Open Pelvic Surgery Research Articles

Factors associated with successful intraoperative oocyte retrieval for fertility preservation during open pelvic surgery for gynecologic indications

ObjectiveThe study investigated factors associated with successful intra-operative oocyte retrieval for fertility preservation during transabdominal gynecologic surgery. Study designA total of 29 patients who underwent intraoperative oocyte retrieval during staging surgery at a single academic hospital from May 2014 to August 2022 were enrolled in this study, and their outcomes were analyzed. ResultsAmong 29 patients who underwent intra-operative oocyte retrieval during staging surgery, oocytes were obtained in 24 patients, representing 82.8 % of the retrieval rate (24/29), and two patients returned to use cryopreserved oocytes (6.9 %). Among 24 women who succeeded in obtaining oocytes, 20 patients succeeded in oocyte cryopreservation, and two patients proceeded to embryo cryopreservation. The cryopreservation rate was 91.7 % (22/24). All patients with failed oocyte retrieval (n = 5) and cryopreservation (n = 7) were diagnosed with malignancy. AMH of those with successful cryopreservation oocytes was higher than those without cryopreservation (4.10 ng/mL vs. 1.18 ng/mL, p = 0.003). A higher portion of the unstimulated cycle was observed in those with failed cryopreservation (8.3 % vs. 40.0 %, p = 0.01). No complications were noted. ConclusionFor women planning to undergo open pelvic surgery, intra-operative oocyte retrieval is a feasible option. High serum AMH and ovarian stimulation before surgery may predict successful oocyte cryopreservation.

Surgeon Estimated Blood Loss is Discordant with Calculated Blood Loss in Acetabular and Pelvic Fracture Surgery.

To compare blood loss as estimated by surgeon estimated blood loss (EBL), the Gross formula, and the HB equation in open pelvic and acetabular surgery. Retrospective cohort study. Single Level I academic trauma center. We included 710 patients 18-89 years of age who underwent acetabular or pelvic surgery for management of fracture between 2008 and 2018. Surgical treatment for management of acetabular or pelvic fracture and blood transfusion when deemed clinically appropriate in the perioperative setting. Surgeon EBL, calculated blood loss (using the Gross formula, a Gross formula derivative, and the HB equation with both Moore and Nadler blood volume estimations). 192 patients (27%) received intraoperative blood transfusions. Surgeon EBL significantly differed from all formulas except the Gross/ Nadler and the modified Gross/ Nadler calculations. Gross and HB calculation methods yielded similar results in the overall cohort, but yielded significantly different results in the subgroup analysis. Use of a corrective transfusion factor mildly improved correlation of the Gross equation with EBL. At high levels of blood loss, surgeon EBL predictions became more discordant with calculated blood loss values. When assessing only patients who did not receive transfusions, concordance improved. Blood loss in pelvic and acetabular surgery is challenging to quantify, and this study demonstrates discordance between formula predictions and surgeon estimated blood loss. At higher levels of blood loss, this discrepancy worsens. This exploratory study highlights the need for the development of improved methods of quantifying blood loss in orthopaedic trauma surgery. Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

A retrospective study comparing postoperative opioid prescribing practices in an academic medical centre.

In the midst of the North American opioid crisis, identifying and intervening on drivers of high-risk opioid prescriptions is an important step towards reducing iatrogenic harm. We aimed to identify factors associated with variations in high-risk opioid discharge prescriptions, following select surgical procedures, to guide future quality improvement initiatives. This retrospective cohort study analyzed 1322 patients who underwent select open pelvic and open abdominal surgeries between January 1 and December 31, 2017, in a tertiary health care centre in Montreal. Patients who underwent open abdominal surgeries were prescribed significantly higher daily doses of morphine milligram equivalents (MME) (45 mg; interquartile range, 30-60), than patients who underwent either a caesarean delivery (20 mg, 20-20) or a hysterectomy (30 mg, 22-30). After adjustment for multiple potential confounders, abdominal surgery was associated with 4 times the odds of receiving more than 50 MME at hospital discharge compared with pelvic surgeries (odds ratio, 3.96; 95% confidence interval, 1.31-11.97). The availability of postoperative preprinted order sets with fixed high doses of opioids was also highly associated with the outcome. In our institution, some surgeries were more likely to receive high-risk opioid prescriptions at discharge. Efforts to optimize safer prescribing practices should address the creation and/or updating of preprinted order sets to reflect current best practice guidelines. This initiative could be overseen by hospital pharmacy and therapeutics committees.

