Changes In Surgical Technique Research Articles

Have urinary function outcomes after radical prostatectomy improved over the past decade?

Changes in surgical technique and postoperative care that target improvements in functional outcomes are widespread in the literature. Radical prostatectomy (RP) is one such procedure that has seen multiple advances over the past decade. The objective of this study was to leverage RP as an index case to determine whether practice changes over time produced observable improvements in patient-reported outcomes. This study analyzed patients undergoing RP by experienced surgeons at a tertiary care center with prospectively maintained patient-reported outcome data from 2008 to 2019. Four patient-reported urinary function outcomes at 6 and 12 months after RP were defined with a validated instrument: good urinary function (domain score ≥ 17), no incontinence (0 pads per day), social continence (≤1 pad per day), and severe incontinence (≥3 pads per day). Multivariable logistic regressions evaluated changes in outcomes based on the surgical date. Among 3945 patients meeting the inclusion criteria, excellent urinary outcomes were reported throughout the decade but without consistent observable improvements over time. Specifically, there were no improvements in good urinary function at 12 months (P = .087) based on the surgical date, and there were countervailing effects on no incontinence (worsening; P = .005) versus severe incontinence (improving; P = .003). Neither approach (open, laparoscopic, or robotic), nor nerve sparing, nor membranous urethral length mediated changes in outcomes. In a decade with multiple advances in surgical and postoperative care, there was evidence of improvements in severe incontinence, but no measurable improvements across 3 other urinary outcomes. Although worsening disease factors could contribute to the stable observed outcomes, a more systematic approach to evaluating techniques and implementing patient selection and postoperative care advances is needed. Although there have been advances in radical prostatectomy over the past decade, consistent observable improvements in postoperative incontinence were not reported by patients. To improve urinary function outcomes beyond the current high standard, the approach to studying innovations in surgical technique needs to be changed, and further development of other aspects of prostatectomy care is needed.

235. Complication rate evolution across 10-year enrollment period of a prospective multicenter database

<h3>BACKGROUND CONTEXT</h3> ASD is a complex pathology that benefits greatly from surgical treatment despite being associated with high rates of complications. Despite continuous innovation, little is known regarding the association between changes in surgical techniques and complications. <h3>PURPOSE</h3> To investigate the evolution of patient profiles and surgical complications across a single prospective multicenter database. <h3>STUDY DESIGN/SETTING</h3> Retrospective review of prospective data. <h3>PATIENT SAMPLE</h3> This study included 947 adult spinal deformity patients surgically treated between 2008 and 2018. <h3>OUTCOME MEASURES</h3> Complication types and rates. <h3>METHODS</h3> Surgical ASD patients (TK >60°, SVA >5cm, PT >25° or Cobb angle >20°) with minimum 2-year follow-up were included and stratified into 3 equal groups by date of surgery. Demographic, preoperative data, surgical information, and complications were compared across time using a moving average of 316 patients to delineate those enrolled at the beginning of the study (Early) from the most recent one (Late). <h3>RESULTS</h3> Among the total, 947/1260 (67%) patients completed their 2-year follow-up with an enrollment rate of 7.7±4.1 patients per month. Compared to the Early phase (Oct 2008 and Nov 2012), patients enrolled more recently (Jan 2016 to Jan 2018) were older (Age: 56.7±15yovs 64.3±12.3), sicker (CCI: 1.46±1.6 vs 2.08±1.78), more disabled (ODI: 42.6±19.4 vs 45.7±15.3; PCS: 32.8±10.4 vs 29.7±8.5), with more pronounced sagittal deformity (SRS-Schwab type N: 26.3% vs 50.9%: PI-LL modifier ++: 37.1% vs 46.8%) (all p<0.05). Changes in surgical treatment included an increase use of IBF (61% vs 69.9%), more ACR/3CO use (21% vs 37%) and a decrease in 3CO rate (21% vs 12%), shorter fusion (11.2±4 vs 9.8±5), more supplemental rods (0.3% vs 26.9%) and BMP use (64.1% vs 80.1%) (all p<0.05), but no significant difference in invasiveness (91.2±37.1 vs 86.0±36.9 p=0.06). LOS decrease by 1 day, EBL by 500 cc and rate of ICU stay decrease from 71% to 53% (all p <0.001). There was no significant difference in overall complication rate (73% vs 67.4% p=0.14) despite a significant decrease in major complications requiring a reoperation (27.6% vs17.4% p=0.002) driven by a decrease in implant (8.3% vs 4.1% p=0.032) and radiographic failures (12.7% vs 5.7% p=0.002). Rate of major operative complication decreased (11.8% vs 6.7% p=0.028) while rate of major radiographic complication increased (0.6% vs 5.7% p<0.001) leading to a stable rate of major complications without reoperation (28.3% vs 27.9% p=0.92). No significant difference in minor complication rate (38.7% vs 34.2% p=0.24) The moving average analysis revealed a steady decrease in major complications associated to a reoperation (from 28% to 17%). The lowest peak of major complications (21%) occurred between Feb 2014 and Oct 2016, and the lowest overall complication rate (62%) occurred between July 2014 and Feb 2017. <h3>CONCLUSIONS</h3> Despite an increase in patient complexity including older, more medical morbidities and larger deformities, complication rates did not increase and the rate of complications requiring surgery decreased over time. These findings likely reflect evolutions in practice improvement including use of supplemental rods, PJK prophylaxis, BMP use, and targeting age-appropriate deformity corrections. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Abstract PS1-05: Trends in breast-conserving surgery in Mexico after the implementation of a public health insurance system

