Surgical Morbidity Research Articles

Management and outcomes of chest wall rhabdomyosarcoma: A report from the Children's Oncology Group Soft Tissue Sarcoma Committee.

Rhabdomyosarcoma (RMS) of the chest wall presents unique management challenges and local control considerations. The benefit of complete excision is uncertain and must be weighed against potential surgical morbidity. Our aim was to assess factors, including local control modality, associated with clinical outcomes in children with chest wall RMS. Forty-four children with RMS of the chest wall from low-, intermediate-, and high-risk Children's Oncology Group studies were reviewed. Predictors of local failure-free survival (FFS), event-free survival (EFS), and overall survival (OS) were assessed, including clinical characteristics and staging, primary tumor anatomic locations, and local control modalities. Survival was assessed by Kaplan-Meier analysis and the log-rank test. Tumors were localized in 25 (57%) and metastatic in 19 (43%), and they involved the intercostal region (52%) or superficial muscle alone (36%). Clinical group was I (18%), II (14%), III (25%), and IV (43%), and ultimately 19 (43%) patients had surgical resection (upfront or delayed), including 10 R0 resections. Five-year local FFS, EFS, and OS were 72.1%, 49.3%, and 58.5%, respectively. Univariate factors associated with local FFS included age, International Rhabdomyosarcoma Study (IRS) group, extent of surgical excision, tumor size, superficial tumor location, and presence of regional or metastatic disease. Other than tumor size, the same factors were associated with EFS and OS. Chest wall RMS has variable presentation and outcome. Local control is a significant contributor to EFS and OS. Complete surgical excision, whether upfront or after induction chemotherapy, is usually only possible for smaller tumors confined to the superficial musculature but is associated with improved outcomes. While overall outcomes remain poor for patients with initially metastatic tumors, regardless of local control modality, complete excision may be beneficial for patients with localized tumors if it can be achieved without excess morbidity.

Thyroid Hormone Levels and Anti-thyroidal Drugs Do Not Correlate with Ease of Surgical Dissection or Morbidity for Thyroidectomy for Graves’ Disease

Lushefski, Kelcie Nicole MD; Oxenberg, Jacqueline MD; Gallagher, Alexandria DO; Wolf, Mary PA-C Author Information

Impact of SARS-CoV-2 on surgical services in a Scottish remote and rural setting.

The SARS-CoV-2 (COVID-19) pandemic has brought about instability in healthcare providers worldwide; this includes rural settings that had fewer cases of COVID-19 in the first year of the pandemic. This article examines the impact of COVID-19 on the surgical services offered at the Balfour Hospital, Orkney Islands, Scotland in the UK and the impact the pandemic had indirectly on the service in 2020. The authors conducted a retrospective study concentrating on surgical services including emergency hospital presentations and the number of cancer diagnoses, specifically colorectal. Colorectal malignancies were specifically investigated as in the Balfour Hospital they are primarily diagnosed by surgeons. Focus was on diagnosis and outcomes between June 2020 and October 2020, in comparison with the previous year. This time period was chosen because surgical services reconvened after a period of inactivity due to the COVID-19 pandemic. The types of emergency admission into the Balfour Hospital during this time were examined, as well as delayed surgeries and the impact of delaying surgery. The data show that, although the prevalence of cancers diagnosed was static, patients presented at a much later stage, with significant impact on prognosis and quality of life. Aside from cancer diagnosis, non-urgent work was significantly disrupted due to the pandemic in 2020. The average waiting time for non-urgent clinic consultation increased from 6 weeks to 18 weeks during this period. The number of patients awaiting endoscopic investigations increased threefold. There was also an increase in the number of emergency admissions due to complications of disease. Although the effects of COVID-19 have been felt nationwide, the impact is more exaggerated in rural communities such as Orkney due to the small population. It is likely the indirect impact on surgical morbidity and mortality in Orkney in 2020 was disproportionately higher than the impact of COVID-19 in the local community. Furthermore, due to limited island resources, a significant number of patients required transfer to tertiary centres for management of complications. This is a unique issue affecting rural communities.

Reoperation in Chiari-1 Malformations.

