Ambulatory Basis Research Articles

BN SO57 - Transversus Abdominis Plane (TAP) Block in Laparoscopic and Robot-Assisted Cholecystectomy: Is it worth the effort?

Abstract Background Minimal access cholecystectomy is a common procedure undertaken worldwide. These are usually performed on an ambulatory basis and given the short timeline, strategies to optimize pain control and reduce nausea or vomiting are key factors to facilitate early hospital discharge. There has been studies showing that both TAP block and wound infiltration deliver superior pain relief after laparoscopic cholecystectomy, but TAP blocks are not used routinely after cholecystectomy in the U.K. This study aims to assess the efficacy of post-operative subcostal TAP block in laparoscopic and robot-assisted cholecystectomy in reducing post-operative opioid requirements and facilitating same day discharge. Method A retrospective cohort analysis was performed at a single centre (January 2022 – July 2023). Patients undergoing laparoscopic or robot assisted cholecystectomy under a single surgeon who performs cholecystectomy with additional use of postoperative TAP block were included. The primary outcome of post-operative opioid requirements was assessed. Secondary outcomes included length of post-operative stay and individual morphine/fentanyl requirements. Results Among 87 patients, 22(25.3%) underwent TAP block and 65(74.7%) had local anaesthetic infiltration of the port sites. Of the two cohorts, there were no significant differences in the age, M:F ratio or ASA grade. There were more obese patients (BMI > 30kg/m2) in the TAP block cohort (63.6% vs 47.7%; p= 0.012). Of the patients in the TAP block, 88.2% were discharged the same day. 95.5% of these patients had no post-operative morphine or fentanyl requirements.The difference in outcomes were not statistically significant. There were no post-procedural complications from use of the TAP block in any patient. Conclusion These results demonstrate that use of TAP block can provide a safe alternative approach for post-operative analgesia, with low post-operative opioid requirements and facilitation of same-day discharge.

The “vegetables first” dietary habit correlates with higher-level functional capacity in older adults with diabetes

BackgroundSome studies suggest that the habit of eating vegetables may initially be correlated with maintenance of a higher-level functional capacity; however, such a correlation has not been demonstrated. This study aimed to correlate the habit of eating vegetables first and higher-level functional capacity in older adults with diabetes.MethodsPatients aged ≥ 60 years who were treated at Japanese Red Cross Ise Hospital on an ambulatory basis were included in this study. A self-administered questionnaire using the Tokyo Metropolitan Institute of Gerontology Index of Competence (TMIG-IC) was used to evaluate higher-level functional capacity. Participants were instructed to answer the questionnaire regarding the order in which they consumed the mentioned food types, and based on their answers, they were classified into “no order of eating,” “carbohydrates first,” “protein first,” and “vegetables first” groups. Multiple regression analyses with the TMIG-IC score as a dependent variable and the order of eating as explanatory variables were used to determine the partial regression coefficients of the “vegetables first” dietary habit with higher-level functional capacity.ResultsThis study included 346 patients. The adjusted partial regression coefficients of the “carbohydrates first,” “protein first,” and “vegetables first” dietary habits with the TMIG-IC score were 0.27 (95% confidence interval [CI], − 0.29 to 0.84), 0.17 (95% CI, − 0.54 to 0.90), and 0.77 (95% CI, 0.23 to 1.31), respectively.ConclusionsThe habit of eating vegetables first was correlated with higher-level functional capacity in older adults with diabetes.

Lutetium-177 on ambulatory basis, a radiation safety approach

The overarching objective of the study is to assess the applicability of 177Lu-PSMA-617 for the treatment of metastatic castration-resistant prostate cancer and 177Lu-DOTATATE for neuroendocrine tumors in an ambulatory context. To this end, the study determines the effective half-life of these two commercial versions of the isotope during the first 24 h of treatment. These measurements are then used to estimate the external dose absorbed by caregivers and the amount of 177Lu to be discharged into the sewage network in the case of ambulatory treatment. The study utilized live dosimetry measurements of 18 hospitalized patients during 24 h. The detector was placed above the bed and the data was collected every 5 min. Data was processed, visualized, and analyzed using several Python libraries. 177Lu-PSMA and 177Lu-DOTATATE average effective half-life during hospitalization was 6.42 ± 0.14 h and 4.25 ± 0.09 h, respectively. Predicted external dose for caregivers was estimated to be less than 0.1 mSv/cycle. Around 0.45 GBq of 177Lu would be discharged into the sewage network in case of 177Lu-DOTATATE and 0.3 GBq in case of 177Lu-PSMA. From a radiological safety point of view, it is safe to treat with 177Lu on an ambulatory basis. However, in future studies, the amount of 177Lu discharged into wastewater should be considered.

