Prolonged Catheterization Research Articles

Comparing postoperative voiding dysfunction after mid-urethral sling using either a Babcock or Kelly clamp tensioning technique

The objective was to compare postoperative urinary retention using the Babcock and Kelly clamps for retropubic midurethral sling (RPS) tensioning. This was a retrospective cohort of isolated RPS procedures from December 2010 through April 2016 by five fellowship-trained surgeons at two institutions. Slings were tensioned with a Babcock clamp by grasping a 3-mm midline fold of mesh (RPS-B) or a Kelly clamp as a spacer between the sling and suburethral tissue (RPS-K). Assessment of urinary retention included the primary outcome of postoperative catheterization and several secondary outcomes, including discharge home with a catheter, within 1year of surgery. Analysis of covariance was used to compute the mean difference in duration of catheterization and log-binomial regression was used to calculate risk ratios (RR) and 95% confidence intervals (CI). We included 240 patients. The RPS-B group had a lower body mass index and was more likely to be menopausal, have had pelvic organ prolapse surgery, and have a lower maximum urethral closure pressure than the RPS-K group. The mean duration of catheterization was similar, as demonstrated by the crude (0.21days [-0.30-0.71]) and BMI-adjusted (0.07days [-0.41-0.55]) mean difference in duration of catheterization. The incidence of postoperative OAB symptoms was comparable between the groups (BMI-adjusted RR: 0.95 (0.80-1.1)), and the incidence of revision did not differ (p = 0.7). The Babcock and Kelly clamp tensioning techniques appear comparable, with a low incidence of prolonged postoperative catheterization. Most catheters were removed on the day of the surgery. It is reasonable to tension retropubic midurethral slings with either method.

Catheter-related complications and survival among incident hemodialysis patients in Singapore.

Hemodialysis is the main modality of renal replacement therapy in Singapore. However, a majority of the patients in Singapore are initiated on hemodialysis via a catheter. This study examines the complication rates and factors predicting catheter-related bloodstream infections and mortality rates in patients who were initiated on hemodialysis at our institution. This is a single-center retrospective analysis of incident hemodialysis patients who were initiated on renal replacement therapy between 1 January 2010 and 31 December 2012. Catheter-related bloodstream infection risk factors, organisms, and associated mortality were analyzed. The catheter-related bloodstream infection and exit site infection incidence rates were 0.75 and 0.50 per 1000 catheter days, respectively. The mean duration to first catheter-related bloodstream infection episode was 182.47 ± 144.04 catheter days. Prolonged catheter duration was found to be a risk factor for catheter-related bloodstream infection. Compared to patients initiated on dialysis via arteriovenous fistula, initiation of dialysis via catheter is strongly associated with increased mortality (6.0% vs 14.5%; p = 0.02). In particular, the presence of diabetes mellitus and development of catheter-related bloodstream infection was associated with increased mortality ( p = 0.04 and 0.05, respectively). In addition, patients who began hemodialysis before being seen by a nephrologist were associated with decreased mortality (3.4% vs 13.0%; p = 0.03). In conclusion, prolonged duration of catheter insertion is found to be a risk factor for catheter-related bloodstream infection in hemodialysis patients, and its development is associated with increased mortality. Early referral to a nephrologist and creation of arteriovenous fistula in pre-end-stage renal disease patients are pivotal in improving the outcomes of patients.

The impact of time to catheter removal on short-, intermediate- and long-term urinary continence after radical prostatectomy

To assess the impact of prolonged catheterization time on 1-week (short-term), 3-month (intermediate-term) and 1-year (long-term) UC. Between 2008 and 2015, 6918 men underwent RP by four high-volume surgeons. Exclusion criteria were baseline urinary incontinence (UI) and radiotherapy prior or within 12months after RP. For the remaining 4111 patients, data on short-, intermediate- and long-term UC were available for 3989, 2490 and 1967 patients, respectively. UC was defined as the use of zero or 1-safety pad/24h. Time to catheter removal was categorized into ≤ 7, 8-14 and ≥ 15days. To assess the impact of catheterization time on short-, intermediate- and long-term UI, uni- and multivariable logistic regression analyses adjusted for age, BMI, prostate volume, pathological tumor stage, Charlson comorbidity index and nerve-sparing technique were performed. Post-RP UC rates at 1week for catheterization of ≤ 7, 8-14 and ≥ 15days were 31.2, 27.4 and 18.0%. For the same groups, 3-month and 1-year UC rates were 82.7, 79.2 and 74.1% as well as 90.8, 91.6 and 88.2%, respectively. In multivariate logistic regressions, longer catheterization time was associated with worse short- and intermediate UI (OR 15days: 2.19 and 1.54; p = ≤ 0.001 and p = 0.04). This difference dissipated at 1 year after RP (p > 0.05). While longer catheterization is associated with worse short- and intermediate-term UC, it has no adverse impact on long-term UC.