(1) Background: The issue of unsuccessful surgery for Chiari-1 malformation (CM-1), as well as its potential causes and possible solutions, remains poorly documented and studied. (2) Methods: From a retrospective review of a personal series of 98 patients undergoing treatment for CM-1 during the past 10 years, we created two study groups. Group 1: 8 patients (8.1%) requiring additional surgeries owing to postoperative complications (7 cerebrospinal fluid leakage, 1 extradural hematoma); 7 patients (7.1%) undergoing reoperations for failed decompression during the follow-up. Group 2: During the same period, we also managed 19 patients who had previously been operated on elsewhere: 8 patients who required adequate CM-1 treatment following extradural section of the filum terminale; 11 patients requiring reoperations for failed decompression. Failed decompression was managed by adequate osteodural decompression, which was associated with tonsillectomy (6 cases), subarachnoid exploration (8 cases), graft substitution (6 cases), and occipito-cervical fixation/revision (1 case). (3) Results: There was no mortality or surgical morbidity in Group 1. However, one patient's condition worsened due to untreatable syrinx. In Group 2, there were two cases of mortality, and surgical morbidity was represented by functional limitation and pain in the patient who needed revision of the occipitocervical fixation. Twenty patients improved (58.8%), 6 remained unchanged (32.3%), 1 worsened (2.9%) and 2 died (5.9%). (4) Conclusions: The rate of complications remains high in CM-1 treatment. Unfortunately, a certain rate of treatment failure is unavoidable, but it appears that a significant number of re-operations could have been avoided using proper indications and careful technique.

Route of delivery does not impact postnatal surgical morbidity in pregnancies affected by fetal achondroplasia

PurposePregnancies affected by maternal or fetal achondroplasia present unique challenges. The optimal route of delivery in fetuses with achondroplasia has not been established. Our objective was to determine whether the route of delivery affects postnatal achondroplasia–related surgical burden. MethodsWe conducted a secondary analysis of Achondroplasia Natural History Study (CLARITY), which is a multicenter natural history cohort study of patients with achondroplasia. Achondroplasia-related surgical morbidity, which we defined as the need for one or more postnatal achondroplasia–related surgeries, was assessed in relation to the route of delivery and whether the mother also had achondroplasia. Rate of each individual surgery type (otolaryngology, brain, foramen magnum, spine, and extremity) was also assessed in relation to the route of delivery. ResultsEight hundred fifty-seven patients with achondroplasia with known route of delivery and known maternal stature were included. Three hundred sixty (42%) patients were delivered vaginally, and 497 (58%) patients were delivered by a cesarean delivery. There was no difference in the odds of requiring any postnatal achondroplasia–related surgery in those with achondroplasia who were delivered vaginally compared with those delivered by cesarean birth (odds ratio 0.95, 95% CI = 0.68-1.34, P = .80). No difference was present in the odds of requiring any postnatal achondroplasia–related surgery when route of delivery was compared for fetuses born to 761 average stature mothers (odds ratio 1.05, 95% CI = 0.74-1.51, P = .78). There was also no difference in the odds of requiring each of the individual achondroplasia-related surgeries by route of delivery, including cervicomedullary decompression. ConclusionOur study suggests that it is reasonable for average stature patients carrying a fetus with achondroplasia to undergo a trial of labor in the absence of routine obstetric contraindications.

The impact of neoadjuvant immunotherapy on perioperative outcomes and survival after esophagectomy for esophageal cancer

