Surgical Failure Rate Research Articles

Comparison of Clinical Outcomes Among Deceased Donor Kidney Transplant Recipients Before and After Utilizing Estimated Posttransplant Survival Score for Kidneys Allocation in Malaysia

The Malaysian Kidney Allocation System implemented in 2020 includes only kidney transplant candidates with estimated posttransplant survival (EPTS) score of ≤20%, in replacement of Malaysian Organs Sharing System, which was based solely on dialysis vintage. We aim to compare the clinical outcomes of deceased-donor kidney transplant recipients (DDKTRs) with EPTS ≤20% to those with EPTS >20%. All DDKTRs between January 1, 2015, and December 29, 2020, were included and categorized into 2 groups: EPTS ≤20% and EPTS >20%. Cox regression was performed to evaluate the association of EPTS score and patient survival. The rate of postoperative complications, graft failure and patient survival were compared between 2 groups. Data were analyzed with SPSS v26 and R v4.0.4. The study complies with the Helsinki Congress and the Istanbul Declaration. We included 159 DDKTRs, with a median follow-up of 25 months (range, 10-60 months). The mean age of those with EPTS ≤20% was 32.2 ± 3.4 years and those with EPTS >20% was 46.0 ± 6.7 years, and the median EPTS score were 16% (range, 12%-18%) and 38% (range, 27%-56.5%), respectively. EPTS score was associated with patient survival (hazard ratio, 1.031; 95% CI 1.010-1.052; P=.003), and the cutoff points of 30% and above were associated with worse survival. It showed good discrimination (C-index, 0.729; 95% CI 0.579-0.878; P=.003) and the optimal cutoff value was 38% (65.5% sensitivity, 68.8% specificity, 17.8% positive predictive value, and 95.8% negative predictive value). Both groups had similar rate of surgical complications (P=.191), graft failure (P=.503), and patient survival (P=.654), but those with EPTS >20% had higher incidence of urinary tract infection (9.3% vs 27.6%, P=.016). There was no difference in clinical outcomes using an EPTS cutoff point of 20% but worse patient survival if higher cutoff point was used.

The utilization of hyperbaric oxygenation therapy in hypospadias repair: a systematic review and meta-analysis

This study aimed to evaluate the efficacy and safety of Hyperbaric Oxygen Therapy (HBOT) use in hypospadias repair through systematic review and meta-analysis of comparative studies. A systematic literature search was performed in May 2021. Comparative studies assessing the surgical outcome of hypospadias repair between control versus HBOTutilization were identified andevaluated according to Cochrane collaboration recommendations. The assessed outcome includes hypospadias repair failures and graft failure for staged repair using a buccal graft. Relative risk with corresponding95% confidence intervals (CI) wereextrapolated. A random-effect model was used to generate pooled effect estimates. Heterogeneity and inter-study variability were assessed using Chi-square and I-square. Subgroup analysis was performed according to primary repair versus redo-hypospadias with buccal graft. PROSPERO registration (CRD42021251423). Five comparative studies with 576 cases (301 HBOT versus 275 controls) were included. Overall pooled effect estimates showed that the HBOT group has significantly lesser hypospadias repair failure (RR 0.52, 95%CI 0.37, 0.72). Subgroup analysis on the use of HBOT for graft take showed lesser graft failure compared to the control group(RR 0.20, 95%CI 0.05, 0.75), while the use of HBOT for primary and redo single staged hypospadias repair showed lesser complicationrate (RR 0.56, 95%CI 0.40, 0.78). Based on ROBINS-I assessment, all included comparative studies are determined to be of serious risk of bias mainly due to presence ofconfounding. The currently available low-quality of evidence suggests that compared to control groups, HBOT as an adjunctive intervention to complicated hypospadias repair was able to reduce surgical outcome failure and graft failure rates.

A systematic approach for successful repair of radiated and non-radiated ureteral injuries.

