Surgeon Preference Research Articles

Treatment of lumbar intervertebral disc herniation - a review of the latest therapeutic methods

Introduction and purpose: The aim of this study is to provide a comprehensive description of intervertebral disc herniation, with a focus on the lumbar spine, including the current conservative and modern surgical treatment options such as minimally invasive procedures.
 State of Knowledge: Spinal pain is a prevalent cause of disability in developed countries, with an increasing number of people affected by this condition. Intervertebral disc herniation resulting from degenerative changes is a common pathology, particularly in the lumbar and cervical spine. This condition involves the protrusion of the nucleus pulposus, which exerts pressure on the spinal roots, causing irritation. While the prognosis for herniated nucleus pulposus is usually positive and many patients can undergo conservative treatment, some may require a surgery. Due to advancements in technology, the current goal is to minimize tissue trauma during hernia repair procedures.
 Conclusions: Due to advances in treatment of lumbar intervertebral disc herniation, patients can achieve better clinical outcomes and improved quality of life. Conservative treatment should be considered as the first line treatment in a majority of cases. Surgery is usually a last resort when conservative treatment proves insufficient. No surgical method seems to be unequivocally superior to the others, so its choice is tailored to the individual patient's needs and depends on the surgeon's preferences and experience. Recent advances in endoscopic spine surgery are providing new insights into disc surgery and pain management strategies.

Use of Silicon T-Tube for Subglottic Stenosis and Tracheal Stenosis.

The management of subglottic and tracheal stenosis is challenging for any ENT surgeon. The treatment choice depends on the site, severity of stenosis, patient symptoms, and surgeon preferences. The various options for the management include endoscopic balloon dilatation, various types of laryngotracheoplasty, resection anastomosis, and insertion of a silicon T-tube. Compared to the above, silicon T-tube stenting is a better alternative, as it is a onetime procedure, easy to perform with fewer chances of complications. Shiann Yann lee technique is a form of laryngotracheoplasty with long-term stenting using silicon T-tube. This article analyzed our silicon T-Tube insertion result in patients with subglottic and tracheal stenosis using this technique. In this retrospective study, we included a total of 21 patients with subglottic and tracheal stenosis who underwent silicon T-Tube insertion. Data regarding the site of stenosis, procedure, complications, and outcome were analyzed. Out of 21 patients, nine patients had subglottic stenosis (42.8%), 8 had cervical tracheal stenosis (38.09%), 3 had thoracic tracheal stenosis (14.28%), and 1 (4.7%) had combined subglottic and cervical tracheal stenosis. Out of 21 patients,7 (33.3%) have undergone successful removal of silicon T-Tube so far, one death due to medical reasons, and 13 patients (61.9%) are still on Silicon tube on regular follow-up. They are comfortable with the tube in situ. Silicon T-Tube for benign acquired laryngotracheal stenosis with Shiann Yann Lee's technique is effective, safe with less complication, and good acceptability and tolerance by the patient.

Endoscopic third ventriculostomy with choroid plexus cauterization: predictors of long-term success and comparison with shunt placement for primary treatment of infant hydrocephalus.

Endoscopic third ventriculostomy (ETV) with choroid plexus cauterization (CPC) can avoid ventriculoperitoneal shunt (VPS) dependence in very young hydrocephalic children, although long-term success as a primary treatment in North America has not been previously reported. Moreover, optimal age at surgery, impact of preoperative ventriculomegaly, and relationship to prior cerebrospinal fluid (CSF) diversion remain poorly defined. The authors compared ETV/CPC and VPS placement for averting reoperation, and they evaluated preoperative predictors for reoperation and shunt placement after ETV/CPC. All patients under 12 months of age who underwent initial hydrocephalus treatment via ETV/CPC or VPS placement at Boston Children's Hospital between December 2008 and August 2021 were reviewed. Analyses included Cox regression for independent outcome predictors, and both Kaplan-Meier and log-rank rank tests for time-to-event outcomes. Cutoff values for age and preoperative frontal and occipital horn ratio (FOHR) were determined with receiver operating characteristic curve analysis and Youden's J index. In total, 348 children (150 females) were included with principal etiologies of posthemorrhagic hydrocephalus (26.7%), myelomeningocele (20.1%), and aqueduct stenosis (17.0%). Of these, 266 (76.4%) underwent ETV/CPC and 82 (23.6%) underwent VPS placement. Treatment choice largely reflected surgeon preferences before practice shifted toward endoscopy, with endoscopy not considered for > 70% of initial VPS cases. ETV/CPC patients trended toward fewer reoperations, and Kaplan-Meier analysis estimated that 59% of patients would achieve long-term shunt freedom through 11 years (median 42 months of actual follow-up). Among all patients, corrected age < 2.5 months (p < 0.001), prior temporizing CSF diversion (p = 0.003), and excess intraoperative bleeding (p < 0.001) independently predicted reoperation. Among ETV/CPC patients, corrected age < 2.5 months (p = 0.031), prior CSF diversion (p = 0.001), preoperative FOHR > 0.613 (p = 0.011), and excessive intraoperative bleeding (p = 0.001) independently predicted ultimate conversion to VPS. The actual VPS insertion rates remained low in patients who were ≥ 2.5 months old at ETV/CPC either with prior CSF diversion (2/10 [20.0%]) or without prior CSF diversion (24/123 [19.5%]); however, the actual VPS insertion rates increased in patients who were < 2.5 months old at ETV/CPC with prior CSF diversion (19/26 [73.1%]) or without prior CSF diversion (44/107 [41.1%]). ETV/CPC successfully treated hydrocephalus in most patients younger than 1 year irrespective of etiology, averting observed shunt dependence in 80% of patients ≥ 2.5 months of age regardless of prior CSF diversion and in 59% of those < 2.5 months of age without prior CSF diversion. For infants aged < 2.5 months with prior CSF diversion, particularly those with severe ventriculomegaly, ETV/CPC was unlikely to succeed unless safely delayed.

