Hematoma Rate Research Articles

Quilting Suture Technique After Mastectomy: A Meta-Analysis.

There is no level 1a evidence testing quilting suture (QS) technique after mastectomy on wound outcomes. The aim of this systematic review and meta-analysis evaluates QS and association with surgical site occurrences as compared to conventional closure (CC) for mastectomy. MEDLINE, PubMed, and Cochrane Library were systematically searched to include adult women with breast cancer undergoing mastectomy. The primary endpoint was postoperative seroma rate. Secondary endpoints included rates of hematoma, surgical site infection (SSI), and flap necrosis. The Mantel-Haenszel method with random-effects model was used for meta-analysis. Number needed to treat was calculated to assess clinical relevance of statistical findings. Thirteen studies totaling 1748 patients (870 QS and 878 CC) were included. Seroma rates were statistically significantly lower in patients with QS (OR [95%CI] = .32 [.18, .57]; P < .0001) than CC. Hematoma rates (OR [95%CI] = 1.07 [.52, 2.20]; P = .85), SSI rates (OR [95%CI] = .93 [.61, 1.41]; P = .73), and flap necrosis rates (OR [95%CI] = .61 [.30, 1.23]; P = .17) did not significantly vary between QS and CC. This meta-analysis found that QS was associated with significantly decreased seroma rates when compared to CC in patients undergoing mastectomy for cancer. However, improvement in seroma rates did not translate into a difference in hematoma, SSI, or flap necrosis rates.

Two-Stage Implant-Based Breast Reconstruction Using Intraoperative Fluorescence Imaging: A Propensity Score-Matched Analysis.

Limited comparability between study groups can generate significant selection and observer bias when evaluating the efficacy of the SPY system and fluorescence imaging for implant-based breast reconstruction. In this study, the authors compared the surgical outcomes and complications during the first stage of reconstruction between reconstructions evaluated intraoperatively with fluorescence imaging using the SPY system and clinical assessment using a matched analysis. The authors conducted a retrospective review of patients undergoing total mastectomy and immediate two-stage implant-based breast reconstruction with TEs from January of 2011 to December of 2020. The rate of complication, time for TE-to-implant exchange, and time to start radiotherapy were compared between groups (intraoperative fluorescence imaging versus clinical assessment) using a propensity score-matched analysis. After propensity score matching, 198 reconstructions were evaluated. There were 99 reconstructions in each group. The median time for TE-to-implant exchange (140 days versus 185 days; P = 0.476) and time to initiate adjuvant radiotherapy (144 days versus 98 days; P = 0.199) were comparable between groups. The 30-day rate of wound-related complications (21% versus 9%; P = 0.017) and 30-day rate of wound-related unplanned interventions were significantly higher in reconstructions evaluated with clinical assessment when compared with the SPY system (16% versus 5%; P = 0.011). A higher 30-day rate of seroma (19% versus 14%; P = 0.041) and hematoma (8% versus 0%; P = 0.004) were found in reconstructions assessed intraoperatively with the SPY system. After matching, reconstructions evaluated with fluorescence imaging exhibited a lower incidence of early wound-related complications when compared with clinical evaluation alone. Nonetheless, the Wise pattern for mastectomy was found to be the only independent predictor associated with early wound-related complications. Therapeutic, III.

PC39. Two-stage Implant-based Breast Reconstruction Using Intraoperative SPY: A Propensity Score-matched Analysis

PURPOSE: Limited comparability between study groups can generate significant selection and observer bias when evaluating the efficacy of SPY system and fluorescence imaging for implant-based breast reconstruction (IBBR). Herein, we compared the surgical outcomes and complications during the first stage of reconstruction between reconstructions intraoperatively evaluated with fluorescence imaging using the SPY system and clinical assessment using a matched analysis. METHODS: We conducted a retrospective review of patients undergoing total mastectomy and immediate two-stage IBBR with TEs between January 2011 and December 2020. The rate of complication, time for TE-to-implant exchange, and time to start radiotherapy were compared between groups (intraoperative fluorescence imaging versus clinical assessment) using a propensity score-matched analysis. RESULTS: After propensity score matching, 198 reconstructions were evaluated. Ninety-nine reconstructions in each group. The median time for TE-to-implant exchange (140-days versus-185 days p=0.476) and time to initiate adjuvant radiotherapy (144-days versus 98-days, p=0.199) were comparable between groups. The 30-day rate of wound-related complications (21% versus 9%, p=0.017) and 30-day rate of wound-related unplanned interventions were significantly higher in reconstructions evaluated with clinical assessment when compared to SPY system (16% versus 5%, p=0.011). A higher 30-day rate of seroma (19% versus 14%, p=0.041) and hematoma (8% versus 0%, p=0.004) were found in reconstructions intraoperatively assessed with SPY. CONCLUSION: After controlling most demographic and surgical variables between groups, fluorescence imaging decreased the rate of wound-related complications and wound-related unplanned operations in the early postoperative period.