No Appendix is Too Short—Simultaneous Mitrofanoff Catheterizable Vesicostomy and Malone Antegrade Continence Enema (MACE) for Children with Spina Bifida

To present the results of simultaneous creation of both Mitrofanoff stoma and Malone antegrade continence stoma (MACE) using simple division of the appendix and a cecal extension method. Between June 2011 and November 2016, simultaneous Mitrofanoff and MACE was performed in 16 children (12 children-simple division of the appendix, 4 children-appendicovesicostomy and cecal extension of the appendix). Extension of the appendix was achieved by tubularization of the excised cecal flap next to the short appendicular stump. The new extended channel was then wrapped by cecal wall. Follow-up was 40 months (10-74 months). Currently, in all children, both stomas are easily catheterizable. Obstruction of MACE occurred in 5 children (4 with split appendix, 1 with extended appendix); Mitrofanoff stomal stenosis occurred in 1 child. Endoscopic revision and prolonged catheterization of stenotic stomas were effective in all cases. Wound infection and dehiscence was noted in 2 children (both with split appendix). Drainage and intravenous antibiotics were effective. All Mitrofanoffs are continent. In 4 children there is incident minor leakage of the MACE (3 with split appendix and in 1 with extended appendix). The split appendix procedure is feasible. Cecal extension of the appendix seems to be a good option when the appendix is too short for a simple split procedure.

Central line-associated bloodstream infections and catheter dwell-time: A theoretical foundation for a rule of thumb

Many clinicians know from experience and medical epidemiological literature that the risk of central line-associated bloodstream infections (CLABSI) increases rapidly with a prolonged catheter dwell-time, but how this infection risk increases over time remains obscure. In this manuscript, a clinically useful rule of thumb is derived, stating that the risk of CLABSI increases in a quadratic fashion with the increase in catheter dwell-time. The proposed rule of thumb could be considered a quick and effortless clinical tool to rationally predict the pattern of CLABSI risk with an increasing catheter dwell-time

Arteriovenous Fistula Maturation in Prevalent Hemodialysis Patients in the United States: A National Study

Arteriovenous fistulas (AVFs) are the preferred form of hemodialysis vascular access, but maturation failures occur frequently, often resulting in prolonged catheter use. We sought to characterize AVF maturation in a national sample of prevalent hemodialysis patients in the United States. Nonconcurrent observational cohort study. Prevalent hemodialysis patients having had at least 1 new AVF placed during 2013, as identified using Medicare claims data in the US Renal Data System. Demographics, geographic location, dialysis vintage, comorbid conditions. Successful maturation following placement defined by subsequent use identified using monthly CROWNWeb data. AVF maturation rates were compared across strata of predictors. Patients were followed up until the earliest evidence of death, AVF maturation, or the end of2014. In the study period, 45,087 new AVFs were placed in 39,820 prevalent hemodialysis patients. No evidence of use was identified for 36.2% of AVFs. Only 54.7% of AVFs were used within 4 months of placement, with maturation rates varying considerably across end-stage renal disease (ESRD) networks. Older age was associated with lower AVF maturation rates. Female sex, black race, some comorbid conditions (cardiovascular disease, peripheral artery disease, diabetes, needing assistance, or institutionalized status), dialysis vintage longer than 1 year, and catheter or arteriovenous graft use at ESRD incidence were also associated with lower rates of successful AVF maturation. In contrast, hypertension and prior AVF placement at ESRD incidence were associated with higher rates of successful AVF maturation. This study relies on administrative data, with monthly recording of access use. We identified numerous associations between AVF maturation and patient-level factors in a recent national sample of US hemodialysis patients. After accounting for these patient factors, we observed substantial differences in AVF maturation across some ESRD networks, indicating a need for additional study of the provider, practice, and regional factors that explain AVF maturation.