The Effect of Ventilation Mode in Anesthesia on Renal Mobility During Retrograde Intrarenal Surgery. Single-Blind Randomized Study.

Renal mobility can present challenges for surgeons during stone fragmentation. The respiratory setup of the mechanical ventilator during RIRS might affect renal mobility. The aim of this study was to evaluate the effect of high ventilation (HV) and standard ventilation (SV) modes on renal mobility during RIRS. Patients who underwent RIRS at a single center between November 2020 and November 2021 were retrospectively included in the study. Renal mobility was measured under fluoroscopic view in HVandSV modes during retrograde pyelography. The surgeon, who was absolutely blind about mechanical ventilation modes, was asked to assess the renal movement grade. After the ventilation mode was changed, the surgeon reassessed renal mobility. The data and the surgeon's assessment were recorded and compared to each other. A total of 86 patients with a mean age of 48.6 ± 15.7 years were included in the study. There was a significant difference between the SV and HV modes in terms of renal mobility in fluoroscopic view (17.1±6.1 mm and 13.6 ± 5.2mm, respectively; p=0.007). According to the surgeon's assessments, the grade of renal mobility was found to be significantly higher in the SV group 2.8 ±1.1 compared to the HV group 2.2 ± 0.8 (p=0.001). Renal movement increased significantly under fluoroscopic vision as the renal grading of the surgeon increased(p=0.013). This data demonstrated that the surgeon's assessment of renal mobility was significantly correlated with fluoroscopic kidney movement. Kidney movement was decreased significantly in HV mode during RIRS according to both fluoroscopic findings and surgeon assessment. Most surgeries of mobile kidneys were performed in HV mode, due to the surgeon's preference.

Scheduled Postoperative Ketorolac Does Not Decrease Opiate Use following Free Flap Breast Reconstruction.

In the setting of the opioid crisis, managing postoperative pain without the exclusive use of opiates has become a topic of interest. Many hospitals have begun implementing enhanced recovery after surgery protocols to decrease postoperative complications, hospital costs, and opiate utilization. Ketorolac has been added to many of these protocols, but few studies have examined its effects independently. A retrospective chart review was performed on all patients that received autologous breast reconstruction from October 2020 to June 2022 at an academic institution. We identified patients who did and did not receive postoperative ketorolac. Use of ketorolac was based upon surgeon preference. The two groups were compared in basic demographics, reconstruction characteristics, length of stay, complications, reoperations, and morphine milligram equivalents (MMEs). One-hundred ten patients were included for the analysis, with 55 receiving scheduled postoperative ketorolac and 55 who did not receive ketorolac. There were seven incidences of postoperative complications in each group (12.7%, p = 1.00). The total mean postoperative MMEs were 344.7 for the nonketorolac group and 336.5 for the ketorolac group (p = 0.81). No variable was found to be independently associated with postoperative opiate use. Ketorolac was not found to contribute significantly to any postoperative complication. In this study, the use of ketorolac did not significantly reduce opiate use in a cohort of 110 patients. Surgeons should consider whether the use of ketorolac alone is the best option to reduce postoperative opiate use following free flap breast reconstruction.

A comparative study of two single-stage oral mucosal substitution urethroplasty (Kulkarni and Asopa) in the surgical treatments of lichen sclerosus urethral strictures.

Long-segment lichen sclerosus (LS) urethral stricture is a challenge for urologists. Limited data are available for surgeons to make a surgical decision between Kulkarni and Asopa urethroplasty. In this retrospective study, we investigated the outcomes of these two procedures in patients with LS urethral stricture. Between January 2015 and December 2020, 77 patients with LS urethral stricture underwent Kulkarni and Asopa procedures for urethroplasty in the Department of Urology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine (Shanghai, China). Of the 77 patients, 42 (54.5%) underwent the Asopa procedure and 35 (45.5%) underwent the Kulkarni procedure. The overall complication rate was 34.2% in the Kulkarni group and 19.0% in the Asopa group, and no difference was observed ( P = 0.105). Among the complications, no statistical difference was observed in the incidence of urethral stricture recurrence ( P = 0.724) or glans dehiscence ( P = 0.246) except for postoperative meatus stenosis ( P = 0.020). However, the recurrence-free survival rate between the two procedures was significantly different ( P = 0.016). Cox survival analysis showed that antiplatelet/anticoagulant therapy use ( P = 0.020), diabetes ( P = 0.003), current/former smoking ( P = 0.019), coronary heart disease ( P < 0.001), and stricture length ( P = 0.028) may lead to a higher hazard ratio of complications. Even so, these two techniques can still provide acceptable results with their own advantages in the surgical treatment of LS urethral strictures. The surgical alternative should be considered comprehensively according to the patient characteristics and surgeon preferences. Moreover, our results showed that antiplatelet/anticoagulant therapy use, diabetes, coronary heart disease, current/former smoking, and stricture length may be contributing factors of complications. Therefore, patients with LS are advised to undergo early interventions for better therapeutic effects.