Lower urinary tract symptoms in an elderly women caused by degeneration of the pubic symphysis

BackgroundLower urinary tract symptoms are very common in elderly women, and transvaginal delivery and multiple deliveries have been confirmed to be risk factors. Transvaginal delivery and multiple deliveries may lead to an increase in pubic symphysis degeneration.Case presentationA 79-year-old woman consulted a urologist because of worsening lower urinary tract symptoms such as frequent urination and urodynia. Color ultrasound and cystoscopy suggested the possibility of a bladder mass. A lump on the anterior wall of the bladder was observed although the surface mucosa was normal. Physical examination showed obvious tenderness in the posterior area of the pubic symphysis. Further urological computed tomography (CT) and pelvic magnetic resonance imaging (MRI) showed a nodular bony protuberance in the posterior part of the pubic symphysis, which was more obvious than before, with compression changes near the anterior wall of bladder. Open pelvic surgery showed that nodular bone tissue originating from the pubic symphysis significantly oppressed the anterior wall of the bladder behind the pubic symphysis. After resection of the nodule, the lower urinary tract symptoms were relieved significantly.ConclusionsPubic symphysis degeneration caused by transvaginal delivery may be an important cause of lower urinary tract symptoms in women. Pelvic CT or MRI is necessary to diagnosis this condition.

PD33-04 PRIOR SURGICAL EXPERIENCE AND THE IMPACT ON PERIOPERATIVE OUTCOMES IN ROBOT-ASSISTED PARTIAL NEPHRECTOMY: A MULTICENTER ANALYSIS WITH 2,500 PATIENTS

PD33-04 PRIOR SURGICAL EXPERIENCE AND THE IMPACT ON PERIOPERATIVE OUTCOMES IN ROBOT-ASSISTED PARTIAL NEPHRECTOMY: A MULTICENTER ANALYSIS WITH 2,500 PATIENTS

Surgical counts in open abdominal and pelvic surgeries in a university hospital: a best practice implementation project.

Counting of accountable items used during surgery, frequently called 'the count', is a fundamental practice to ensure that items such as surgical instruments, sponges and sharps are not forgotten within patients. Although inadvertently leaving behind a sponge or instrument at the end of an operation is a rare event, it is an error that may have serious implications. The aim of this evidence implementation project was to contribute to promoting evidence-based practice in surgical counts in open abdominal and pelvic surgeries and thereby improving the outcomes of the surgical patients at a surgical centre of a university hospital. The current evidence implementation project used the JBI Practical Application of Clinical Evidence System and Getting Research into Practice (GRiP) audit and feedback tool. The JBI Practical Application of Clinical Evidence System and GRiP framework for promoting evidence-based healthcare involves three phases of activity: first, establishing a project team and undertaking a baseline audit based on evidence-informed criteria; second, reflecting on the results of the baseline audit and designing and implementing strategies to address non-compliance found in the baseline audit informed by the JBI GRiP framework; third, conducting a follow-up audit to assess the outcomes of the interventions implemented to improve practice, and identify future practice issues to be addressed in subsequent audits. These three phases were performed over a period of 6 months, from August 2017 to March 2018. The baseline audit revealed deficits between old and best practice in all criteria. Barriers for implementation of a protocol for surgical counts were identified, and strategies were implemented. The postimplementation (follow-up) audit showed improvement in compliance with best practice in six of the audit criteria selected except two, a multidisciplinary team approach to decrease retained surgical items, and limited staff hand-offs during surgical procedures to ensure the same team is present in all counting episodes. The main achievements of the study included substantial increases in compliance with best practice. However, registration and report and commitment of all members of surgical team to apply the entire protocol, avoiding to skip any step, persist as challenges.

