When the men (preoperative IIEF-5 score 22-25) were assessed at 90 days after RARP, 181/299 (61%) had erections inadequate for intercourse. If IIEF-5 scores of 1-6 were used, 142/181 men (78%) would be targeted for early intervention. By contrast, if 0-24% fullness was used, 88/181 men (49%) would be targeted. If both the IIEF-5 score and %fullness were used, this would be reduced to 77/181 men (43%). CONCLUSIONS: We introduce %fullness as a qualitative adjunct to the IIEF-5 score, and separately as a 90-day predictor of 2-year potency recovery. This initial report is hypothesis-generating, such that the use of %fullness enables the identification of men who are most likely to benefit from early, secondary intervention.

Multimodal intraoperative monitoring during reduction of spine burst fracture and dislocation prevents neurologic injury.

This study aims to evaluate the application of multimodal intraoperative monitoring (MIOM) in surgical treatment for spine burst fracture and dislocation (SBFD) patients.Eleven patients who underwent posterior reduction and instrumentation (PRI) for SBFD from June 2014 to July 2016 were included into the study. The function of the spinal cord was monitored by MIOM. The muscle strength of the lower extremities and American Spinal Injury Association (ASIA) scores were, respectively, evaluated (before surgery, and at 1, 3, 6, and 12 months after surgery). Furthermore, the extent of reduction was also assessed.Muscle strength recovery, ASIA score changes, and the extent of reduction were correlated with MIOM results. Among the 11 patients who received surgery under MIOM, 8 patients with negative MIOM results during the operation did not demonstrate neurological deterioration postoperatively and exhibited improvements in ASIA scores during follow-ups. However, among the 3 patients who encountered MIOM events (case 4, 7, and 8), 2 patients avoided nerve lesion and 1 patient suffered from neurologic deterioration postoperatively.The application of MIOM technology during PRI surgery may detect spinal cord impairment at the early stage, and operative schemes can be modified before permanent nerve compromise is triggered by surgical manipulation.

Nerve-Sparing Technique during Laparoscopic Radical Hysterectomy: Critical Steps.

STUDY OBJECTIVE: To show the feasibility and safety of nerve-preserving laparoscopic radical hysterectomy (type C1 Querleu-Morrow Classification [1]) for the treatment of early cervical cancer. DESIGN: A surgical video article (Canadian Task Force classification III). SETTING: A university hospital (University Hospital of Barcelona, Barcelona, Spain). PATIENTS: Nerve-preserving radical hysterectomy is performed in a patient with Fédération Internationale de Gynécologie et d'Obstétrique stage 1B1 cervical cancer with deep stromal invasion. INTERVENTIONS: Three steps are fundamental for the removal of the cérvix with a safe oncologic margin and preservation of the pelvic autonomic nerves [2]. 1. Step 1: for the correct preservation of the pelvic splanchnic nerves (ventral roots from spinal nerves S2-S4) and the inferior hypogastric plexus during the section of the paracervix, it is essential to identify the deep uterine vein. This vein will correspond with the inferior limit of the dissection. 2. Step 2: during the dissection of the uterosacral ligament and after dissecting the Okabayashi space, the inferior hypogastric nerve is isolated. This nerve runs 2 cm parallel below the uterosacral ligament in the peritoneal leaf of the broad ligament. 3. Step 3: during the section of the vesicouterine ligament, the lateral side must be preserved because it includes the medial and inferior vesical veins that drain to the deep uterine vein. CONCLUSION: Nerve-sparing laparoscopic radical hysterectomy is an attractive surgical approach for early-stage cervical cancer. Direct visualization of the pelvic autonomic nervous system (sympathetic and parasympathetic branches) innervating the bladder and rectum makes the nerve-sparing approach a safe and feasible procedure.

Nerve-sparing radical cystectomy has a beneficial impact on urinary continence after orthotopic bladder substitution, which becomes even more apparent over time.