The Role of Postoperative Dressing in Hypospadias Surgery: A Systematic Review and Meta-analysis of the Pediatric Literature.

This study aimed to describe the available dressings and their management in patients undergoing hypospadias repair and compare postoperative outcomes with and without dressing and between the different dressing types. A comprehensive electronic literature search of PubMed, Embase, and Cochrane Library was conducted to obtain studies, published in the period 1990 to 2021, reporting on the dressing used following hypospadias surgery. All information regarding the dressing was considered as primary endpoints, whereas surgical outcomes were assessed as secondary outcomes. Thirty-one studies containing 1,790 subjects undergoing hypospadias repair were included. Dressings were divided into three categories: nonadherent to the wound, adherent to the wound, and glue-based dressings. Most authors preferred to remove/change the dressing in the ward and the median time of removal/change was 6.56 postoperative days. The dressing removal appeared as the most frequent factor generating parental anxiety. The median rate of wound-related complications was 8.18%, of urethroplasty complications 9.08% and of reoperations 8.18%. Meta-analysis of outcomes showed higher risk of reoperations using conventional dressing, with no differences in urethroplasty and wound-related complications rates between conventional and glue-based dressings. Furthermore, the use of dressing reported increased risk of wound-related complications compared with no dressing, without significant differences regarding occurrence of urethroplasty complications and reoperations. The current evidence confirmed that there is no difference in outcomes of hypospadias repair depending on a certain dressing type. To date, surgeon's preference remains the main factor determining the choice for a specific dressing or for no dressing at all.

A RETROSPECTIVE ANALYSIS OF THE DEFINITIVE MANAGEMENT OF OPEN TALUS FRACTURES, COMPARING ORIF AND TIBIOCALCANEAL FUSIONS, AT A MAJOR TRAUMA CENTRE: COHORT STUDY AND AUDIT OF BOAST 4 GUIDELINES

Open talus fracture are notoriously difficult to manage and they are commonly associated with a high level of complications including non-union, avascular necrosis and infection. Currently, the management of such injuries is based upon BOAST 4 guidelines although there is no suggested definitive management, thus definitive management is based upon surgeon preference. The key principles of open talus fracture management which do not vary between surgeons, however, there is much debate over whether the talus should be preserved or removed after open talus fracture/dislocation and proceeded to tibiocalcaneal fusion.A review of electronic hospital records for open talus fractures from 2014-2021 returned foureen patients with fifteen open talus fractures. Seven cases were initially managed with ORIF, five cases were definitively managed with FUSION, while the others were managed with alternative methods. We collected patient's age, gender, surgical complications, surgical risk factors and post-treatment functional ability and pain and compliance with BOAST guidelines. The average follow-up of the cohort was four years and one month. EQ-5D-5L and FAAM-ADL/Sports score was used as a patient reported outcome measure. Data was analysed using the software PRISM.Comparison between FUSION and ORIF groups showed no statistically significant difference in EQ-5D-5L score (P = 0.13), FAAM-ADL (P = 0.20), FAAM-Sport (P = 0.34), infection rate (P = 0.55), surgical times (P = 0.91) and time to weight bearing (P = 0.39), despite a higher proportion of polytrauma and Hawkins III and IV fractures in the FUSION group.FUSION is typically used as second line to ORIF or failed ORIF. However, there are a lack of studies that directly compared outcome in open talus fracture patients definitively managed with FUSION or ORIF. Our results demonstrate for the first time, that FUSION may not be inferior to ORIF in terms of patient functional outcome, infection rate, and quality-of-life, in the management of patients with open talus fracture patients. Of note, as open talus fractures have increased risks of complications such as osteonecrosis and non-union, FUSION should be considered as a viable option to mitigate these potential complications in these patients.

PD06-06 INSTITUTIONAL AND SURGEON VARIATION IN PRACTICE WITHIN THE PEDIATRIC KIDNEY STONE (PKIDS) CARE IMPROVEMENT NETWORK