Abstract Introduction Although temporal trends in breast conserving surgery (BCS) have been described for developed countries like the United States (US), there is a lack of information regarding the uptake of breast conservation in developing regions of the world. In developing countries, the implementation of breast conservation might be hindered by the availability of radiation therapy, lack of training among surgeons, or concerns regarding compliance with follow-up care and surveillance. In 2006, the Mexican government created Seguro Popular, which provided coverage for breast cancer care for all Mexican women, thus potentially mitigating the difficulties with obtaining care after BCS and improving access to multidisciplinary care. We undertook an overview of ten years of breast cancer surgery at our Mexican cancer center following the implementation of Seguro Popular, and explored changes in surgical technique over time. Methods A retrospective cohort analysis was conducted using the National Cancer Institute of Mexico (INCAN) database from 2006 to 2016. All patients with a diagnosis of breast cancer seen during that period were included. Patients who received surgery for breast cancer where then grouped together based on the type of surgery (mastectomy versus BCS). The effect of the year of diagnosis and of clinical stage at the time of presentation was evaluated. Logistic regression was used to model temporal trends in use of BCS over mastectomy for three 3-year periods (2006-2009, 2010-2012, and 2013-2016). Results The patient cohort consisted of 5289 women from the INCAN database, of which 4519 received some form of local surgical treatment. Sixty-one percent (n = 2764) had locally advanced disease (stages IIB-IIIC) at the time of presentation, and a quarter (n = 1156) had ≥60 days between diagnosis and receipt of surgical treatment. Eighty percent of the patients in the entire cohort (n = 3611) were treated with mastectomy, while 20% (n = 908) received BCS. For the 2006-2009 period, out of 1596 total surgeries, 9.9% were BCS (n = 158). The proportion of BCS increased for each of the other two studied periods, being 18.5% for the 2010-2012 period (n = 276/1490), and 33.1% for the 2013-2016 period (n = 474/1433) (p&amp;lt;0.01 for trend). While the increase in BCS was significant for all stages, it was most pronounced for women with early-stage disease (Stages I-IIA), going from 17% in 2006-2009 to 52% in 2013-2016 (p&amp;lt;0.01), than in those with locally-advanced disease (6.5 to 18%, p&amp;lt;0.01). Conclusions In the ten years after the start of the Seguro Popular public insurance program, the proportion of BCS at a Mexican cancer center increased significantly, particularly for women with early-stage disease. The rates seen at INCAN for the period between 2013-2106 resemble those reported by the US National Cancer Database, in which approximately 61% of women with stage I-II breast cancer and 20% of women with stage III disease receive BCS. Potential reasons for the increase in the uptake of BCS include improved access to adjuvant radiation therapy, improved access to systemic treatment, and higher adherence to follow-up care after the start of Seguro Popular, as well as improvements in surgical training. In addition, changes in BCS may also be related to improvements in the implementation of multidisciplinary teams over time, which may lead to a more homogeneous and comprehensive care. Our results show that improving access to care for patients living in developing countries positively impacts the uptake of BCS for women with breast cancer. Citation Format: Enrique Bargalló-Rocha, Nancy Reynoso-Noveron, Jaime Corona, Nereida Esparza-Arias, María Teresa Ramírez-Ugalde, Caros Daniel Robles-Vidal, Robin Shaw-Dulin, Armen Stankov, Rafael Vazquez-Romo, Patricia Villarreal-Colin, Sergio Aguilar-Villanueva, Jaime Hidalgo-Bahena, Milagros Perez-Quintanilla, Fernando U Lara-Medina, Juan Alejandro Torres, Enrique Soto-Perez-de-Celis, Paula Cabrera-Galeana, Alejandro Mohar, Abelardo Meneses-García. Trends in breast-conserving surgery in Mexico after the implementation of a public health insurance system [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS1-05.