OBJECTIVE: To analyse urinary continence in long-term survivors after radical cystectomy (RC) and orthotopic bladder substitution (OBS) according to attempted nerve-sparing (NS) status. PATIENTS AND METHODS: We analysed 180 consecutive patients treated at our department between 1985 and 2007, who underwent RC with OBS, and survived ≥10 years after RC. We stratified patients by attempted NS status and evaluated continence outcomes using descriptive statistics and Cox proportional hazards regression models. A secondary analysis evaluated erectile function as a quality control for attempted NS. RESULTS: The median (interquartile range [IQR]) age at RC was 62 (57-71) years. Of 180 patients, attempted NS status was none in 24 (13%), unilateral in 100 (56%), and bilateral in 56 (31%). After a median (IQR) follow-up of 169 (147-210) months, 160 (89%) patients were continent during daytime and 124 (69%) during night-time. In multivariable analysis, any degree of attempted NS was significantly associated with daytime continence (odds ratio [OR] 2.08, 95% confidence interval [CI] 1.05-4.11; P = 0.04). Correspondingly, any attempted NS was significantly associated with night-time continence (OR 2.51, 95% CI 1.08-5.85; P = 0.03). Recovery of erectile function at 5 years was also significantly associated with attempted NS (P < 0.001). CONCLUSION: Nerve-sparing during RC and OBS was associated with better long-term continence outcomes. This becomes more apparent as the patients age with their OBS. We advocate a NS RC whenever an OBS is considered.

The neurovascular structure-adjacent frozen-section examination (NeuroSAFE) approach to nerve sparing in robot-assisted laparoscopic radical prostatectomy in a British setting - a prospective observational comparative study.

OBJECTIVES: To evaluate the neurovascular structure-adjacent frozen-section examination (NeuroSAFE) technique in a British setting in men undergoing robot-assisted laparoscopic radical prostatectomy (RALP) . PATIENTS AND METHODS: We retrospectively analysed our prospectively maintained database of patients who underwent RALP between November 2008 and February 2017. We examined preoperative pathological and functional parameters, intraoperative nerve sparing (NS), postoperative histology, as well as functional and oncological follow-up. We compared those who had a NeuroSAFE approach and those who had NS without NeuroSAFE. We also compared all the RALPs before and after the introduction of NeuroSAFE. Statistical analysis was done using the two-tailed t-test and chi-squared analysis. RESULTS: This single surgeon series included 417 RALPs, including 120 NeuroSAFEs. The NeuroSAFE cohort had a greater proportion of D'Amico high-risk disease (30.8% vs 9.6%, P < 0.001), higher Gleason scores and higher pT stage compared to the non-NeuroSAFE NS cohort. After the introduction of NeuroSAFE, more preoperatively potent men underwent bilateral NS with pT2 disease (84.6% vs 66.3%, P = 0.002) and more overall NS were performed in patients with pT3 disease (65.1% vs 36.7%, P = 0.012). Overall positive surgical margin (PSM) rates were lower in the NeuroSAFE cohort compared to those who had NS without NeuroSAFE (9.2% vs 17.8%, P = 0.04). The 12-month potency rates were also higher in the NeuroSAFE cohort for both bilateral (77.3% vs 50.9%, P = 0.009) and unilateral (70.6% vs 40%, P = 0.04) NS. Pad-free continence was also higher in the NeuroSAFE group (85.7% vs 70.9%, P = 0.019), but there was no significant difference between those who were wearing ≤1 safety pad. Although we only had short-term oncological follow-up, it did not significantly differ between the two groups. CONCLUSION: Adoption of NeuroSAFE allowed us to offer NS in higher risk patients, whilst reducing PSM rates and at the same time improving potency at 12 months.

Robot-assisted nerve-sparing radical prostatectomy using near-infrared fluorescence technology and indocyanine green: initial experience.