BackgroundSuccessful ureteral reconstruction is challenging, particularly in radiated fields. We characterize and directly compare surgical outcomes in modern cohorts of radiated and non-radiated patients undergoing ureteral reconstruction utilizing a systematic approach to pre-operative assessment. We hypothesize that radiated patients will undergo more complex ureteral reconstructions and experience higher rates of surgical failure and complications compared to nonradiated patients.MethodsConsecutive cases of ureteral reconstruction for acquired ureteral injury performed by a single surgeon from 2010–2018 were retrospectively reviewed. Clinical data were collected including pre-operative bladder capacity, ureteral injury characteristics, and surgical technique. Ileal ureter and autotransplantation were classified as “complex” ureteral repairs, and surgical success was defined as freedom from surgical revision of the ureteral anastomosis and/or ureteral stenting.ResultsThere were 47 ureteral reconstructions performed including 17 (36%) radiated patients. Radiated patients had lower pre-operative bladder capacity and were more likely to undergo complex repairs compared to non-radiated patients (35% vs. 7%, P=0.01). Overall surgical success was high (98%) and similar between radiated (94%) and non-radiated groups (100%) at median follow up of 30 months. Clavien grade 3–4 complications occurred in 18% of radiated and 10% of non-radiated patients (P=0.48).ConclusionsCareful pre-operative evaluation and appropriate selection of surgical technique facilitates high and similar success of ureteral reconstruction in radiated and non-radiated patients. Complex ureteral repairs were more common in radiated patients, however the majority of radiated ureteral injuries (65%) were reconstructed without tissue transfer. Radiated patients had lower pre-operative bladder capacities, but similar surgical morbidity, renal function, and persistent urge incontinence compared to non-radiated patients.

Factors Affecting Final Surgical Outcome of Combined Trabeculotomy-Trabeculectomy in Primary Congenital Glaucoma.

PurposeTo evaluate different pre-operative variables on the success of combined trabeculotomy–trabeculectomy (CTT) surgery in patients with primary congenital glaucoma (PCG) to predict those at higher risk for surgical failure and for proper parent counseling.Patients and MethodsSixty-three eyes of patients with PCG were treated either with CTT without augmentation, or CTT augmented with mitomycin-C (0.2 mg/mL) in both subconjunctival space and under scleral flap for 3 minutes, or with CTT augmented with a collagen implant under both the scleral flap and the conjunctiva. Cases showed surgical failure was reported and evaluated in relation to different pre-operative variables.ResultsComplete success (IOP ≤21 mmHg) was achieved in 52 cases (82.5%). Cumulative success probability was calculated using Kaplan-Meier survival analysis, proving that higher pre-operative intraocular pressure (IOP) was associated with higher failure rates (28.6% for pre-operative IOP ≥30 mmHg versus 4.8% for IOP <30 mmHg), with P value = 0.007.ConclusionCTT is an effective surgical intervention in PCG patients without sight threatening complications. Univariate survival analysis showed higher rates of surgical failure in patients with higher pre-operative IOP, while other pre-operative variables were irrelevant.

ASA Physical Status Classification and Complications Following Facial Fracture Repair.

To investigate the association between American Society of Anesthesiologists (ASA) physical status classification and rates of postoperative complications in patients undergoing facial fracture repair. Patients were divided into 2 cohorts based on the ASA classification system: Class I/II and Class III/IV. Chi-square and Fisher's exact tests were used for univariate analyses. Multivariate logistic regressions were used to assess the independent associations of covariates on postoperative complication rates. A total of 3575 patients who underwent facial fracture repair with known ASA classification were identified. Class III/IV patients had higher rates of deep surgical site infection (P = .012) as well as bleeding, readmission, reoperation, surgical, medical, and overall postoperative complications (P < .001). Multivariate regression analysis found that Class III/IV was significantly associated with increased length of stay (P < .001) and risk of overall complications (P = .032). Specifically, ASA Class III/IV was associated with increased rates of deep surgical site infection (P = .049), postoperative bleeding (P = .036), and failure to wean off ventilator (P = .027). Higher ASA class is associated with increased length of hospital stay and odds of deep surgical site infection, bleeding, and failure to wean off of ventilator following facial fracture repair. Surgeons should be aware of the increased risk for postoperative complications when performing facial fracture repair in patients with high ASA classification.

Race as a Predictor of Recurrence and Complications After Urethroplasty in Men With Urethral Stricture Disease