Disparities in cancer care: Is there a benefit for increased use of inpatient chemotherapy (IPC) in safety-net hospitals?

e13690 Background: Safety net hospitals provide care to a large number of vulnerable patients (pts) regardless of their ability to pay (1). These pts often have barriers to acceptance at many hospitals, including lack of or poor insurance, social and economic challenges. Additionally, pts frequently present with more advanced disease (2). Systemic treatment is preferentially administered on an ambulatory basis given several factors: clear financial incentives; effective supportive care; the association of good performance status (PS) with better outcomes; and patient preference (3). Only a few malignancies require inpatient systemic treatment. Strong social support is required for safe and effective ambulatory care, thus especially challenging pts at safety net hospitals in which social constraints are common. Methods: We reviewed patterns of IPC to determine efficacy and outcomes over a 3-year period at a safety net hospital, examining: malignancy type, reason for IPC treatment, treatment regimen (typically outpatient or inpatient), length of stay, and survival. Results: 82 pts met criteria. 56% had hematologic or HIV-associated malignancies. Solid tumor types included GI, breast, GYN, GU and small cell malignancies. Reasons for IPC were progression, worsening symptoms, declining PS in 55% and social constraints in 11%. Patient death within 3 months of IPC, or direct discharge to hospice/nursing home occurred in 42%. Further outpatient chemotherapy was never given in 50%. Death occurred in 15% of pts on the same hospitalization as the IPC; several additional pts were readmitted and died within one month. Individuals receiving IPC due to poor social support frequently required rapid rehospitalization, had poor outpatient follow-up, or died shortly thereafter. Three month survival was more favorable in pts with multiple myeloma or those admitted for drug-desensitization. Conclusions: Outcomes, including survival and rapid rehospitalization, were poor for pts receiving typical outpatient regimens on an inpatient basis whether due to social constraints, declining PS or worsening symptoms. A large percentage of pts never received further chemotherapy. IPC is costly, undesired by pts, and is often not a good use of resources. Pts with highly responsive cancers with fair to good PS had acceptable outcomes. IPC should be reserved for such pts if alternative outpatient regimens are not available. Earlier discussion of hospice and goals should not be replaced by chemotherapy. Institutional unavailability of key oral agents and limited outpatient resources often contribute to IPC. Better access to modern agents, enhanced social support, enlarged and better supported outpatient resources, as well as improved decision making improve cancer care. Our results do not support IPC as a frequent approach to cancer care in safety net hospitals. 1. Popescu, JAMA 2019. 2. Farkas, JCO 2012. 3. Mor, J Clin Epid 1988.

Care of the Pediatric Patient for Ambulatory Tonsillectomy With or Without Adenoidectomy: The Society for Ambulatory Anesthesia Position Statement.

The landscape of ambulatory surgery is changing, and tonsillectomy with or without adenoidectomy is one of the most common pediatric surgical procedures performed nationally. The number of children undergoing tonsillectomy on an ambulatory basis continues to increase. The 2 most common indications for tonsillectomy are recurrent throat infections and obstructive sleep-disordered breathing. The most frequent early complications after tonsillectomy are hemorrhage and ventilatory compromise. In areas lacking a dedicated children's hospital, these cases are managed by a nonpediatric specialized anesthesiologist and general otolaryngology surgeon. In response to requests from our members without pediatric fellowship training and/or who care for pediatric patients infrequently, the Pediatric Committee of the Society for Ambulatory Anesthesia (SAMBA) developed a position statement with recommendations for the safe perioperative care of pediatric patients undergoing tonsillectomy with and without adenoidectomy in freestanding ambulatory surgical facilities. This statement identifies children that are more likely to experience complications and to require additional dedicated provider time that is not conducive to the rapid pace and staffing ratios of many freestanding ambulatory centers with mixed adult and pediatric practices. The aim is to provide health care professionals with practical criteria and suggestions based on the best available evidence. When high-quality evidence is unavailable, we relied on group consensus from pediatric ambulatory specialists in the SAMBA Pediatric Committee. Consensus recommendations were presented to the Pediatric Committee of SAMBA.

(168) Combining Varicocelectomy and Penile Venous Stripping for Patients with Varicocele and Erectile Dysfunction on an Ambulatory Basis