You have accessJournal of UrologyCME1 Apr 2023PD06-06 INSTITUTIONAL AND SURGEON VARIATION IN PRACTICE WITHIN THE PEDIATRIC KIDNEY STONE (PKIDS) CARE IMPROVEMENT NETWORK Nicolas Fernandez, Jonathan Ellison, Zi Wang, Jing Huang, David Chu, Pankaj Dangle, Renea Sturm, Andrew Stec, Ryan Hsi, Christina Ching, Wayland Wu, Caleb Nelson, Brian Augelli, Jing Karchin, and Gregory Tasian Nicolas FernandezNicolas Fernandez More articles by this author , Jonathan EllisonJonathan Ellison More articles by this author , Zi WangZi Wang More articles by this author , Jing HuangJing Huang More articles by this author , David ChuDavid Chu More articles by this author , Pankaj DanglePankaj Dangle More articles by this author , Renea SturmRenea Sturm More articles by this author , Andrew StecAndrew Stec More articles by this author , Ryan HsiRyan Hsi More articles by this author , Christina ChingChristina Ching More articles by this author , Wayland WuWayland Wu More articles by this author , Caleb NelsonCaleb Nelson More articles by this author , Brian AugelliBrian Augelli More articles by this author , Jing KarchinJing Karchin More articles by this author , and Gregory TasianGregory Tasian More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003230.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The strength of the evidence base supporting surgical management of urinary stone disease for pediatric patients is weak. Using data from the PKIDS Network, we aimed to describe characteristics of institutions and surgeons in PKIDS and factors associated with selection of surgical intervention modality for different clinical scenarios. METHODS: Surgeons in the PKIDS Network completed intake surveys at site activation between February 2020 and September 2022. Surgeon questionnaires collected demographics, clinical and surgical management preferences. Institutional questionnaires collected site characteristics about case volume, equipment availability, and infrastructure. Assessment of preference between surgery type (URS, SWL, PCNL) was evaluated using 4 different clinical scenarios included in the surgeon survey (A) 2 cm kidney stone, B) 9 mm proximal ureteral stone, C) 1.5 cm lower pole kidney stone, D) 1 cm non lower pole kidney stone. Four multivariable linear regression models were built to evaluate the association between surgeon and institutional characteristics and the choice of surgical intervention for each of the 4 clinical scenarios. Principal component analysis was performed to identify clusters of characteristics that influenced surgical intervention. RESULTS: A total of 31 sites and 148 surgeons with a mean of 9.7 years in practice (SD=8.7 years) completed surveys. There was wide variation in surgeon preferences for type of surgical intervention; equipoise was greatest for URS versus PCNL for a 1.5cm kidney stone (Figure 1). Principal component analysis identified 3 clusters of factors influencing surgeon preferences: A. Stone characteristics (size, location, and density), B. Patient characteristics (symptoms, history of urinary tract infections, comorbidities, and prior surgical history) and C. Other (complications, reimbursement, radiation exposure and number of anesthetics). CONCLUSIONS: Wide heterogeneity in the characteristics and preferences of surgeons who surgically manage pediatric patients with urinary stones was identified. A cohort of surgeons expressed preference for surgical modality driven primarily by kidney stone features, another by patient features, and a third by other variables. Source of Funding: Patient Centered Outcomes Research Institute (PECORI) © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e157 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nicolas Fernandez More articles by this author Jonathan Ellison More articles by this author Zi Wang More articles by this author Jing Huang More articles by this author David Chu More articles by this author Pankaj Dangle More articles by this author Renea Sturm More articles by this author Andrew Stec More articles by this author Ryan Hsi More articles by this author Christina Ching More articles by this author Wayland Wu More articles by this author Caleb Nelson More articles by this author Brian Augelli More articles by this author Jing Karchin More articles by this author Gregory Tasian More articles by this author Expand All Advertisement PDF downloadLoading ...

Comparative analysis of superior capsule reconstruction between long head of biceps tendon autograft and human dermis allograft.

Although many superior capsule reconstruction (SCR) techniques are currently practiced in clinical settings, guidelines for choosing the appropriate graft material are lacking. Therefore, at most times, the surgeon's personal preference becomes the deciding factor. This study compared 2 fairly recent SCR techniques-SCR with biceps tendon (BT) autograft and SCR with human dermis (HD) allograft-by evaluating clinical and radiologic outcomes to aid the surgeon's decision in choosing the appropriate graft. Thirty-one patients underwent SCR using BT autograft (SCR BT), and 22 underwent SCR using HD allograft (SCR HD). SCR BT was selected for patients with a partial BT tear <20%, no severe inflammation signs, and favorable anchor conditions. SCR HD was performed in patients with a BT tear >20%, a superior labrum anterior-posterior (SLAP) lesion, severe inflammation, or subluxation. Range of motion (ROM), strength and shoulder function scoring, plain radiography, and magnetic resonance imaging were evaluated before and after surgery at regular intervals. In the SCR BT group, forward flexion ROM increased from 122°±43° to 149°±18° at 2 years postoperatively, whereas in the SCR HD group, forward flexion ROM improved from 129°±28° to 149°±18°. In the SCR BT group, internal rotation (IR) ROM increased from 5±3 to 6±2 at 2 years postoperatively, whereas in the SCR HD group, IR ROM improved from 5±3 to 6±1. Although ROM, strength, visual analog scale score, American Shoulder and Elbow Surgeons score, and Constant score all improved 2 years after surgery, no statistically significant differences were found. Six months after surgery, graft thickness was 3.58±0.384 mm in the SCR BT group and 2.49±0.326 mm in the SCR HD group (P<.001). At 2 years postoperatively, graft thickness was 3.54±0.399 mm in the SCR BT group and 2.49±0.306 mm in the SCR HD group (P<.001). The SCR HD group showed a negative correlation of -0.475 between graft thickness and IR ROM (P=.026). In the SCR BT group, a negative correlation of -0.466 was found between graft thickness and IR ROM (P=.008). A positive correlation of 0.363 was found between IR ROM and the acromiohumeral distance when the results were compared before and 2 years after surgery (P=.045). Both SCR using BT autograft and SCR using HD allograft tissue showed favorable results, and no significant difference was noted between the 2 techniques. Given that the 2 techniques show equally favorable results, the surgeon's personal preference in choosing the SCR technique appears to be acceptable. Understanding the costs and patient's characteristics may aid the surgeon in deciding on the graft material.

Arthroscopic resection of localized tenosynovial giant cell tumor in the deep infrapatellar bursa: a case report

Tenosynovial giant cell tumor (TGCT) is a rare disease characterized by the proliferation of the synovial membrane of a joint, tendon sheath, or bursa. TGCTs in joints are subdivided into the diffuse or localized type. The localized TGCT most frequently affects the knee and may occur in any knee compartment. The most common localization is the Hoffa’s fat pad, followed by the suprapatellar pouch and the posterior capsule. Here, we describe a case of a histopathologically proven TGCT of the knee, found in an unusual localization in the deep infrapatellar bursa, which was diagnosed by magnetic resonance imaging. The tumor was entirely arthroscopically resected. The patient had no further complaints following the operation, and there was no recurrence at the 18-month follow-up. Even though TGCT of the knee is uncommon, it should not be overlooked by orthopedic and trauma surgeons, and excision should be regarded as a reliable treatment option. The form of surgical treatment, either open or arthroscopic, should be determined based on a combination of the surgeon's preference and the best approach to the anatomical location of the disease.

