UroLift and Rezum: minimally invasive surgical therapies for the management of benign prostatic hyperplasia.

INTRODUCTION Minimally invasive surgical therapies for benign prostatic hyperplasia (BPH) are popular alternatives to the gold standard transurethral resection of the prostate (TURP). These procedures have fewer discernable side effects on urinary and sexual function, when compared to TURP, making it a desirable option for many patients. MATERIALS AND METHODS: We provide an updated literature review on the current landscape of minimally invasive modalities, specifically the prostatic urethral lift (UroLift) and water vapor thermal therapy (Rezum), for the surgical treatment of BPH. RESULTS: Both UroLift and Rezum have demonstrated excellent efficacy and durability in relieving lower urinary tract symptoms (LUTS) in the BPH patient. When compared to TURP, these minimally invasive therapies can be performed in an outpatient setting, with decreased hospitalization, operative and catheterization times, which minimizes overall healthcare costs. Moreover, these therapies have no discernable adverse effects on sexual function (both ejaculatory and erectile) or sexual satisfaction, making it a desirable option for many patients. CONCLUSIONS: Both the UroLift and Rezum are office-based, minimally invasive techniques capable of providing durable, and significant relief of LUTS secondary to BPH. In select patients, they demonstrate comparable efficacy to TURP with the added advantage of preserving sexual function and minimizing patient morbidity and healthcare cost. An individualized, shared decision-making approach is essential in selecting the optimal treatment option for each patient.

Aquablation of the prostate: a review and update.

INTRODUCTION Historically, transurethral resection of the prostate (TURP) was considered the endoscopic "gold standard" surgical treatment of benign prostatic hyperplasia (BPH). Over the years, several other endoscopic procedures emerged, including the size-independent holmium laser enucleation of the prostate (HoLEP). In an effort to reduce the cost and morbidity associated with traditional endoscopic techniques, novel minimally invasive techniques have been developed, one of which is Aquablation. This review is an update of a previously published review article looking at the most recently published available data on Aquablation. MATERIALS AND METHODS: This review article covers the technical aspects of Aquablation and provides an update on the recently published literature regarding Aquablation compared to TURP and HoLEP. RESULTS: At up to 3 years of follow up, Aquablation performs favorably when compared to TURP in terms of alleviation of lower urinary tract symptoms (LUTS) and preservation of sexual function compared to TURP. Safety profile was similar between Aquablation and TURP. CONCLUSIONS: Aquablation is a safe and effective method of treating LUTS associated with BPH. At up to 3 years of follow up, it has shown a durable with efficacy similar to TURP.

Time to Reimplantation: Waiting Longer Confers No Added Benefit.

BACKGROUND: While the preferred surgical treatment for chronic periprosthetic joint infection (PJI) in North America is a 2-stage exchange arthroplasty, the optimal time between first-stage and reimplantation surgery remains unknown. This study was conceived to examine the association between time to reimplantation and treatment failure. METHODS: Using an institutional database, we identified PJI cases treated with 2-stage exchange arthroplasty between 2000 and 2016. Musculoskeletal Infection Society criteria were used to define PJI, and treatment failure was defined using Delphi criteria. The interstage interval between first-stage and reimplantation surgery for each case was collected, alongside demographics, patient-related and organism-specific data. Multivariate logistic regression analyses were used to examine association with treatment failure. RESULTS: Our final analysis consisted of 282 patients with an average time to reimplantation of 100.2 days (range, 20-648). Sixty-three patients (22.3%) failed at 1 year based on Delphi criteria. Time to reimplantation was not significantly associated with failure in both univariate (P = .598) and multivariate (P = .397) models. However, patients reimplanted at >26 weeks were twice as likely to fail in comparison to those reimplanted within <26 weeks (43.8% vs 21.1%), and this finding reached marginal significance (P = .057). Patients who failed had significantly more comorbidities (P = .008). Charlson comorbidity index was the only variable significantly associated with treatment failure in regression analysis (odds ratio, 1.40; 95% confidence interval, 1.06-1.86; P = .019). CONCLUSION: The length of the interstage interval was not a statistically significant predictor of failure in patients undergoing 2-stage exchange arthroplasty for PJI.