INTRODUCTION: Indocyanine green (ICG) is a fluorescent molecule that provokes detectable photon emission. The use of ICG with near-infrared (NIR) imaging system (Akorn, Lake Forest, IL) has been described during robotic partial nephrectomy (RAPN) as an adjunctive means of identifying renal artery and parenchymal perfusion. We propose the use of the ICG with NIR fluorescence during laparoscopic robot-assisted radical prostatectomy (RARP), to identify the benchmark artery improving the preservation of neurovascular bundle and to improve the visualization of the vascularization and then the hemostasis. METHODS: From April 2015 to February 2016, 62 patients underwent to RARP in our Urology Unit. In 26 consecutive patients, in the attempt to have a better visualization of neurovascular bundles, we used to inject ICG during the procedure. We evaluated the percentage of identification of neurovascular bundles using NIR fluorescence. Then, we evaluated complications related to injection of ICG and operative time differences between RARP with and without ICG injection performed by the same surgeons. RESULTS: We identified prostatic arteries and neurovascular bundles using NIR fluorescence technology in all patients (100%). There was not any increase in the operative time compared with RARP without ICG injection performed by the same surgeons. Complications related to injection of ICG did not occurred. CONCLUSIONS: In our experience, even if on a limited number of patients, the application of ICG with NIR fluorescence during RARP is helpful to identify the benchmark artery of neurovascular bundle.

Thrombo-embolic prevention after transcatheter aortic valve implantation.

Transcatheter aortic valve implantation (TAVI) has emerged as a valuable treatment alternative to surgical aortic valve replacement among patients with symptomatic aortic stenosis at increased surgical risk. The rapid technological evolution from early to current-generation TAVI systems with low-profile delivery catheters, bioprosthetic valves with proven midterm durability, and improved positioning and retrieval features have made important contributions to the widespread clinical use of this minimal invasive therapy. Although peri-procedural and long-term thrombotic and bleeding events after TAVI remain a relevant concern, the optimal antithrombotic strategy and duration to mitigate these risks remain unclear. This review provides an overview of recent insights in this field, and highlights current and future antithrombotic trials focusing on optimizing outcomes in patients undergoing TAVI.

Short- and Long-term Functional Outcomes and Quality of Life after Radical Prostatectomy: Patient-reported Outcomes from a Tertiary High-volume Center.

BACKGROUND: Results from population-based studies and the Prostate Testing for Cancer and Treatment trial reported worse urinary continence (UC) and erectile function (EF) for radical prostatectomy (RP) patients compared with their radiation or active surveillance counterparts. OBJECTIVE: To investigate functional outcomes for patients undergoing RP in a high-volume center. DATA, SETTING, AND PARTICIPANTS: A total of 8573 consecutive RP patients (2008-2012) were analyzed. INTERVENTION: RP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Standardized questionnaires assessing EF, UC, and quality of life (QoL), were completed at baseline and annually thereafter. UC was defined as use of 0 or 1 safety pad/d, whereas the regular use of 1 pad/d was considered incontinent. EF was defined as ≥3 points in the International Index of Erectile Function question two. QoL was assessed using the EORTC-QLQ-C30 Global Health/QoL item. Statistics relied on comparison of means and proportions. RESULTS AND LIMITATIONS: EF and UC rates significantly decreased after RP. Overall, 12-mo, 24-mo, and 36-mo EF rates were 45%, 51%, and 53%, but reached up to 65.7% in preoperatively potent patients with bilateral nerve sparing. At 36 mo, 13% reported problems in their partnership. However, at the same time point, 77% were satisfied with their sexual intercourse. UC rates were 89.1%, 91.3%, and 89.0% at 12-mo, 24-mo, and 36-mo postoperatively. Mean EORTC-QLQ-C30 scores ranged from 74 to 79 and remained constant compared to baseline. CONCLUSIONS: Although varying definitions hinder direct comparisons to other studies, functional outcomes seemed favorable for patients undergoing RP in a high-volume center and most patients reported excellent QoL. PATIENT SUMMARY: Results of functional outcomes (urinary continence and potency) after radical prostatectomy are better in a high-volume center compared with those obtained from population-based data, and most patients report excellent quality of life after radical prostatectomy.

In Vogue: Ketamine for Neuroprotection in Acute Neurologic Injury.