ObjectiveTo determine the role of race in surgical outcomes of and complications after urethroplasty. MethodsA single institution, retrospective review was conducted from 2011 to 2019 on male patients ≥18 years of age who underwent urethroplasty. Exclusion criteria included previous urethral cancer, lack of follow up, or revision urethroplasty. Failure of urethroplasty was defined as requiring revision surgery or recurrence on imaging or cystoscopy. Risk factors for recurrence were determined using descriptive statistics, Wilcoxon comparisons, and multivariate logistic regression. ResultsThree hundred and seven patients were identified with 234 patients meeting inclusion criteria. 63.2% identified as White/Caucasian (CA), 32.5% Black/African American (AA), and 4.3% other race. Mean age was 49.4 years. Between CA and AA patients, there was no difference in mean age, body mass index, smoking status, prior urethroplasty, or prior dilation/DVIU. CAs were more likely to have a fossa navicularis stricture compared to AAs (P = .0094), but there were no significant differences in bulbar, penile, or posterior stricture rates (all P >.05) or length (P = .32). The overall stricture recurrence rate was 15.8% with a median of 242 days to recurrence and no significant difference by race for either outcome (P = .83, P = .64). The only predictor of stricture recurrence was prior dilation/DVIU (P = .0404, OR 2.3, 95% CI 1.0, 5.6). Overall complication rate was 17.5%, with no difference between CA and AAs rates (P = .83) or complication type (P = .62). ConclusionThere was no significant difference in the rate of surgical failure for urethral stricture repair based on race. The only predictor of surgical failure was having a prior urethral dilation/DVIU.

Ahmed glaucoma valve implantation for secondary glaucoma post-vitrectomy.

Ahmed glaucoma valv (AGV) implantation is one of the successful surgical methods in secondary glaucoma that develops after pars plana vitrectomy (PPV). In our study, we aimed to evaluate the 1-year results of AGV implantation in patients with a history of PPV. A total of 26 patients who underwent AGV implantation after PPV were included in our retrospective study. Fourteen of 26 patients had AGV implantation due to neovascular glaucoma (NVG) and 12 of them had secondary refractory galucoma. Data of these two groups of patients were evaluated in terms of IOP reduction, number of medication use, surgical complete and qualified success, surgical failure, and complications. The mean IOP was 29.54 ± 4.87mmHg at the preoperative of AGV implantation and 12.88 ± 4.17 at the twelfth month visit in overal group. There was no statistically significant difference between two groups in terms of IOP in preoperative and all postoperative visits (p > 0.05). The mean intervals between PPV and AGV implantation were 67 ± 34days in NVG and 391 ± 500days in non-NVG group (p = 0.017). In overall group, 91.7% of patients had improvement in BCVA at the twelfth month visit. Complete and qualified surgical success rates were 75%, 83.3% in NVG group and 50%, 91.7% in non-NVG group, respectively. There was no devastating complication in both groups. AGV implantation is a safe and effective surgical method in uncontrolled IOP elevations after PPV. While surgical success and failure rates were similar between etiologies, the time required for AGV implantation after PPV was shorter in NVG etiology.

Outcome of surgical treatment for bone metastases caused by colorectal cancer.

Cancer of the lower intestinal tract, although relatively common, rarely metastasizes to the skeleton. The treatment of metastatic bone disease due to colorectal cancer has thus been poorly described and treatment decisions are therefore difficult. The aim of this study was to describe the outcome of orthopedic surgery in patients with pathological fractures from colorectal cancer and investigate factors that correlate with patient survival, since it influences treatment decisions. Retrospective review of data collected in a prospectively collected database. 36 patients (38 fractures) who underwent surgery between 2000 and 2019 for metastatic bone disease caused by colorectal cancer were included. Most metastases were localized in the axial skeleton and 33/36 patients already had visceral metastases. Patients with pathological fractures from colorectal cancer had poor prognosis, with only 5/36 surviving more than 1 year, median survival being 3 months. Patients presenting with a single skeletal metastasis had a superior overall survival (P≤0.001). Post-operative complications were common, noted in 11 patients, and the surgical failure rate was considerable. Although relatively rare, bone metastases should be suspected in patients with colorectal cancer presenting with signs and symptoms of spinal cord compression or skeletal pain. In this case, the presence of a solitary skeletal lesion is a favorable prognostic sign. Awareness for local complications after surgery should be high.

Meshplasty in Ventral &amp;Incisional Hernia (A Comparative Study between Onlay &amp; Inlay Techniques)