28. Enhanced Recovery After Surgery (ERAS) Protocol Allows Safe Same-day Discharge in Expander Based and Oncoplastic Breast Reconstruction

PURPOSE: Data following Enhanced Recovery After Surgery (ERAS) with same-day discharge in breast reconstruction is limited. This study evaluates early postoperative outcomes following same-day discharge in tissue expander-immediate breast reconstruction (TE-IBR) and oncoplastic breast reconstruction (OBR). METHODS: A single-institution retrospective review of TE-IBR patients from 2017-2022 and OBR patients from 2014-2022. Patients were divided by procedure and recovery pathway: Group 1 (TE-IBR, overnight admission), Group 2 (TE-IBR, ERAS), Group 3 (oncoplastic, overnight admission), and Group 4 (oncoplastic, ERAS). Group 1 and 2 were subdivided by implant location: Group 1a (pre-pectoral) and 1b (sub-pectoral); Group 2a (pre-pectoral) and 2b (sub-pectoral). Demographics, comorbidities, complications, and reoperations were analyzed. RESULTS: 160 TE-IBR patients (Group 1: 91; Group 2: 69) and 60 OBR patients (Group 3: 8; Group 4: 52) were included. Of the 160 TE-IBR patients, 73 underwent pre-pectoral reconstruction (Group 1a: 25; Group 2a: 48) and 87 underwent sub-pectoral reconstruction (Group 1b: 66; Group 2b: 21). There were no differences in demographics and comorbidities between Groups 1 and 2. Group 3 had a higher average BMI than Group 4 (37.6 vs 32.2, p <0.022). There was no significant difference between Groups 1a and 2a or between Groups 1b and 2b in rates of infection, hematoma, TE loss, or reoperations. Notably, no ERAS patients required hospital admission. Group 3 and Group 4 showed no significant difference in any complications or in reoperations. CONCLUSION: Our research shows that same-day discharge in both TE-IBR and OBR does not increase risk for major complications or reoperations.

Intramural Hematoma of Gastrointestinal Tract in People with Hemophilia A and B.

People with hemophilia (PWH), especially severe hemophilia, often experience bleeding episodes, which occur mostly at major joints. Intramural hematoma of the gastrointestinal (GI) tract is a rare, potentially life-threatening clinical bleeding manifestation in PWH. Prompt identification and timely administration of clotting factor concentrates are of utmost importance for effective management and optimal patient outcomes. In this report, we present the case of a 48-year-old male with severe hemophilia A. The patient developed a spontaneous intramural hematoma of the jejunum, leading to signs of acute abdomen, bloody stool, and paralytic ileus. Conservative management with factor VIII (FVIII) infusion was successfully administered. However, within a span of three months, the patient suffered from a recurrent episode of intramural hematoma, which was again effectively treated with conservative therapy. Subsequently, prophylactic FVIII therapy was administered to the patient, resulting in the absence of recurrence for over three years. Inspired by this case, we conducted a comprehensive review of the relevant literature and gathered data from 79 reported cases of intramural hematoma that were documented between the years 1956 and 2022. We classified these cases based on the site affected within the gastrointestinal (GI) tract (spread across five different locations) and proceeded to conduct a simple pooling analysis on the data collected, which subsequently revealed that the overall mortality rate of intramural hematoma in people with hemophilia (PWH) was found to be 12.2%, while children have a higher mortality rate (23.3%) than adults (4.9%). We hope this case report and literature review increase awareness of this rare bleeding manifestation in PWH, the effectiveness of conservative treatment, and the possibility of prophylaxis against recurrence.

Significant Correlation between Structural Changes in the Net-like Appearance on Postoperative Cranial Magnetic Resonance Images and Hematoma Recurrence in Cases of Chronic Subdural Hematoma.

Organized hematoma, which exhibits a net-like appearance on imaging studies, is one of the predisposing factors for the recurrence of chronic subdural hematoma. Patients who are positive for the net-like appearance are often treated with only burr hole surgery. We investigated the relationship between postoperative structural changes in the net-like appearance and the recurrence rate of chronic subdural hematoma. Of the 949 patients with chronic subdural hematoma treated with primary burr hole surgery between January 2010 and April 2021 at our hospital, 268 who were considered positive for the net-like appearance on T2- and T2 star-weighted magnetic resonance images were extracted. We followed the structural changes in the net-like appearance postoperatively and subsequently classified the patients into three groups: decreasing type, shifting type, and no change and deterioration type. The relationship between each structural change and the recurrence rate in the three groups was investigated. Postoperative recurrence requiring surgery occurred in 3.5% of the subjects with decreasing type, 0% with shifting type, and 100% with deterioration type of the net-like appearance (P < 0.05), indicating differences in the recurrence rates according to postoperative structural changes in the magnetic resonance images (MRI) features of chronic subdural hematoma. Our results indicate that the risk of postoperative chronic subdural hematoma recurrence can be predicted by focusing on the structural changes in the postoperative net-like appearance on MRI.

