Independent Risk Factors For Reoperation Research Articles

1221 A CONTEMPORARY ANALYSIS OF SUCCESS RATES AND RISK FACTORS FOR FAILURE OF MINIMALLY INVASIVE URETERAL REIMPLANTATION VS. OPEN URETERAL REIMPLANTATION

You have accessJournal of UrologyTechnology & Instruments: Robotics - Malignant Disease & Benign Disease I1 Apr 20121221 A CONTEMPORARY ANALYSIS OF SUCCESS RATES AND RISK FACTORS FOR FAILURE OF MINIMALLY INVASIVE URETERAL REIMPLANTATION VS. OPEN URETERAL REIMPLANTATION Taylor Vaughan, Eric Rovner, Jonathan Picard, and Stephen Savage Taylor VaughanTaylor Vaughan Charleston, SC More articles by this author , Eric RovnerEric Rovner Charleston, SC More articles by this author , Jonathan PicardJonathan Picard Charleston, SC More articles by this author , and Stephen SavageStephen Savage Charleston, SC More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1511AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Minimally invasive (MIS) ureteral reimplantation has recently been documented as providing equivalent surgical outcomes when compared to open surgery. Although feasible, it is unclear how well this compares to a contemporary open approach or what factors may suggest that an open approach is preferred. The goal of this study is to evaluate outcomes after MIS and open ureteral reimplantation and identify preoperative factors to help guide selection of operative approach. METHODS A single institution, retrospective analysis was performed on patients who underwent either MIS (laparoscopic or robotic) or open ureteral reimplantation from 2004 through June 2011. Patients were separated into 2 groups defined by initial reimplant approach. Preoperative, perioperative and postoperative data were obtained and compared using student's t tests. A subsequent analysis was performed evaluating patients who required re-operation. Preoperative data were used in attempt to identify independent risk factors for re-operation. RESULTS From 2004 through June 2011, 12 patients underwent MIS ureteral reimplant and 30 underwent open surgery. Preoperative characteristics revealed patients selected to undergo MIS were significantly older (52.5 vs. 43.9 p≤0.05) vs. those who underwent open surgery. Additionally, the MIS group had a longer time from diagnosis to operation (23.9 vs. 7.3 months p≤0.05) and higher rates of ability to stent the pathologic ureter preoperatively (83% vs. 54% p≤0.05). Those who underwent MIS had less estimated blood loss (EBL) (149 vs. 261cc p≤0.05), lower perioperative complication rates (17% vs. 50% p≤0.05), and shorter hospital stay (2.8 vs. 5.8d p≤0.05). Patients in the MIS group did experience a higher need for future reoperation (25% vs. 0% p≤0.005). On secondary analysis of the MIS group, BMI was found to be an independent predictor of patients requiring re-operation (35.5 vs. 25.9 kg p≤0.005). CONCLUSIONS MIS ureteral reimplantation was shown in this study to result in less EBL, lower perioperative complication rates and shorter hospital stays. Higher re-operation rates were seen in the MIS group and BMI >30 was one factor contributing to this result. Problems with this study may include a potential selection bias in which patients undergo MIS vs. open surgery and the etiology of their ureteral injury. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e494 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Taylor Vaughan Charleston, SC More articles by this author Eric Rovner Charleston, SC More articles by this author Jonathan Picard Charleston, SC More articles by this author Stephen Savage Charleston, SC More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Abstract 17048: Fifteen Year Follow-Up After Aortic Root Replacement with Stentless Biological Valve Conduits: Homograft versus Freestyle