Introducion&Objectives: Ventral hernia of both types spontaneous & incisional are commonly encountered in surgical practice. Despite the frequency of surgical repair, perfect results continue to elude surgeons & the rate of surgical failure may approach 10- 30%. Nowadays meshplasty is regarded as ideal procedure for hernia repair & actually primary suture repair is abandoned except for hernia with defect size of less than 2.5cm.Different types of mesh used for repair &different sites of placement described including onlay, inlay, sublay & sandwich pattern with different results. Aim of this study is to evaluate meshplasty in ventral &incisional hernia &to compare between onlay &inlay techniques in regard of operative ease, time, early& late postoperative complications. Design: Prospective comparative study. Patients and Methods: This study was conducted on (60) patients with ventral &incisional hernia admitted to surgical department of Kirkuk general hospital between the periods Feb-2010 to Feb-2013. All patients were grouped randomly into two groups: Group (1) including (30) patients with onlay meshplasty &Group (2) including (30) patients with inlay technique. Results: The age of the patients was ranged (22-75) years with mean age of (48.5) years. Most of the patients were at fourth decade (48.3%) (n=29). (70%) of all patients (n=42) were females & (30%) of them (n=18) were males. (66.6%) of all patients (n=40) had incisional hernia & (33.3%) of patients with spontaneous hernia (n=20). The operative time in patients of Group (1) onlay technique was (60-100) minutes compared to (50-80) minutes in patients of Group (2) inlay technique. (3) Patients (10%) of Onlay Group developed seroma, (2) patients (6.6%) had deep wound infection. None of all patients of either group had sinus or enterocutanous fistula. (4)patients(13.3%) of Onlay Group had recurrence of their hernia during(12)months period follow up but only one patient (3.3%) of Inlay Group developed recurrence during same period of follow up. Conclusion:-Inlay meshplasty for repair of ventral abdominal hernia is more effective& gives better results in regard of operative ease, time, early &postoperative complications.

Intermediate-term outcomes of the Aurolab aqueous drainage implant in neovascular glaucoma

PurposeTo assess the outcomes of the non-valved Aurolab aqueous drainage implant (AADI) in neovascular glaucoma (NVG).MethodsData of consecutive patients with NVG who underwent AADI and had a minimum follow-up of...

The robotic surgery learning curve of a surgeon experienced in video-assisted thoracoscopic surgery compared with his own video-assisted thoracoscopic surgery learning curve for anatomical lung resections.

Robotic surgery, although it shares some technical features with video-assisted thoracoscopic surgery (VATS), offers some advantages, such as ergonomic design and a 3-dimensional view. Thus, the learning curve for robotic lung resection could be expected to be shorter than that of VATS for surgeons who are proficient in VATS. The goal of this study was to analyse the robotic learning curve of a VATS experienced surgeon and to compare it to his own VATS learning curve for anatomical lung resections. We conducted a retrospective observational study based on the prospectively recorded data of the first 150 anatomical lung resections performed with VATS (75 cases) and with the robotic (75 cases) approach by the same surgeon in our centre. Learning curves were analysed using the cumulative sum method to assess the trends for total operating time and surgical failure (intraoperative complications, conversion, technical postoperative complications and reintervention) across case sequences. Subsequently, using adequate statistical tests, we compared the postoperative outcomes in both groups. The median operating time was similar for both approaches (P = 0.401). Surgical failure rate was higher for the robotic cases (21.3% vs 12%; P = 0.125). Based on cumulative sum analyses, operating time decreased starting with case 34 in the VATS group and with case 32 in the robotic cohort. Surgical failure tended to decline starting with case 28 in the VATS group and with case 32 in the robotic group. Perioperative results were similar in both groups. When we compared robotic and VATS learning curves for anatomical lung resection, we did not find any differences. Postoperative outcomes were also similar with both approaches.

Is routine 24-hour urine calcium measurement useful during the evaluation of primary hyperparathyroidism?

BackgroundPrimary hyperparathyroidism and familial hypocalciuric hypercalcemia have similar biochemical profiles, and calcium-to-creatinine-clearance ratio helps distinguish the two. Additionally, 24-hour urine calcium >400 mg/day indicates surgery and guidelines recommend obtaining 24-hour urine calcium preoperatively. Our aim was to assess how 24-hour urine calcium altered care in the evaluation of suspected primary hyperparathyroidism. MethodsConsecutive patients assessed for primary hyperparathyroidism from 2018 to 2020 were reviewed. Primary hyperparathyroidism was diagnosed by 2016 American Association of Endocrine Surgeons Parathyroidectomy Guidelines criteria. 24-hour urine calcium-directed change in care was defined as familial hypocalciuric hypercalcemia diagnosis, surgical deferment for additional testing, or 24-hour urine calcium >400 mg/day as the sole surgical indication. ResultsOf 613 patients, 565 (92%) completed 24-hour urine calcium and 477 (84%) had concurrent biochemical testing to calculate calcium-to-creatinine-clearance ratio. 24-hour urine calcium was <100 mg/day in 9% (49/565) and calcium-to-creatinine-clearance ratio was <0.01 in 17% (82/477). No patient had confirmed familial hypocalciuric hypercalcemia, although 1 had a CASR variant of undetermined significance. When calcium-to-creatinine-clearance ratio was <0.01, familial hypocalciuric hypercalcemia was excluded by 24-hour urine calcium >100 mg/day (56%), prior normal calcium (16%), renal insufficiency (11%), absence of familial hypercalcemia (3%), normal repeat 24-hour urine calcium (10%), or interfering diuretic (1%). 24-hour urine calcium-directed change in care occurred in 25 (4%), including 4 (1%) who had genetic testing. Four-gland hyperplasia was more common with calcium-to-creatinine-clearance ratio <0.01 (17% vs calcium-to-creatinine-clearance ratio ≥ 0.01, 4%, P < .001), but surgical failure rates were equivalent (P = .24). Conclusion24-hour urine calcium compliance was high, and results affected management in 4%, including productive identification of hypercalciuria as the sole surgical indication in 2 patients. When calcium-to-creatinine-clearance ratio <0.01, clinical assessment was sufficient to exclude familial hypocalciuric hypercalcemia and only 1% required genetic testing. 24-hour urine calcium should be ordered judiciously during primary hyperparathyroidism assessment.