Hemostatic Net in Facelift Surgery: A 5-Year Single-Surgeon Experience.

The Hemostatic Net has been promoted as a safe and effective method to prevent hematoma formation following facelift procedures. To date there is little published evidence to validate the replicability and effectiveness of the technique. This study presents 2 cohorts of facelift patients from a single surgeon's practice to assess the impact of the Hemostatic Net on hematoma formation. The records of 304 patients were reviewed in whom the Hemostatic Net was placed following a facelift between July 2017 and October 2022. Data was collected and assessed for complications and compared with a control group of 359 patients who underwent a facelift procedure by the same surgeon between 1999 and 2004. A total of 663 patients were included. In this retrospective cohort study, analysis of available data showed a significantly reduced hematoma rate of 0.6% in the intervention group compared to 3.9% in the control group (p = 0.006722). The use of the Hemostatic Net is a safe, reproducible and effective technique in reducing the risk of hematoma in facelift surgery.

Wide Awake Local Anesthesia No Tourniquet (WALANT) technique improves the efficiency of distal nerve blocks for carpal tunnel release

BackgroundAxillary block is the standard for carpal tunnel release (CTR), providing effective anesthesia, and tolerance of tourniquet. Conversely, distal blocks are less used due to poor tolerance of tourniquet. Wide Awake Local Anesthesia No Tourniquet (WALANT), proposed for hand and wrist surgeries, avoids its use. This study assesses the benefits of the addition of WALANT to distal blocks during endoscopic CTR (eCTR). MethodsThis randomized, open-label, controlled trial prospectively enrolled 60 patients scheduled for eCTR. Patients were randomized to receive distal blocks at the wrist combined to either a high arm tourniquet (Distal block group) or a WALANT in the area of surgery (Distal + Walant group). The primary endpoint was the global pain score summing pain scores related to puncture, local anesthetic injection, pneumatic tourniquet, surgical procedure, tourniquet deflation, and residual sensitivity after surgery. ResultsMean global pain score was significantly reduced in the Distal + Walant group (0.5 ± 1.4 vs. 2.2 ± 2.4; p < 0.001). No need for an additional anesthetic procedure was required in the Distal + Walant group. Even if the quality of visualization was high in both groups, it was better in the Distal block group (5 [5–5] vs. 4 [4–5]; p < 0.001). No rescue tourniquet was necessary for the Distal + Walant group. The rate of hematoma 15 days post-surgery was significantly reduced in the Distal + Walant group (20% vs. 57%; p < 0.01). ConclusionsThe addition of WALANT to distal blocks is adapted for eCTR. This combined technique decreases perioperative pain scores, provides good surgery conditions, and reduces the risk of postoperative hematoma. Clinical trial number and registry URLThe trial was registered on ClinicalTrials.gov (NCT04494100) on July 31, 2020 https://clinicaltrials.gov/ct2/show/NCT04494100?term=CMC+ambroise+pare&cntry=FR&draw=4&rank=28.

Prevention of Postoperative Complications by Prepectoral versus Subpectoral Breast Reconstruction: A Systematic Review and Meta-Analysis.

Implant-based breast reconstruction has evolved over time. However, the effects of prepectoral breast reconstruction (PBR) compared with those of subpectoral breast reconstruction (SBR) have not been clearly defined. Therefore, this study aimed to compare the occurrence of surgical complications between PBR and SBR to determine the procedure that is effective and relatively safe. The PubMed, Cochrane Library, and EMBASE databases were searched for studies published until April of 2021 comparing PBR and SBR following mastectomy. Two authors independently assessed the risk of bias. General information on the studies and surgical outcomes were extracted. Among 857 studies, 34 and 29 were included in the systematic review and meta-analysis, respectively. Subgroup analysis was performed to clearly compare the results of patients who underwent postmastectomy radiation therapy. Pooled results showed that prevention of capsular contracture (OR, 0.57; 95% CI, 0.41 to 0.79) and infection control (OR, 0.73; 95% CI, 0.58 to 0.92) were better with PBR than with SBR. Rates of hematoma, implant loss, seroma, skin-flap necrosis, and wound dehiscence were not significantly different between PBR and SBR. PBR considerably improved postoperative pain, BREAST-Q score, and upper arm function compared with SBR. Among postmastectomy radiation therapy patients, the incidence rates of capsular contracture were significantly lower in the PBR group than in the SBR group (OR, 0.14; 95% CI, 0.05 to 0.35). The results showed that PBR had fewer postoperative complications than SBR. The authors' meta-analysis suggests that PBR could be used as an alternative technique for breast reconstruction in appropriate patients.