Abstract Introduction Varicocelectomy is a well-established procedure for varicocele testis over one century. It has recently been advanced to minimally invasive surgery types such as laparoscopic or Da Vinci varicocelectomy. Should we question why the approach is beyond the shortest-cut route? Despite penile venous surgery is still cautious in treating patients with erection dysfunction (ED), an anatomy-based penile venous stripping has been conducted for decades, however. It is common to encounter patients with two disease entities. Could the shortest-cut approach be available? Objective We sought to report a novel approach for this purpose on an ambulatory basis. Methods From October 2013 to October 2020, 68 men aged from 28 to 68 years consulted us with erectile dysfunction and varicocele testis, at least grade II. Dual pharmaco-cavernosography and sonography are the primary tools for confirmation, respectively. The abridged five-item version of the International Index of Erectile Function (IIEF-5) erection hardness scales (EHS) was used to assess erection restoration. Acupuncture-assisted local anesthesia was routinely applied on an ambulatory basis. Neither electrocautery nor suction apparatus was used in the entire procedure. They underwent penile venous stripping (PVS) via circumferential approach and, subsequently, to the deeper portion of the erection-related veins via a pubic longitudinal method; later, bi-lateral varicocelectomy was conducted while the spermatic cord was hooked out. The PVS entails stripping one deep dorsal vein and two cavernosal veins after every specific emissary vein is microscopically ligated closest to the outer tunica, whereas the para-arterial veins are segmentally ligated. The visibility of the pampiniform plexus was enhanced by the squeezing method. Finally, the wound was meticulously repaired using a 6–0 nylon suture. Postoperative cavernosography was routinely made for comparison. Radiopacity was used to compare the penile crus, Corpora cavernosa, and femur cortex. Follow-up was made via INTERNET every six months, one year, and then yearly. Results The average follow-up period was 5.2±1.2 years, and the surgery time was 6.3±1. 5 hours, respectively. The blood loss is negligible. The radiopacity was unexceptionally enhanced postoperatively. There was a significant difference (P<0.01) between the preoperative (9.9±2.6) vs. Postoperative IIEF-5 scores (20.6±2.4). The EHS improved on at least one scale. Overall, the post-ejaculation testicular aching was no more bothered in all 23 patients who sustained preoperatively in 6 months postoperatively. Conclusions This combination of physiologically penile venous stripping and bilateral varicocelectomy appears feasible for patients with erectile dysfunction and varicocele via a circumferential and pubic approach on an ambulatory basis. Disclosure No.

(282) Penile Crural Dysplasia is a New Identified Factor for Erectile Dysfunction

Abstract Introduction Given the penile fibro-vascular assembly was just thoroughly interpreted recently and inspired by impotent patients' questions during daily practice, so does the penile venous stripping (PVS), which is deemed controversial thus far. Despite primary impotence (PI) being ascribed to psychogenic origin, in the large repository of PVS treating PI, some 5 % remain refractory in the last decade, an analysis deemed required. Objective We sought to report penile crural dysplasia or hypoplasia that prevents sustainability compared to most PVS males thus far. Methods A retrospective analysis was conducted internationally on 45 consecutive young men with PI from 2013 to 2023. They were allocated into the crural dysplasia group (CDG, n=8), defined as a 50% diameter difference between the largest penile crus and corresponding corpus cavernosum or a 25% diameter difference of bilateral penile crura, and no crural-dysplasia group (NCG, n=37). On an ambulatory basis under acupuncture-aided local anesthesia, neither electrocautery nor a suction apparatus is used, with a circumferential or semi-circumcision followed by a pubic longitudinal approach, the PVS entailed the erection-related vein, including stripping a deep dorsal vein, two cavernosal veins after each emissary's vein was firmly ligated closest to the outer tunic layer with a 6–0 nylon suture. In contrast, the four para-arterial veins were only segmentally ligated. The overlying fascia layers and skin were approximated with a 6–0 nylon and 5–0 chromic suture for the skin, as did the semi-circumcision wound if it existed. The abridged 5-item version of the International Index of Erectile Function (IIEF-5) score system and the erection hardness scale (EHS) were used to assess erection restoration; preoperative data were based on masturbation; additionally, a radio-opacity index was used for comparison of the femoral cortex and that of penile crus preoperative and postoperative, respectively. Follow-up was primarily made via either INTERNET or telephone yearly. After this May, we introduced an autologous venous patch to augment the crural hypoplasia with a promising outcome on two new patients. Statistically, IBM SPSS 21.0 was used. Results The follow-up time was from 0.1 to 10.0 years, averaging 5.7 ± 1.1 years in the CDG and NCG groups, respectively. The blood loss is negligible. There is no difference between the operation time (4.9−0.8 hours vs. 4.8 ± 0.7 hours, p> 0.88) for the CG and EG group, respectively. In both groups, there is a significant of IIEF-5 scores, EHS (5.7±2.0 vs. 15.9±2.1, 1.8±0.8 vs. 2.5±0.6; 5.8 ±2.1 vs. 22.4±1.1, 1.8±0.9 vs. 3.6±0.3; both P<0.001) between the CDG and NCG. The preoperative radio-opacity of penile crura was unexceptionally enhanced postoperatively. In the NCG, 89.1% (33/37) are gratified; in contrast, 37.5% are satisfied in the CDG five years postoperatively, although surgery benefit is unexceptional reported. A close follow-up is going on with the two new males. Conclusions Penile crural hypoplasia is an unidentified contributor to primary impotence, although a larger sample size and longer-term follow-up are warranted. Disclosure No.

(309) A Novel Circumferential Reconstructive Surgery For Male Erection Restoration and Corporoplasty Based on De Novo Penile Fibro-vascular Assembly