Blood transfusion trends by disease category in the United States, 2000 to 2014

BackgroundBetter understanding of blood usage rates could identify trends in transfusion practices over time and inform more efficient management. MethodsInpatient admissions from the Healthcare Cost and Utilization Project National Inpatient Sample and State Inpatient Databases were analyzed for packed red blood cell (PRBC), plasma, platelet, and whole blood (WB) transfusions. The transfusion rates per admission and per prevalent case were calculated. Prevalence estimates were from the Global Burden of Disease 2017 study (GBD). ResultsFrom 2000 to 2014, blood usage rates for most causes peaked around 2010. Across all causes, PRBC were the most commonly transfused component, followed by plasma, platelets, and WB. However, the relative use of each type varied by cause. Nutritional deficiencies (1.75 blood product units across all components per admission; 95 % uncertainty interval (UI) 1.62–1.87), neoplasms (0.95; 0.87–1.04), and injuries (0.92; 0.86 – 0.98) had the greatest blood use per admission. Cardiovascular diseases (96.9 units per 1000 prevalent cases; 89.3–105.0) and neoplasms (92.7 units per 1000 prevalent cases; 84.3–101.5) had the greatest blood use per prevalent case. Across all admissions, over three million blood units were saved in 2014 compared to 2011 due to transfusing at a reduced rate. ConclusionsBlood transfusion rates decreased from 2011 to 2014 in the United States. This decline occurred in most disease categories, which points towards broad strategies like patient blood management systems and disease specific improvements like changes in surgical techniques being effective.

Ileal Pouch-Anal Anastomosis for Ulcerative Colitis: An Australian Institution's Experience.

PurposeWe report outcomes and evaluate patient factors and the impact of surgical evolution on outcomes in consecutive ulcerative colitis patients who had restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) at an Australian institution over 26 years.MethodsData including clinical characteristics, preoperative medical therapy, and surgical outcomes were collected. We divided eligible patients into 3 period arms (period 1, 1990 to 1999; period 2, 2000 to 2009; period 3, 2010 to 2016). Outcomes of interest were IPAA leak and pouch failure.ResultsA total of 212 patients were included. Median follow-up was 50 (interquartile range, 17 to 120) months. Rates of early and late complications were 34.9% and 52.0%, respectively. Early complications included wound infection (9.4%), pelvic sepsis (8.0%), and small bowel obstruction (6.6%) while late complications included small bowel obstruction (18.9%), anal stenosis (16.8%), and pouch fistula (13.3%). Overall, IPAA leak rate was 6.1% and pouch failure rate was 4.8%. Eighty-three patients (42.3%) experienced pouchitis. Over time, we observed an increase in patient exposure to thiopurine (P = 0.0025), cyclosporin (P = 0.0002), and anti-tumor necrosis factor (P < 0.00001) coupled with a shift to laparoscopic technique (P < 0.00001), stapled IPAA (P < 0.00001), J pouch configuration (P < 0.00001), a modified 2-stage procedure (P = 0.00012), and a decline in defunctioning ileostomy rate at time of IPAA (P = 0.00002). Apart from pouchitis, there was no significant difference in surgical and chronic inflammatory pouch outcomes with time.ConclusionDespite greater patient exposure to immunomodulatory and biologic therapy before surgery coupled with a significant change in surgical techniques, surgical and chronic inflammatory pouch outcome rates have remained stable.

Improvement in Brazilian Butt Lift (BBL) Safety With the Current Recommendations from ASERF, ASAPS, and ISAPS.

In 2017, the ASERF Gluteal Fat Grafting Task Force reported gluteal fat grafting to be a high-risk procedure and recommended specific surgical techniques to decrease the risk of pulmonary fat embolism (PFE). The aim of this study was to determine whether ASAPS and ISAPS members were aware of the 2017 recommendations, what their current surgical techniques were, whether they had changed their techniques based on the 2017 recommendations, and whether the incidence of PFEs had changed since the recommendations were published. An anonymous web-based survey was conducted among members of ASAPS and ISAPS. It included the questions from the 2017 survey, as well as questions about awareness of the Task Force recommendations and subsequent change in surgical techniques. In the 2 years following the publication of the recommendations, the incidence of any PFE was 1 in 2492 compared with 1 in 1030 reported in 2017 (P = 0.02). Trends indicated a decreased mortality rate from 1 in 3448 in 2017 to 1 in 14,952 in 2019. Ninety-four percent of respondents were aware of the recommendations. Only 0.8% of surgeons in the current survey reported injecting in deep muscle, compared with 13.1% in 2017 (P < 0.01). Compared with 4.1% in 2017, 29.8% of respondents in our survey reported that they only injected with cannulas ≥4.1 mm (P < 0.01). Only 4% of respondents reported angling the cannula down in the current survey, compared with 27.2% in 2017 (P < 0.01). It appears that members were aware of the 2017 recommendations. There was a significant decrease in recent PFE and trends showed a change to safer techniques and an improvement in safety of the procedure.