Urinary tract infection in renal transplant recipients at a tertiary care center in India.

Our objective was to determine incidence, predisposing factors, and microbiological profile of urinary tract infection (UTI) in renal transplant recipients in our center. This was cross-sectional observational study, conducted at the Department of Nephrology, Army Hospital Research and Referral, Delhi, India. Two hundred and ten renal transplant recipients were studied over one year. Out of 210 transplant recipients, 69 (32.86%) had UTI. Majority (59/69) had undergone live renal transplantation and 10 cases had received cadaveric grafts. Forty-nine patients had primary infection while 20 patients had recurrences. The mean age of patients with UTI was 38.63 ± 10 years. The incidence of UTI was higher in females (42.25%) than males (28.06%, P = 0.038). Majority of patients in younger age group (age <30 years) were female (58.82%). Males were predominantly affected in higher (>30 years) age group (61.54%). Most common causative agent was Escherichia coli (72.46%). Gram-negative bacilli accounted for 94.20% (65/69) while Gram-positive cocci for 5.8% (4/69) of positive cultures. Multidrug resistance was highest in Klebsiella pneumoniae (100%). Fifteen cases with UTI were detected to have underlying urinary tract abnormalities, most common being urethral stricture (60%). One patient was detected to have broken double J stent in the renal pelvis which led to recurrent E. coli infection. Forty-eight patients (69.57%) developed acute graft dysfunction secondary to UTI. Female sex (P = 0.038), urinary tract abnormality (P <0.01), prolonged Foley's catheterization (P <0.01), prolonged hospitalization after transplantation (P <0.01), new-onset diabetes after transplantation (P <0.01), and coexisting hepatitis C infection (P = 0.012) were statistically significant predisposing factors for UTI in renal transplant recipients.

Modern diagnostics and treatment of posttraumatic hydrocephalus

One of the frequent consequences of severe traumatic brain injury is posttraumatic hydrocephalus that not only hampers the processes of consciousness recovery, rehabilitation, and social adaptation of patients but also is the cause of disability. Pathological processes underlying the clinical picture of posttraumatic hydrocephalus and the relationship between CSF circulation disorders and structural changes in the brain substance have not been adequately studied. Of particular importance are patients in the chronic vegetative or minimally conscious state, recovery from which is blocked by posttraumatic hydrocephalus. The question of reversibility of impaired consciousness depending on the disease duration has remained open. High risks of purulent-inflammatory complications of shunting surgery are especially important in patients with chronic infection foci (tracheostomy, gastrostomy, epicystostomy, prolonged bladder catheterization, pressure ulcers, etc.), but their actual effect on the shunting outcomes has not been revealed. Posttraumatic hydrocephalus remains a topical neurosurgical problem requiring clarification of its diagnostic criteria, differentiation from atrophy-related ventriculomegaly, and comprehensive development of pathogenetic and therapeutic aspects.

Robotic Inguinal Hernia Repair

Laparoscopic inguinal hernia repair has certain advantages over open repair including less pain and earlier return to normal activity. Concurrent robotic inguinal hernia repair at the time of prostatectomy has been shown to have a lower recurrence rate than open repair. Robotic surgery adds high definition visualization and articulating instruments which enhances dexterity that makes laparoscopic hernia repair more refined. A series of robotic, laparoscopic, inguinal hernia repairs by a single surgeon with an extensive laparoscopic hernia experience at a single institution was undertaken to determine the role of robotic laparoscopic inguinal hernia repair in minimally invasive surgery. Five hundred forty-two laparoscopic inguinal hernia operations were performed from April 2012 through December 2015. There were 154 cases of robotic transabdominal preperitoneal procedures done during that time. Hospital records and follow-up care were prospectively reviewed and data collected for age, sex, American Society of Anesthesia class, and operative time. Follow-up was done at 2, 8, and 16 weeks after surgery. All patients consented for the study. Ninety percent of the patients were male. Age averaged 57.04 years with a range of 21 to 85 years. American Society of Anesthesia averaged 2.01 with comorbidities of hypertension, hypercholesterolemia, and gastroesophageal reflux disease being the most common. Body mass index was between 19 and 31.6, averaging 24.34. Twenty-five patients (16%) had an umbilical hernia repair done concomitantly. Operating room time ranged from 25 to 140 minutes with an average of 63.6 minutes decreased as experience increased. One patient with a large, left scrotal hernia was converted to open; one patient developed perforated sigmoid diverticulitis seven days postop and case #5 recurred indirectly after a direct hernia repair. Four patients required prolonged postoperative Foley catheterization. Robotic inguinal hernia repair is safe and effective. Operating room time was longer than standard laparoscopic herniorrhaphy but decreased with experience. A single-port platform may have use in patients with umbilical hernias, 16 per cent, and will need to be studied.