Abstract Introduction Albeit the present human penile anatomy has remained unchanged for three thousand centuries, and extensive study has been conducted on anatomical architecture and male potency reconstructive strategies for many centuries, it might not above be sustainable. Objective Given only evidence can speak volumes, and practice is the criterion for testing truth, we sought to report an innovative circumferential approach for fulfilling penile erection restoration and morphology reconstruction on an ambulatory basis microsurgical in recent years. Methods From October 2013 to October 2020, 33 men aged 21–59 underwent penile venous stripping (PVS) and corporoplasty via a circumferential approach on an ambulatory basis. The abridged five-item version of the International Index of Erectile Function (IIEF-5), erection hardness scales (EHS), and cavernosography was used for assessment, as required. The PVS entails stripping one deep dorsal vein and two cavernosal veins after every specific emissary vein is microscopically ligated closest to the outer tunica, whereas the para-arterial veins are segmentally ligated. Subsequently, a tunic corporoplasty is conducted before and after artificial erection with autologous venous wall bi-layered patches, whereby a water-tight running suture is undertaken for the inner layer and interrupted for the second layer for idealizing penile morphology using 6-0 nylon. Results The average follow-up period was 5.1±1.3 years, and the surgery time was 5.2±1. 4 hours, respectively. The radiopacity was unexceptionally enhanced postoperatively. There was a significant difference (P<0.01) between the preoperative (9.8±2.7) vs. Postoperative IIEF-5 scores (20.7±2.3). The EHS improved on at least one scale. The penile shape (<10°) was deemed reported in 93.9% (31/33) patients. Conclusions This combination of physiologically penile venous stripping and anatomy-based corporoplasty is ideally suited to the simultaneous restoration of penile erectile function and morphological reconstruction via a circumferential approach. Disclosure No.

(314) Combing Penile Venous Stripping and Bilateral Varicocelectomy Benefit Patients with Erectile Dysfunction Secondary to Prostatectomy

Abstract Introduction Albeit present human penile anatomy has remained unchanged for three thousand centuries and extensive study has been conducted on anatomical architecture and male potency reconstructive strategies for many centuries, it might not above be sustainable. Objective Given only evidence can speak volumes, and practice is the criterion for testing truth, we sought to report an innovative circumferential approach for fulfilling penile erection restoration and morphology reconstruction on an ambulatory basis microsurgical in recent years Methods From October 2013 to October 2020, 33 men aged 21–59 underwent penile venous stripping (PVS) and corporoplasty via a circumferential approach on an ambulatory basis. The abridged five-item version of the International Index of Erectile Function (IIEF-5), erection hardness scales (EHS), and cavernosography were used for assessment, as required. The PVS entails stripping one deep dorsal vein and two cavernosal veins after every specific emissary vein is microscopically ligated closest to the outer tunica, whereas the para-arterial veins are segmentally ligated. Subsequently, a tunic corporoplasty is conducted before and after artificial erection with autologous venous wall bi-layered patches, whereby a water-tight running suture is undertaken for the inner layer and interrupted for the second layer for idealizing penile morphology using 6-0 nylon. Results The average follow-up period was 5.1±1.3 years, and the surgery time was 5.2±1. 4 hours, respectively. The radiopacity was unexceptionally enhanced postoperatively. There was a significant difference (P<0.01) between the preoperative (9.8±2.7) vs. Postoperative IIEF-5 scores (20.7±2.3). The EHS improved on at least one scale. The penile shape (<10°) was deemed reported in 93.9% (31/33) patients. Conclusions This combination of physiologically penile venous stripping and an anatomy-based corporoplasty is ideally suited to the simultaneous restoration of penile erectile function and morphological reconstruction via a circumferential approach. Disclosure No.

Optimising Same Day Emergency Care (SDEC) Delivery Within a Leading Tertiary Cancer Centre in Southeast Wales

Expansion and enhancement of Same Day Emergency Care at Velindre Cancer Centre during 2022 compromises of Ambulatory Care Unit, Assessment Unit, Patient Support Unit and Immunotherapy toxicities service.
 To provide better value-based healthcare we have introduced an Immunotherapy Toxicities service plus expanded the existing Ambulatory Care Unit and Patient Support Unit providing 12-hour weekday working including a weekend service. 
 The need for a dedicated Immunotherapy service was highlighted following NHS data which anticipated a growth of 240% in Immunotherapy treatments over the next 5 years with Immunotherapy treatments having already increased by 49% from 2018/19 to 2020/21. 
 Without investment this would have led to increasing admissions in South East Wales Health Boards by over 320 patients per annum. This increase would perpetuate the strain on the Ambulatory Unit within VCC and Local Health Boards emergency departments due to the need to admit the patients experiencing toxic side-effects with no viable alternative.
 The development of the Immunotherapy service has allowed for a clear alternative to emergency/unscheduled admission by ensuring robust pathways are in place, 24/7 resilience and support of toxicities, increased patient and staff education in managing toxicities and rapid treatment and management of patients. 
 The Ambulatory Care provision has expanded working hours as well as supporting a weekend service to ensure more timely interventions for patients on a same day basis, enhancing care and clinical outcomes plus removing additional demand on Local Health Boards by preventing admission. 
 Since 2019 the Patient Support Unit has seen a 51% reduction for inpatient admissions for head and neck cancer with the average monthly bed days for patients reduced by 45%. Through service expansion it has been predicted that admissions and length of stay are likely to reduce by a further 10-15%. This will further decrease the burden on external services such as acute hospitals with an ever growing demand on the services.
 The expansion has improved access to a skilled multidisciplinary team including specialist nurses, dieticians, speech and language therapists, physiotherapists and occupational therapists who will all work together to ensure all patients are cared for through robust interventions with timely follow ups.
 The model of delivery is innovative and forward thinking and endorsed by patients and staff alike. The joint MDT allows professionals to anticipate, ameliorate and treat complex and rapidly changing symptoms as an outpatient. 
 The services discussed are essential in reducing the burden on internal and external services whilst ensuring the patient has the best possible outcome. Through clear robust pathways and an upskilled workforce, the service will be sustainable for years to come whilst patients are dealt with in the best way possible in an Ambulatory manner.
 The outcome is a sustainably funded, evidence-based patient-centred service offered in a day case setting, that anticipates and manages complex toxicities and challenging symptoms that develop at different points during the treatment pathway. With these side effects managed on an ambulatory basis, it prevents patients requiring prolonged inpatient admission, a wider benefit for our partners in Local Health Boards.