PD42-01 DRAINED VERSUS NON-DRAINED INFLATABLE PENILE PROSTHESIS IMPLANTATION: A MULTICENTER PROSPECTIVE PILOT STUDY ON A LARGE COHORT

You have accessJournal of UrologyCME1 Apr 2023PD42-01 DRAINED VERSUS NON-DRAINED INFLATABLE PENILE PROSTHESIS IMPLANTATION: A MULTICENTER PROSPECTIVE PILOT STUDY ON A LARGE COHORT Daniar Osmonov, Ahmed Ragheb, Petry Tim, Ahmed Eraky, Carlo Bettocchi, Glenn Lamers, Koenraad Van Renterghem, Marina Tropmann-Frick, Klaus-Peter Jünemann, Giulio Garaffa, Hartmut Porst, Ahmed Mohamed, and Steven Wilson Daniar OsmonovDaniar Osmonov More articles by this author , Ahmed RaghebAhmed Ragheb More articles by this author , Petry TimPetry Tim More articles by this author , Ahmed ErakyAhmed Eraky More articles by this author , Carlo BettocchiCarlo Bettocchi More articles by this author , Glenn LamersGlenn Lamers More articles by this author , Koenraad Van RenterghemKoenraad Van Renterghem More articles by this author , Marina Tropmann-FrickMarina Tropmann-Frick More articles by this author , Klaus-Peter JünemannKlaus-Peter Jünemann More articles by this author , Giulio GaraffaGiulio Garaffa More articles by this author , Hartmut PorstHartmut Porst More articles by this author , Ahmed MohamedAhmed Mohamed More articles by this author , and Steven WilsonSteven Wilson More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003352.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Despite the wide utilization of post-inflatable penile prosthesis (IPP) implantation drainage, many surgeons still regard it as a potential source of infection. Our aim was to understand the risks and benefits of post-IPP drainage and optimal duration. METHODS: Patients underwent IPP implantation for the first time by four European high volume surgeons through penoscrotal access receiving similar perioperative antibiotics. They were divided into 3 groups based on the presence and duration of drainage. Group 1 (n=114) had no drain placed, Group 2 had a drain placed for 24 hours (n=114) and Group 3 had a drain placed for 72 hours (n=117). The presence or absence of postoperative (PO) scrotal hematoma and prosthesis infection were evaluated and compared between the groups via scrotal ultrasound (US) examination carried out 24 hours then 3 and 10 days PO. All patients were followed up postoperatively for a minimum of 80 days. RESULTS: The patients from Group 3 demonstrated a statistically significant lower incidence of hematoma on the 10th PO day: (n=1, 0.9%) compared to Group 2: (n=11, 9.6%) and Group 1: (n=8, 7%, p=0.013). However, on the 3rd PO day, which showed the highest hematoma prevalence, there was a statistically significant lower incidence of hematoma in Groups 3 and 2: (0.9% and 7%, respectively) versus Group 1: (11.4%, p=0.004). Hematoma rates followed the same order after the first day of surgery for Groups 1-3: 8.8% (n=10), 5.3% (n=6), and 1.7% (n=2), respectively. (p=0.054). Five patients (4.4%) in Group 1 and four patients (3.5%) in Group 2 developed an IPP associated infection, opposed to only a single patient (0.85%) in Group 3. CONCLUSIONS: Prolonged scrotal drainage for 72 hours after virgin IPP implantation significantly reduces hematoma and infection rates. It is likely that hematoma formation per se, is a predisposing factor for IPP infection. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1111 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniar Osmonov More articles by this author Ahmed Ragheb More articles by this author Petry Tim More articles by this author Ahmed Eraky More articles by this author Carlo Bettocchi More articles by this author Glenn Lamers More articles by this author Koenraad Van Renterghem More articles by this author Marina Tropmann-Frick More articles by this author Klaus-Peter Jünemann More articles by this author Giulio Garaffa More articles by this author Hartmut Porst More articles by this author Ahmed Mohamed More articles by this author Steven Wilson More articles by this author Expand All Advertisement PDF downloadLoading ...

Blood Pressure Challenge Reduces Hematomas in Gender-Affirming Mastectomy: A Retrospective Chart Review of 92 Consecutive Patients.

Gender-affirming mastectomy is a common surgery for the treatment of gender incongruence and gender dysphoria and improves quality of life. Hematoma rates for gender-affirming double incision mastectomies are between 2.8% and 8.1%. This study aims to investigate the utility of a blood pressure challenge, whereby the patient's blood pressure is medically increased intraoperatively to reveal bleeding vessels that can be addressed with additional hemostasis before skin closure, to reduce postoperative hematoma. A retrospective chart review of patients who underwent gender-affirming double incision mastectomies over a 6-year period by a single surgeon was conducted. Surgeries were separated into a blood pressure challenge experimental group and a non-blood pressure challenge control group. Demographics, surgical characteristics, and postoperative complications were compared between the 2 cohorts using Pearson χ2, Fisher exact, t tests, univariate logistic regression, and multivariable logistical regression. Significance was established at P < 0.05. A total of 92 patients (184 breasts) were included with 32 patients (64 breasts) in the control group and 60 (120 breasts) in the blood pressure challenge group. In the control group, there were 5 hematomas (7.81%) compared with 1 (0.83%) in the blood pressure challenge group (P = 0.02). On univariate logistical regression analysis, blood pressure challenge was the only variable significantly associated with hematoma (odds ratio, 0.1; 95% confidence interval, 0.01-0.63; P = 0.04). On multivariable logistical regression, after controlling for age, body mass index, smoking status, and mass of excised breast tissue, patients who underwent blood pressure challenge demonstrated lower hematoma rates (odds ratio, 0.08; 95% CI, 0.004-0.59; P = 0.04). Using an intraoperative blood pressure challenge was associated with reduced hematoma rates. Guidelines for blood pressure challenge goals should be established to standardize care and reduce complications in gender-affirming mastectomies.