Management of open complicated abdomen

Critically-ill patients may have their abdomens opened as a result of primary pathology (damage-control laparotomy in trauma, soiled peritoneum from perforated hollow viscus, necrotizing pancreatitis), or as treatment for abdominal compartment syndrome (defined as new organ dysfunction associated with intra-abdominal hypertension).The incidence and implications of intra-abdominal hypertension and abdominal compartment syndrome (ACS) in particular, are currently debated.Intra-abdominal hypertension (IAH) is defined as a sustained intra-abdominal pressure ≥ 12 mmHg. Grading is possible; Grade I = IAP 12 to 15 mmHg, Grade II = IAP 16 to 20 mmHg, Grade III = IAP 21 to 25 mmHg, Grade IV = IAP >25 mmHg. Management principles include reduction of intra-abdominal gas (NGT and flatus) and intra-abdominal fluid (the latter may be interstitial or intra-peritoneal), and ensuring the abdominal wall is as compliant as possible. Definitive management is to open the abdomen however, the benefits and use of the open abdomen (OA) approach are unclear. The rates of OA appear to be reducing worldwide.The reduction in the incidence of ACS requiring laparostomy may be related to global changes in resuscitation targets1, rather than changes in surgical techniques. In particular, the notion of ‘fluid de-resuscitation’ may be implicated in improved outcomes.The decision to leave the abdomen open after emergent laparotomy seems to be dependent on the surgical specialty of the operating surgeon, and is a common approach applied in victims of blunt abdominal trauma2.Complications of the open abdomen relate mainly to nutritional status and long-term abdominal complications. The most feared abdominal complication relates to the inability to close the abdominal fascia, with associated increases in mortality, fistula formation, and ventral hernias.Current critical care focus is on the prevention of the open abdomen. For intra-abdominal hypertension and acute compartment syndrome, medical management aimed at reduction of abdominal wall pressure and evacuation of intra-abdominal contents (including fluid) are cornerstone strategies. The use of neuromuscular blocking agents is controversial; short-term benefit may be outweighed by long-term complications.For the de novo open abdomen, current research suggests a possible role for more aggressive early closure (primary or before day 5, latest day 8). Further research is required to confirm whether primary closure is safe. Temporary closure techniques using a combination of negative abdominal wall pressure in combination with partial mesh reduction seems to be helpful in increasing successful abdominal closure rates3.Aggressive infection control and nutritional support after 72 hours is key. Common to both scenarios is the need for careful, judicious fluid management; organ perfusion must be optimized, but not at the expense of massive bowel and abdominal wall edema. The latter complicates healing and closure4.A final question is whether extubating patients with an open abdomen is safe and feasible. The literature provides a resounding yes to this issue5.

Radiation Dose to the Eye Lens Through Radiological Imaging Procedures at the Surgical Workplace During Trauma Surgery.

Background: Due to the drastic reduction of the eye lens dose limit from 150 mSv per year to 20 mSv per year since 2018, the prospective investigation of the estimated dose of the eye lens by radiological imaging procedures at the surgical site during trauma surgery in the daily work process was carried out. This was also necessary because, as experience shows, with changes in surgical techniques, there are also changes in the use of radiological procedures, and thus an up-to-date inventory can provide valuable information for the assessment of occupationally induced radiation exposure of surgical personnel under the current conditions. Methods: The eye lens radiation exposure was measured over three months for five trauma surgeons, four hand surgeons and four surgical assistants with personalized LPS-TLD-TD 07 partial body dosimeters Hp (0.07). A reference dosimeter was deposited at the surgery changing room. The dosimeters were sent to the LPS (Landesanstalt für Personendosimetrie und Strahlenschutzausbildung) measuring institute (National Institute for Personal Dosimetry and Radiation Protection Training, Berlin) for evaluation after 3 months. The duration of the operation, occupation (assistant, surgeon, etc.), type of surgery (procedure, diagnosis), designation of the X-ray unit, total duration of radiation exposure per operation and dose area product per operation were recorded. Results: Both the evaluation of the dosimeters by the trauma surgeons and the evaluation of the dosimeters by the hand surgeons and the surgical assistants revealed no significant radiation exposure of the eye lens in comparison to the respective measured reference dosimeters. Conclusions: Despite the drastic reduction of the eye lens dose limit from 150 mSv per year to 20 mSv per year, the limit for orthopedic, trauma and hand surgery operations is well below the limit in this setting.