Risk factors for small bowel obstruction after open rectal cancer resection

BackgroundSmall bowel obstruction (SBO) is observed in around 10% of patients with prior open abdominal surgery. Rectal resection causes the highest readmission rates. The aim of this study was to investigate risk factors for readmission for SBO and causes for SBO in patients who needed surgery following rectal cancer surgery.MethodsA population-based registry with prospectively gathered data on 752 consecutive patients with rectal cancer who underwent open pelvic surgery between January 1996 and January 2017 was used. Univariable and multivariable regression analysis was performed, and the risk of SBO was assessed.ResultsIn total, 84 patients (11%) developed SBO after a median follow-up time of 48 months. Of these patients, 57% developed SBO during the 1st year after rectal cancer surgery. Surgery for SBO was performed in 32 patients (4.3%), and the cause of SBO was stoma-related in one-fourth of these patients. In the univariable analysis previous RT and re-laparotomy were found as risk factors for readmission for SBO. Re-laparotomy was an independent risk factor for readmission for SBO (OR 2.824, CI 1.129–7.065, P = 0.026) in the multivariable analysis, but not for surgery for SBO. Rectal resection without anastomoses, splenic flexors mobilization, intraoperative bleeding, operative time were not found as risk factors for SBO.ConclusionsOne-tenth of rectal cancer patients who had open surgery developed SBO, most commonly within the 1st postoperative year. The risk of SBO is greatest in patients with complications after rectal cancer resection that result in a re-laparotomy.

Minimally Invasive Surgery for Anterior Pubic Rami Fractures Under Fluoro-Navigation Using the Medtronic O Arm System and Calcium Phosphate for Internal Fixation

Introduction: The incidence of anterior pubic rami fractures in elderly female patients over the age of 65 has been reported to be 64 %. Osteoporosis plays a role with these fractures, as they are caused by minimal low energy injuries from a fall. Indications for internal fixation of anterior pelvic ring are controversial because of the etiology being low energy trauma and the location being a non-weight bearing surface. In contrast to conventional open pelvic surgery, percutaneous screw fixation has gained popularity in the treatment of pelvic fractures, mainly because of minimal soft tissue damage, less operative blood loss, early surgical intervention, and comfortable mobilization of the patient. The use of calcium phosphate as a form of internal fixation further advances the advantages of minimally invasive surgery for internal fixation with less morbidity by the use of screw fixation. The incorporation of fluoro-navigation is a new surgical technique in orthopedic trauma surgery. (Figure 1) This study is to report our clinical results of fluoro-navigation surgery in anterior pelvic pubic rami fractures using calcium phosphate as the fixation of choice. This is the first report of this method of treatment using a new combination of visualization and internal fixation. Materials and Methods: From April 2018 to December 2019, 30 patients with anterior pubic rami fractures were treated with percutaneous cannulated calcium phosphate delivery under Medtronic O arm (fluoro-navigation) control. There were 5 male and 25 females, with a mean age of 84.6 years (range 80-104) for females and mean age of 90 years (84 – 99) for the 5 males. According to the AO and Orthopedic Trauma Association classification, all were considered lateral compression types of fractures. All patients were operated on when their general medical condition stabilized after emergency management and admission. The pain score on admission was reported as 10/10 in all cases. Plain standard pelvic x-rays were obtained on admission as well as CT scans of the pelvis. All the anterior pubic rami fractures were fixed using percutaneous delivery of calcium phosphate with the Zimmer trocar system by one senior surgeon. The Medtronics O arm fluoro-navigation was used in all cases. The surgeon was familiar with the navigation system and had much experience in the computer-assisted percutaneous placement of the trocars. Results: A total of 30 patients were treated with this new combination of surgical treatment of anterior pubic rami fractures. No screws were inserted or found to be necessary for fracture treatment. Each case used 2 trocars from the kits supplied from Zimmer. One end delivery trocar was directed to the inferior pubic ramus fracture and the second which was a side delivery trocar was used for the superior pubic ramus fracture. A total of 10 cc of calcium phosphate was used in each case, 5 cc per trocar. The position of the trocars were placed using the fluoro-navigation control of the O arm. Once the trocars were properly placed the calcium phosphate was delivered and viewed under flouro control and then again viewed with the spin sequence using the Medtronics O arm. Total patient time in the operating room was 56 minutes; Total surgery time was 26 minutes. Anesthesia in most cases was MAC or light sedation with local skin infiltration using 1% lidocaine. Blood loss during the operation was considered very minimal with derma bond used to cover the percutaneous sites as well as a small band-aid. No superficial or deep infections occurred. No patient sustained recognized neurologic, vascular, or urologic injury because of the percutaneous pubic rami fixation with calcium phosphate. Extravasation of the calcium phosphate from the fracture’s sites did not pose any sequelae with soft tissue injury or with fracture healing. All patients were encouraged to get out of bed and weight bear according to comfort on post-op day 1. All fractures united at the last follow-up. Conclusions: This study presented for the first time two new techniques for the operative treatment of pubic rami fractures of the pelvis. The delivery of calcium phosphate for fracture fixation of pubic rami fractures has been found to be safe, minimally invasive, providing pain relief and stability permitting early mobilization. The addition of intra-operative fluoro- navigation technique makes the fracture treatment an accurate, and rapid method for the treatment of pubic rami fractures. Consistency of the operative procedure and teaching are mandatory for the success of this procedure. The learning curve for most orthopedists should be very short. The outcomes have been shown to benefit patient mobilization, decrease morbidity and decrease hospital stay