Use of Routine Home Health Care and Deviations From an Uncomplicated Recovery Pathway After Radical Prostatectomy

To evaluate the statistical association between routine home health use after prostatectomy, short-term surgical outcomes, and payments. We identified all men who underwent a robotic radical prostatectomy from April 1, 2014, to October 31, 2015, in the Michigan Urological Surgery Improvement Collaborative (MUSIC) with insurance from Medicare or a large commercial payer. We calculated rates of "routine" home care use after prostatectomy by urology practice. We defined "routine" home care as home care initiated within 4 days of discharge among patients discharged without a pelvic drain. We then compared emergency department (ED) visits, readmissions, prolonged catheter use, catheter reinsertion rates, and 90-day episode payments, in unadjusted and using a propensity-adjusted analysis, for those who did and did not receive home care. We identified 647 patients, of whom 13% received routine home health care. At the practice level, the use of routine home care after prostatectomy varied from 0% to 53% (P = .05) (mean: 3.6%, median: 0%). Unadjusted, patients with routine home care had increased ED visits within 16 days (15.5% vs 6.9%, P <.01), similar rates of catheter duration for >16 days (3.6% vs 3.0%, P = .79) and need for catheter replacement (1.2% vs 2.5%, P = .46), and a trend toward decreased readmissions (0% vs 4.1%, P = .06). Only the increased ED visits remained significant in adjusted analyses (P <.01). Home health had an average payment of $1000 per episode. Thirteen percent of patients received routine home health care after prostatectomy, without improved outcomes. These findings suggest that patients do not routinely require home health care to improve short-term outcomes following radical prostatectomy, however, the appropriate use of home health care should be evaluated further.

Septic abdominal gossypiboma: A life threatening surgical site infection

Gossypiboma is an uncommon surgical iatrogenic complication due to the retention of textile material inside natural cavities, especially in abdomen. An important aspect of gossypiboma is linked to the kind of inflammatory-triggered reaction: aseptic or pyogenic. In pyogenic reactions, granulomas and pus appear as a response to contaminated material left in the abdomen. Most patients are symptomatic, and clinical history and physical examination combined with computed tomography are essential to establish the diagnosis. The complication has similar pathophysiology from intra-abdominal abscess, however, has worse clinical course, poor prognosis and needs operative removal. Therefore, the gossypiboma deserves special attention and should be considered as a severe surgical site infection involving organs and/or spaces. Prevention is the key point to control the complication and is based on a systematic and systematized conference of such materials at the end of an operation. The purpose of this paper is to show for the first time all pathophysiologic steps of pyogenic gossypiboma. Moreover, to remind the risk factors associated to fungal infection (female, age, acute care unit stay, upper intestinal tract perforation, prolonged broad spectrum antibacterial therapy, parenteral nutrition and central venous catheter placement). At the same time, highlight that early antifungal therapy (Candida glabrata), should be kept in mind and should not be neglected as these was the agent involved in this patient’s death. Finally, alert the surgeons about this severe surgical site infection, which may lead to litigation.

Time-dependent analysis of incidence, risk factors and clinical significance of pneumothorax after percutaneous lung biopsy.