Accuracy of the newly developed Zimmer Biomet Root Aiming guide in tibial tunnel creation compared with that of conventional guides

Background/objectiveAccurate tibial tunnel creation is crucial for successful transtibial pullout repair of medial meniscus (MM) posterior root tears (MMPRTs). This study aimed to evaluate the accuracy of the newly developed Zimmer Biomet Root Aiming (ZeBRA) guide for transtibial pullout repair of MMPRTs. MethodsThis study included 50 patients who underwent transtibial pullout repair using the Unicorn Meniscal Root (UMR) (n = 25) and ZeBRA (n = 25) guides. The expected anatomic centre (AC) and tibial tunnel centre (TC) were assessed using three-dimensional postoperative computed tomography (CT) images. The expected AC was defined as the centre of the circle tangent to the triangular footprint of the MM posterior root. The expected AC and TC on the tibial surface were assessed using the percentage-based posterolateral location on the tibial surface. The absolute distance between the AC and TC (mm) was evaluated. ResultsThe mean AC location was 76.1% ± 3.1% posterior and 40.8% ± 2.1% lateral, whereas the mean TC location was 76.7% ± 5.3% posterior and 37.2% ± 3.6% lateral using the UMR guide and 75.8% ± 3.1% posterior and 36.5% ± 2.4% lateral using the ZeBRA guide. No significant difference was observed in the absolute distance between the UMR and ZeBRA guides (3.9 ± 1.4 and 3.8 ± 1.3 mm, respectively; p = 0.617). ConclusionsThe newly developed ZeBRA guide allows accurate tibial tunnel creation, and its accuracy is comparable to that of the conventional UMR guide. Tibial tunnels were created at optimal positions using both guides, and the choice of the guide would depend on the surgeon's preference.

MP26-05 SINGLE-PORT VS. MULTIPORT PARTIAL NEPHRECTOMY: 6-MONTH INTERMEDIATE OUTCOMES

You have accessJournal of UrologyCME1 Apr 2023MP26-05 SINGLE-PORT VS. MULTIPORT PARTIAL NEPHRECTOMY: 6-MONTH INTERMEDIATE OUTCOMES Jennifer L Nguyen, Teona Iarajuli, Katherine Kim, Jacquelyn Roth, Martin Malik, Allison Brown, Hunter Hasley, Simon Gelman, Mutahar Ahmed, and Michael Stifelman Jennifer L NguyenJennifer L Nguyen More articles by this author , Teona IarajuliTeona Iarajuli More articles by this author , Katherine KimKatherine Kim More articles by this author , Jacquelyn RothJacquelyn Roth More articles by this author , Martin MalikMartin Malik More articles by this author , Allison BrownAllison Brown More articles by this author , Hunter HasleyHunter Hasley More articles by this author , Simon GelmanSimon Gelman More articles by this author , Mutahar AhmedMutahar Ahmed More articles by this author , and Michael StifelmanMichael Stifelman More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003254.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: This study aims to compare intermediate outcomes in patients following single port (SP) and multiport (MP) robotic-assisted partial nephrectomy (RAPN). METHODS: This prospective, single-center study involved patients who underwent SP or MP RAPN (based on surgeon preference), performed by two surgeons between 2017 and 2022, with at least 6 months of follow-up. Linear and logistic regression analyses were performed to estimate the difference in outcomes between SP and MP, adjusting for the operating surgeon. RESULTS: Overall, 48 patients underwent SP and 185 MP RAPN (20.6% vs. 79.4%) with minimum 6 month follow up. Table 1 summarizes demographics between the SP and MP cohorts and confirms no differences except for more females in the SP group. Table 2 summarizes the intermediate outcomes at 6 month follow up. There was no difference in disease recurrence or hernia incidence. There were significant differences in preservation of GFR (10.5, p = 0.004) despite similar changes in creatinine in the SP group. CONCLUSIONS: Based on our analyses, SP partial nephrectomy is an effective treatment with similar recurrence rates and hernia incidence at 6 months post surgery compared to MP . We did note an improvement in post op 6 month GFR for the SP group. The clinical significance of this is unclear as the change in creatinine was no different between the SP and MP groups. Larger multi-institutional studies are underway to evaluate if SP may have a protective effect on renal function. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e353 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jennifer L Nguyen More articles by this author Teona Iarajuli More articles by this author Katherine Kim More articles by this author Jacquelyn Roth More articles by this author Martin Malik More articles by this author Allison Brown More articles by this author Hunter Hasley More articles by this author Simon Gelman More articles by this author Mutahar Ahmed More articles by this author Michael Stifelman More articles by this author Expand All Advertisement PDF downloadLoading ...

