Identifying Preoperative Predictors of Operative Time and Their Impact on Outcomes in Robot-Assisted Partial Nephrectomy.

Objective: To identify preoperative characteristics in patients with renal masses that influence operative time during robot-assisted partial nephrectomy (RAPN) and evaluate the relationship between operative time and length of stay (LOS), complication rates, and overall outcome. Materials and Methods: We queried our institutional database to identify a cohort of patients who underwent RAPN by two experienced robotic surgeons between 2012 and 2019. A multivariable regression model was developed to analyze operative time, LOS, and any grade complication within 30 days postoperatively using the bootstrap resampling technique. Results: A total of 392 patients were included. On multivariable analyses, prior abdominal surgery (p = 0.001) was associated with 22 minutes of increase in operating room time, as well as adhesive perirenal fat (22 minutes, p = 0.001). For each one unit increase in nephrometry score, there was a 4-minute increase in operating room time (p = 0.028), and for each one-cm increase in tumor size, there was an associated 12-minute increase in operating room time (p < 0.001). For each 1 year increase in age, there was an associated 0.024-day increase in LOS [odds ratio (OR) (0.013-0.035)]; in addition, for every one-cm increase in tumor size there was a 0.18-day associated increase in LOS [OR (0.070-0.28)]. Each 1-hour increase in operating room time was associated with a 0.25-day increased LOS [OR (0.092-0.41)]. Only tumor size was found to be associated with any grade complication. Conclusions: Patients with a history of abdominal surgery, larger complex tumors, and significant Gerota's fat undergoing robotic partial nephrectomy should anticipate longer operative times. Older patients with larger tumors and longer operative times can anticipate a longer LOS. Tumor size appears to be the common determinant of all three outcomes: operative time, LOS, and any grade Clavien complication.

Robotic Sacral Colpopexy Using Autologous Fascia Lata Compared with Mesh.

Objective: The objective is to compare robotic sacral colpopexy (RSC) utilizing autologous fascia lata with RSC with synthetic mesh in the treatment of pelvic organ prolapse (POP). Methods: We performed a prospective nonrandomized case comparison trial at a single institution. We compared RSC utilizing either synthetic mesh or autologous fascia lata in women with symptomatic POP, stages II through IV. The primary outcome was anatomic prolapse recurrence determined by the Pelvic Organ Prolapse Quantification (POP-Q) examination. Secondary outcomes included patient-reported outcomes such as the Urogenital Distress Inventory-6 (UDI-6) and Incontinence Impact Questionnaire-7 (IIQ-7). Complications were also recorded and categorized using the Clavien-Dindo (CD) system. The hypothesis is that autologous fascia lata would provide equivalent anatomic and patient-reported outcomes compared with mesh while eliminating mesh-related complications. Results: Sixty-four women underwent RSC with 19 (29.7%) receiving fascia lata graft. The overall operative time was greater in the fascia lata group with mean fascia lata harvest time of 24.8 ± 7.4 minutes. Intragroup comparisons of the fascia and mesh groups demonstrated significant improvement in pelvic measurements as well as patient-reported outcomes. Intergroup comparison demonstrated equivalent success rates at 12.1 ± 8.7 months follow-up. There was one apical failure in the fascia lata RSC group; however, the difference was not statistically significant (p = 0.30). Significant complications in the fascia lata harvest group included two CD-II and one CD-IIIb. In the mesh group there was one mesh erosion requiring surgical excision (CD-IIIb). Conclusion: This is the first comparison between RSC with autologous fascia lata and mesh. Short-term anatomic outcomes were similar with autologous fascia lata use without the risk of mesh erosion. Morbidity from graft harvest site was not trivial. These results emphasize the need for a randomized controlled trial.

Perioperative Outcomes and Quality of Life after Repair of Recurrent Hiatal Hernia Are Compromised Compared with Primary Repair.