To evaluate the time-dependent incidence, risk factors and clinical significance of percutaneous lung biopsy (PLB)-related pneumothorax. From January 2012-November 2015, 3,251 patients underwent 3,354 cone-beam CT-guided PLBs for lung lesions. Cox, logistic and linear regression analyses were performed to identify time-dependent risk factors of PLB-related pneumothorax, risk factors of drainage catheter insertion and those of prolonged catheter placement, respectively. Pneumothorax occurred in 915/3,354 PLBs (27.3 %), with 230/915 (25.1 %) occurring during follow-ups. Risk factors for earlier occurrence of PLB-related pneumothorax include emphysema (HR=1.624), smaller target (HR=0.922), deeper location (HR=1.175) and longer puncture time (HR=1.036), while haemoptysis (HR=0.503) showed a protective effect against earlier development of pneumothorax. Seventy-five cases (8.2 %) underwent chest catheter placement. Mean duration of catheter placement was 3.2±2.0 days. Emphysema (odds ratio [OR]=2.400) and longer puncture time (OR=1.053) were assessed as significant risk factors for catheter insertion, and older age (parameter estimate=1.014) was a predictive factor for prolonged catheter placement. PLB-related pneumothorax occurred in 27.3 %, of which 25.1 % developed during follow-ups. Smaller target size, emphysema, deeply-located lesions were significant risk factors of PLB-related pneumothorax. Emphysema and older age were related to drainage catheter insertion and prolonged catheter placement, respectively. • One-fourth of percutaneous lung biopsy (PLB)-related pneumothorax occurs during follow-up. • Smaller, deeply-located target and emphysema lead to early occurrence of pneumothorax. • Emphysema is related to drainage catheter insertion for PLB-related pneumothorax. • Older age may lead to prolonged catheter placement for PLB-related pneumothorax. • Tailored management can be possible with time-dependent information of PLB-related pneumothorax.

Population structure and molecular genetic characterization of clinical Candida tropicalis isolates from a tertiary-care hospital in Kuwait reveal infections with unique strains.

Candida tropicalis is a frequently isolated yeast species causing bloodstream, urinary tract and other infections particularly in patients admitted to intensive care units (ICUs) and those requiring prolonged urinary catheterization (UC) or receiving broad-spectrum antibiotics (BSA). This study investigated clinical characteristics and genetic relatedness among C. tropicalis strains isolated from patients at Al-Amiri Hospital in Kuwait. C. tropicalis strains (n = 63) isolated from blood, genito-urinary, respiratory (RT) and digestive (GIT) tracts and wound sites from 54 patients were used. All isolates were phenotypically identified and tested against six antifungal drugs by using Vitek 2 system. Molecular identification was performed by PCR amplification of rDNA. Fingerprinting was achieved by 6-loci-based multilocus sequence typing (MLST) and data were analyzed by BioNumerics software for phylogenetic relationships. Patients mean age was >65 years and >20% patients were hospitalized in ICUs. Most patients had underlying conditions that included UC, BSA, diabetes and RT/GIT abnormalities. Most candiduria cases had UC, ureteric stent or suprapubic catheters. All isolates were identified as C. tropicalis by Vitek 2 and by species-specific PCR. Sixty-two isolates were susceptible to all tested antifungal drugs. MLST identified 59 diploid sequence types (DSTs) including 54 newly-identified DSTs. C. tropicalis isolates from multiple sites of same patient usually belonged to different DSTs. Interestingly, 56 of 57 isolates from 48 patients belonged to unique genotypes. Only six isolates from six patients belonged to three DSTs (clusters), however, C. tropicalis strains in each cluster were isolated >3 months apart. Our data show diverse origins of C. tropicalis infections in Kuwait as most isolates were unique strains. There was no obvious correlation between cluster isolates with time of isolation and/or hospital ward of their origin. This study presents the first MLST analysis of C. tropicalis isolates from Middle East and may be useful for studying genetic relationships among global C. tropicalis strains.

Short-term Peripheral Venous Catheter-Related Bloodstream Infections: A Systematic Review.

Short-term peripheral venous catheters (PVCs) are commonly used in healthcare settings. To determine the magnitude of bloodstream infections (BSIs) related to their use, PubMed, article bibliographies, and the authors' library were searched for pertinent articles. The incidence of PVC-related BSIs was 0.18% among 85063 PVCs. Short-term PVCs accounted for a mean of 6.3% and 23% of nosocomial BSIs and nosocomial catheter-related BSIs, respectively. Prolonged dwell time and catheter insertion under emergent conditions increased risk of PVC-related bloodstream infection (PVCR-BSI). If approximately 200 million PVCs are successfully inserted into adult patients each year in the United States, there may be many PVCR-BSIs occurring yearly. Clinicians should obtain blood cultures in patients with evidence of PVC infection and systemic symptomatology such as fever, carefully inspect the PVC insertion site in bacteremic or fungemic patients, and remove PVCs associated with localized infection with or without associated BSI.