MP40-18 PROSTATE CANCER DETECTION RATE OF TRANSPERINEAL PROSTATE BIOPSY: COGNITIVE VERSUS SOFTWARE FUSION, A MULTICENTER ANALYSIS

You have accessJournal of UrologyCME1 Apr 2023MP40-18 PROSTATE CANCER DETECTION RATE OF TRANSPERINEAL PROSTATE BIOPSY: COGNITIVE VERSUS SOFTWARE FUSION, A MULTICENTER ANALYSIS Michael Hung, Eric Li, Sean A Fletcher, Sofia Gereta, Ashley Ross, Christian P Pavlovich, Timothy D McClure, Mohamad E Allaf, Edward M Schaeffer, and Jim C Hu Michael HungMichael Hung More articles by this author , Eric LiEric Li More articles by this author , Sean A FletcherSean A Fletcher More articles by this author , Sofia GeretaSofia Gereta More articles by this author , Ashley RossAshley Ross More articles by this author , Christian P PavlovichChristian P Pavlovich More articles by this author , Timothy D McClureTimothy D McClure More articles by this author , Mohamad E AllafMohamad E Allaf More articles by this author , Edward M SchaefferEdward M Schaeffer More articles by this author , and Jim C HuJim C Hu More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003278.18AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Transrectal ultrasound guided biopsy (TR-Bx) is the predominant method of prostate cancer diagnosis in the US with transperineal prostate biopsy (TP-Bx) gaining adoption owing to a lower risk of infection. Landmark studies have demonstrated that MRI prior to TR-Bx improves detection of clinically significant prostate cancers (csPCa), and several software fusion platforms exist to aid in needle targeting. The use of cognitive or software fusion in the TP-Bx setting has not been explored. We sought to evaluate the detection rate of csPCa in TP-Bx performed with MRI targeted cognitive fusion (CF) versus software fusion (SF). METHODS: A multicenter retrospective cohort of men undergoing MRI guided TP-Bx for the indication of elevated PSA, suspicious lesion on MRI, or active surveillance, were included in this study. Variables included age, PSA, prostate volume, PIRADS scores, number of cores sampled, and pathologic outcomes. CF and SF techniques were selected based on surgeon preference, utilizing either the PrecisionPoint system (Perineologic, Cumberland, MD) or standard stepper and brachytherapy grid. Systematic biopsies along with MRI targeted cores were obtained for all patients. Multivariable logistic regression was used to determine factors associated with csPCa. RESULTS: In total, 494 men (197 cognitive, 297 software fusion) underwent MRI guided TP-Bx. Baseline age, PSA, number of targets, and PIRADS scores were similar among both groups (Table 1). A higher proportion of men who underwent CF were biopsy naïve (90% vs 72%, p≤0.01). Significantly more cores were obtained in the SF group (median 22 (17–26) vs 16 (15–18), p<0.01) and target sizes were smaller in the SF group, median 6.3 mm2 (4 mm2-10.4 mm2) vs 8 mm2 (4.4 mm2-14.4 mm2), p<0.01). The unadjusted detection rate of csPCa was higher in the CF group (51% vs 39%). On multivariable analysis fusion technique was not a predictor of csPCa glandwide (OR 1.4, 95% CI 0.88–2.25, p=0.17), or in the target lesion specifically (OR 0.98, 95% CI 0.57-1.68, p=0.95). CONCLUSIONS: Our multicenter analysis demonstrates no difference in the detection of csPCa in TP-Bx utilizing MRI guided CF vs SF. Since SF platforms are quite costly, CF via TP-Bx is appealing as it is not only safer than TR-Bx but also more cost-effective than using SF technology. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e552 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Michael Hung More articles by this author Eric Li More articles by this author Sean A Fletcher More articles by this author Sofia Gereta More articles by this author Ashley Ross More articles by this author Christian P Pavlovich More articles by this author Timothy D McClure More articles by this author Mohamad E Allaf More articles by this author Edward M Schaeffer More articles by this author Jim C Hu More articles by this author Expand All Advertisement PDF downloadLoading ...

343 The Influence of Dynamic Data in Adult Spinal Deformity Surgery Planning and Patient Candidacy: A Preliminary Study

OBJECTIVES/GOALS: Adult spinal deformity is commonly treated by spine surgeons. Patient treatment planning and surgical candidacy are dependent on static measurements and inconsistent heuristics which lead to high complication rates and poor outcomes. This study tests the role of supplemental longitudinal and dynamic patient data in improving surgical planning. METHODS/STUDY POPULATION: Ten adult spinal deformity surgeons at Johns Hopkins Hospital were interviewed for 30 minutes by the study team. The script was reviewed by the institutional review board to alleviate any risk of bias. Two patient sets were curated utilizing previously treated, anonymized patient data sets from a non-surveyed practitioner. Each patient set was coupled with relevant radiographic imaging (MRIs, CTs, and plain radiographs) and pertinent clinical information that is collected in a standard clinic visit. Surgeons were presented with a patient and asked to note their specific surgical plan. Subsequently, surgeons were presented with four sets of supplemental dynamic spine data and asked to note their surgical plan for each set. Shaprio-Wilks and Mann-Whitney U tests were used to assess data normality and nonnormality. RESULTS/ANTICIPATED RESULTS: Preliminary data has shown inconsistency in both surgical selection and surgical type amongst physicians when presented with initial clinical findings and radiographic reports for base patient cases. There was minimal consensus among surgeons on the number of levels fused and interbody spacer usage. Early results show that dynamic spine data may be beneficial in creating consistency between surgeons, despite inter-surgeon variability in surgical planning without this data. Posture, pain location, pain severity, and quantified activity throughout the day have been referenced as the most useful dynamic spine data to consider. Amongst all providers, the availability of dynamic spine data resulted in a change in surgical planning. DISCUSSION/SIGNIFICANCE: Recent publications have shown that spine surgery patient candidacy and surgical planning are dependent on heuristics. This has led to inconsistencies amongst surgeon preferences and increases in improper patient selection for procedures. Incorporating longitudinal dynamic data may lead to increased consistency and improved patient outcomes.