PD42-04 BLOOD THINNERS: DO THEY NEED TO BE HELD FOR IPP SURGERY?

You have accessJournal of UrologyCME1 Apr 2023PD42-04 BLOOD THINNERS: DO THEY NEED TO BE HELD FOR IPP SURGERY? Niki Parikh, Reza Roshandel, Ryan Griggs, Gerard Henry, Paul Perito, Coral Gables, Saint Helena, and Tobias Kohler Niki ParikhNiki Parikh More articles by this author , Reza RoshandelReza Roshandel More articles by this author , Ryan GriggsRyan Griggs More articles by this author , Gerard HenryGerard Henry More articles by this author , Paul PeritoPaul Perito More articles by this author , Coral GablesCoral Gables More articles by this author , Saint HelenaSaint Helena More articles by this author , and Tobias KohlerTobias Kohler More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003352.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Inflatable penile prosthesis (IPP) placement on active anticoagulation (AC) is controversial. Techniques utilized to decrease complications include use of malleable implant, partial inflation of IPP for hemostasis, and placement of drain; however risk and benefits must be weighed. We sought to assess outcomes of IPP in men on AC in a multi-institutional study. METHODS: Data from 3 high-volume implant centers was retrospectively analyzed. Demographics, comorbidities, secondary procedures, drain placement/output, and complications were recorded. Aspirin was excluded as it is not routinely held. Center 1 utilizes a penoscrotal approach without drain placement, center 2 a penoscrotal approach with drain placement (removal when output <50 mL/8 hours), and center 3 an infra-pubic approach with drain for 3 days. RESULTS: 202 patients were continued on AC throughout surgery. 112 patients were on clopidogrel, 35 warfarin, 38 apixaban, 1 enoxaparin, 15 rivaroxaban, and 1 on combination therapy with clopidogrel and enoxaparin. AC requirement included peripheral vascular disease (55%), CHF (11%), cardiac stents (11.6%), DVT/PE/history of thrombosis (7%), atrial fibrillation (11%), cardiac valves (2.2%), stroke (1.3%), and preventive (0.9%). Nine patients on AC (3.98%) experienced complications including 4 significant events (1.9%): 1 major retropubic bleed requiring transfusion, 3 IPP infections and 5 minor events: 3 minor hematomas, 1 minor wound dehiscence and 1 CT negative stroke event. Drain outputs for center 3 averaged 113 ml, 81 ml, and 30 ml of output per day respectively with a total average output average of 223 ml and experienced no hematomas nor infections. Drain output for center 2 averaged 121 ml with the majority or patients having the drain for only one day. Drain output was significantly higher than historical non-AC controls (121 vs. 72 ml p=.001) but there was no difference in hematoma rate. Three hematomas and 1 infection occurred in this group. AC type, revision surgery, scrotoplasty, or reservoir technique did not affect outcomes nor drainage (p>.05). Complication rate (IPP infection and hematoma rate) where not different when compared to large cohorts from respective institutions. CONCLUSIONS: In high-volume implant centers, major complication rate of 1.9% occurred in IPP patients on AC. Although IPP is feasible in this patient population, drain for 3 days and submuscular reservoir placement may be indicated. In most, elective IPP surgery should be delayed until it is safe to discontinue anticoagulation. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1112 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Niki Parikh More articles by this author Reza Roshandel More articles by this author Ryan Griggs More articles by this author Gerard Henry More articles by this author Paul Perito More articles by this author Coral Gables More articles by this author Saint Helena More articles by this author Tobias Kohler More articles by this author Expand All Advertisement PDF downloadLoading ...