Prognostic Value of Preoperative Pro-B-Type Natriuretic Peptide: Early Predictor of Cardiovascular Complications and Mortality After Major Abdominal Surgery.

Background and objectivesIn surgical patients, coronary disease is the main cause of perioperative mortality. The incidence of serious cardiovascular complications is reported as 5% with a probability of 1-2% of death from the cardiac cause in major non-cardiac surgery. B-type natriuretic peptide (BNP) is a sensitive and specific predictor of left ventricular systolic dysfunction and predicts first cardiovascular event and death in the general population. The recent guidelines recommended the use of pro-BNP for independent perioperative prognosis in cardiac patients undergoing non-cardiac surgery. The aim of this study is to assess the predictive value of raised pro-BNP levels in patients who underwent major abdominal surgery and evaluate its relationship with cardiovascular complications and mortality occurring up to 30 days after surgery.Materials and methodsWe reviewed the medical records of patients undergone surgical procedures in the abdominal region lasting more than two hours, requiring postoperative high dependence or intensive care and an expected hospital stay of at least three days. All types of open or laparoscopic-assisted abdominal or pelvic surgeries that were evaluated for preoperative pro-BNP levels were included in the study. During the postoperative period, all patients were followed for cardiac complications and mortality for 30 days after surgery. Postoperative adverse cardiac events were predefined as angina pectoris, myocardial infarction, cardiogenic dyspnea, acute arrhythmias (atrial fibrillation/flutter, ventricular fibrillation/tachycardia), acute hypertensive event (hypertensive emergency or urgency), congestive heart failure, acute pulmonary edema, or primary cardiac death. While non-cardiac complications were also documented as either pulmonary, septic, postsurgical site infection, and other systemic complications. Subsequently, a survival analysis was done for the discretion of cardiovascular complications and mortality.ResultsThe mean age of the study population was found to be 50.22 ± 14.28 years, mean pro-BNP levels were 909.29 ± 3950.04, and mean days of hospital stay were 7.43 ± 4.49 days. The 30-day postoperative all-cause mortality was found to be 9.8%. Hypertension and diabetes were frequent comorbidities amongst the study population. The mean preoperative pro-BNP levels were found higher in the male gender (p=0.071), also found higher in those with cardiovascular complications (p=0.006) and mortality (p=0.057). Receiver operating characteristic (ROC) analysis showed cardiovascular outcomes with a cut-off value of pro-BNP at 143 pg/ml, AUC of 0.891, at a sensitivity of 91%, positive predictive value (PPV) of 96%, a specificity of 75%, and negative predictive value (NPV) of 58%, while the same for mortality at a cut-off value of 164 pg/ml was found with AUC of 0.815, at a sensitivity of 84%, a specificity of 66%, PPV of 97%, and NPV of 21%. The unadjusted odds ratio for cardiovascular complications was found to be 17.857 (95% CI: 6.56-48.60) while that for mortality was 10.863 (95% Cl: 2.29-51.37). The Kaplan-Meier survival curves showing elevated pro-BNP levels were significantly associated with cardiovascular events, with 30 days mortality at a cut-off value of 164 pg/ml.ConclusionPro-BNP is a useful marker in postoperative patients for not only predicting cardiovascular outcomes as cited by many previous studies but also mortality.