P14.03 Adult medulloblastoma: Influence of risk stratification and molecular subtypes on chemotherapy efficacy

Abstract BACKGROUND Incidence of medulloblastoma (MB) in adults is about 1%. Optimal treatment for adult medulloblastoma has not been defined. Published datasets were acquired over a long period of time, during which there were changes in surgical technique, radiotherapy, chemotherapy regimens; often disease stage was not considered in the analyses. Recently discovered molecular subgroups are not taken into account in studies concerning treatment of medulloblastoma in adults. MATERIAL AND METHODS Study includes 64 patients with medulloblastoma (median age 26.5 years (15–62)), who were first admitted to Burdenko Neurosurgery Institute for surgery from 2000 to 2017. 100 % patients included in the study received radiotherapy - craniospinal irradiation, 36 Gy (20 x 1.8 Gy) with boost to primary site (2 cm around tumor bed) up to 55 Gy total dose. 41 patients (64%) received chemotherapy (ChT). Chemotherapy was started 4–6 weeks after finishing craniospinal irradiation, the regimen included cisplatin 25 mg/m2 days 1–4+etoposide 100 mg/m2 days 1–4+cyclophosphamide 600 mg/m2 days 1–4; the cycles repeating every 28 days, 6 cycles in total. Treatment volume didn’t correspond with risk group and/or molecular genetic subgroup (these parameters were determined retrospectively). Median follow-up time is 4.45 years. RESULTS 53% patients had classic histology MB, 27% - desmoplastic, 20% - large cell/anaplastic. High risk (HR), standard risk (SR) and unspecified risk (UR) groups included 23, 16 and 25 patients respectively. Molecular subgroup testing was performed in 39 cases: SHH-activated - 59%, WNT-activated - 18%, GROUP4 - 23%. Median time to tumor progression (MTTP) in patients who received radio-chemotherapy versus radiotherapy alone was 4.3 and 2.64 years, respectively (p=0.264). The differences in MTTP were the most pronounced in SR and UR patients who received radio-chemotherapy (5.5 and 6.0 months, respectively) versus radiotherapy alone (1.5 and 2.0 months, respectively). HR patients showed the least difference in MTTP for radiotherapy (2.0 years) versus radio-chemotherapy (2.5 years), p=0.093. The SHH-subgroup patients had MTTP of 3.1 years (3.1 and 3.0 years for ChT+ and ChT-, respectively). GROUP4 patients had MTTP of 4.3 years (4.3 and 1.5 years for ChT+ and ChT-, respectively). All WNT-subgroup patients received chemotherapy, MTTP was 9.0 years. Median overall survival cannot be defined in any of the subgroups. CONCLUSION Chemotherapy in adult medulloblastoma patients increases MTTP in SR and UR patients. Low efficacy of chemotherapy for high risk medulloblastoma urges search for more efficacious treatment protocols. WNT-activated adult medulloblastoma has the highest MTTP among other molecular subgroups.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Development of a Complete En-Bloc Technique with Direct Bladder Neck Incision: A Newly Modified Approach for Holmium Laser Enucleation of the Prostate.

Introduction: The objectives of this study were to introduce a newly developed approach for holmium laser enucleation of the prostate (HoLEP) called the "complete en-bloc technique," and to compare the clinical outcomes of this approach with those of previously performed procedures. Methods: This study retrospectively assessed the perioperative findings from 548 patients with benign prostatic hyperplasia (BPH) undergoing HoLEP who were divided into the following groups according to the consecutive changes in surgical techniques: group A (n = 236), the three-lobe technique; group B (n = 137), the conventional en-bloc technique; and group C (n = 175), the complete en-bloc technique with direct bladder neck incision. Results: There were no significant differences in major clinical characteristics or urinary symptoms among groups A, B, and C. Although there was no significant difference in the resected prostate weight among the three groups, the enucleation time was significantly shorter and total laser energy was significantly lower in group C than in groups A and B. Therefore, the enucleation efficiency, calculated by dividing the resected prostate weight by the enucleation time, was significantly greater in group C than in groups A and B. Furthermore, no significant differences in the postoperative urinary symptoms, including the International Prostate Symptom Score (IPSS), quality of life, maximum flow rate, postvoid residual, and persistent stress urinary incontinence rate, were noted among the three groups, and there were no significant differences in the incidences of major perioperative complications, including the blood transfusion, bladder injury, urethral stricture, and bladder neck sclerosis among the three groups. Conclusions: These findings suggest that our complete en-bloc technique can improve the clinical outcomes of HoLEP in BPH patients, even in difficult cases, considering its markedly improved enucleation efficiency.