V09-05 ROBOTIC-ASSISTED VAGINOPLASTY WITH PERITONEAL COVERAGE (COMPLETE APICAL GRAFT CLOSURE VS. PERITONEAL CAP)

You have accessJournal of UrologyCME1 Apr 2023V09-05 ROBOTIC-ASSISTED VAGINOPLASTY WITH PERITONEAL COVERAGE (COMPLETE APICAL GRAFT CLOSURE VS. PERITONEAL CAP) Arman Walia, Vi Nguyen, Aditya Bagrodia, and Jennifer Anger Arman WaliaArman Walia More articles by this author , Vi NguyenVi Nguyen More articles by this author , Aditya BagrodiaAditya Bagrodia More articles by this author , and Jennifer AngerJennifer Anger More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003317.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Penile inversion vaginoplasty is a common technique for feminizing gender-affirming surgery in which a vaginal canal can be created from full thickness scrotal skin graft. Based on surgeon preference or when scrotal skin is limited, the Davydov technique described for patients with vaginal agenesis can be used (Zhao et al). In this approach, the proximal canal is formed from peritoneum as a peritoneal cap. However, a peritoneal cap may not necessary in those with adequate graft length. Here we demonstrate a modified Davydov technique is which the apex of the vaginal canal is closed and peritoneal flaps are utilized for coverage and blood supply only, rather than inclusion as the neovaginal apex. METHODS: We utilized a standard pelvic robotic port placement using the Da Vinci Xi. Side docking allows for perineal dissection and penile disassembly. Posterior dissection is performed similar to robotic prostatectomy. The peritoneum is incised and Denonvillier’s followed. The perineal surgeon directs the robotic surgeon in avoiding the rectum. Under vision from above the perineal surgeon enters the dissected space. With guidance from below, the robotic surgeon separates the lateral levator muscle until the opening is calibrated to vaginal stent diameter. Vaginal packing can be placed to facilitate remaining perineal work. The lateral peritoneal flaps are created by incising peritoneum over the external iliac artery distally. Flap length is assessed to avoid constriction over the sigmoid, and further released as needed. After confirming adequate length, the canal is delivered from below. The apex can be closed prior to delivery or robotically. The anterior peritoneal flap is harvested by continuing the lateral dissections in an inverted "U". The lateral flaps are then secured to the canal with barbed suture. Depending on patient anatomy, the anterior flap can be rotated for coverage or simply advanced posteriorly. The anterior and posterior peritoneal flaps are then approximated over the canal apex to provide blood supply to the graft. RESULTS: The above technique has been applied to our last 5 penile inversion vaginoplasty patients. Each had an unremarkable postoperative recovery and is doing well at follow up. CONCLUSIONS: Gender-affirming surgery is a growing field with evolving techniques. A robotic-assisted approach provides additional visibility and maneuverability. A modified Davydov technique for peritoneal coverage can be added to our surgical repertoire for patients with adequate canal length so that the vaginal graft can be fully closed at the apex. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e838 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Arman Walia More articles by this author Vi Nguyen More articles by this author Aditya Bagrodia More articles by this author Jennifer Anger More articles by this author Expand All Advertisement PDF downloadLoading ...

„Minimally invasive glaucoma surgery“ – Kammerwinkelbasierte Verfahren im Vergleich

Surgical procedures are playing an increasing role in the care of patients with glaucoma. Within the last decade, new surgical procedures have been established, which are summarized under the term minimally invasive glaucoma surgery (MIGS). Awide variety of different procedures are aimed at the structures in the angle of the anterior chamber, such as the trabecular meshwork and Schlemm's canal, to improve the physiological outflow or to improve the alternative uveoscleral outflow. The implementation of the treatment goal differs in the individual procedures, as does the maximum pressure reduction that can be achieved. Compared to trabeculectomy with the use of cytostatic agents, the achievable pressure reduction is usually significantly lower. In contrast, the significantly lower intraoperative and postoperative complication rates are emphasized as an advantage of these procedures. With increasing clinical experience and the growth of sufficient data on these new surgical procedures, awell-founded classification in the treatment algorithm of glaucoma surgery becomes easier; nevertheless, due to the small differences with respect to efficacy and safety profile, the final decision for an individual procedure often remains dependent on the surgeon's personal preferences.

MP62-14 EFFICACY AND SAFETY OF TWO DISPOSABLE CIRCUMCISION SUTURE DEVICES FOR CIRCUMCISION IN ADULTS: A PROSPECTIVE COMPARATIVE MULTICENTER STUDY