ObjectiveImmunotherapy for esophageal cancer is relatively novel but increasingly used. This study evaluated the early use of immunotherapy as an adjunct to neoadjuvant chemoradiotherapy before esophagectomy for locally advanced disease. MethodsPerioperative morbidity (composite of mortality, hospitalization ≥21 days, or readmission) and survival of patients with locally advanced (cT3N0M0, cT1-3N + M0) distal esophageal cancer in the National Cancer Database from 2013 to 2020 who underwent neoadjuvant immunotherapy plus chemoradiotherapy or chemoradiotherapy alone followed by esophagectomy were evaluated using logistic regression, Kaplan–Meier curves, Cox proportional hazards methods, and propensity-matched analysis. ResultsImmunotherapy was used in 165 (1.6%) of 10,348 patients. Younger age (odds ratio, 0.66; 95% confidence interval, 0.53-0.81; P < .001) predicted immunotherapy use, which slightly delayed time from diagnosis to surgery versus chemoradiation alone (immunotherapy 148 [interquartile range, 128-177] days vs chemoradiation 138 [interquartile range, 120-162] days, P < .001). There were no statistically significant differences between the immunotherapy and chemoradiation groups for the composite major morbidity index (14.5% [24/165] vs 15.6% [1584/10,183], P = .8). Immunotherapy was associated with a significant improvement in median overall survival (69.1 months vs 56.3 months, P = .005) and 3-year overall survival in univariate analysis (65.6% [95% confidence interval, 57.7-74.5] vs 55.0% [53.9-56.1], P = .005), and independently predicted improved survival in multivariable analysis (hazard ratio 0.68 [95% confidence interval, 0.52-0.89], P = .006). Propensity-matched analysis also showed that immunotherapy use was not associated with increased surgical morbidity (P = .5) but was associated with improved survival (P = .047). ConclusionsNeoadjuvant immunotherapy use before esophagectomy for locally advanced esophageal cancer did not lead to worse perioperative outcomes and shows promising results on midterm survival.

Extended pelvic lymph node dissection in muscle invasive bladder cancer.

Bilateral pelvic lymph node dissection (PLND) at the time of radical cystectomy (RC) provides important staging information and oncologic benefit in patients with bladder cancer. The optimal extent of the PLND remains controversial. Our aim is to highlight nodal mapping studies and the data that guides optimization of both staging and oncologic outcomes. We then review contemporary randomized trials studying the extent of PLND. A recent randomized trial (RCT) powered for a 15% improvement in recurrence-free survival (RFS) of extended (e) over limited (l)PLND was completed but failed to identify this large difference in outcome. Concerns over study design limit the ability to interpret the oncologic results. Importantly, ePLND minimally changed surgical morbidity. An ongoing, similar RCT (SWOG S1011) powered to detect a 10% difference in RFS has completed accrual, but no published outcomes are available. RC and ePLND can provide cure in 33% of LN positive bladder cancer patients. Current data support a 5% improvement in RFS if ePLND is routinely used in MIBC patients. Two randomized trials powered to identify much larger (15 and 10%) improvements in RFS are unlikely to identify such an ambitious benefit by extending the PLND.

Abstract 2385: Targeting mannose receptor expression on macrophages for sentinel lymph node mapping in endometrial cancer: murine model

Abstract Background: Sentinel lymph node (SLN) mapping has been used in various cancer surgery including endometrial cancer as a targeted assessment tool for identifying lymph node metastases, an alternative for complete lymphadenectomy to minimize surgical morbidity. Neomannosyl human serum albumin (MSA) targets the macrophage mannose receptor CD206 which is highly expressed in metastatic lymph node. The aim of this study was to evaluate the effectiveness of indocyanine green-neomannosyl human serum albumin (MSA:ICG) which targets macrophage mannose receptor CD206 for SLN mapping. Methods: LN targeting ability was examined on mouse footpad models of uterine cancer using MSA:ICG and ICG for comparison. Seven mice with uterine cancer and 2 mice without cancer as a control group were each assigned to MSA:ICG and ICG groups. After injection of tracers, fluorescence images were taken and SLN biopsy was done to confirm LN metastasis status. We compared the signal-to-background ratio (SBR) according to time. Results: In both MSA:ICG and ICG group, 16 lymph nodes out of 18 were detected using fluorescence imaging (detection rate: 88.9%). Four lymph nodes in MSA:ICG group and 5 lymph nodes in ICG group were metastatic among 16 lymph node each group. Excluding lymph nodes that were not detected, the SBR after the injection of MSA:ICG group was significantly higher than ICG group in metastatic LN (MSA:ICG 4.36 vs ICG 3.07, p&amp;lt;0.001), non-metastatic lymph nodes (MSA:ICG 3.11 vs ICG 1.93, p=0.001), and normal control lymph nodes (MSA:ICG 1.38 vs ICG 0.54, p&amp;lt;0.001). Comparing signal intensity according to CD206 expression, there was no difference in SBR values between the two groups in patients without CD206 expression, but the MSA group had a statistically significantly higher SBR value than the ICG group (p&amp;lt;0.001) in patients with CD206 moderate or high expression. Conclusions: This study showed that MSA:ICG may be an effective tracer for sentinel lymph node mapping. In addition, the metastatic lymph nodes expressing CD206 showed higher signal than normal lymph nodes in MSA:ICG group, unlike in ICG group. Further studies using larger animal models and clinical trials are needed to confirm this result. Citation Format: Hyun-Woong Cho, OK Hwa Jeon, Sanghoon Lee, Hyun Koo Kim, Jae Kwan Lee, Jin Hwa Hong. Targeting mannose receptor expression on macrophages for sentinel lymph node mapping in endometrial cancer: murine model [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 2385.