Failure of Posterior Capsulolabral Repair is Correlated with Percent of Glenoid Bone Loss

Objectives:The purpose of this study was to evaluate previously described advanced MRI measures specific to posterior bone loss on both standard and manually reformatted MRIs in patients who underwent posterior shoulder capsulolabral repair. It was hypothesized that those who failed surgical repair would have increased posterior glenoid bone loss and decreased glenoid width.Methods:Athletes greater than 18 years of age with unidirectional posterior instability treated with arthroscopic repair were evaluated at 2 year minimum follow-up. Traditional MRIs measurements from nineteen patients who failed arthroscopic posterior shoulder capsulolabral repair were compared with 56 patients who did not. MRIs were then manually reformatted and these measurements were repeated as well as recently described measures of defect slope, bone loss angle, and defect length.Results:Glenoid width loss and percent glenoid bone loss were significantly greater on both the corrected and non-corrected MRI images (25.5 mm vs 28.8 mm, p<0.001; 6.8% vs 4.6%, p=0.008) in those that failed surgery. There was no difference in glenoid version or other measurements between the failures and non-failures. On non-corrected MRIs, percentage glenoid bone loss was significantly overestimated by 2% when compared to the corrected scans (p<0.0001, 95% CI [-2.7, -1.1]). A critical amount of 11% glenoid bone loss resulted in a 10 times higher surgical failure rate while 15% bone loss resulted in a 25 times higher failure rate.Conclusions:Risk factors for failure of arthroscopic posterior shoulder capsulolabral repair include greater glenoid bone width loss and greater glenoid bone loss percentage. Failure to appropriately align axial MRI rotation affects the characteristics of the sagittal images, leading to overestimation of glenoid bone loss percentage which may have surgical implications. Although 11% glenoid bone loss implicated a 10 times higher surgical failure rate and 15% bone loss has a 25 times higher failure rate, posterior capsulolabral repair is an overall successful intervention.

Learning curve of single-incision laparoscopic totally extraperitoneal repair (SILTEP) for inguinal hernia.

Laparoscopic totally extraperitoneal hernia repair (TEP) is a widely used treatment for inguinal hernia. Single-incision laparoscopic TEP (SILTEP) has attracted the attention of several surgeons, given its superior cosmetic results and patient satisfaction, as well as comparable outcomes to multiport surgery. Nonetheless, no relevant studies have evaluated the learning curve (LC) of SILTEP in terms of both operation time (OT) and surgical failure. Therefore, we aimed to investigate the LC of SILTEP for inguinal hernia. Medical records of 180 patients who underwent SILTEP performed by a single surgeon from a single institution between October 2012 and November 2017 were retrospectively reviewed. The LC was analyzed using the moving average method and cumulative sum control chart (CUSUM) for OT and surgical failure. Surgical failure was defined as the need for additional ports, open conversion, severe postoperative complications (Clavien-Dindo ≥ IIIa), and recurrence. Eight patients who underwent combined surgery or bilateral hernia repair were excluded from the OT analysis. From CUSUM graphs, the study period was divided into three phases: OT-phases 1 (1st-32nd), 2 (33rd-83rd), and 3 (84th-172nd) for OT and failure-phases 1 (1st-29th), 2 (30th-58th), and 3 (59th-180th) for surgical failure. Mean OTs were statistically different in the three OT phases (64.6 vs. 50.8 vs. 35.2min; p < 0.001). Open conversion (31.0% vs. 0% vs. 2.5%) and additional port insertion (6.9% vs. 24.1% vs. 2.5%) stabilized consecutively at failure-phases 2 and 3 (p < 0.001). Surgical failure rates decreased to 5.7% by failure-phase 3 (37.9% vs. 24.1% vs. 5.7%; p < 0.001). For an experienced laparoscopic surgeon, we estimated that approximately 60 cases are needed to overcome the LC for SILTEP in terms of both reducing OT and achieving a surgical failure rate < 10%. Further proficiency could be achieved after approximately 85 SILTEP procedures with a stable OT of approximately 35min.