Medicare fails to compensate additional surgical time and effort associated with revision arthroplasty.

In comparison to primary total knee arthroplasty, surgical time was 1.8 times greater for all knee revisions and 2.4 times greater for complex knee revisions. Knee revisions had an 8.5% higher rate of 90-day repeat procedures. In comparison to primary total hip arthroplasty, surgical time was 1.8 greater for all hip revisions and 2.6 fold greater for complex hip revisions. Hip revisions had a 3.4% higher rate of 90-day repeat procedures. Practices based on revisions or complex revisions alone would see a 32% and 50% decrease in reimbursement respectively compared to the ones based on primary arthroplasty. The projected future increase in primary arthroplasties and the relative incentive to perform primary arthroplasty may soon put patient access to physicians willing to perform revision arthroplasty at risk.

Dental clearance prior to elective arthroplasty may not be needed for everyone.

We investigated the prevalence and risk factors for preoperative dental clearance failure in joint arthroplasty patients. Over a 5-month period, all patients scheduling total joint arthroplasty completed a dental questionnaire. Data collected included demographics, medical and dental history, dental hygiene practices, frequency of dental care, and results of dental clearance. Of the 300 patients, 35 (12%) failed dental clearance. Risk factors included tobacco use, poor flossing habits, history of tooth extraction, age, narcotic use, and lack of a dentist visit within 12 months. Of 189 patients who lacked the 3 least prevalent risk factors (tobacco use, narcotic use, no dental visit within 12 months), 11 (6%) failed dental clearance. Selective dental clearance based on patient risk stratification may be a reasonable approach.

Clostridium difficile is common in patients with postoperative diarrhea after hip and knee arthroplasty.

Clostridium difficile is an antibiotic-associated gastrointestinal infection that has detrimental consequences. We sought to determine the incidence of C. difficile in TJA patients with postoperative diarrhea, to determine risk factors for C. difficile infection, and to establish the incidence of C. difficile-related complications. Our institutional protocol includes screening for C. difficile in all patients with diarrhea after TJA. We identified 121 such patients over four years with twenty-eight (23%) testing positive for C. difficile. Revision arthroplasty and prolonged postoperative antibiotic use were risk factors for C. difficile infection. With our protocol of screening and immediate treatment of C. difficile positive patients, we found no C. difficile-associated complications.

Why are total knee arthroplasties failing today--has anything changed after 10 years?

The purpose of this study was to determine the frequency and cause of failure after total knee arthroplasty and compare the results with those reported by our similar investigation conducted 10 years ago. A total of 781 revision TKAs performed at our institution over the past 10 years were identified. The most common failure mechanisms were: loosening (39.9%), infection (27.4%), instability (7.5%), periprosthetic fracture (4.7%), and arthrofibrosis (4.5%). Infection was the most common failure mechanism for early revision (<2 years from primary) and aseptic loosening was the most common reason for late revision. Polyethylene (PE) wear was no longer the major cause of failure. Compared to our previous report, the percentage of revisions performed for polyethylene wear, instability, arthrofibrosis, malalignment and extensor mechanism deficiency has decreased.

The routine use of atypical cultures in presumed aseptic revisions is unnecessary.