Subcutaneous analgesic system versus epidural for post-operative pain control in surgical pediatric oncology patients

Background/PurposePediatric oncology patients often undergo open operations for tumor resection, and epidural catheters are commonly utilized for pain control. Our purpose was to evaluate whether a subcutaneous analgesic system (SAS) provides equivalent post-operative pain control. MethodsAn IRB approved, retrospective chart review of children age <18 undergoing open abdominal, pelvic or thoracic surgery for tumor resection between 2017 and 2019 who received either epidural or SAS for post-operative pain control was performed. Comparisons of morphine milligram equivalents (MME), pain scores, and post-operative course were made using parametric and non-parametric analyses. ResultsOf 101 patients, median age was 7 years (2 months–17.9 years). There were 65 epidural and 36 SAS patients. Transverse laparotomy was the most common incision (41%), followed by thoracotomy (29%). Pain scores, MME, urinary catheter days, and post-operative length of stay (LOS) were similar between the two groups. Urinary catheter use was more common in epidural patients (70% vs 30%, p = <0.001). SAS patients had faster time to ambulation and time to regular diet by 1 day (p = 0.02). Epidural patients more commonly had a complication with the pain device (20% vs 3%, p = 0.02) and were more likely to be discharged with narcotics (60% vs. 40%, p = 0.04). Charges associated with the hospital stay were similar between the two groups. ConclusionIn pediatric oncology patients undergoing open abdominal, pelvic, and thoracic surgery, SAS may provide similar pain control to epidural, but with faster post-operative recovery, fewer complications, and less discharge narcotic use. A prospective study is needed to validate these results. Type of StudyRetrospective Comparative Level of EvidenceLevel III

TAPB and RSB protects cardiac diastolic function in elderly patients undergoing abdominopelvic surgery: a retrospective cohort study.

BackgroundDiastolic dysfunction, an early manifestation and clinical symptom of heart failure with preserved ejection fraction, can be influenced by various anesthesia management strategies. Trans-esophageal echocardiography was used to undertake to assess left ventricular diastolic function during anesthesia maintenance using sevoflurane alone and sevoflurane combining with transversus abdominis plane block and rectus sheath block in elderly patients with diastolic dysfunction undergoing abdominopelvic surgery.MethodsThirty-eight patients were divided into two groups in this retrospective study, sevoflurane and sevoflurane combining with TAPB and RSB according to employing different anesthesia maintenance schemes. The parameters HR, MAP, CVP, E, A, E/A, e, a, e/a, and E/a were obtained immediately after anesthesia induction hemodynamics stability (HR1, MAP1, CVP1, E1, A1, E1/A1, e1, a1, e1/a1, and E1/a1) and 1 hour later (HR2, MAP2, CVP2, E2, A2, E2/A2, e2, a2, e2/a2, and E2/a2).ResultsTransmitral diastolic Doppler flow characteristics illustrated E/A significant decreases in the S group but increases in the ST group (p = 0.02 < 0.05) 1 hour after anesthesia induction hemodynamic stability. Tissue Doppler imaging characteristics showed a more significant increase e/a (P = 0.005 < 0.05) and decreases in a value (p = 0.009 < 0.05) in the ST group 1 hour after anesthesia induction hemodynamics stability.ConclusionsMaintaining anesthesia with sevoflurane combining with TAPB and RSB was more suitable for protecting cardiac diastolic function than sevoflurane alone in elderly patients with diastolic dysfunction undergoing open abdominal and pelvic surgery.