Defining Critical Glenoid Bone Loss in Posterior Shoulder Capsulolabral Repair

Background: Although critical bone loss for anterior instability is well defined, a clinically significant threshold of posterior bone loss has not been elucidated. Hypothesis: Patients with failed arthroscopic posterior shoulder capsulolabral repair will have increased posterior glenoid bone loss with a defined critical threshold. Study Design: Case control study; Level of evidence, 3. Methods: Athletes older than 18 years with unidirectional posterior instability treated with arthroscopic repair were evaluated at 2-year minimum follow-up. Failure was defined as revision surgery, American Shoulder and Elbow Surgeons (ASES) score of <60, or subjective stability score of >5. Magnetic resonance imaging (MRI) measurements from 19 patients with failed arthroscopic posterior shoulder capsulolabral repair were compared with 56 patients whose surgery was successful. MRI measures included glenoid version, labral version, glenoid width, labral width, percentage bone loss using the circle technique, labral height, percent subluxation, and recently described measures of defect slope, bone loss angle, and defect length. The P value threshold was set at .05, and a multivariable logistic regression analysis was performed for evaluation of risk of surgical failure. Results: Smaller glenoid width and greater percentage glenoid bone loss (25.5 ± 0.68 mm vs 28.8 ± 0.47 mm; P < .001; 6.8% ± 0.64% vs 4.6% ± 0.43%; P = .008) were seen in those patients with failed surgery. There was no difference in glenoid version or other measurements between the failures and nonfailures. A cutoff of 11% glenoid bone loss resulted in a 10.4 times statistically higher surgical failure rate, while a 15% bone loss resulted in a 24.4 times statistically higher failure rate. Six patients had >11% bone loss (range, 11.1 to 19.3) and 1 patient had >15% bone loss. Conclusion: Risk factors for failure of arthroscopic posterior shoulder capsulolabral repair include smaller glenoid bone width and greater percentage of glenoid bone loss. A threshold of 11% posterior glenoid bone loss implicated a 10 times higher surgical failure rate, while a threshold of 15% led to a 25 times higher surgical failure rate. Surgical failure of posterior capsulolabral repair, however, is relatively rare as it is an overall successful intervention.

19 The impact of obesity on native tissue repair outcomes: A secondary analysis of the OPTIMAL trial data

The Operations and Pelvic Muscle Training in the Management of Apical Support Loss (OPTIMAL) trial was a multi-site, prospective randomized trial which compared sacrospinous ligament fixation (SSLF) and uterosacral ligament suspension (ULS) surgical outcomes, and also evaluated the impact of perioperative pelvic muscle training (PMT). Increasing body mass index (BMI) is associated with increased risk of pelvic organ prolapse and the prevalence of obesity is increasing worldwide. The purpose of this study is to better understand the impact of obesity on the results of native tissue vaginal apical suspension procedures. This study is a secondary analysis of data collected during the OPTIMAL trial, which is now a deidentified public dataset in the NIH Data and Specimen Hub database. Subgroup analysis of patients who received SSLF or ULS procedures and PMT or usual care was performed to determine if there were differences in surgical failure rates across a range of BMIs after two years. The sample size in this analysis was 297; not all of the original OPTIMAL data was available due to the deidentification process. Data were analyzed using ANOVA test, Tukey’s HSD post-hoc analysis, Fisher’s exact test, and Wald correct proportion risk difference test which is a method of identifying 95% confidence intervals. There were 75, 120, 63, and 39 patients in the normal, overweight, class 1 obesity, and class 2 obesity or greater BMI subgroups, respectively. The groups were not significantly different based on surgical arm or PMT arm, smoking, estrogen use, menopausal status, or number of cesarean sections (Table 1). However, there were differences in age, race, and number of vaginal births. In each BMI subgroup, the surgical failure rates and risk differences were not significantly different for the surgical or PMT arms (Table 2). Interestingly, the surgical failure rate increased in the ULS group with increasing BMI (normal = 30.56%, overweight = 30.16%, class 1 obese = 40.63%, class 2 obese or greater = 45%). Additionally, the risk difference between ULS and SSLF groups increased with BMI (normal = 5.34%, overweight = 8.44%, class 1 obesity = 1.92%, class 2 obesity or greater = 23.95%). The risk of surgical failure between ULS and SSLF, or PMT and usual care, is not significantly associated with increasing BMI. However, the increasing failure rate of ULS and difference in failure rates of ULS compared to SSLF with increasing BMI in our study may indicate an association if analyzed for a longer time period.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