Objectives: The choice of biologic aortic valve substitute for aortic root replacement is multifaceted. Herein, we report the compared long-term outcome of two type of stentless biologic valve conduits namely homograft and Fresstyle bioprosthesis used to replace the aortic root and followed prospectively up to 15 years. Methods: Between 1993 and 2011, 188 patients underwent elective primary aortic root replacement with a stentless bioprosthetic aortic valve with (n=38) or without (n=150) CABG. Among these patients, 98 Freestyle and 90 homografts were implanted. All clinical and echocardioraphic data were collected prospectively. Mean overall follow-up was 8.5±3.9 years (range: 0.1-15). It was 8.4±3.8 years for Freestyle, and 8.5±4.0 years for homografts, and complete in all patients. Results: Patient characteristics were comparable between groups except for age and number of pre-operative diagnosis of endocarditis ( p <0.0001) and moderate/severe aortic insufficiency ( p <0.008). The mean age was significantly higher in the Freesstyle (65.4±8.5years) compared to homograft (48.1±13.0 years) group ( p < 0.0001). Hospital mortality was comparable between the Freestyle and the homograft group (5.1% versus 7.8%, p =0.6). Ten and 15-years survival was 66.7% and 53.0% in the Freestyle versus 89.9% and 69.1% in the homograft group, respectively ( p <0.001). Freedom from reoperation due to structural valve deterioration (SVD) at 10 and 15 years was 98.8% and.92.7% for the Freestyle compared to 87.4% and 68.6% in the homografts group, respectively ( p =0.009). Independent risk factors for reoperation for SVD were age (OR:1.1, CI: 1.02-1.1, p =0.002), and use of homograft (OR:7.7, CI: 1.7-35.5, p =0.008). Independent risk factors for poorer long-term survival were age (OR 1.2, CI: 1.1-1.3, p =0.001), and lenght of hospital stay (OR 2.9, CI: 1.5-3.8, p =0.0003). Mean pressure gradient at the end of follow-up was 8.5±6.2 mm Hg for the Freestyle and 9.9±9.1 mm Hg for the homograft patients. Conclusion: The choice of stentless biologic valve for aortic root reconstruction have no influence on early and long-term survival. The use of biologic root reconstruction with Freestyle bioprostheses provides a better freedom from reoperation due to SVD compared to homografts.

Thirty-Year Experience With the Arterial Switch Operation

We evaluated the results of the arterial switch operation (ASO) being performed at our institution for more than 30 years and identified risk factors for mortality and reoperation. Clinical outcome of 332 consecutive patients with transposition of the great arteries undergoing ASO was retrospectively analyzed, using surgical reports, medical charts, and latest follow-up echocardiography. Statistical analysis was performed using the Kaplan-Meier method and univariable and multivariable binary logistic and Cox regression analyses. In-hospital mortality was 11.4%. At 15 years, estimated overall survival was 85.2%, and estimated freedom from reoperation was 74.0%. Cross-clamp time (p=0.001) and absence of the Lecompte maneuver (p=0.001) were identified as independent risk factors for in-hospital mortality, whereas coronary problems during surgery (p=0.009) and postoperative pacemaker implantation (p<0.001) were independent risk factors for late mortality. Independent risk factors for reoperation were higher age at the time of the ASO (p=0.002), presence of arch abnormalities (p<0.001), coronary problems during surgery (p=0.005), and duration of ventilation (p<0.001). At latest echocardiography, moderate or severe neoaortic regurgitation was present in 3.4% of the patients. Overall, 30 years of experience with the ASO shows good survival and event-free survival rates. Coronary transfer problems during surgery were found to be an important risk factor for late mortality and reoperation. However, coronary anatomy other than 1LCx-2R and an intramural course of the left coronary artery or left anterior descending artery were not risk factors for mortality or reoperation. Neoaortic regurgitation does not seem to form a major problem.

Risk Factors for Re-operation Following Tubularized Incised Plate Urethroplasty: A Comprehensive Analysis

To review our 10-year experience with tubularized incised-plate (TIP) urethroplasty and determine the risk factors for reoperation. The hospital records of 391 patients underwent the TIP procedure from April 1997 to September 2007 were reviewed retrospectively. Data were collected with respect to patient demographics, characteristics of the hypospadias malformation, intraoperative factors and postoperative outcome. Complications requiring reoperation were identified. Univariate and multivariate analyses were used to identify risk factors for reoperation. Median age at surgery was 2 years (range, 0.5-16). Median follow-up was 11 months (range, 3-96). Neourethral complications requiring re-operation developed in 48 patients. A total of 52 reoperations were required because of fistulae (25/6%), neourethral disruption (13/3%), meatal stenosis (13/3%), and stricture (1/0.3%). The re-operation rate was significantly higher in the presence of interrupted sutures, chordee requiring dorsal plication, penoscrotal or proximal shaft defects, a lack of neourethral vascular tissue coverage, and in children over 4 years of age. Multivariate analysis identified the last 3 of these variables as independent risk factors for reoperation. In addition to position of the urethral meatus and the absence of vascular covering flaps, we found that an age over 4 years at the time of surgery is an additional independent risk factor for neourethral complications requiring reoperation.