Paraesophageal hernia repair (PEHR) is burdened by high recurrence rates that frequently lead to redo PEHR. Revisional surgery, because of higher complexity, higher risk of injury, and the intrinsic risk of recurrence, has increased likelihood of higher complication rates and decreased quality of life (QOL) postoperatively. We aimed to compare perioperative outcomes and QOL after revisional and primary PEHR. A retrospective review of all patients who underwent PEHR for a recurrent hernia between January 2011 and July 2016 was completed. These were matched with a contemporary cohort of patients who underwent primary PEHR by age, gender, and BMI. Perioperative measures were compared. The patients were invited to complete the Gastrointestinal Quality of Life Index (GIQLI) to assess response to surgical intervention. There were 24 patients (group 1) who underwent revisional PEHR, and they were matched to 48 patients (group 2) who had a primary hernia repair. Thirteen patients in group 1 responded to the survey (54%), whereas 21 patients' responses were received from group 2 (44%). Conversion rates, LOS, and mean Gastrointestinal Quality of Life Index scores were significantly different between the two groups. Reoperative procedures for paraesophageal and hiatal hernias are burdened by higher conversion rates and length of stay, with similar overall complication rates. Patients who are undergoing repair of a recurrent hernia should be preoperatively counseled, and should have realistic expectations of their GI QOL after surgery.

A contemporary population-based analysis of the incidence, cost, and outcomes of postoperative delirium following major urologic cancer surgeries.

PURPOSE: Postoperative delirium (PD) is associated with poor outcomes and increased health care costs. The incidence, outcomes, and cost of delirium for major urologic cancer surgeries have not been previously characterized in a population-based analysis. MATERIALS AND METHODS: We performed a population-based, retrospective cohort study of patients with PD at 490 US hospitals between 2003 and 2013 to evaluate the incidence, outcomes, and cost of delirium after radical prostatectomy, radical nephrectomy, partial nephrectomy, and radical cystectomy (RC). Delirium was defined using ICD-9 codes in combination with postoperative antipsychotics, sitters, and restraints. Regression models were constructed to assess mortality, discharge disposition, length of stay (LOS), and direct hospital admission costs. Survey-weighted adjustment for hospital clustering achieved estimates generalizable to the US population. RESULTS: We identified 165,387 patients representing a weighted total of 1,097,355 patients. The overall incidence of PD was 2.7%, with the greatest incidence occurring after RC, with 6,268 cases (11%). Delirious patients had greater adjusted odds of in-hospital mortality (odds ratio [OR] = 3.65, P<0.001), 90-day mortality (OR = 1.47, P = 0.013), discharge with home health services (OR = 2.25, P<0.001), discharge to skilled nursing facilities (OR = 4.64, P<0.001), and a 0.9-day increase in median LOS (P<0.001). Patients with delirium also experienced a $2,697 increase in direct admission costs (P<0.001), with the greatest costs incurred in RC patients ($30,859 vs. $26,607; P<0.001). CONCLUSIONS: Patients with PD after urologic cancer surgeries experienced worse outcomes, prolonged LOS, and increased admission costs. The greatest incidence and costs were seen after RC. Further research is warranted to identify high-risk patients and devise preventative strategies.

The impact of age at the time of radiotherapy for localized prostate cancer on the development of second primary malignancies.