How Patients who needed CT scans on an ambulatory basis are scanned and reviewed in a major teaching hospital

Abstract Aim This study focuses on the status of service provision for Emergency General Surgical patients requiring Ambulatory CT scans at a major teaching hospital. Method CT scans that took place between May 2023 – July 2023 where patients who received scans were reviewed and categorized between Urology and EGS. Results During the 13-week study, we were able to scan 233 patients (17.92 scans per week) in total between both specialties where 82 scans were for EGS patients (35%). All of these patients were reviewed by a member of the EGS team before they were booked for ambulatory scans at an allotted time and date where patients were scanned at an average of 2.15 days after initial review. After the scan, the patients are reviewed in the Ambulatory Clinic with their results where decisions were made. 93% of the patients were seen on the same day after the scan. Most wait was 11 days due to delay of scanning. Of all the scans 75% of the scans are for common indication for scans in an Ambulatory setting. Indication for scanNumberDiverticular20Post-operative collections14Appendicitis11Non-specific abdominal pain10Hernias8 Conclusion After symptomatic management, scanning and reviewing patients on an ambulatory pathway is effective in both receiving scans in a timely manner as well as making timely appropriate decisions regarding their cause of presentation. It also helps reducing the number of patients going into the acute team.

Interventional Pulmonology: Extending the Breadth of Thoracic Care.

Interventional pulmonary medicine has developed as a subspecialty focused on the management of patients with complex thoracic disease. Leveraging minimally invasive techniques, interventional pulmonologists diagnose and treat pathologies that previously required more invasive options such as surgery. By mitigating procedural risk, interventional pulmonologists have extended the reach of care to a wider pool of vulnerable patients who require therapy. Endoscopic innovations, including endobronchial ultrasound and robotic and electromagnetic bronchoscopy, have enhanced the ability to perform diagnostic procedures on an ambulatory basis. Therapeutic procedures for patients with symptomatic airway disease, pleural disease, and severe emphysema have provided the ability to palliate symptoms. The combination of medical and procedural expertise has made interventional pulmonologists an integral part of comprehensive care teams for patients with oncologic, airway, and pleural needs. This review surveys key areas in which interventional pulmonologists have impacted the care of thoracic disease through bronchoscopic intervention.

Non-invasive electrocardiographic ventricular mapping based on the equivalent double layer model: different workflows, same accuracy

Abstract Funding Acknowledgements Type of funding sources: None. Background and aim Electrocardiographic imaging (ECGI) is capable of performing activation maps with a single premature beat. The endo-epicardial ECGI system based on the equivalent double layer model (EDL), is a portable system that uses a patient-specific heart torso geometry obtained from a CT-scan or cardiac magnetic resonance (CMR), and a conventional 12-lead ECG. The simplicity of the system allows for its use either as a pre-procedural or intra-procedural tool. The aim of this study was to assess the accuracy of the system in centres using different workflows. Methods We studied consecutive patients referred for ablation of ventricular arrhythmias that had an ECGI performed with the endo-epicardial system based on the EDL model to guide mapping and catheter ablation, at four centres. Three centres performed the ECGI pre-procedurally, two with the use of a bedside portable ECG recorder and one on ambulatory basis with a 12-lead Holter recorder, and ablation was performed either manually or with remote magnetic navigation (RMN). The fourth centre performed the ECGI intra-procedurally, recording the ECG directly from the electrophysiology digital multichannel system, and the ablation was performed manually with the use of intracardiac echo (ICE) in all cases. VAs were localised using a segmental model, which included 22 left ventricular segments (classical 17-segment model, plus the aortic cusps and the papillary muscles), and 12 segments on the right ventricle including 4 on the right ventricular outflow tract (RVOT): Anterior, lateral, right septum and left septum. A perfect match (PM) was defined as a predicted location within the same anatomic segment, whereas a near match (NM) was defined as a predicted location within the same segment or a contiguous one. We studied the three different workflows. Results Sixty-three arrhythmias were studied in 58 patients. The ECGI was performed pre-procedurally with a bedside ECG recorder in 26 cases, pre-procedurally with a Holter recorder in 27 cases and intra-procedurally in 10 cases. The results according to each group are presented in the Table. The accuracy of the ECGI was not different between groups. The system correctly identified the SOO of the VAs in the same or a contiguous segment when compared to the invasive mapping in all patients, regardless of the approach used. The percentage of PM was also not significantly different. The group with ICE guidance had lower fluoroscopy and mapping times, but the success and recurrence rates were similar. Conclusions The results of this multicentre experience show that this ECGI system, using a conventional 12 -lead ECG is simple and accurate across different clinical workflows, and presents a useful and versatile tool to facilitate planning the ablation strategy as well as intra-procedural guidance for mapping and ablation of patients with VAs.