A "flexible tripod" mounted video camera: An economical and effective method to record oculoplastic surgeries.

Recording surgical procedures is of value for teaching and training in residency and fellowship programs. Operating external ophthalmic surgeries is not as easy as recording intraocular surgeries. In this communication, we describe the use of a video recorder mounted on a flexible tripod (Gorillapod®), a commonly available photography accessory; which is fixed to an IV fluid stand. This set up was used to record external ophthalmic surgeries and the recorded videos were of high quality in terms of stability and required no change in surgical technique to ensure that the area of interest was in focus. In our experience, early results show that a flexible tripod offers an economical mount for recording external surgeries with reproducible results.

The mean ten-year results of metal-on-metal hybrid hip resurfacing arthroplasty.

This study presents the long-term survivorship, risk factors for prosthesis survival, and an assessment of the long-term effects of changes in surgical technique in a large series of patients treated by metal-on-metal (MoM) hip resurfacing arthroplasty (HRA). Between November 1996 and January 2012, 1074 patients (1321 hips) underwent HRA using the Conserve Plus Hip Resurfacing System. There were 787 men (73%) and 287 women (27%) with a mean age of 51 years (14 to 83). The underlying pathology was osteoarthritis (OA) in 1003 (75.9%), developmental dysplasia of the hip (DDH) in 136 (10.3%), avascular necrosis in 98 (7.4%), and other conditions, including inflammatory arthritis, in 84 (6.4%). The mean follow-up time was 10.5 years (1 to 20). Using revision for any reason as the endpoint, the overall survivorship at 15 years was 89.4% (95% confidence interval (CI) 86.8 to 91.4). There was a substantial increase between the first and second generation of surgical technique (86.6% vs 90.1%; p = 0.05). Men with idiopathic OA had a 15-year survivorship of 94.5% and women, 82.2% (p = 0.001); gender was not a risk factor after stratification by component size and aetiology. Using revision for excessive wear (ion levels > 7 µg/l associated with symptoms or adverse local tissue reactions) as the endpoint, the 15-year survivorship was 98.5%. Risk factors for revision for all modes of failure were an underlying pathology of hip dysplasia, a contact patch to rim (CPR) distance of 7 mm or less, an age at surgery of 55 years or less, and a femoral component size of 46 mm or less. Specific risk factors for aseptic failure of the femoral component were early surgical technique, a cementless metaphyseal stem, and a body mass index of 24 kg/m2 or less. HRA is a viable concept; metal-on-metal bearings are well suited for this procedure when a well-designed device is properly implanted. The best results were obtained in men with OA, but survivorship was better for other underlying pathologies and for women after changes were made to the technique of implantation. Lifetime durability is a possible outcome for many patients despite a high level of activity. Cite this article: Bone Joint J 2018;100-B:1424-33.

Oncologic, Perioperative Outcomes of Female Radical Cystectomy: Results from a Multicenter Study in Korea.

PurposeThe lower incidence of bladder cancer among women has led to a lack of information on female radical cystectomy (RC). This study aimed to analyze the characteristics related with female RC in a cohort from multiple academic institutions.Materials and MethodsThis was a retrospective review of 384 female patients who underwent RC for bladder cancer. Epidemiologic, perioperative variables including urologic referral periodwith consequent pathologic stage distributions were assessed. The changes in surgical techniques over time were illustrated. Also, we evaluated recurrence-free survival (RFS) at 2 and 5 years and overall survival (OS) at 5 years with stage-specific analyses using the Kaplan-Meier method.ResultsThe mean follow-up time was 35 months (interquartile rage [IQR], 9 to 55). The average time to urologic referral with initial symptoms was 5.5 (IQR, 1 to 6) months and over 20% of patients visited clinics after 6 months. In subsequent stage distributions according to referral period, T2 or higher stage distributions were abruptly increased after 1 year. Overall 2-year/5-year RFS rates were 0.72/0.57 and 5-year OS was 0.61. Notable surgical descriptions were as follows: 91% of patients underwent open RC; 80% of patients underwent an ileal conduit; and 83% of patients received anterior exenteration. However, the proportions of robotic surgery, orthotopic neobladder and organ sparing cystectomy have increased recen-tly.ConclusionWe identified the general characteristics and changes in pattern of female RC. Our results also suggest that women are susceptible to delays in referral to an urologist and are at greater risk for worse prognosis.

