Prospective randomized study evaluating ultrasound versus fluoroscopy guided sacral InterStim® lead placement: A pilot study.

OBJECTIVE: To investigate the use of intraoperative ultrasound during stage I InterStim® sacral lead placement. METHODS: A total of 40 patients were randomly assigned to undergo InterStim® lead placement utilizing fluoroscopy or ultrasound guidance. Patients were blinded for the duration of the study. The surgeon and staff were blinded until after induction of anesthesia. Patients met criteria for refractory overactive bladder, fecal incontinence, or both. The ICIQ-OABqol, OABSS, and FIQL validated questionnaires were used pre- and post-operatively. Primary endpoint was total fluoroscopy time. Secondary endpoints were total radiation exposure and total number of foramen needle skin punctures. RESULTS: Forty patients were enrolled, twenty in the ultrasound and twenty in the fluoroscopy only arm. Mean age was 60 (SD = 14.4) and mean BMI 32 (SD = 7.2). Twenty-seven patients (67.5%) had urinary symptoms, four (10%) fecal incontinence, and nine (22.5%) had mixed symptoms. Radiation exposure time was reduced by 70.5 s (P = 0.002), radiation exposure was decreased by 42.3 mGy (P = 0.017), and the number of needle skin punctures decreased by 3.6 (P = 0.035) with use of ultrasound. Mean OR time in minutes was 55.5 in ultrasound and 58.2 in fluoroscopy group (P = 0.53). There were no statistically significant differences in questionnaire scores between groups. CONCLUSION: Ultrasound guided placement of foramen needle during Stage I sacral neuromodulation results in reduction of radiation exposure to the patient, surgeon, and operating room staff. Further studies are necessary to determine the learning curve and efficacy of this technique.

Are Postoperative Laboratory Studies Following Robotic Assisted Radical Prostatectomy Necessary?

INTRODUCTION: We evaluated the necessity of obtaining routine postoperative laboratory studies, such as complete blood count and basic metabolic panel, after robotic assisted radical prostatectomy. METHODS: This study is a retrospective review of 200 robotic assisted radical prostatectomy cases performed over a year and a half at our institution. The incidences of laboratory abnormalities were examined along with any clinical intervention. Patient demographics, tumor stage, Gleason score, operative time, estimated blood loss, length of hospital stay, presence of comorbidities and postoperative laboratory studies were extracted from the electronic medical record. The costs of laboratory studies were tabulated to further analyze potential savings to patients. RESULTS: Only 15 (7.5%) patients demonstrated laboratory abnormalities that required medical intervention. Of these 15 patients, all demonstrated hypokalemia that was treated with potassium supplementation. Patients with longer lengths of stay demonstrated higher percentages of medical intervention. The costs of these laboratory studies were calculated at $8,840. CONCLUSIONS: Lower blood loss and transfusion rates with the advent of robotic assisted radical prostatectomy along with the results described in this study provide greater evidence that postoperative laboratory studies may be futile. By eliminating these laboratory studies, substantial cost savings are realized if extrapolated across the United States. This study is limited in its evaluation of complications from different types of medical centers, higher risk patients, postoperative laboratory studies impact on symptomatic patients, and absence of emergency room visits or hospital readmissions.

Reduction in postoperative ileus rates utilizing lower pressure pneumoperitoneum in robotic-assisted radical prostatectomy.

Robotic-assisted radical prostatectomy (RARP) is the most commonly performed surgery for prostate cancer. This is a study comparing differences in postoperative outcomes between pneumoperitoneum pressures of 15 mmHg and 12 mmHg. Retrospective chart review was performed on 400 patients undergoing RARP over a 5 year period. A combination of Fisher's exact test and ANOVA were utilized for statistical analysis. Age, BMI, Gleason score, positive margin rate, complication rates, blood loss, and operative times were similar in both groups. Length of stay and postoperative ileus rates were significantly less in the 12 mmHg group (p < 0.05). RARP can be safely performed utilizing a lower pressure pneumoperitoneum. Decreasing insufflation pressures from 15 to 12 mmHg can further lead to decreased rates of postoperative ileus.

Hemostatic plug: novel technique for closure of percutaneous nephrostomy tract.

Percutaneous nephrolithotomy (PCNL) is a standard treatment for patients with large or complex kidney stones. The procedure has traditionally included postoperative placement of a nephrostomy tube to allow for drainage and possible reentry. This practice was first implemented after complications incurred after tubeless PCNL in a small patient population. Recently, tubeless PCNL has reemerged as a viable option for selected patients, resulting in decreased pain and analgesic use, shorter hospitalization, quicker return to normal activity, and decreased urine extravasation. Gelatin matrix sealants are occasionally used in nephrostomy tract closure. Techniques for delivery of these agents have been ill described, and placement may be performed with varying results. We present a literature review comparing tubeless PCNL to its traditional variant with indications for use of each, as well as a comparison of agents used in closure. Finally, we outline a novel, reproducible technique for closure of the dilated percutaneous renal access tract.