Musculoskeletal disorders among urologists-is there anassociation with open pelvic surgery? : Results of a national survey

In urology, the health implications of open pelvic surgery (OPS) on the patient have been the subject of numerous studies. However, health effects on the surgeon have not yet been sufficiently considered. The present study investigates the relationship between musculoskeletal disorders in urological surgeons and their activity in OPS. From the point of view of occupational physiology, exemplary operations in OPS were examined using the key indicator method (KIM). In addition, aweb-based survey among German clinicians was carried out. From the collected variables, models for the prediction of the endpoints pain and disc herniation (DH) were generated by multivariate logistic regression. Risk assessment of the operations with KIM could show that OPS presents asignificantly increased physical workload and thus potential physical overstraining. Of the 605 participants in the survey, 35.4% were urologists performing OPS, 32.0% were urologists not performing OPS and 32.6% were gastroenterologists (control groups). Activity in OPS had an odds ratio (OR) of 1.09 (confidence interval [CI]: 0.72-1.66, p = 0.69) for predicting pain, and an OR of 1.14 for prediction of DH CI: 0.66-1.94; p = 0.64). Statistically significant factors influencing the perception of pain were BMI, gender and work ability index (WAI), whereas age and WAI were significant for the occurrence of DH. Our survey could not show that surgeons practicing OPS have a significantly increased rate of musculoskeletal disorders or, in particular, an increased rate of DH in comparison to the control groups. Nevertheless, the rate of reported complaints among all clinicians surveyed is high, and the random risk assessment of the examplary OPS operations could also demonstrate the risk of physical overstraining. Further considerations should therefore be made as to how reduce the strain on the musculoskeletal system.

V13-12 ADNEXAL MANAGEMENT AT THE TIME OF ELECTIVE PELVIC SURGERY IN WOMEN

You have accessJournal of UrologyFemale Pelvic Surgery (V13)1 Apr 2020V13-12 ADNEXAL MANAGEMENT AT THE TIME OF ELECTIVE PELVIC SURGERY IN WOMEN Adam Miller*, David Yang, and Brian Linder Adam Miller*Adam Miller* More articles by this author , David YangDavid Yang More articles by this author , and Brian LinderBrian Linder More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000970.012AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Ovarian cancer has the highest mortality rate of all gynecologic cancers and is the fifth leading cause of cancer mortality in women with a lifetime risk of 1.4%. Despite advances in medicine, there has only been marginal improvement in survival over the past 50 years, mainly due to limited screening. It is known that many ovarian cancers are derived from the fallopian tube and not directly from the ovary. As such, opportunistic salpingectomy with or without oophorectomy has been proposed as a way to decrease ovarian cancer risk in patients undergoing routine pelvic surgery for other indications. The objective of our video is to discuss the role, feasibility, and surgical technique of opportunistic salpingectomy with or without oophorectomy for ovarian cancer risk reduction at the time of open, laparoscopic, or robotic pelvic surgery for another indication. METHODS: We present opportunistic salpingectomy and salpingo-oophorectomy in three patients. The first two cases highlight examples of this technique performed during robotic pelvic surgery and the third case is an example performed during open pelvic surgery. RESULTS: In our video, salpingectomy and salpingo-oophorectomy are performed with minimal added operative time or blood loss. No complications occurred due to the additional procedure. CONCLUSIONS: Salpingectomy and salpingo-oophorectomy for ovarian cancer risk reduction is a safe, feasible option for patients undergoing pelvic surgery. Surgeons familiar with operating in this location should consider opportunistic salpingectomy or salpingo-oophorectomy in females who are no longer interested in fertility preservation and who are undergoing routine pelvic surgery for another indication. Source of Funding: N/A © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1214-e1214 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Adam Miller* More articles by this author David Yang More articles by this author Brian Linder More articles by this author Expand All Advertisement PDF downloadLoading ...

Extended versus inpatient thromboprophylaxis with heparins following major open abdominopelvic surgery for malignancy: a systematic review of efficacy and safety

BackgroundPatients undergoing open abdominopelvic procedures for malignancy are at high risk of postoperative venous thromboembolism (VTE). This risk can be mitigated with prophylaxis; however, optimum duration in this population remains unknown. Our objective was to conduct a systematic review of contemporary literature on the use of heparin thromboprophylaxis following major open pelvic surgery for malignancy, comparing the efficacy and safety of extended duration to inpatient treatment.MethodsA study protocol describing search strategy and inclusion and exclusion criteria was developed and registered with PROSPERO. A literature review was conducted in accordance with the protocol.ResultsLiterature review identified only 4 studies directly comparing extended and inpatient duration prophylaxis, with a combined population of 3198 and 3135 patients for VTE rate and bleeding events, respectively. Despite many studies reporting lower VTE rates in patients receiving extended prophylaxis, no statistically significant difference in rates of postoperative VTE (p = 0.18) or bleeding complications (p = 0.43) was identified between patients receiving extended duration prophylaxis and those receiving inpatient only prophylaxis.ConclusionOn the review of contemporary literature, no significant difference was found in rates of postoperative VTE or bleeding complications between patients receiving extended duration heparin VTE prophylaxis and those receiving inpatient prophylaxis after open abdominopelvic surgery for malignancy.This raises the question of how extended duration prophylaxis has become common practice in this population, and whether this needs to be re-evaluated.