You have accessJournal of UrologyCME1 Apr 2023MP62-14 EFFICACY AND SAFETY OF TWO DISPOSABLE CIRCUMCISION SUTURE DEVICES FOR CIRCUMCISION IN ADULTS: A PROSPECTIVE COMPARATIVE MULTICENTER STUDY Alessia Celeste Bocchino, Esaú Fernández-Pascual, Carlos Toribio-Vázquez, Celeste Manfredi, Guillermo Urdaneta, Carlos Balmori, Andrea Cocci, Nicola Mondaini, and Juan Ignacio Martínez-Salamanca Alessia Celeste BocchinoAlessia Celeste Bocchino More articles by this author , Esaú Fernández-PascualEsaú Fernández-Pascual More articles by this author , Carlos Toribio-VázquezCarlos Toribio-Vázquez More articles by this author , Celeste ManfrediCeleste Manfredi More articles by this author , Guillermo UrdanetaGuillermo Urdaneta More articles by this author , Carlos BalmoriCarlos Balmori More articles by this author , Andrea CocciAndrea Cocci More articles by this author , Nicola MondainiNicola Mondaini More articles by this author , and Juan Ignacio Martínez-SalamancaJuan Ignacio Martínez-Salamanca More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003320.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Disposable circumcision suture devices have been developed to optimize outcomes of circumcision, one of the most common surgical procedures worldwide. The aim of this study is to evaluate the efficacy and safety of two different disposable circumcision suture devices (DCSDs) and compare their surgical outcomes. METHODS: A prospective comparative multicenter study was performed between November 2019 and October 2021. Patients with congenital or acquired phimosis were included. Patients underwent circumcision using a DCSD (CircCurerTM or the ZSR® device) according to the surgeon preference and device availability. Postoperative follow-up was scheduled at 1 week and 2 months for all patients. RESULTS: A total of 215 patients were enrolled, 120 underwent circumcision using CircCurerTM (Group A) and 95 patients using ZSR® (Group B). No differences were observed in baseline characteristics between the two groups (p>0.05). Mean (SD) operative time was 7.0 (2.5) minutes with no significant difference between the groups (p=0.678). Seven patients (5.8%) in Group A and 2 (2.1%) in Group B required accessory stitches (p=0.156). Four subjects (3.3%) in Group A and 1 (1.1%) in group B presented hematoma (p=0.266). Surgical site infection occurred in 1 (0.8%) in Group A and 2 (2.1%) in Group B (p=0.413). Metal clips fell out spontaneously in 39 patients (32.5%) of Group A and 47 (49.5%) of Group B (p<0.001). Median (IQR) Numeric Rating Scale (NRS) for postoperative pain was 2.5 (0-4) in Group A and 2.0 (0-4) in Group B (p=0.284). At 2 months, patients of both groups reported a median (IQR) satisfaction of 9 (8-9) points (p=0.469). CONCLUSIONS: DCSDs appear to allow effective and safe circumcision, with short operative times, uncommon and mild complications, and high patient satisfaction; although there are several devices with some relevant differences on the market. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e867 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alessia Celeste Bocchino More articles by this author Esaú Fernández-Pascual More articles by this author Carlos Toribio-Vázquez More articles by this author Celeste Manfredi More articles by this author Guillermo Urdaneta More articles by this author Carlos Balmori More articles by this author Andrea Cocci More articles by this author Nicola Mondaini More articles by this author Juan Ignacio Martínez-Salamanca More articles by this author Expand All Advertisement PDF downloadLoading ...

“Around the global hand table”: Hand surgeon and therapist perspectives on overcoming barriers to relative motion orthotic intervention in the management of zones V-VI finger extensor tendon repairs

IntroductionAn international survey of therapists cited 2 barriers (physician preference and departmental policy) to the implementation of a relative motion extension (RME) orthosis/early active motion (EAM) approach. Study Designe-survey PurposeTo glean insight from hand surgeons and hand therapists regarding their awareness and experiences in implementing or not implementing an RME orthosis/EAM approach for management of finger zones V-VI extensor tendon repairs. MethodsTwo e-surveys, one to hand surgeons and the other to hand therapists were distributed. Participants were asked 8-open ended questions with the opportunity for additional comment. ResultsNine of 11 surgeons and 10 of 11 therapists (clinicians/educators/administrators) who were surveyed, participated. All respondents from 7 countries were aware of the RME/EAM approach, with only 1 surgeon and 2 therapists not implementing. Surgeons once aware, quickly implement; therapists in this survey implemented about 2.5 years after learning of the approach. Surgeon use was influenced more by their peers than the evidence while therapist knowledge came from professional meetings. Therapists teaching at university-level and continuing education integrate the approach. DiscussionAlthough the RME orthosis/EAM approach has been around for 4 decades, awareness for the hand surgeons and therapists surveyed has only been over the past 20 years. Surveyed surgeons like to visualize how the RME concept works and therapists depend more on the evidence. To overcome barriers to RME/EAM implementation, several strategies are outlined. ConclusionAlthough a small survey, valuable comments provide insight for addressing the previously cited barriers. Strategies for increasing awareness and fostering implementation of an RME orthosis/EAM approach are offered by international hand surgeons and therapists surveyed regarding the commonly cited barriers of surgeon preference and department procedures.

Current Indications for Spinal Endoscopic Surgery and Potential for Future Expansion.

Endoscopic spine surgery (ESS) has evolved as a safe, effective, and efficient alternative for minimally invasive spine surgery (MISS). The innovation of full-endoscopic systems makes definitive decompression surgery through different approaches feasible. The approach can be determined according to the location of the target lesion or the surgeon's preference. During the past 2 decades, ESS has expanded its indications from lumbar to cervical spines. Except for decompression, endoscopy-assisted fusion surgery is also developing. However, ESS is still evolving and has a steep learning curve. The revolution of technologies and ESS techniques will enable surgeons to treat various spinal diseases more practically. In recent years, the application of the computer-assisted navigation system and augmented reality have reformed imaging quality and interpretation. The endoscopic rhizotomy techniques have opened a new way for MISS of chronic low back pain. This review introduces the current indications of ESS and its potential future expansion.