Neurologic deterioration following acute injury to the central nervous system may be amenable to pharmacologic intervention, although, to date, no such therapy exists. Ketamine is an anesthetic and analgesic emerging as a novel therapy for a number of clinical entities in recent years, including refractory pain, depression, and drug-induced hyperalgesia due to newly discovered mechanisms of action and new application of its known pharmacodynamics. In this focused review, the evidence for ketamine as a neuroprotective agent in stroke, neurotrauma, subarachnoid hemorrhage, and status epilepticus is highlighted, with a focus on its applications for excitotoxicity, neuroinflammation, and neuronal hyperexcitability. Preclinical modeling and clinical applications are discussed.

Reality of nerve sparing and surgical margins in surgeons' early experience with robot-assisted radical prostatectomy in Japan.

OBJECTIVE: To analyze nerve sparing performance at an early stage of robot-assisted radical prostatectomy, and the correlation between the surgeons' experience and the risk of a positive surgical margin in patients treated with robot-assisted radical prostatectomy. METHODS: Patients' records from January 2009 to March 2013 were retrospectively reviewed, and 3469 patients with localized prostate cancer were identified at 45 institutions. Individual surgeon's experience with nerve sparing was recorded as the number of nerve sparing cases among total robot-assisted radical prostatectomies beginning with the first case during which nerve sparing was carried out. Patients were selected by propensity score matching for nerve sparing, and predictive factors of positive surgical margins were analyzed in patients with and without positive surgical margins. RESULTS: A total of 152 surgeons were studied, and the median number of robot-assisted radical prostatectomy cases for all surgeons was 21 (range 1-511). In all, 54 surgeons (35.5%) undertook nerve sparing during their first robot-assisted radical prostatectomy case. For 2388 patients selected with (1194) and without (1194) nerve sparing, predictive factors for positive surgical margin were high initial prostate-specific antigen level (P < 0.0001), high biopsy Gleason score (P = 0.0379), presence of neoadjuvant hormone therapy (P = 0.0002) and surgeon's experience with >100 cases (P = 0.0058). Thus, nerve sparing was not associated with positive surgical margins. CONCLUSION: The surgeon's experience influences the occurrence of positive surgical margins, although a considerable number of surgeons carried out nerve sparing during their early robot-assisted radical prostatectomy cases. Surgeons should consider their own experience and prostate cancer characteristics before carrying out a nerve sparing robot-assisted radical prostatectomy.

Magnetic Resonance Imaging Signal Characteristics of Medishield: Early Postoperative Profile in a Rabbit Interlaminotomy Model.

OBJECTIVE: Application of Medishield to the nerve root is common during spinal surgery to create a mechanical barrier from pain mediators and reduce scar formation. However, Medishield's signal characteristics on magnetic resonance imaging (MRI) have not yet been examined. METHODS: Microsurgical interlaminotomy was performed on 2 lower lumbar segments in 17 adult New Zealand white rabbits. After dural exposure, applications of 1 mL (autologous blood clot or Medishield) were randomized for each level. On postoperative days 1 through 3, various MRI sequences in 1.5T were performed including T1-weighted, T2-w, T1-gadolinium-weighted, susceptibility-weighted and turbo inversion recovery magnitude (TIRM) sequence. Signaling characteristics were analyzed by 3 blinded observers. Inter-rater agreement was calculated using Fleiss's kappa coefficient (κ). Positive and negative likelihood ratios in detecting Medishield by MRI were determined. RESULTS: Of 24 MRIs performed, TIRM sequence identified Medishield with the highest likelihood ratio. Medishield's positive likelihood ratio was highest (5.8) on postoperative day 1 with interobserver agreement of 93% (κ = 0.75); these rates declined to 2.5 and 1.4 on postoperative days 2 and 3 with interobserver agreements of 71% (κ = 0.43) and 83% (κ = 0.67), respectively. Medishield adherence was confirmed in each rabbit by histologic examinations. CONCLUSION: Understanding that radiologic detection of Medishield diminished over time as its signal characteristics became less distinguishable from a blood clot is essential in clinical practice. Medishield was detected on postoperative day 1 but not 2 days later after hemodynamic changes had occurred. These results may provide a guide for postoperative findings, such as differential diagnosis of hematoma.