Adhesion-Related Complications Are Less Likely After Laparoscopic Surgery

Adhesions develop in 80% to 90% of patients who undergo open abdominal or pelvic surgery. In a 1999 study, one third of patients who had open surgery

A survey of perioperative intravenous lidocaine use by anaesthetists in Australia and New Zealand.

Perioperative intravenous lidocaine administration by anaesthetists is purported to confer a variety of benefits across a range of surgical procedures. It remains unclear whether the available evidence regarding efficacy and safety is sufficient to influence Australasian practice broadly, and whether significant barriers to uptake exist. We therefore conducted a survey of Fellows of the Australian and New Zealand College of Anaesthetists to evaluate patterns of lidocaine use, and perceptions relating to benefit and safety. Of 979 survey invitations, 295 (30.1%) responded. Of these, 51.9% of anaesthetists incorporate lidocaine administration into their practice. Amongst users, the most common indication is open abdominal or pelvic surgery (88.9%), with the principal intent of reducing acute pain and opioid use (both 92.2%). Only 51% perceive lidocaine to have a role in the prevention of chronic post-surgical pain, and less than a third administer it for operations strongly linked to this condition. Nearly all (91%) users deliver the drug by intraoperative bolus and infusion, with the majority using doses between 1.0 and 1.5 mg/kg for both the bolus and the hourly infusion rate. When parallel local anaesthetic techniques are employed, 44.4% restrict the dose, 37.3% turn the lidocaine infusion off first and 15.7% make no modifications. Most respondents terminate infusions by the end of surgery (52.3%) or in the post-anaesthesia care unit (26.8%). Few deliver postoperative infusions without electrocardiographic monitoring (5.9%). There were no reports of life-threatening events. The dichotomy in Australasian use of perioperative lidocaine revealed by this survey confirms that large multicentre trials are now required to guide practice accurately.

The St Mark's retractor.

The St Mark's retractor is an instrument essential in open pelvic surgery. It is of great help in exposing structures deep in the narrow pelvis. This rigid retractor has specific properties including a shaped hollow handle with two prominences on the upper ridge, a 90° angle in the blade and a varying angle from blade to handle. The slightly curved blade is 6 cm wide and 12·5 cm or 18 cm deep. Lipped and non‐lipped blades are available (Fig. 1). Although the instrument is known internationally as ‘St Mark's retractor’, its origin and creator are unknown. In this article, the authors aim to describe the origin of this useful instrument in order to appreciate its historical value and acknowledge its developer. Open in a separate window Figure 1 St Mark's retractors

Extended or Inpatient Thromboprophylaxis with Heparins Following Major Open Pelvic Surgery for Malignancy – A Systematic Review of Efficacy and Safety

Extended or Inpatient Thromboprophylaxis with Heparins Following Major Open Pelvic Surgery for Malignancy – A Systematic Review of Efficacy and Safety

A retrospective evaluation of the impact of patient ethnicity on the use of epidural analgesia or blood transfusions in children undergoing major oncologic surgery