BACKGROUND: In presumed aseptic hip and knee revisions, it is common practice to send intraoperative cultures to screen for occult infection. Currently no guidelines exist for the routine use of acid-fast bacillus (AFB) and fungal cultures in this setting. QUESTIONS/PURPOSES: We established (1) the rate of positive fungal and AFB cultures in aseptic hip and knee revision arthroplasties, (2) factors associated with positive fungal and AFB cultures, (3) the likelihood that positive cultures represent true-positive results, and (4) the hospital charges of sending fungal and AFB cultures routinely. METHODS: We retrospectively evaluated all 1717 presumed aseptic hip and knee revisions performed from January 2006 to November 2011: 1139 patients had at least one intraoperative fungal culture and 1133 patients had at least one intraoperative AFB culture, with 923 and 920, respectively, achieving 1-year followup. The Musculoskeletal Infection Society criteria were used to classify subsequent infections. We attempted to identify risk factors for positive cultures. RESULTS: We observed six (0.5%) patients with positive AFB cultures and 19 (1.7%) with positive fungal cultures. Patients undergoing reimplantation procedures were more likely to have a positive fungal culture. The true-positive rate was 0% and 0.1% for AFB and fungal cultures, respectively. The total hospital charges for these cultures over the time frame of our study were USD 1,315,533. CONCLUSIONS: Given the extremely low rate of true-positive AFB and fungal cultures in presumed aseptic revision joint arthroplasty and the charges associated with maintaining these cultures, we believe their routine use is unwarranted. LEVEL OF EVIDENCE: Level III, prognostic study. See the Instructions for Authors for a complete description of evidence.

Systemic Manifestation of Periprosthetic Joint Infection Is Associated With Increased In-Hospital Mortality.

Introduction Periprosthetic joint infection (PJI) is one of the most devastating complications of total joint arthroplasty. Systemic symptoms of infection may indicate a patient who is at a higher risk of serious complications. The goal of this study was to determine if systemic symptoms of infection in the setting of PJI were associated with greater in-hospital mortality. Materials and methods We used our institutional database to identify all patients urgently treated for deep PJI from 2002-2012. Records were reviewed to collect demographics, surgical data, vital signs prior to surgical intervention, blood and intraoperative culture results, preoperative intensive care unit (ICU) admissions, and deaths that occurred during the hospital admission. Patients were classified as having systemic inflammatory response syndrome (SIRS) based on the criteria established by the American College of Chest Physicians and the Society of Critical Care Medicine. Results During the 10-year timeframe of our study, 484 patients were treated emergently for deep infection, with 130 (27%) meeting SIRS criteria preoperatively and 31 (6%) of the patients with SIRS having positive blood cultures. Patients with positive blood cultures and SIRS demonstrated a higher in-hospital mortality rate (p < 0.001). Neither SIRS nor SIRS with positive blood cultures were associated with ICU admission. Discussion Occasionally, PJI can spread beyond the affected joint, showing physical symptoms of systemic illness and bacteremia. This study demonstrates that patients with SIRS and positive blood cultures are at an increased risk of in-hospital mortality. These patients should be monitored closely before definitive treatment in order to minimize their mortality risk.

Mechanical Complications of Hip and Knee Spacers Are Common.

Introduction Two-stage revision is frequently used for the treatment of periprosthetic joint infection (PJI). Because antibiotic-loaded cement spacers are constructed and implanted as temporary devices, mechanical complications are possible. The purpose of our study was to define the incidence of such mechanical complications, determine associated risk factors, and establish if such complications influence the subsequent success of PJI treatment. Methods We identified patients who received an antibiotic spacer for the treatment of PJI at a single center over a six-year timeframe. Medical records and all radiographs were collected and reviewed. Radiographic changes over time were recorded, and mechanical complications were noted. We used multivariate logistic regression analysis to assess risk factors for mechanical spacer complications and assess whether such complications influence the likelihood of subsequent reimplantation and ultimate component retention. Results A total of 236 patients were included in the study. There were 82 hip spacers (28% dynamic and 72% static) with a mechanical complication rate of 8.5% and 154 knee spacers (44% dynamic and 56% static) with a mechanical complication rate of 18.2%. Knee spacers were significantly more likely to have mechanical complications than hip spacers. Other risk factors for mechanical complications included bone loss and elevated body mass index (BMI). Bone loss and advanced age were found to be independent risk factors for failure to undergo second-stage reimplantation. Mechanical spacer failure was not an independent risk factor for the likelihood of subsequent reimplantation or ultimate component retention. Conclusions Mechanical complications of antibiotic spacers are common but do not appear to negatively impact the likelihood of subsequent reimplantation or component retention. In knee spacers and in patients with bone loss or elevated BMI, appropriate patient counseling and strategies to prevent such complications are recommended.