Complications of central lines in neonates admitted to a level III Neonatal Intensive Care Unit

Objective: To investigate the incidence and risk factors for central line related complications in neonates.Methods: A retrospective cohort study of infants who underwent central line (CL) placement, from 1 July 2014 to 31 June 2016, was conducted in Neonatal Intensive Care Unit of Centro Hospitalar de São João. Infants hospitalized more than 2 d and CLs placed for more than 24 h were included. Patients’ demographic characteristics, hospital data, and information on CLs were collected. Indwelling complications were compared between infant groups and types of CL inserted.Results: A total of 400 CLs were inserted in 240 infants with a CL utilization ratio of 0.64. Overall CL complication rate was 29.6 per 1000 catheter days. Of all complications, central line-associated bloodstream infection had the highest incidence (12.4 per 1000 catheter days). Infiltration was the most reported mechanical complication. Non-umbilical catheters showed a significantly higher incidence of complications than umbilical ones. Low gestational age, low birth weight, prolonged catheter stay, long duration of total parenteral nutrition, and peripherally inserted central catheter placement were associated with a higher risk of indwelling complication.Conclusions: The implementation of measures to prevent catheter-related complications must be a priority in care of vulnerable neonates.

PD58-06 SURGICAL SKILL AND PATIENT OUTCOMES AFTER ROBOT-ASSISTED RADICAL PROSTATECTOMY

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Quality Improvement & Patient Safety I1 Apr 2017PD58-06 SURGICAL SKILL AND PATIENT OUTCOMES AFTER ROBOT-ASSISTED RADICAL PROSTATECTOMY James O. Peabody, Rodney L. Dunn, Andrew Brachulis, Tae Kim, Susan Linsell, Brian R. Lane, Richard Sarle, James Montie, David C. Miller, Khurshid R. Ghani, and Michigan Urological Surgery Improvement Collaborative James O. PeabodyJames O. Peabody More articles by this author , Rodney L. DunnRodney L. Dunn More articles by this author , Andrew BrachulisAndrew Brachulis More articles by this author , Tae KimTae Kim More articles by this author , Susan LinsellSusan Linsell More articles by this author , Brian R. LaneBrian R. Lane More articles by this author , Richard SarleRichard Sarle More articles by this author , James MontieJames Montie More articles by this author , David C. MillerDavid C. Miller More articles by this author , Khurshid R. GhaniKhurshid R. Ghani More articles by this author , and Michigan Urological Surgery Improvement Collaborative More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2621AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The empirical relationship of surgical skill on patient outcomes after robotic surgery is unknown. In the Michigan Urological Surgery Improvement Collaborative (MUSIC), we assessed the association between peer review of technical skill and short-term operative outcomes following robot-assisted radical prostatectomy (RARP). METHODS Surgeons performing RARP in MUSIC were invited to submit a representative video of a nerve-sparing procedure. Edited video clips of the vesico-urethral anastomosis from 29 surgeons underwent blinded review by 56 peer surgeons for global robotic skill using the Global Evaluative Assessment of Robotic Skills (GEARS) tool (maximum score 25) using a custom-designed web-based secure registry. Each surgeon underwent video review by at least 9 peer surgeon reviewers. Surgeons were ranked on GEARS scores and sorted into quartiles of skill. Using a mixed logistic regression model adjusted for surgeon as a random effect, we then assessed the relationship between the highest (Q4) and lowest (Q1) skill quartiles and risk-adjusted peri-operative complication rates at the patient level using data from a prospective registry involving 2,256 patients. RESULTS Compared to surgeons in the lowest 25% (Q1) of skill ratings, surgeons in the top 25% (Q4) for skill had lower rates of excess blood loss (>400 cc) (OR=0.47, p=0.01), and less events of urethral catheter replacement after its removal (OR=0.62, p=0.07) (Figure). There were no differences between Q1 and Q4 performance quartiles when comparing readmission rates (OR=1.16, p=0.58) or prolonged urethral catheter (>16 days) duration outcomes (OR=1.41, p=0.27). CONCLUSIONS The technical skill of practicing robotic surgeons performing the anastomosis during RARP varied widely, and better skill was associated with superior results for selective patient outcomes. Future work will need to study the relationship between skill and long-term patient reported outcomes to determine if quality improvement initiatives focused on surgical skill lead to improved patient care. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e1129 Advertisement Copyright & Permissions© 2017MetricsAuthor Information James O. Peabody More articles by this author Rodney L. Dunn More articles by this author Andrew Brachulis More articles by this author Tae Kim More articles by this author Susan Linsell More articles by this author Brian R. Lane More articles by this author Richard Sarle More articles by this author James Montie More articles by this author David C. Miller More articles by this author Khurshid R. Ghani More articles by this author Michigan Urological Surgery Improvement Collaborative More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Management of vesicovaginal fistulas (VVFs) in women following benign gynaecologic surgery: A systematic review and meta-analysis.