PD42-12 DELAYED CLOSED-SUCTION DRAIN REMOVAL AFTER INFLATABLE PENILE PROSTHESIS: A MULTI-INSTITUTIONAL EXPERIENCE

You have accessJournal of UrologyCME1 Apr 2023PD42-12 DELAYED CLOSED-SUCTION DRAIN REMOVAL AFTER INFLATABLE PENILE PROSTHESIS: A MULTI-INSTITUTIONAL EXPERIENCE Luke Shumaker, Nicholas Zulia, Jonathan Beilan, Emmett Kennady, Nicolas Ortiz, and Adam Baumgarten Luke ShumakerLuke Shumaker More articles by this author , Nicholas ZuliaNicholas Zulia More articles by this author , Jonathan BeilanJonathan Beilan More articles by this author , Emmett KennadyEmmett Kennady More articles by this author , Nicolas OrtizNicolas Ortiz More articles by this author , and Adam BaumgartenAdam Baumgarten More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003352.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: There is little published data regarding percutaneous drain (PD) duration after inflatable penile prosthesis (IPP) placement. The dissection associated makes scrotal hematomas common in the first 72 hours. Maintaining a percutaneous drain represents a strategy to reduce scrotal hematoma formation. However, a percutaneous tract also represents a feasible path for seeding of a new prosthesis. Given the severe consequences of infection, establishing comparable outcomes for delayed drain removal patients is necessary. Here we detail rates of infection, hematoma, device explantation and other standard post IPP metrics in a multi-institutional cohort with delayed PD removal (48-hours or greater). METHODS: Data was collected retrospectively for 224 patients undergoing virgin IPP placement with delayed PD removal. Cases were performed by three surgeons at three high-volume centers between 01/01/2020 and 3/31/2022. It was the practice of these surgeons to leave PDs 48 hours or greater. 15 patients had PDs removed before 48 hours due to scheduling, patient preference, or inadvertent removal. These patients were excluded leaving 209. R for Statistical Computing was used to generate statistics and data visualization. RESULTS: Mean drain duration was 2.8 days. Mean follow-up interval was 170 days. 84 patients (40%) carried the diagnosis of diabetes mellitus with a mean hemoglobin A1c of 7.2. Penoscrotal and infrapubic approaches were employed (114 versus 95). Reservoir location was split between space of Retzius (SOR) and high submuscular with SOR being more common (164 versus 45). 7 discrete hematomas were observed. Despite this small number, Fisher’s exact testing demonstrated significant association between hematoma formation and both anticoagulation and antiplatelet therapy (p<0.01 in both cases). There were 3 device infections (1.4%). 9 patients (4.3%) required revision for non-infectious causes. CONCLUSIONS: Rates of infection and explantation observed in virgin IPP implantation with delayed PD removal are similar to other modern virgin cohorts where drains were not employed. Additional prospective research would be useful to characterize effect of delayed drain removal on hematoma formation, postoperative pain, and interval to device use. Source of Funding: NA © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1115 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Luke Shumaker More articles by this author Nicholas Zulia More articles by this author Jonathan Beilan More articles by this author Emmett Kennady More articles by this author Nicolas Ortiz More articles by this author Adam Baumgarten More articles by this author Expand All Advertisement PDF downloadLoading ...

Biologic versus synthetic mesh in open ventral hernia repair: A systematic review and meta-analysis of randomized controlled trials.

Ventral hernia repair is one of the most common operations performed worldwide, and using mesh is standard of care to decrease recurrence. Biologic meshes are increasingly used to minimize complications associated with synthetic mesh, but with significantly higher cost and unclear efficacy. Until recently, most of the evidence supporting the use of biologic meshes was from retrospective cohorts with high heterogeneity and risk of bias. We aimed to report a meta-analysis of randomized controlled trials comparing the outcomes of synthetic and biologic mesh in elective open ventral hernia repair. A literature search of PubMed, Embase, and Cochrane Library databases was performed to identify randomized controlled trials comparing biologic and synthetic mesh in elective open ventral hernia repairs. The postoperative outcomes were assessed by means of pooled analysis and meta-analysis. Statistical analysis was performed using RevMan 5.4. Heterogeneity was assessed with I2 statistics. A total of 1,090 studies were screened, and 22 were fully reviewed. Four randomized controlled trials and 632 patients were included in the meta-analysis. Fifty-eight percent of patients had contaminated wounds (Wound Classification II-IV). Hernia recurrence (odds ratio 2.75; 95% confidence interval 1.76-4.31; P < .00001; I2= 0%) and surgical site infections (odds ratio 1.53; 95% confidence interval 1.02-2.29; P= .04; I2= 0%) were significantly more common in patients with biologic mesh. The rates of seroma, hematoma, and mesh removal were similar in both groups. As compared to synthetic mesh, biologic meshes resulted in increased hernia recurrences and surgical site infections. Current evidence supports macroporous, uncoated synthetic mesh as the implant of choice for elective open ventral hernia repair, and its use should be considered even in contaminated cases.

397 Direct Carotid Puncture for Mechanical Thrombectomy After Failed Peripheral Access: A Systematic Review and Meta-Analysis