A Video Teaching Tool Is Effective for Training Residents in Hip Arthroplasty Templating.

Work hour restrictions imposed on orthopedic surgery residents since the early 2000s have reduced educational opportunities at the workplace and encouraged alternative strategies for teaching outside the clinical setting. Preoperative templating is essential for safe and effective total hip arthroplasty (THA) and is accurate in predicting final implants. We sought to determine the effectiveness of a video tool for teaching orthopedic residents basic THA templating skills. We developed a video-based teaching tool with instructions on proper THA templating techniques. Ten cases were selected for testing, after excluding patients with severe hip deformities and poor-quality radiographs and only retaining those with concordance between templating by the senior authors and implanted components. The study subjects included three postgraduate year 1 (PGY-1), three PGY-2, and three PGY-5 residents, and three adult reconstruction fellows (PGY-6). Templating skills were assessed before and after watching the instructional video. The evaluation included the size and positioning of femoral and acetabular components, as well as the restoration of leg length. Each templating session was repeated twice. Variance was measured to evaluate consistency in measurements. A linear mixed model and F-test were used for statistical analyses. The number of years in training significantly affected performance prior to exposure to the instructional video. Post-exposure, there was a significant improvement in the accuracy of sizing and positioning of acetabular and femoral components for PGY-1, PGY-2, and PGY-5 residents. The results achieved were comparable to PGY-6 examiners, who did not gain substantial performance benefits from the instructional video. Limb length restoration was less affected by experience or exposure to the video. Component positioning and sizing, as well as leg length discrepancy (LLD), showed a significant decrease in variance after the intervention in all study groups. Video learning is reliable in teaching invaluable skills to orthopedic surgery residents without encroaching on work hours. We conceived a concise video to train orthopedic residents to perform THA templating with proper technique and demonstrated its efficiency and reproducibility.

Revision total hip arthroplasty in younger patients: indications, reasons for failure, and survivorship.

Increasing numbers of total hip arthroplasty (THA) procedures are being performed on younger patients, and the incidence of revision THA in this population is also increasing. The goals of our retrospective study were to survey the surgical indications and reasons for failure and survivorship of revision THA in patients aged < 50 years. We identified 139 cases of revision THA performed over a 6-year period in patients aged < 50 years. The most common reason for revision was aseptic loosening, followed by acetabular liner wear with or without osteolysis. We found an overall 10-year survivorship of 76%. When survivorship was stratified by the indication for revision surgery, revision for wear demonstrated the best 10-year survivorship, while revision for instability or infection exhibited poor survivorship.

Predictors of perioperative blood loss in total joint arthroplasty.