Extended Criteria Donor and Severe Intraoperative Glucose Variability: Association With Reoperation for Hemorrhage in Liver Transplantation

Reoperations for hemorrhage following liver transplantation (OLT) are commonly associated with increased morbidity and mortality. We sought to determine the incidence and risk factors for reoperation for hemorrhage among adult liver transplantations. We retrospectively analyzed 668 patients transplanted between January 2004 and November 2007. Within 30 days following transplantation one hundred eleven patients (16.6%) underwent 156 reoperations for hemorrhage, averaging 1.4 reoperations per patient. More than half of the reoperations occurred during the first 2 postoperative days. One-third of patients required 2 or more reoperations. Multivariate logistic regression analysis showed 4 independent risk factors: grafts from donors with multiple extended criteria, severe intraoperative glucose variability, intraoperative use of vasopressors, and red blood cell transfusion requirement. In conclusion, we identified several independent risk factors for reoperation due to hemorrhage following OLT. Avoidance of severe intraoperative glucose variability and careful evaluation of the benefits and risks of utilizing extended criteria donors must be considered before transplantation.

Long-term outcome after mitral valve repair: a risk factor analysis

Mitral valve repair is the gold standard to restore mitral valve function and is now known to have good long-term outcome. In order to help perioperative decision making, we analyzed our collective to find independent risk factors affecting their outcome. We retrospectively studied our first 175 consecutive adult patients (mean age: 64+/-10.4 years; 113 males) who underwent primary mitral valve repair associated with any other cardiac procedures between January 1986 and December 1998. Risk factors influencing reoperations and late survival were plotted in a uni- and multivariate analyses. Operative mortality was 3.4% (6 deaths, 0-22nd postoperative day (POD)). Late mortality was 9.1% (16 deaths, 3rd-125th POM). Reoperation was required in five patients. Kaplan-Meier actuarial analysis demonstrated a 96+/-1% 1-year survival, 88+/-3% 5-year survival and a 69+/-8% 10-year survival. Freedom from reoperations was 99% at 1 year after repair, 97+/-2% after 5 years and 88+/-6% after 10 years. Multivariate analysis demonstrated that residual NYHA class III and IV (p=0.001, RR 4.55, 95% CI: 1.85-14.29), poor preoperative ejection fraction (p=0.013, RR 1.09, 95% CI: 1.02-1.18), functional MR (p=0.018, RR 4.17, 95% CI: 1.32-16.67), and ischemic MR (p=0.049, RR 3.13, 95% CI: 1.01-10.0) were all independent predictors of late death. Persistent mitral regurgitation at seventh POD (p=0.005, RR 4.55, 95% CI: 1.56-20.0), age below 60 (p=0.012, RR 8.7, 95% CI: 2.44-37.8), and absence of prosthetic ring (p=0.034, RR 4.76, 95% CI: 1.79-33.3) were all independent risk factors for reoperation. Mitral valve repair provides excellent survival. However, long-term outcome can be negatively influenced by perioperative risk factors. Risk of reoperation is higher in younger patients with a residual mitral regurgitation and without ring annuloplasty.

Influence of surgeon's experience and supervision on re-operation rate after hip fracture surgery

To investigate the influence of the performing surgeon's experience and degree of supervision on re-operation rate among patients admitted with a proximal femoral fracture (PFF). Prospective study of 600 consecutive patients with proximal femoral fracture in our multimodal rehabilitation programme, between 2002 and 2004. Re-operation rate was assessed 6 months postoperatively. Surgeons were grouped as unsupervised junior registrars versus experienced surgeons operating or supervising. Fractures were stratified as technically undemanding or demanding. Unsupervised junior registrars operated on 23% (137/600) of all and 15% (56/365) of technically demanding proximal femoral fractures. The latter had a higher re-operation rate within 6 months, compared with the rate when more experienced surgeons were present. In logistic regression analysis combining age, gender, American Society of Anaesthesiologists score, New Mobility Score, time to surgery and type of implant, surgery by unsupervised junior registrars was still a significant independent risk factor for re-operation in technically demanding proximal femoral fractures. Unsupervised junior registrars should not operate on technically demanding proximal femoral fractures.