BackgroundVesicovaginal fistulas (VVF) are the most commonly acquired fistulas of the urinary tract, but we lack a standardized algorithm for their management. Surgery is the most commonly preferred approach to treat women with primary VVF following benign gynaecologic surgery.ObjectiveTo carry out a systematic review and meta-analysis on the effectiveness of operative techniques or conservative treatment for patients with postsurgical VVF. Our secondary objective was to define the surgical time and determine the types of study designs.MethodsPubMed, Old Medline, Embase and Cochrane Central Register of Controlled Trials were used as data sources. This systematic review was modelled on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, including a registration number (CRD42012002097).ResultsWe reviewed 282 full text articles to identify 124 studies for inclusion. In all, 1379/1430 (96.4%) patients were treated surgically. Overall, the transvaginal approach was performed in the majority of patients (39%), followed by a transabdominal/transvesical route (36%), a laparoscopic/robotic approach (15%) and a combined transabdominal-transvaginal approach in 3% of cases. Success rate of conservative treatment was 92.86% (95%CI: 79.54–99.89), 97.98% in surgical cases (95% CI: 96.13–99.29) and 91.63% (95% CI: 87.68–97.03) in patients with prolonged catheter drainage followed by surgery. 79/124 studies (63.7%) provided information for the length of follow-up, but showed a poor reporting standard regarding prognosis. Complications were studied only selectively. Due to the inconsistency of these data it was impossible to analyse them collectively.ConclusionsAlthough the literature is imprecise and inconsistent, existing studies indicate that operation, mainly through a transvaginal approach, is the most commonly preferred treatment strategy in females with postsurgical VVF. Our data showed no clear odds-on favorite regarding disease management as well as surgical approach and current evidence on the surgical management of VVF does not allow any accurate estimation of success and complication rates. Standardisation of the terminology is required so that VVF can be managed with a proper surgical treatment algorithm based on characteristics of the fistula.

Arteriovenous Grafts: Much Maligned But in Need of Reconsideration?

There are substantial variations in arteriovenous fistula (AVF) use among hemodialysis patients in different countries, in different regions of the U.S., and even in different hemodialysis units within a single metropolitan area. These variations persist after adjustment for patient demographics and comorbidities, suggesting that practice patterns play a major role in determining the frequency of AVF use. These observations led to vascular access guidelines urging nephrologists and surgeons to increase AVF creation in patients with chronic kidney disease. Over the past 20 years, as clinicians have adopted these guidelines, the prevalence of AVF use in hemodialysis patients has increased substantially. At the same time, clinicians have recognized important limitations of an unwavering "Fistula First" approach. First, a substantial proportion of AVFs fail to mature even when routine preoperative vascular mapping is used, leading to prolonged catheter dependence. Second, certain patient subgroups are at high risk for AVF nonmaturation. Third, nonmaturing AVFs frequently require interventions to promote their maturation. Fourth, AVFs that require such interventions have shortened cumulative patency. Fifth, arteriovenous grafts (AVG) have several advantages over AVFs, including lower primary failure rates, fewer interventions prior to successful cannulation, and shorter duration of catheter dependence with its associated risk of bacteremia. All these observations have led nephrologists to propose an individualized approach to vascular access, with AVG being preferred in patients who initiate hemodialysis with a catheter, particularly if they are at high risk for AVF nonmaturation and have a relatively short life expectancy.