UNLABELLED: UPDATE The print version of this article has errors that have been corrected in the online version of this article. In the Materials and Methods section, the sentence that reads as "During the study period, our institution offered preoperative autologous blood donation to all patients who were scheduling for total joint arthroplasty with a hemoglobin level of no less than 11 mg/dL or a hematocrit level of at least 33%." in the print version now reads as "During the study period, our institution offered preoperative autologous blood donation to all patients who were scheduling for total joint arthroplasty with a hemoglobin level of no less than 11 g/dL or a hematocrit level of at least 33%." in the online version. In Table III, the footnote that reads as "The values are given as the estimate and the standard error in milligrams per deciliter." in the print version now reads as "The values are given as the estimate and the standard error in grams per deciliter." in the online version. BACKGROUND: Despite advances in surgical and anesthetic techniques, lower-extremity total joint arthroplasty is associated with considerable perioperative blood loss. As predictors of perioperative blood loss and allogenic blood transfusion have not yet been well defined, the purpose of this study was to identify clinical predictors for perioperative blood loss and allogenic blood transfusion in patients undergoing total joint arthroplasty. METHODS: From 2000 to 2008, all patients undergoing unilateral primary total hip or knee arthroplasty who met the inclusion criteria were enrolled in the study. Perioperative blood loss was calculated with use of a previously validated formula. The predictors of perioperative blood loss and allogenic blood transfusion were identified in a multivariate analysis. RESULTS: Eleven thousand three hundred and seventy-three patients who underwent total joint arthroplasty, including 4769 patients who underwent total knee arthroplasty and 6604 patients who underwent total hip arthroplasty, were evaluated. Multivariate analysis indicated that an increase in blood loss was associated with being male (263.59 mL in male patients who had undergone total hip arthroplasty and 233.60 mL in male patients who had undergone total knee arthroplasty), a Charlson Comorbidity Index of >3 (293.99 mL in patients who had undergone total hip arthroplasty and 167.96 mL in patients who had undergone total knee arthroplasty), and preoperative autologous blood donation (593.51 mL in patients who had undergone total hip arthroplasty and 592.30 mL in patients who had undergone total knee arthroplasty). In patients who underwent total hip arthroplasty, regional anesthesia compared with general anesthesia reduced the amount of blood loss. The risk of allogenic blood transfusion increased with the amount of blood loss in the patients who underwent total hip arthroplasty (odds ratio, 1.43 [95% confidence interval, 1.40 to 1.46]) and the patients who underwent total knee arthroplasty (odds ratio, 1.47 [95% confidence interval, 1.42 to 1.51]), but the risk of blood transfusion increased with the Charlson Comorbidity Index only in patients who underwent total knee arthroplasty (odds ratio, 3.2 [95% confidence interval, 1.99 to 5.15]). The risk of allogenic blood transfusion decreased with preoperative autologous blood donation in patients who underwent total hip arthroplasty (odds ratio, 0.01 [95% confidence interval, 0.01 to 0.02]) and patients who underwent total knee arthroplasty (odds ratio, 0.02 [95% confidence interval, 0.01 to 0.03]). CONCLUSIONS: This study identified some clinical predictors for blood loss in patients undergoing total joint arthroplasty that we believe can be used for implementing more effective blood conservation strategies. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Interaction of OKL38 and p53 in regulating mitochondrial structure and function.

The tumor suppressor p53 is a well-known transcription factor controlling the expression of its target genes involved in cell cycle and apoptosis. In addition, p53 also plays a direct proapoptotic role in mitochondria by regulating cytochrome c release. Recently, we identified a novel downstream target of p53, OKL38, which relocalizes from nucleus to mitochondria upon forced expression to induce apoptosis. However, the mechanism underlying OKL38 targeting to mitochondria and apoptosis induction remains unclear. Here, we found that OKL38 interacts with p53 to regulate mitochondria function. After DNA damage, OKL38 colocalizes with p53 to mitochondria in U2OS cells. Further, p53 and OKL38 are targeted to mitochondria in synergy: forced expression of OKL38 leads to p53 localization to mitochondria while the expression of a mitochondria enriched p53 polymorphic variant, p53(R72), leads to OKL38 enrichment in mitochondria. Biochemical analyses found that OKL38 and p53 interact in vivo and in vitro via multiple domains. In cell biological assays, multiple regions of OKL38 mediate its mitochondria localization and induce mitochondria morphology changes. OKL38 induces formation of megamitochondria and increases cellular levels of reactive oxygen species. Furthermore, OKL38 induces cytochrome c release upon incubation with mitochondria. Taken together, our studies suggest that OKL38 regulates mitochondria morphology and functions during apoptosis together with p53.