(535) A Novel Approach for Penile Venous Stripping Surgery and Bilateral Varicocelectomy on an Ambulatory Basis

Abstract Introduction There are varied approaches for conducting varicocelectomy and penile venous surgery, which are not unified or conspicuously, being not above controversy in the later type either in methodology or routes for accessibility thus far. Objective We sought to present this innovative method in a novel combination of a physiological penile venous stripping and bilateral varicocelectomy via a single longitudinal pubic wound on an ambulatory basis. Methods From July 2012 to December 2021, 63 consecutive patients underwent this combined surgery. Primary diagnosis tools are dual cavernosography and doppler sonography. A 4-5cm longitudinal pubic incision is two-thirds above the penile pubic fold. A blunt dissection maneuver using a hemostat or finger creates a space between the Colles' and Buck's fascia. The entire penis is then released with an inside-out maneuver resulting in Buck's fascia being exposed exclusively, followed by firmed ligation of every emissary vein of the corpora cavernosa via 6-7 open-to-open schemes on Buck's fascia, subsequently stripping of the deep dorsal vein (DDV) and paired cavernosal veins (CVs). In contrast, the para-arterial veins are just ligated segmentally. Reduction of the penis is made after Buck's openings are repaired with not too tight square knots with 6-0 nylon. The stripping of the DDV and CVs is completed after 125-137 ligatures until the infra-pubic angle. Finally, the spermatic cord is hooked below the inguinal canal outlet level. On each side of the varicocele, ligation of 8-11 spermatic veins is macroscopically performed at no expense of ruining all other tissues, even the fragile lymphatic vessel. Then meticulous repair is obtained layer by layer. This novel approach is likely the most appropriate method for making a milking maneuver which is helpful in vascular differentiation on both corpora cavernosa and pampiniform plexus during the entire procedure to prevent residual veins from offensive. Results The average follow-up period is 5.3±0.5 years. There is a significant (9.6±2.7 vs. 20.9±2.3; P<0.01) between the preoperative and postoperative IIEF-5 scores. So does the EHS scale (1.6±0.3 vs. 2.9±0.3; P<0.01) between the preoperative and postoperative status. The radiopacity was unexceptionally enhanced postoperatively. Although the intracorporeal retention and erection quality improvement were unexceptional, the satisfaction rate is just 71.4% (45/63). Penile length resumed 3.5 months postoperatively, although two patients initially complained about 1-2 cm postoperative shortage. Conclusions From the physiology viewpoint, we would like to recommend this promising method with which the shortcut to express. Disclosure No

(533) Penile Venous Stripping for Treating Patients with Erectile Dysfunction Secondary to a Minimally Invasive Prostatectomy

Abstract Introduction A minimally invasive prostatectomy becomes a treatment of choice in patients with operable prostate cancer. However, it is not uncommon to encounter patients with erectile dysfunction (ED) secondary to this procedure. Objective Although there are many ED treatment strategies, we want to report a physiological penile venous stripping surgery to those patients whose ED was secondary to prostatectomy and refractory to all medical treatments in the recent decade. Methods From 2012 to 2021, 15 consecutive patients, aged 62 to 79, sustained erectile dysfunction (ED) following a minimally invasive prostatectomy for treating prostate cancer. Meanwhile, their ED was refractory to contemporary varied treatment strategies, including one 70-year-old patient non-responsive to 800 mg sildenafil. All patients received dual cavernosography in which the penile venous anatomy was shown by a pilot cavernosograpy, PGE-1 test in-between, and a veno-occlusive dysfunction (VOD) was documented by pharmaco-cavernosography. Eventually, they underwent a physiologically penile venous stripping surgery (PVSS) for erection restoration from VOD. The ambulatory basis was unexceptionally conducted under acupuncture-assisted local anesthesia. PVSS begins with a circumferential approach, followed by degloving those tissues superficial to the Colles' fascia until the penile base. Next, it entailed stripping a deep dorsal vein and two cavernosal veins while fixing every emissary's vein with 6-0 nylon closest to the outer tunica. In contrast, the two pairs of para-arterial veins were only segmentally ligated. The abridged 5-item version of the International Index of Erectile Function (IIEF-5) score system and corporeal radio-opacity assessed erection restoration. Additionally, the erection hardness scale (EHS) confirmed improvement. Results The prostatectomy was performed in laparoscopic (n=7) and Da Vinci surgical system (n=8) elsewhere. The average follow-up period was 5.3±0.4 years. It was unexceptionally pronounced on the radiopacity of the corpora cavernosa to the femoral cortex, denoting the intracorporeal retention established in the corpora cavernosa after PVSS. It was statistically significant between the preoperative and postoperative IIEF-5 scores (5.9±1.8 vs. 11.8±2.6, P<0.01). The EHS improved at least one scale. Surprisingly, two patients reported gratifying outcomes although they were committed to Parkinsonism. Overall, just 42.9% (9/21) of patients reported unaided sex. The remaining patients required medication aid every five men depending on 20 mg sildenafil and 5 mg vardenafil, respectively. Eventually, four resorted to malleable penile implants, which firmly declined preoperatively. Conclusions PVSS is beneficial in managing some groups of males whose ED is secondary to a minimally invasive prostatectomy, although the sample size is limited. Disclosure No