Influence of hepatic dysfunction in patients who underwent tricuspid valve surgery.

Hepatic dysfunction (HD) is frequently associated with chronic tricuspid regurgitation (TR), and is a risk factor for TR surgery. Late referral of patients with TR is associated with the progression of TR and HD, as well as an increase in surgical morbidity and mortality. Many patients with severe TR suffer from HD; however, their clinical impact is not well documented. This retrospective review was conducted between October 2008 and July 2017. In total, 159 consecutive patients underwent surgery for TR; 101 with moderate to severe TR were included. We divided patients into N (normal liver function; n=56) and HD (HD; n=45) groups. HD was defined as clinically or radiologically diagnosed liver cirrhosis, or a preoperative Model for End-Stage Liver Disease (MELD)-XI score ≥13. Perioperative data were compared between groups, and changes in the MELD score following TR surgery were estimated in the HD group. Long-term survival rates were analyzed, and analyses were performed to obtain the assessment tool and cutoff value to determine the degree of HD affecting late mortality. The preoperative demographics of both groups were similar, excluding the presence of HD. The EuroSCORE II, MELD score, and prothrombin time international normalization ratio were significantly higher in the HD group, and although early mortality was comparable between groups [N group: 0%, HD group: 2.2% (n=1); P=0.446], intensive care unit and hospital stays were significantly longer in the HD group. The MELD score in the HD group temporarily increased immediately after surgery, and then decreased. The long-term survival rates were significantly lower in the HD group. The most suitable tool for predicting late mortality was the MELD-XI score, with a cutoff value of 13 points. Surgery for patients with severe TR can be performed with relatively low morbidity and operative mortality, regardless of associated HD. MELD scores significantly improved after TR surgery in patients with HD. Even with favorable early outcomes, compromised long-term survival with HD suggests the need to develop an assessment tool that can evaluate the appropriate timing for TR surgery.