Use of cumulative summation (CUSUM) as a tool for early feedback and monitoring in robot-assisted radical prostatectomy outcomes and performance.

Today's surgical practice has evolved, with increasing emphasis on quality assurance. Many forms of quality-control monitoring have been suggested, but they are often impractical or difficult to implement. Cumulative summation (CUSUM) is a simple method to provide visual feedback before significant quality issues arise. We present our initial use and practical application of CUSUM in a surgical practice. A retrospective analysis was applied to a prospectively collected database of 577 sequential patients who have undergone robot-assisted radical prostatectomy from a single surgeon over a 10-year period. Outcome measures were analyzed with CUSUM, which included a composite complication score, continence rates, length of hospital stay, biochemical recurrence, and need for adjuvant radiation. If any outcomes were out of control, they would cross the CUSUM failure line. CUSUM chart-plotting for incontinence demonstrated an initial upward slope followed by trending to a new safety limit. Additionally, outcomes in complications and biochemical recurrence did not reach the established safety boundaries. Length of stay and radiation outcomes did initially cross the safety line, but were improved over time. The use of CUSUM in clinical practice can fulfill the need for quality assurance. CUSUM plotting in our practice reflected the initial learning curve, followed by ongoing maintenance and improvement in performance. These changes were consistent with the implementation of changes in surgical techniques. Although this tool was used retrospectively, this strengthens our argument to implement the tool prospectively and assess real-time refinement of surgeon skill. We have demonstrated that CUSUM can be appropriately used to assure quality control in a surgical practice.

Pulmonary Regurgitation- Is the Future Percutaneous or Surgical?

For decades, surgical replacement of the pulmonary valve has been seen as the gold-standard technique. Until the advent of Medtronic's Melody valve, it was the only option. Whilst radical changes in surgical techniques have not been forthcoming, rapid and substantial developments in the techniques and available technology for percutaneous valves now cause us to ask if the gold-standard moniker now belongs in the cath lab. This manuscript explores the recent history and future of a revolution in this large area of congenital cardiac practice.

Postoperative lead migration in deep brain stimulation surgery: Incidence, risk factors, and clinical impact.

IntroductionDeep brain stimulation (DBS) is an effective treatment for multiple movement disorders and shows substantial promise for the treatment of some neuropsychiatric and other disorders of brain neurocircuitry. Optimal neuroanatomical lead position is a critical determinant of clinical outcomes in DBS surgery. Lead migration, defined as an unintended post-operative displacement of the DBS lead, has been previously reported. Despite several reports, however, there have been no systematic investigations of this issue. This study aimed to: 1) quantify the incidence of lead migration in a large series of DBS patients, 2) identify potential risk factors contributing to DBS lead migration, and 3) investigate the practical importance of this complication by correlating its occurrence with clinical outcomes.MethodsA database of all DBS procedures performed at UF was queried for patients who had undergone multiple post-operative DBS lead localization imaging studies separated by at least two months. Bilateral DBS implantation has commonly been performed as a staged procedure at UF, with an interval of six or more months between sides. To localize the position of each DBS lead, a head CT is acquired ~4 weeks after lead implantation and fused to the pre-operative targeting MRI. The fused targeting images (MR + stereotactic CT) acquired in preparation for the delayed second side lead implantation provide an opportunity to repeat the localization of the first implanted lead. This paradigm offers an ideal patient population for the study of delayed DBS lead migration because it provides a large cohort of patients with localization of the same implanted DBS lead at two time points. The position of the tip of each implanted DBS lead was measured on both the initial post-operative lead localization CT and the delayed CT. Lead tip displacement, intracranial lead length, and ventricular indices were collected and analyzed. Clinical outcomes were characterized with validated rating scales for all cases, and a comparison was made between outcomes of cases with lead migration versus those where migration of the lead did not occur.ResultsData from 138 leads in 132 patients with initial and delayed lead localization CT scans were analyzed. The mean distance between initial and delayed DBS lead tip position was 2.2 mm and the mean change in intracranial lead length was 0.45 mm. Significant delayed migration (>3 mm) was observed in 17 leads in 16 patients (12.3% of leads, 12.1% of patients). Factors associated with lead migration were: technical error, repetitive dystonic head movement, and twiddler’s syndrome. Outcomes were worse in dystonia patients with lead migration (p = 0.035). In the PD group, worse clinical outcomes trended in cases with lead migration.ConclusionsOver 10% of DBS leads in this large single center cohort were displaced by greater than 3 mm on delayed measurement, adversely affecting outcomes. Multiple risk factors emerged, including technical error during implantation of the DBS pulse generator and failure of lead fixation at the burr hole site. We hypothesize that a change in surgical technique and a more effective lead fixation device might mitigate this problem.