MP71-12 AMBULATORY ARTIFICIAL URINARY SPHINCTER AND MALE URETHRAL SLING SURGERY HAVE SIMILAR 30-DAY COMPLICATION, REOPERATION, AND READMISSION RATES: A NATIONAL ANALYSIS, 2016-2019

You have accessJournal of UrologyCME1 Apr 2023MP71-12 AMBULATORY ARTIFICIAL URINARY SPHINCTER AND MALE URETHRAL SLING SURGERY HAVE SIMILAR 30-DAY COMPLICATION, REOPERATION, AND READMISSION RATES: A NATIONAL ANALYSIS, 2016-2019 Krishna Ravivarapu, Micah Levy, Christopher Connors, Daniel Wang, Chih Peng Chin, Evan Garden, Olamide Omidele, Francisca Larenas, and Michael Palese Krishna RavivarapuKrishna Ravivarapu More articles by this author , Micah LevyMicah Levy More articles by this author , Christopher ConnorsChristopher Connors More articles by this author , Daniel WangDaniel Wang More articles by this author , Chih Peng ChinChih Peng Chin More articles by this author , Evan GardenEvan Garden More articles by this author , Olamide OmideleOlamide Omidele More articles by this author , Francisca LarenasFrancisca Larenas More articles by this author , and Michael PaleseMichael Palese More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003339.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Prior studies have compared complication rates following artificial urinary sphincter implantation (AUS) and male urethral sling placement (MUS). To the best of our knowledge, this is the first population-based comparative analysis of ambulatory AUS and MUS. METHODS: Data from the American College of Surgeons National Surgical Quality Improvement database from 2016 to 2019 was used to identify all patients who underwent AUS (CPT 53445) and MUS (CPT 53440). Ambulatory surgery patients were selected based on a total hospital length of stay of zero days. We compared baseline characteristics, complication rates, reoperations, and readmissions between ambulatory AUS and MUS cohorts. Multivariate regression analysis controlling for available demographic and comorbidity data was used to evaluate the relationship between procedure type and adverse events. RESULTS: A total of 963 AUS and 550 MUS surgeries were analyzed. Of these, surgery was performed on an ambulatory basis for 27.7% (n=267) of AUS and 60.5% (n=333) of MUS cases. There were no statistically significant changes in utilization of same-day discharge for AUS (p=0.33) or MUS (p=0.82) from 2016 to 2019. Compared to patients undergoing ambulatory MUS, ambulatory AUS patients were more likely to be over 65 years old (74.7% vs. 64.9%), White race (77.7% vs. 58.9%), hypertensive (63.8% vs. 55.6%), insulin-dependent (9.4% vs. 3.9%), chronic steroid users (5.3% vs. 2.1%), and diagnosed with disseminated cancer (2.3% vs. 0.3%) (all p<0.05). There was no difference in overall 30-day complication rates (3.4% AUS vs. 3.3% MUS, p=0.91). Likewise, there were no significant differences in Clavien-Dindo I/II rates (3.0% AUS vs. 2.4% MUS, p=0.64) or Clavien-Dindo IV rates (0.4% AUS vs. 0.9% MUS, p=0.44). There was no significant difference in 30-day reoperation rates (2.3% AUS vs. 1.8% MUS, p=0.69). There was a trend towards higher rates of 30-day readmission rate for ambulatory AUS at 3.4% versus 1.5% for MUS (p=0.13). However, after controlling for patient demographics and comorbidities on multivariate regression analysis, undergoing ambulatory AUS versus MUS did not confer significantly increased odds of 30-day complication (OR 0.71, 95% CI 0.25-1.97, p=.51), reoperation (OR 1.03, 95% CI 0.30-3.61, p=.96), or readmission (OR 1.75, 95% CI 0.45-6.77, p=.42). CONCLUSIONS: Using a national database, we found no significant differences in 30-day complication, reoperation, or readmission rates between ambulatory AUS and MUS. Source of Funding: None. © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1019 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Krishna Ravivarapu More articles by this author Micah Levy More articles by this author Christopher Connors More articles by this author Daniel Wang More articles by this author Chih Peng Chin More articles by this author Evan Garden More articles by this author Olamide Omidele More articles by this author Francisca Larenas More articles by this author Michael Palese More articles by this author Expand All Advertisement PDF downloadLoading ...

Revitalizing Hands: A Comprehensive Review of Anatomy and Treatment Options for Hand Rejuvenation.