PURPOSE: There is a known increased risk of second primary malignancy (SPM) in patients with prostate cancer (CaP) treated with radiotherapy (RT). It is unclear how age at diagnosis influences the risk of SPMs. MATERIALS AND METHODS: Using the 1973 to 2013 Surveillance, Epidemiology, and End Results Program, we studied the impact of age on SPMs (defined as a bladder or rectal tumor) after localized CaP treatment with radical prostatectomy (RP) or RT. SPM risk was compared using inverse probability of treatment weighting (IPTW)-adjusted cumulative incidence function and competing-risk proportional hazard models. Overall survival (OS) in patients with SPM was compared using Kaplan Meier and Cox regression analyses. RESULTS: A total of 579,608 patients met inclusion criteria, and 51.8% of the cohort was treated with RT. The 10- and 20-year cumulative incidences of competing risk (IPTW adjusted) of SPMs were 1.9% (95%CI = 1.8-1.9%) and 3.6% (95%CI = 3.4-3.7%) after RP vs. 2.7% (95%CI = 2.6-2.8%) and 5.4%(95%CI = 5.3-5.6%) after RT. IPTW-adjusted competing risk hazard ratio (HR) of SPM after RT compared to RP was increased in the entire cohort (HR 1.46; 95%CI = 1.39-1.53, P < 0.001) and was highest in the youngest patients: Age <55 HR = 1.83 (95% confidence interval [CI] = 1.49-2.24, P<0.001), Age 55 to 64 HR = 1.66 (95%CI = 1.54-1.79, P < 0.001), Age 65-74 HR = 1.41 (95%CI = 1.33-1.48, P < 0.001), Age ≥75 HR = 1.14 (95%CI = 0.97-1.35, P = 0.112). At 10 years, SPM-specific mortality occurred in 28.9% of patients treated with RT, though OS with SPM was worse in the youngest patients: Age <55 HR = 1.88 (95%CI = 1.25-2.81, P = 0.002), Age 55-64 HR = 1.60 (95%CI = 1.42-1.81, P < 0.001), Age 65-74 HR = 1.40 (95%CI = 1.30-1.52, P < 0.001), Age ≥ 75 HR = 1.27 (95%CI = 1.06-1.53, P = 0.009). All of the age categories had similar median follow-up times. CONCLUSION: At 10 years there is a 1.8% increased incidence of SPM after RT compared to RP, of which <30% of RT-treated patients with an SPM die as a result of a SPM. However, the risk of SPMs was greatest among younger men treated with RT for localized CaP, and this relationship could not be explained solely by follow-up time, latency time, or life expectancy. An improved understanding of those at the highest risk of SPMs may help tailor treatment and surveillance strategies.

Central Pancreatectomy with Pancreaticojejunostomy for an Insulinoma: A Case Report with Literature Review.

Background: Insulinomas are a rare entity commonly treated by resection. Central pancreatectomy represents an uncommon type of resection for pancreatic lesions. Case Presentation: A 77-year-old female underwent a central pancreatectomy with Roux-en-Y pancreaticojejunostomy and pancreatic stump oversew after presenting with symptoms of hypoglycemia concerning for an insulinoma. Her hospital course was uncomplicated and her symptoms resolved after resection. Conclusion: Resection of insulinomas is the preferred approach of treatment, and resection by central pancreatectomy is a safe option for benign lesions in the neck of the pancreas.

Pneumonia is associated with a high risk of mortality after pancreaticoduodenectomy.

BACKGROUND: Pancreatectomy is associated with a high complication rate that varies between 40-60%. Although many specific complications have been extensively studied, postoperative pneumonia has received little attention. METHODS: Patients undergoing pancreaticoduodenectomy (n = 1,090) and distal pancreatectomy (n = 436) from 2002 to 2014 at Thomas Jefferson University Hospital were retrospectively assessed for postoperative pneumonia. Incidence, predictive factors, and outcomes were determined. RESULTS: Pneumonia was diagnosed in 4.3% of patients after pancreaticoduodenectomy and 2.5% after distal pancreatectomy. The majority of the pneumonias were attributed to aspiration (87.2% and 81.8%, respectively). Pneumonias were more frequently severe (Clavien-Dindo grades 4 or 5) in the pancreaticoduodenectomy group compared to the distal pancreatectomy group (55.3% vs 9.1%, P = .006). Post-pancreaticoduodenectomy pneumonia predictors included delayed gastric emptying (odds ratio 8.2, P < .001), oxygen requirement on postoperative day 3 (odds ratio 3.2, P = .005), and chronic obstructive pulmonary disease (odds ratio 3.1, P = .049). In the post-pancreaticoduodenectomy group, pneumonia was associated with a very high 90-day mortality compared with those who did not have pneumonia (29.8% vs 2.1%, P < .001) and had the largest effect on mortality after pancreaticoduodenectomy (odds ratio 9.6, P < .001). A preoperative risk score model for pneumonia post-pancreaticoduodenectomy was developed. CONCLUSION: Pneumonia after pancreaticoduodenectomy is an uncommon but highly morbid event and is associated with a substantially increased risk of perioperative death.