BackgroundThe impact of patient ethnicity on healthcare delivery is well documented. In this study of children who had undergone open abdominal or pelvic surgery for tumor resection, we sought to compare the use of epidural analgesia or intraoperative blood transfusions between Caucasian and non-Caucasian children.MethodsA retrospective study of 139 children was performed. Logistic regression models were used to evaluate the association between the specified perioperative factors and patient ethnicity.ResultsThe average age (standard deviation) was 11 years (± 5), 50% were female, and 58% were Caucasian. Compared to Caucasian children, non-Caucasian children were younger (difference in mean, − 2.6 years; 95% confidence interval [− 4.3, − 0.9], p = 0.003), underwent shorter procedures (difference in mean anesthesia minutes, − 134; 95% confidence interval [− 230, − 39], p = 0.006), and had a lower proportion of patients who received epidural analgesia (66% versus 81%, p = 0.042) or blood transfusions (48% versus 65%, p = 0.039). In the adjusted model, patient ethnicity was not associated with the receipt of epidural analgesia (odds ratio 0.53, 95% confidence interval [0.23, 1.21], p = 0.132) or blood transfusions (odds ratio 0.77, 95% confidence interval [0.29, 2.04], p = 0.600). The use of epidural analgesia or blood transfusions was associated with abnormal coagulation factors (odds ratio 0.32, 95% confidence interval [0.14, 0.71], p = 0.005) and the duration of surgery (odds ratio 1.007, 95% confidence interval [1.005, 1.009], p < 0.001), respectively.ConclusionIn this study of children who had undergone major oncologic surgery, the use of epidural analgesia or blood transfusions was not associated with patient ethnicity.

Robot-assisted radical cystectomy versus open radical cystectomy in patients with bladder cancer (RAZOR): an open-label, randomised, phase 3, non-inferiority trial

Radical cystectomy is the surgical standard for invasive bladder cancer. Robot-assisted cystectomy has been proposed to provide similar oncological outcomes with lower morbidity. We aimed to compare progression-free survival in patients with bladder cancer treated with open cystectomy and robot-assisted cystectomy. The RAZOR study is a randomised, open-label, non-inferiority, phase 3 trial done in 15 medical centres in the USA. Eligible participants (aged ≥18 years) had biopsy-proven clinical stage T1-T4, N0-N1, M0 bladder cancer or refractory carcinoma in situ. Individuals who had previously had open abdominal or pelvic surgery, or who had any pre-existing health conditions that would preclude safe initiation or maintenance of pneumoperitoneum were excluded. Patients were centrally assigned (1:1) via a web-based system, with block randomisation by institution, stratified by type of urinary diversion, clinical T stage, and Eastern Cooperative Oncology Group performance status, to receive robot-assisted radical cystectomy or open radical cystectomy with extracorporeal urinary diversion. Treatment allocation was only masked from pathologists. The primary endpoint was 2-year progression-free survival, with non-inferiority established if the lower bound of the one-sided 97·5% CI for the treatment difference (robotic cystectomy minus open cystectomy) was greater than -15 percentage points. The primary analysis was done in the per-protocol population. Safety was assessed in the same population. This trial is registered with ClinicalTrials.gov, number NCT01157676. Between July 1, 2011, and Nov 18, 2014, 350 participants were randomly assigned to treatment. The intended treatment was robotic cystectomy in 176 patients and open cystectomy in 174 patients. 17 (10%) of 176 patients in the robotic cystectomy group did not have surgery and nine (5%) patients had a different surgery to that they were assigned. 21 (12%) of 174 patients in the open cystectomy group did not have surgery and one (1%) patient had robotic cystectomy instead of open cystectomy. Thus, 302 patients (150 in the robotic cystectomy group and 152 in the open cystectomy group) were included in the per-protocol analysis set. 2-year progression-free survival was 72·3% (95% CI 64·3 to 78·8) in the robotic cystectomy group and 71·6% (95% CI 63·6 to 78·2) in the open cystectomy group (difference 0·7%, 95% CI -9·6% to 10·9%; pnon-inferiority=0·001), indicating non-inferiority of robotic cystectomy. Adverse events occurred in 101 (67%) of 150 patients in the robotic cystectomy group and 105 (69%) of 152 patients in the open cystectomy group. The most common adverse events were urinary tract infection (53 [35%] in the robotic cystectomy group vs 39 [26%] in the open cystectomy group) and postoperative ileus (33 [22%] in the robotic cystectomy group vs 31 [20%] in the open cystectomy group). In patients with bladder cancer, robotic cystectomy was non-inferior to open cystectomy for 2-year progression-free survival. Increased adoption of robotic surgery in clinical practice should lead to future randomised trials to assess the true value of this surgical approach in patients with other cancer types. National Institutes of Health National Cancer Institute.