MP65-11 FRAILTY AMONG BLADDER AUGMENTATION PATIENTS: HEALTH CARE UTILIZATION AND PERIOPERATIVE OUTCOMES

You have accessJournal of UrologyCME1 Apr 2023MP65-11 FRAILTY AMONG BLADDER AUGMENTATION PATIENTS: HEALTH CARE UTILIZATION AND PERIOPERATIVE OUTCOMES Anthony Fadel, Bridget L. Findlay, Boyd R. Viers, and Katherine T. Anderson Anthony FadelAnthony Fadel More articles by this author , Bridget L. FindlayBridget L. Findlay More articles by this author , Boyd R. ViersBoyd R. Viers More articles by this author , and Katherine T. AndersonKatherine T. Anderson More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003323.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: As the population ages, frailty is becoming a more pressing concern for many medical and surgical patients. Studies in urologic oncology have demonstrated an association between frailty and increased utilization of health care resources and 30-day morbidity. There is a paucity of literature surrounding frailty in patients undergoing benign pelvic reconstructive surgery. Herein, we aim to study the impact of frailty on healthcare utilization and perioperative outcomes following adult bladder augmentation. METHODS: Data was collected from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) from 2005-2020 on adult patients who underwent bladder augmentation for various indications. A frailty score was assigned to each patient according to the Five Item Frailty Index (DMII, HTN, COPD, functional health status, and CHF). Baseline characteristics were compared across frailty scores. Univariate and multivariate risk-adjusted regression models were developed to identify predictors of healthcare utilization (i.e., prolonged length of stay (PLOS), 30-day readmissions (AR), discharge to continued care (DCC), and overall resource utilization (HRU) which is a composite of the other 3 outcomes). Secondary outcomes of interest included 30-day complication rates. RESULTS: 941 patients underwent bladder augmentation during the study period, the majority were males (75%) with a median age of 60. An increase in frailty index was significantly associated with an increase in HRU (p-value<0.05, Figure 1), even after adjusting for baseline characteristics such as ASA class. In addition, female sex was associated with lower HRU (OR 0.32, p-value < 0.001). Patients with higher frailty (≥2) also had more complications (28.9%) compared to those with a lower frailty index of≤1 (12.8%, p-value<0.001). CONCLUSIONS: Frailty in adults undergoing bladder augmentation is associated with greater HRU and surgical morbidity. Our study highlights the importance of frailty in benign pelvic surgery as well as the need for future studies directed at interventions to optimize frail patients. Source of Funding: None. © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e895 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Anthony Fadel More articles by this author Bridget L. Findlay More articles by this author Boyd R. Viers More articles by this author Katherine T. Anderson More articles by this author Expand All Advertisement PDF downloadLoading ...

The Utilization of Fresh Frozen Cartilage in Asian Rhinoplasty: A New Approach

Asian rhinoplasty generally requires augmentation procedures rather than reduction. Alloplastic grafts are fraught with higher complication rates. Autologous cartilage grafts are safer. However, Asian patients typically do not have adequate septal cartilages, and other autologous cartilage grafts may cause surgical site morbidities, prolonged surgical time, and complications, including warping and infection. Asian rhinoplasties were performed using fresh frozen cartilage by the senior author. Patients' demographics and medical histories were recorded. Anthropometric measurements (nasofrontal angle, nasofacial angle, nasolabial angle, and Goode ratio) were taken on two-dimensional photographs. FACE-Q scales were used to assess patient-reported outcomes. Five Asian patients underwent rhinoplasty using the fresh frozen cartilage and were followed up for an average period of 14.2 ± 3.35 months. There was no resorption, warping, or infection. Anthropometric measurements showed no significant changes 2-4 months or 8-20 months after surgery. At the time of the 1-year follow-up, mean FACE-Q Satisfaction with Nose, and Satisfaction with Nostrils scores improved from 35.2 ± 10.06 to 60 ± 15.48 (P = 0.0002), and 42.6 ± 20.31 to 59.8 ± 38.21 (P = 0.12), respectively. Fresh frozen cadaveric cartilage is a novel option for Asian rhinoplasty. Our study demonstrated its safety and satisfying surgical outcomes.