23 Repeat minimally invasive abdominal sacrocolpopexy for recurrent prolapse

The objective of this video is to demonstrate techniques for minimally invasive abdominal sacrocolpopexy for recurrent pelvic organ prolapse after prior sacrocolpopexy. Sacrocolpopexy is considered by many to be the gold standard for repair of apical pelvic organ prolapse. Although rates of surgical failure and repeat surgery are low, prolapse recurrence can occur after sacrocolpopexy. In this video, we review recurrence rates of prolapse after minimally invasive abdominal sacrocolpopexy (MI-SCP), discuss two cases of prolapse recurrence following MI-SCP and subsequent surgical repair of recurrence with repeat MI-SCP, and present clinical tips and tricks for repeat MI-SCP. Through both cases, we illustrate three key principles for approaching a repeat MI-SCP: assessment of prior surgical repair and identification of cause of anatomic failure, re-establishment of normal anatomy via lysis of adhesions, and resection of prior mesh and/or attachment of new mesh. The use of robotic assistance for dissection is also demonstrated. Despite the high durability of sacrocolpopexy, prolapse recurrence can still occur over time. Appropriate cases of prolapse recurrence can be managed in a minimally invasive manner with repeat MI-SCP.

01 5-Year surgical outcomes of transvaginal apical approaches in women with advanced pelvic organ prolapse

To compare 5-year surgical outcomes of uterosacral ligament suspension (ULS) versus (vs) sacrospinous ligament fixation (SSLF) in women with advanced pelvic organ prolapse (POP). Secondarily, to explore differences in outcomes between advanced vs stage II POP. A secondary analysis was conducted in a subset of women with advanced (stages III-IV) POP from a multicenter randomized trial comparing (1) SSLF vs ULS and (2) perioperative behavioral with pelvic floor muscle training (BPMT) vs usual care. Publicly accessible de-identified datasets of the index trial with 5-year follow-up were analyzed. The primary outcome was time to surgical failure, defined as (1) apical descent >1/3 into vaginal canal or anterior/posterior vaginal wall beyond the hymen, (2) bothersome vaginal bulge symptoms, or (3) retreatment (pessary or surgery) for POP. Secondary outcomes included symptom severity measured by the Pelvic Organ Prolapse Distress Inventory (POPDI), and adverse events (AEs). Outcomes in women with advanced stage POP were also compared to those with stage II POP. Of 285 women in the index study, 90 of 147 (61.2%) in the ULS group and 88 of 138 (63.8%) in SSLF had advanced POP. Baseline characteristics did not differ between groups (mean age ULS = 61.0 ± 10.1 vs SSLF = 60.2 ± 9.9, P = 0.58). Surgical failure increased over 5 years in both groups with no intergroup difference (P = 0.42, Figure). By year 5, the estimated surgical failure rate was 67.7% for ULS vs 71.5% for SSLF (adjusted difference [a-diff] = 3.8; 95% CI = 21.9, 14.2). No difference was noted in individual failure components (Figure); anatomic: 56.7% ULS vs 65.2% SSLF (a-diff = 8.4; 95% CI = 28.0, 11.2), symptomatic: 38.8% ULS vs 43.1% SSLF (a-diff = 4.3; 95% CI = 22.6, 14.1), retreatment: 20.0% USL vs 15.9% SSLF (a-diff = 4.1; 95% CI = 9.4, 17.7). POPDI scores improved from baseline to 5 years in both groups without intergroup difference (ULS = 68.0 ± 61.1 vs SSLF = 69.9 ± 60.3, a-diff = 0.1; 95% CI = 20.0, 19.9). AEs such as granulation tissue, suture exposure, and midurethral sling exposure did not differ over 5 years. Comparing women with advanced stages vs stage II POP, the estimated surgical failure did not differ over 5 years; 69.8% advanced vs 55.7% stage II (a-diff = 14.1%; 95% CI = 33.7, 5.6). However, anatomic failure was higher in women with advanced POP (61.1% advanced vs 33.8% stage II, a-diff = 27.3%; 95% CI = 47.5, -7.0). There was no difference in symptomatic failure (41.4% advanced vs 33.3% stage II, a-diff = 8.1; 95% CI = 25.3, 9.1) or retreatment (11.7% advanced vs 8.0% stage II, a-diff = 3.6; 95% CI = 12.0, 4.7). In women with advanced stage POP, surgical failure, symptom severity, and AEs did not differ between ULS and SSLF over 5 years. Compared to stage II POP, women with advanced POP had higher anatomic failure.