Antibiotic Prophylaxis in Radical Prostatectomy: Comparison of 2-Day and More than 2-Day Prophylaxis.

The efficacy of antibiotic prophylaxis in radical prostatectomy (RP) remains to be established. We retrospectively compared the occurrence of perioperative infections after RP between the 2 different antibiotic protocols. This study involved 428 cases of laparoscopic radical prostatectomy (LRP). After excluding patients who had no perioperative urine culture data, 313 consecutive patients who underwent LRP for prostate carcinoma were classified into 2 groups according to the duration of antimicrobial prophylaxis. To group 1 (153 patients), a second-generation cephalosporin was administered for less than 2 days, whilst the remaining 160 patients in group 2 were administered the drug for more than 2 days. The overall incidence of postoperative bacteriuria was 50.8%, being significantly higher in group 1 (56.9%) than in group 2 (45%). The incidence of surgical site infection (SSI) was significantly higher in group 1 (5.2%) than in group 2 (0.6%). Multivariate analysis revealed that old age, duration of antibiotics for more than 2 days, and duration of Foley catheter placement were independently associated with postoperative infectious complications (all, P < 0.05). Multivariate analysis revealed that duration of antibiotics for more than 2 days, duration of Foley catheter placement, and duration of surgical drain placement were independently associated with postoperative SSI (all, P < 0.05). The incidence of postoperative bacteriuria and SSI were higher in patients who received antibiotics for a short duration. Based on our results, we demonstrated that the outcome of postoperative infectious complications is dependent on old age, short antibiotic administration duration, and prolonged Foley catheterization. Prolonged drain placement is associated with SSI, whilst a longer duration of antibiotics use and prolonged Foley catheterization are associated with a decrease in the incidence of SSI.

A case of base rate bias, or are adolescents at a higher risk of developing complications after catheterizable urinary channel surgery?

Adolescents are considered to be at high risk of developing complications after lower genitourinary tract reconstruction. This perception may be due to base rate bias, where clinicians favor specific information (adolescents with complications), while ignoring more general information (number of total adolescents being followed). The goal of this study was to assess whether age was a true risk factor for subfascial and stomal revisions after continent catheterizable urinary (CCU) channel procedures. Consecutive patients aged <21 years and who underwent appendicovesicostomy and Monti surgery at the present institution were retrospectively reviewed; demographic and surgical data were collected. Time to subfascial or stomal revision was stratified by age at initial surgery (child: <8, preteen: 8-12, adolescent: 13-17, adult: ≥18 years old) and analyzed with Cox proportional-hazards regression. Secondary analyses included: different age categories at initial surgery (<8, 8-11, 12-15, 16-19, ≥20 years), analyzing age as a continuous and a time-varying covariate. Of the 510 patients with CCU channels (median age at surgery: 7.9 years), 63 (12.4%) had subfascial and 53 (10.4%) had stomal revision (median follow-up: 6.8 years). Median age at subfascial and stomal revision was 11.3 and 10.3 years, respectively. Preteens contributed 33.0% and adolescents contributed 29.3% of the total follow-up time (3263.9 person-years). Over 80% of revisions occurred within 5 years of surgery, regardless of age at initial surgery (P≥0.57) (Summary table). On multivariate analysis, age at initial surgery was not associated with undergoing subfascial (P≥0.62) or stomal revisions (P≥0.69). Montis were 2.1 times more likely than appendicovesicostomies to undergo a subfascial revision (P=0.03). No other variables were associated with the risk of subfascial or stomal revision (P≥0.11). Secondary analyses provided similar results. Since the median age at surgery was 8 years old and most complications occurred within the first 5 years of follow-up, it is not surprising that most revisions occurred in 8-13 year olds. Pediatric urologists appear to base their impression of adolescents being "high risk" on specific information (adolescents having complications), while subconsciously ignoring more general information (adolescents represent a large proportion of patients in follow-up). This study had several limitations: channel complications treated non-surgically (e.g. prolonged catheterization) were not included. The findings may not be generalizable to other genitourinary reconstructive procedures or clinical settings. While complications were twice as high in Monti channels than appendicovesicostomies, no single age group was at increased risk. The impression that adolescents are a high-risk group appears to represent a base rate bias.