Reoperations are common following VATS for spontaneous pneumothorax: study of risk factors

To identify risk factors for reoperation following surgery for spontaneous pneumothorax. This is a retrospective clinical study conducted on 240 consecutive patients operated on for spontaneous pneumothorax in Lund University Hospital between January 1996 and December 2003. Patient information was gained from medical charts and operation reports. Logistic regression analysis was used to evaluate risk factors. Median follow-up was 54 months. Video-assisted thoracoscopic surgery (VATS) was used in 93% of the patients, where bullectomy with or without pleurodesis/pleurectomy was performed in most cases. Conversion to anterolateral thoracotomy was required in 6 cases (2.3%). Operative mortality (<30 days) was 0.8% (0% after VATS). Altogether 35 patients (13.7%) required a reoperation. Twenty patients were reoperated on within one month from surgery, most often due to prolonged air leakage (n=13, 5.1%) and bleeding (n=6, 2.3%). Fifteen patients (5.8%) were reoperated on because of recurrent pneumothorax, on average 17 months (range 1-39 months) after the primary operation. Significant independent risk factors for reoperation were; young age, operations performed for secondary pneumothorax due to emphysema and recurrent pneumothorax. The risk was also increased in patients where wedge resection was not performed. However, the type of pleurodesis or pleurectomy was not related to increased risk. A considerable number of patients require reoperation after VATS for pneumothorax. Most reoperations are due to prolonged air leakage or recurrent pneumothorax. The risk for reoperation is increased in younger patients, patients operated for recurrent or secondary pneumothorax, and in cases where pulmonary wedge resection is not performed.

Late incidence and determinants of reoperation in patients with prosthetic heart valves.

Reoperation is a relatively common event in patients with prosthetic heart valves, but its actual occurrence can vary widely from one patient to another. With a focus on bioprosthetic valves, this study examines risk factors for reoperation in a large patient cohort. Patients (N=3233) who underwent a total of 3633 operations for aortic (AVR) or mitral valve replacement (MVR) between 1970 and 2002 were prospectively followed (total 21,179 patient-years; mean 6.6+/-5.0 years; maximum 32.4 years). The incidence of prosthetic valve reoperation and the impact of patient- and valve-related variables were determined with actual and actuarial methods. Fifteen-year actual freedom from all-cause reoperation was 94.1% for aortic mechanical valves, 61.4% for aortic bioprosthetic valves, 94.8% for mitral mechanical valves, and 63.3% for mitral bioprosthetic valves. In both aortic and mitral positions, current bioprosthesis models had significantly better durability than discontinued bioprostheses (15-year reoperation odds-ratio 0.11+/-0.04; P<0.01 for aortic, and 0.42+/-0.14; P=0.009 for mitral). Current bioprostheses were significantly more durable in the aortic position than in the mitral position (14.3+/-6.8% more freedom from 15-year reoperation; (P=0.018)). Older age was protective, but smoking was an independent risk factor for reoperation after bioprosthetic AVR and MVR (hazard ratio for smoking 2.58 and 1.78, respectively). In patients with aortic bioprostheses, persistent left ventricular hypertrophy at follow-up and smaller prosthesis size predicted an increased incidence of reoperation, while this was not observed in patients with mitral bioprostheses. These analyses indicate that current bioprostheses have significantly better durability than discontinued bioprostheses, reveal a detrimental impact for smoking after AVR and MVR, and indicate an increased reoperation risk in patients with a small aortic bioprosthesis or with persistent left ventricular hypertrophy after AVR.