Primary Lacrimal Canaliculitis with clinically detected concretions: One-snip punctoplasty with lateral canaliculotomy vs. punctum sparing canalicular curettage

To compare two distinct surgical techniques in the management of chronic Primary Lacrimal Canaliculitis (PLC) with clinically detectable concretions. Inclusion criteria: Patients presenting with symptoms consistent with the diagnosis of primary lacrimal canaliculitis (PLC) with ocular involvement were gathered. Gomori-Grocott Methenamine Silver test was used for concretion staining. Two groups were identified based on the surgical technique. Group A consisted of patients who underwent a punctum sparing canalicular curettage using a chalazion curette, while the patients in Group B underwent one-snip punctoplasty with lateral canaliculotomy. Failure was defined as recurrence of the initial symptoms at any time (ocular and canalicular inflammation with purulent discharge and pouting punctum). The results were analyzed by comparisons using a Fisher's exact test. Ninety-six consecutive patients (96) with a confirmed diagnosis of PLC underwent surgical treatment between 1987 and 2017. Data were collected and divided based on the surgical technique discussed above (Group A and B). Group A: 51 cases with a mean follow-up time of 22 months [1-224] presented with a mean age of 51.5 [25-83] and a surgical failure rate of 19.6%. Group B: 45 patients with a mean follow-up time of 27 months [1-176], a mean age of 68 [17-87] years and a surgical failure rate of 4.4%. Statistical significance was demonstrated, with a p-value of 0.033, odds ratio (OR) of 0.1936 and Standard Deviation (SD) at a 95% confidence interval of [0.0195-0.9885]. One-snip punctoplasty with lateral canaliculotomy is a simple, fast and effective procedure that allows better anatomical visualization intraoperatively and is thus shown to be statistically superior to punctum sparing canalicular curettage using a chalazion curette.

Hardware failure and reoperation after hybrid anterior cervical corpectomy and discectomy for multilevel spondylotic disease: A retrospective single-institution cohort study

Background contextHybrid cervical corpectomy/ACDF (HCC-ACDF) is commonly utilized to treat multilevel cervical myelopathy; however, the incidence and mechanisms of hardware failure remain largely uncharacterized. PurposeWe report our experience with this procedure with the goal of describing and better understanding post-operative failures. MethodsThe records of 20 consecutive patients who underwent HCC-ACDF for multilevel CSM between June 2015 and December 2018 at this Hospital (blinded) were retrospectively reviewed. All patients were followed for at least 1 year after surgery and were therefore included in the study. Outcome measures include incidence of and reason for subsequent posterior cervical surgery, incidence of and reason for subsequent anterior cervical surgery, progressive symptomatic myelopathy, radiographic hardware failure, and net reduction of pre-operative kyphosis. Continuous variables are reported with means and standard deviations. Fisher’s exact test was used to compare outcomes of binary variables. Results20 patients (mean age 60) underwent anterior HCC-ACDF for 3-level CSM. Mean clinical follow up was 26 months (range: 12–56 months). Mean operative time was 205 min and mean blood loss was 105 mL. Radiographic fusion was achieved in 15 of 18 (83%) patients for whom adequate radiographic follow-up was available. HCC-ACDF resulted in an average restoration of 4 degrees of cervical lordosis (standard deviation: 7.3 degrees). One patient (5%) developed symptomatic hardware failure requiring additional surgery. One patient (5%) developed progressive myelopathy within 4 months of surgery. 2 others (10%) developed adjacent segment disease within 2 years of surgery. Three of 20 patients (15%) required subsequent posterior surgery. ConclusionsRates of hardware failure after HCC-ACDF in our series compare favorably with reports of multilevel anterior corpectomy but are higher than those reported in previous series of HCC-ACDF. No patient characteristics were significantly associated with rates of surgical failure.