INTRODUCTION: Direct carotid puncture (DCP) is an alternative route for mechanical thrombectomy (MT), especially in patients with difficult anatomy preventing access through the femoral or radial routes. However, DCP has increased morbidity and mortality due to access site complications related to cervical hematomas. METHODS: A systematic search of electronic databases from inception to March 2022 identified 197 related articles for screening. After applying inclusion and exclusion criteria, 10 studies were included, and data was extracted and analyzed using meta-analysis of proportions. RESULTS: 213 patients were included in this analysis, of which 44% also received intravenous thrombolysis. The overall success rate was 84% (95% CI, 73.66–90.85%; I2 = 25.6%; p = 0.64). The average time to recanalization was 30.33 minutes (95%CI, 23.04–37.62 min; I2 = 89.5%; p &lt; 0.01) and 74% had good reperfusion (TICI &gt;2a) (95% CI, 67–79%; I2 = 0%; p = 0.81). The overall complication rate was 20.38% (95%CI, 15.48–26.35%; I2 = 0%; p = 0.55). The rate of cervical hematomas was 18% (95% CI, 12–16%; I2 = 70%; p = 0.27), of which 24.92% required surgical evacuation (95% CI, 27.5–95.9%; I2 = 70%; p = 0.67). Other reported complications included carotid dissection, pseudoaneurysm, jugular vein puncture, and stroke related to access. The 90-day mortality rate from all causes was 35% based on 7 studies (95% CI, 22.5– 49.9%; I2 = 44.8%; p = 0.08). The mRS at last follow-up was 4.09 (95% CI, 3.68–4.49; I2 = 6.8%; p = 0.37). CONCLUSIONS: DCP is a reasonable alternative in patients that fail femoral and radial access for MT and the success rate of access with DCP is 84% with a TICI 2B or TICI 3 achieved in 74% of patients. The complications are mostly related to bleeding at the access site. The high rate of morbidity and mortality warrant further studies to improve the safety of DCP.

Preoperative Optimization Before Ventral Hernia Repair: A Systematic Review and Meta-analysis.

Obesity is associated with an increased risk of ventral hernia development and recurrence rates after ventral hernia repair (VHR). The metabolic derangements caused by obesity can also lead to many postoperative complications. Therefore, it is a common practice to attempt weight loss before VHR. However, there is still no consensus on optimal preoperative management for obese patients with a ventral hernia. This study aims to perform a meta-analysis to evaluate the effect of preoperative weight optimization on VHR outcomes. We performed a literature search of PubMed, Scopus, and Cochrane Library databases to identify studies comparing obese patients who underwent surgical or non-surgical weight loss interventions before undergoing hernia repair surgery to obese patients who underwent hernia repair surgery without prehabilitation. Postoperative outcomes were assessed by means of pooled analysis and meta-analysis. Statistical analysis was performed using RevMan 5.4. Heterogeneity was assessed with I2 statistics. One thousand six hundred nine studies were screened and 13 were thoroughly reviewed. Five studies comprising 465 patients undergoing hernia repair surgery were included. No differences in hernia recurrence [odds ratio (OR) 0.66; 95% CI 0.23-1.89; P=0.44; I2=20%], seroma (OR 0.70; 95% CI 0.25-1.95; P=0.50; I2=5%), hematoma (OR 2.00; 95% CI 0.5-7.94; P=0.45; I2=0%), surgical site infection (OR 1.96; 95% CI 0.52-7.40; P=0.32; I2=0%), and overall complication (OR 0.80; 95% CI 0.37-1.74; P=0.58; I2=40%) rates were noted when comparing patients who underwent a preoperative weight loss intervention (prehabilitation or bariatric surgery) versus those who did not. In the subgroup analysis of patients who underwent bariatric surgery, we found no difference in hernia recurrence (OR 0.64; 95% CI 0.12-3.33; P= 0.59; I2=41%) or overall complications (OR 1.14; 95% CI 0.36-3.64; P=0.82; I2=64%). In the subgroup analysis of patients who lost weight versus patients who did not, there was no significant difference in overall complication rates (OR 0.86; 95% CI 0.34-2.21; P=0.76; I2=55%). We found similar hernia recurrence, seroma, hematoma, and surgical site infection rates in patients who underwent preoperative optimization. These findings underline the need for prospective studies to define the optimal role of preoperative optimization and weight loss in obese patients undergoing ventral hernia repair.

The Effects of Tranexamic Acid in Breast Surgery: A Systematic Review and Meta-Analysis.

Tranexamic acid (TXA) is used in trauma and surgical settings. Its role in reducing postoperative blood loss in breast surgery remains unclear. The primary objective of this study was to determine the effect of TXA on postoperative blood loss in breast surgery. Searches of the PubMed, Ovid MEDLINE, Embase, CINAHL, and Cochrane Central Register of Controlled Trials databases were performed from inception to April 3, 2020. Inclusion criteria were any retrospective reviews, prospective cohort studies, and randomized controlled trials that administered TXA (topical or intravenously) in the context of breast surgery. Quality of studies were evaluated using the risk of bias in randomized trials tool and the risk of bias in nonrandomized studies of interventions tool. Data were pooled, and a meta-analysis was performed. In total, seven studies were included, representing 1226 patients (TXA, 632 patients; control, 622 patients). TXA was administered as follows: topically (20 mL of 25 mg/mL TXA intraoperatively; n =258 patients), intravenously (1 to 3 g perioperatively; n = 743 patients), or both (1 to 3 g daily up to 5 days postoperatively; n = 253 patients). TXA administration reduced hematoma formation in breast surgery (risk ratio, 0.48; 95% CI, 0.32 to 0.73), with no effect on drain output (mean difference, -84.12 mL; 95% CI, -206.53 to 38.29 mL), seroma formation (risk ratio, 0.92; 95% CI, 0.60 to 1.40), or infection rates (risk ratio, 1.01; 95% CI, 0.46 to 2.21). No adverse effects were reported. The use of TXA in breast surgery is a safe and effective modality with low-level evidence that it reduces hematoma rates without affecting seroma rates, postoperative drain output, or infection rates.