Trends in Minimally Invasive Hysterectomy Techniques for Nonmalignant Conditions in a Defined Population

Background: Minimally invasive surgical techniques are increasingly being used for performing hysterectomy. We assessed changes in surgical techniques for hysterectomy that happened during the last decade among the complete Icelandic population. Methods: Databases in all hospitals in the country were searched to identify all women undergoing hysterectomy during the years 2001-2010 inclusive. Information on age at surgery, indication for surgery, surgical techniques, additional intraoperative procedures, and length of hospital stay was gathered. Two 5-year periods, 2001-2005 and 2006-2010, were compared. The proportion of minimally invasive surgery (MIS) was calculated. Results: There were 5,288 hysterectomies that were performed, giving a mean annual incidence of 352/100,000 women. The proportion of MIS increased from 30 to 74% at the main university hospital (p < 0.0001), where the mean hospital stay decreased from 5.4 to 1.7 days. Fewer oophorectomies were performed during the second 5-year period. The most common diagnoses were fibromyomas and abnormal uterine bleeding. The rate of recorded complications was low. A decreasing yearly incidence was observed from 389/100,000 in 2001 to 266/100,000 by 2010. Conclusion: For benign indications, the surgical approach has changed markedly with a high proportion of the operations being performed with minimally invasive techniques, mainly at a secondary/tertiary level.

Epsilon Aminocaproic Acid to Reduce Blood Loss and Transfusion After Total Hip and Total Knee Arthroplasty

BackgroundTotal hip and knee arthroplasty (THA and TKA) are associated with significant blood loss and some patients require postoperative blood transfusion. While tranexamic acid has been studied extensively among this population, we tested the hypothesis that epsilon aminocaproic acid (EACA) can reduce blood loss and transfusion after joint arthroplasty. MethodsIn April 2014, our Veterans Affairs Medical Center introduced a protocol to administer EACA during THA and TKA. No antifibrinolytics were used previously. We retrospectively compared blood loss and incidence of transfusion among patients who underwent primary arthroplasty in the year before standardized administration of EACA with patients having the same procedures the following year. Blood loss was measured as delta hemoglobin (preoperative hemoglobin − hemoglobin on postoperative day 1). All patients undergoing primary THA or TKA were included. Patients having revision surgery were excluded. ResultsWe identified 185 primary arthroplasty patients from the year before and 184 from the year after introducing the EACA protocol. There were no changes in surgical technique or attending surgeons during this period. Delta hemoglobin was significantly lower in the EACA group (2.7 ± 0.8 mg/dL) compared to the control group (3.4 ± 1.1 mg/dL) (P < .0001). The incidence of blood transfusion was also significantly lower in the EACA group (2.7%) compared to the control group (25.4%) (P < .0001). There was no difference in venous thromboembolic complications between groups. ConclusionWe demonstrated reductions in hemoglobin loss and transfusion following introduction of the EACA protocol in patients undergoing primary arthroplasty. EACA offers a lower cost alternative to TXA for reducing blood loss and transfusion in this population.

Anterior subcapsular cataract caused by forceful irrigation during implantation of a posterior chamber phakic intraocular lens with a central hole

To report the rare entity of anterior subcapsular cataract after implantation of a posterior chamber phakic intraocular lens (pIOL) with a central hole. Department of Ophthalmology, Goethe-University, Frankfurt, Germany. Retrospective case series. Medical reports were reviewed of patients with vision loss caused by anterior subcapsular cataract after implantation of the V4c Visian Implantable Collamer Lens with a central hole. Patients were identified during regular follow-up visits between January and September 2015. Possible causative factors, such as microbial contamination of surgical instruments, type of ophthalmic viscosurgical device (OVD) and irrigation substance, intracameral application of mydriatics and antibiotics, duration of surgeries, and surgical technique were analyzed. Eleven eyes of 8 patients showed white opacification behind the anterior capsule of the crystalline lens 1day postoperatively. Opacification led to a significant loss of corrected distance visual acuity in all eyes. In 9 eyes, the pIOL was explanted and in 8 eyes, phacoemulsification with IOL implantation was performed. All other analyzed possible causative factors were excluded; thus, the opacification was attributed to the surgical technique of OVD removal by irrigation with a cannula in the presence of a central hole in the pIOL. After the surgical technique was adapted, no further cases of anterior subcapsular cataract occurred. Anterior subcapsular cataract was induced during implantation of a pIOL with a central hole by cannula irrigation with enforced stream onto the capsule through that hole. This entity can be avoided by a change in surgical technique.