Dorsal hand rejuvenation is gaining popularity as a solitary procedure and adjunct to face and neck rejuvenation treatments. As the hands age, the skin loses elasticity and becomes more translucent, the veins, joints, and tendons appear more prominent, and the bones become more noticeable. These changes are due to intrinsic and extrinsic factors. Current treatment methods include the injection of dermal fillers and autologous fat grafting. Anatomic studies to ensure the successful implementation of rejuvenation procedures identified three separate fascial layers in the dorsum, from superficial to deep. More recent re-evaluations revealed a less distinct, inseparable, sponge-like fascial layer. All authors agree that the superficial dermal layer is probably the optimal location for the injection of volumizing materials because it is free of anatomical structures. Many methods for harvesting, preparing, and injecting fat grafts to the dorsum of the hand have been described in the past three decades. Both filler and fat-graft procedures are performed on an ambulatory basis under local anesthesia. Good results with low postoperative and long-term complication rates and high patient satisfaction have been reported.

Critical limb ischaemia in the time of COVID-19: establishing ambulatory service provision.

The coronavirus disease 2019 (COVID-19) pandemic enforced changes to healthcare services at a pace and extent not seen previously in the NHS. The Royal Devon and Exeter provides regional vascular surgery services. A consultant-led urgent 'hot clinic' was established, providing patients with ambulatory care. We aim to describe the service for critical limb ischaemia (CLI) before and during the COVID-19 pandemic, and evaluate this against recommended best practice. Retrospective review of electronic databases and records of patients with CLI during a non-COVID vs COVID-19 period. Primary outcome measures were those established by guidance from the Vascular Society of Great Britain and Ireland. Non-COVID vs COVID-19: total patients n=97 vs 96, of which CLI patients n=29 vs 21. Median length of stay 15 vs 0 days (p<0.001); median time from referral to specialist review 0 vs 3days (p<0.001); multidisciplinary team meeting (MDT) recorded 3% vs 29%; median time to intervention 6 vs 8 days; conservative management 52% vs 67%; endovascular 28% vs 10%; open surgery 21% vs 24%; 30-day survival 79% vs 76%. COVID-19 imposed a major change to the service for patients with CLI with a focus on ambulatory care pathways for diagnosis and intervention. We observe a significant reduction in overall length of stay with no clinically significant change in time to consultant review, time to imaging, overall management strategy or outcomes. The results of this study show that patients with CLI can be managed safely and effectively on an ambulatory basis in accordance with established best practice.

Clinical care pathways for ambulatory total shoulder arthroplasty.

Total shoulder arthroplasty (TSA) is growing in popularity and is increasingly done on an ambulatory basis. This review examines recent developments in anesthesia and analgesia for ambulatory shoulder surgery. Pathway components are discussed and a sample pathway is described. Adoption of pathways for shoulder surgery improves patient experience by reducing pain, opioid use, and side effects while improving patient satisfaction. Long-acting nerve blockade using adjuvants like dexamethasone provide long-lasting analgesia without rebound pain. Peripheral nerve blockade provides better analgesia than peri-articular injection of local anesthetic. There are multiple approaches to nerve blockade for shoulder surgery to consider, including interscalene, superior trunk, supraclavicular, and anterior suprascapular nerve blocks. Multimodal analgesia should include acetaminophen and nonsteroidal anti-inflammatory drugs, but routine gabapentinoids should not be used. Anesthesiologists should lead the way to create and implement pathways for ambulatory total shoulder arthroplasty, incorporating appropriate patient selection, patient education, long-lasting nerve blockade, and multimodal analgesia.

P15 Audit of outcome of ambulatory care emergency surgery patients

Abstract Introduction A proportion of emergency surgical patients are discharged with outstanding tasks (clinical review, imaging to be requested or results followed-up) pending. The turnaround time of these tasks typically placed at the bottom of the emergency surgical on-call list is dependent on the on-call registrar or house officer. The aim was to analyse the outcomes of pending tasks on ambulatory care emergency surgical patients and explore means to improve. Methods A retrospective audit of emergency surgical patients from October to December 2021 was performed using the daily on-call list database. Results Among the 149 patients with pending tasks on an ambulatory care basis, 80 were excluded (duplicate entries, unclear tasks, non-valid reasons). 38% of patients remained on the list for more than 24 hours with pending tasks. Only 75% of patients had pending tasks completed. Patients waited for 3.3 hours on average (59 to 350 minutes) for clinical review by the registrar or house-officer. The reasons for the delay in clinical review and task completion narrowed down to inappropriate timing (scheduled return in the mornings, when the on-call team are either busy with the ward round or in theatres) and time restraints. Conclusion Based on the above findings, it would be beneficial for our hospital to have a surgical hot clinic with staggered appointments rather than ad hoc return to the ambulatory unit. This would improve waiting times and would allow outstanding tasks to be completed by the surgical registrar or clinical fellow during clinic, increasing patient satisfaction. Take-home message A dedicated surgical hot clinic will reduce patient waiting times, increase overall patient satisfaction and ensure completion of outstanding clinical tasks.