How to insert a full-thickness skin graft: a continuous quilting technique

Full-thickness skin grafts (FTSGs) are usually secured with tie-over bolster dressings, quilting (or basting) sutures or a combination of both. This guide describes a modified technique of securing FTSGs by way of a continuous quilting suture to increase surgical efficiency. Stabilisation and prevention of haematoma are two important factors to allow a skin graft to take to its recipient site. This is most commonly provided by a tie-over dressing after suturing the graft in place. The technique of utilising quilting sutures placed in the graft as an alternative to bolster dressings has also been well documented. There has been no evidence to suggest a difference in rates of haematoma, seroma, neovascularisation and graft survival between these two techniques.

Artificial cerebrospinal fluid use during burr-hole surgery and reoperation rate in patients with chronic subdural hematoma: an analysis using a nationwide inpatient database

BackgroundThe optimal surgical procedure to reduce the recurrence rate of chronic subdural hematoma (CSDH) after burr-hole surgery remains to be established. This study aimed to investigate the association between artificial cerebrospinal fluid (ACF) use during burr-hole surgery and reoperation rate in patients with CSDH.MethodIn this retrospective cohort study, we used the Japanese Diagnostic Procedure Combination inpatient database. We identified patients aged 40–90 years who were hospitalized for CSDH and had undergone burr-hole surgery within 2 days of admission, between July 1, 2010 and March 31, 2019. We performed a one-to-one propensity score-matched analysis to compare the outcomes between patients with and without ACF irrigation during burr-hole surgery. The primary outcome was reoperation within 1 year of surgery. The secondary outcome was the total hospitalization costs.ResultsOf the 149,543 patients with CSDH from 1100 hospitals, ACF was used in 32,748 patients (21.9%). Propensity score matching created highly balanced 13,894 matched pairs. In the matched patients, the reoperation rate was significantly lower in the ACF users than that in the non-users group (6.3% vs. 7.0%, P = 0.015), with a risk difference of −0.8% (95% confidence interval, −1.5 to −0.2). There was no significant difference in the total hospitalization costs between the two groups (5079 vs. 5042 US dollars, P = 0.330).ConclusionsACF use during burr-hole surgery may be associated with lower reoperation rate in patients with CSDH.

Long-term outcomes after traumatic brain injury in elderly patients on antithrombotic therapy.

Elderly patients receiving antithrombotic treatment have a significantly higher risk of developing an intracranial hemorrhage when suffering traumatic brain injury (TBI), potentially contributing to higher mortality rates and worse functional outcomes. It is unclear whether different antithrombotic drugs carry a similar risk. This study aims to investigate injury patterns and long-term outcomes after TBI in elderly patients treated with antithrombotic drugs. The clinical records of 2999 patients ≥ 65 years old admitted to the University Hospitals Leuven (Belgium) between 1999 and 2019 with a diagnosis of TBI, spanning all injury severities, were manually screened. A total of 1443 patients who had not experienced a cerebrovascular accident prior to TBI nor presented with a chronic subdural hematoma at admission were included in the analysis. Relevant clinical information, including medication use and coagulation lab tests, was manually registered and statistically analyzed using Python and R. In the overall cohort, 418 (29.0%) of the patients were treated with acetylsalicylic acid before TBI, 58 (4.0%) with vitamin K antagonists (VKA), 14 (1.0%) with a different antithrombotic drug, and 953 (66.0%) did not receive any antithrombotic treatment. The median age was 81 years (IQR = 11). The most common cause of TBI was a fall accident (79.4% of the cases), and 35.7% of the cases were classified as mild TBI. Patients treated with vitamin K antagonists had the highest rate of subdural hematomas (44.8%) (p = 0.02), hospitalization (98.3%, p = 0.03), intensive care unit admissions (41.4%, p < 0.01), and mortality within 30 days post-TBI (22.4%, p < 0.01). The number of patients treated with adenosine diphosphate (ADP) receptor antagonists and direct oral anticoagulants (DOACs) was too low to draw conclusions about the risks associated with these antithrombotic drugs. In a large cohort of elderly patients, treatment with VKA prior to TBI was associated with a higher rate of acute subdural hematoma and a worse outcome, compared with other patients. However, intake of low dose aspirin prior to TBI did not have such effects. Therefore, the choice of antithrombotic treatment in elderly patients is of utmost importance with respect to risks associated with TBI, and patients should be counselled accordingly. Future studies will determine whether the shift towards DOACs is mitigating the poor outcomes associated with VKA after TBI.