Twenty-year clinical experience with porcine bioprostheses

For the past 25 years, porcine valves have been the most widely implanted bioprosthesis, thereby becoming the standard for comparison with newer bioprosthetic valves. We retrospectively analyzed 2,879 patients who underwent aortic (AVR; n = 1,594) or mitral (MVR; n = 1,285) valve replacement between 1971 and 1990. Follow-up was 97% complete and extended to 20 years (total, 17,976 patient-years). Patient age ranged from 16 to 94 years; mean age in patients who underwent AVR was 60 +/- 15 (+/- standard deviation) years; that for patients who underwent MVR was 58 +/- 13 years. The operative mortality rates were 7% +/- 1% (70% confidence limits) for AVR and 10% +/- 1% for MVR. Actuarial estimates of freedom from structural valve deterioration at 10 and 15 years were 78% +/- 2% (SE) and 49% +/- 4%, respectively, for the AVR subgroup; and 69% +/- 2% and 32% +/- 4%, respectively, for the MVR subgroup (AVR > MVR; p < 0.05). Estimates of freedom from reoperation at 10 and 15 years were 76% +/- 2% and 53% +/- 4%, respectively, for the AVR subgroup and 70% +/- 2% and 33% +/- 4%, respectively, for the MVR subgroup (AVR > MVR; p < 0.05). Estimates of freedom from thromboembolism at 10 and 15 years were 92% +/- 1% and 87% +/- 2%, respectively, for the AVR subgroup and 86% +/- 1% and 77% +/- 3%, respectively, for the MVR subgroup (AVR > MVR; p < 0.05). Estimates of freedom from anticoagulant-related hemorrhage at 10 and 15 years were both 96% +/- 1% for the AVR subgroup and 93% +/- 1% and 90% +/- 2%, respectively, for the MVR subgroup (AVR > MVR; p < 0.05). Estimates of freedom from valve-related mortality at 10 and 15 years were 86% +/- 1% and 78% +/- 3%, respectively, for the AVR subgroup and 84% +/- 2% and 70% +/- 4%, respectively, for the MVR subgroup (p = not significant). Multivariate analysis (Cox model) showed younger age, later year of operation, and valve site (MVR > AVR) to be significant risk factors for structural valve deterioration. Younger age, later year of operation, valve site (MVR > AVR), and renal insufficiency were the significant, independent risk factors for reoperation. Multivariate analysis revealed that higher New York Heart Association functional class, longer cardiopulmonary bypass time, congestive heart failure, renal insufficiency, and longer cross-clamp time were significant risk factors for valve-related mortality. Valve manufacturer did not emerge as a factor in any analysis. These long-term results with porcine bioprostheses were satisfactory, particularly in older patients and those undergoing AVR. As expected, younger age was a significant risk factor for structural valve deterioration and reoperation in both groups. Surprisingly, the durability of porcine bioprosthetic valves has not improved over time, which possibly can be attributed to more enhanced postoperative surveillance and earlier reintervention. These first-generation Hancock and Carpentier-Edwards porcine bioprostheses achieved similar long-term performance.

Intermediate results after complete repair of tetralogy of Fallot in neonates

From July 1988 through September 1993, 30 neonates with symptomatic tetralogy of Fallot underwent complete repair. Sixteen patients had tetralogy and pulmonary stenosis, 9 had pulmonary atresia, 3 had nonconfluent pulmonary arteries, and 2 had both pulmonary atresia and nonconfluent pulmonary arteries. The median age at operation was 11 days (mean ± standard error of the mean, 12.6 ± 2.9 days), with a mean weight of 3.1 ± 0.1 kg (range 1.5 to 4.4 kg). Preoperatively, 14 patients were receiving an infusion of prostaglandin, 13 were mechanically ventilated, and 6 required inotropic support. Right ventricular outflow tract obstruction was managed by a limited transannular patch in 25 patients, infundibular muscle division with limited resection in 15, and insertion of a right ventricle-pulmonary artery valved aortic homograft conduit in 5 patients. Follow-up was complete at a median interval of 24 months (range 1 to 62 months). There were no hospital deaths and two late deaths, for 1-month, 1-year, and 5-year actuarial survivals of 100%, 93%, and 93%, respectively. The hazard function for death had a rapidly declining single phase that approached zero by 6 months after the operation. Both late deaths occurred in patients with tetralogy of Fallot and pulmonary atresia who had undergone aortic homograft conduit reconstruction, so that the only independent risk factor for death was the use of a valved homograft conduit (p ≤ 0.005). Eight patients required reoperation, resulting in 1-month, 1-year, and 5-year freedom from reoperation rates of 100%, 93%, and 66%, respectively. Indications for reoperation were branch left pulmonary artery stenosis in 5 patients, residual right ventricular outflow tract obstruction in 2 patients, and severe pulmonary insufficiency in 1 patient. Independent risk factors for reoperation included an intraoperative pressure ratio between the right and left ventricles of 0.75 or greater ( p = 0.01), Doppler residual left pulmonary artery stenosis of 15 mm Hg or more, or Doppler right ventricular outflow tract obstruction gradient of 40 mm Hg or more at hospital discharge ( p = 0.002 and 0.02, respectively). This series demonstrates the safety of early hemodynamic repair of symptomatic tetralogy of Fallot in neonates. It also emphasizes the importance of relieving all sources of right ventricular outflow tract obstruction at the initial operation, particularly that located at the site of insertion of the ductus arteriosus, which may be difficult to diagnose in the neonate before ductal closure occurs. The safety and efficacy of valved aortic homograft conduits in neonates requires further investigation. (J T horac C ardiovasc S urg 1995;109:332-44)