PD03-08 SURGICAL AND FUNCTIONAL OUTCOMES OF BILATERAL SYNCHRONOUS ADRENALECTOMY FOR FUNCTIONAL TUMORS: A COHORT STUDY

You have accessJournal of UrologyCME1 Apr 2023PD03-08 SURGICAL AND FUNCTIONAL OUTCOMES OF BILATERAL SYNCHRONOUS ADRENALECTOMY FOR FUNCTIONAL TUMORS: A COHORT STUDY Keshav Agarwal, Rashmi Ramachandran, Nikhil Tandon, and Rajeev Kumar Keshav AgarwalKeshav Agarwal More articles by this author , Rashmi RamachandranRashmi Ramachandran More articles by this author , Nikhil TandonNikhil Tandon More articles by this author , and Rajeev KumarRajeev Kumar More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003220.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Bilateral synchronous adrenalectomy has the potential for significant surgical and functional morbidity. We reviewed our 15-year experience with bilateral synchronous adrenalectomy to assess safety, surgical outcomes, morbidity and impact on health-related quality of life. METHODS: In an IRB approved study, we reviewed our prospective database of patients who underwent bilateral synchronous adrenalectomy for functional tumours between April 2008 and August 2022. Demographic profile, metabolic and radiological parameters, operative details and complications were recorded. Follow-up was obtained either in-person or telephonically and analysed for resolution of symptoms, quality of life using the WHO-QoL BREF questionnaire and complications of chronic steroid intake. RESULTS: During the study period, 337 adrenalectomies were performed which were bilateral in 51 patients, 48 undergoing both surgeries synchronously. 33 of these 48 patients had bilateral pheochromocytomas and 15 had Cushing’s syndrome. Among patients with Cushing’s syndrome, three had life-threatening symptoms requiring urgent bilateral surgery. Clinical details are given in Table 1. 40 patients had transperitoneal laparoscopic surgery and 8 underwent open surgery (Table 2). There were two intraoperative and 7 post-operative complications. 43 patients were available for follow-up. All had resolution of symptoms, BMI changes, and only two patients continued to receive one antihypertensive medication. Episodes of steroid deficiency occurred in 7 patients while steroid excess occurred in 3 patients. Quality of life was satisfactory in all patients in all domains. CONCLUSIONS: Bilateral synchronous adrenalectomy is safe and feasible in patients with functional adrenal tumors. It leads to symptom resolution with amelioration of hypertension and BMI changes with satisfactory overall quality of life. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e77 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Keshav Agarwal More articles by this author Rashmi Ramachandran More articles by this author Nikhil Tandon More articles by this author Rajeev Kumar More articles by this author Expand All Advertisement PDF downloadLoading ...

Procedure Costs of Peripheral Nerve Graft Reconstruction

A retrospective cross-sectional observational study using the US all-payer PINC AI Healthcare Database examined facility procedure costs and cost drivers in patients undergoing allograft or autograft repair of an isolated single peripheral nerve injury between January 2018 and August 2020. Inpatient repairs were limited to nerve-specific DRGs. Multivariable regression evaluated risk-adjusted procedure cost differences. Peripheral nerve graft repairs (n = 1363) were more frequent in the outpatient setting, and more than half involved the use of allograft nerve. Procedure costs for allograft and autograft repair were not significantly different in the outpatient (P = 0.43) or inpatient (P = 0.71) setting even after controlling for other risk factors. Operating room cost was significantly higher for autograft in outpatient (P < 0.0001) but not inpatient (P = 0.46), whereas allograft implant cost was significantly higher in both settings (P < 0.0001). No significant differences in procedure costs for autograft and allograft repair in inpatient and outpatient settings were found using real-world data. Future research should explore longer-term costs.

PD13-05 LONG-TERM ONCOLOGICAL OUTCOMES OF OFFICE-BASED FULGURATION OF TA LOW-GRADE NON MUSCLE INVASIVE BLADDER CANCER: A LARGE SINGLE CENTER SERIES

You have accessJournal of UrologyCME1 Apr 2023PD13-05 LONG-TERM ONCOLOGICAL OUTCOMES OF OFFICE-BASED FULGURATION OF TA LOW-GRADE NON MUSCLE INVASIVE BLADDER CANCER: A LARGE SINGLE CENTER SERIES Christian Vitug, Katherine Lajkosz, Julian Chavarriaga, Andres Llano, Shayan Din, Eunice Villegas, Cynthia Kuk, Bruce Gao, Otto Hemminiki, Dhiral Kot, Jimmy Misurka, Theodorus Van Der Kwast, Christopher Wallis, Michael Jewett, Mark Soloway Aventura, Fl, Neil Fleshner, Girish Kulkarni, and Alexandre Zlotta Christian VitugChristian Vitug More articles by this author , Katherine LajkoszKatherine Lajkosz More articles by this author , Julian ChavarriagaJulian Chavarriaga More articles by this author , Andres LlanoAndres Llano More articles by this author , Shayan DinShayan Din More articles by this author , Eunice VillegasEunice Villegas More articles by this author , Cynthia KukCynthia Kuk More articles by this author , Bruce GaoBruce Gao More articles by this author , Otto HemminikiOtto Hemminiki More articles by this author , Dhiral KotDhiral Kot More articles by this author , Jimmy MisurkaJimmy Misurka More articles by this author , Theodorus Van Der KwastTheodorus Van Der Kwast More articles by this author , Christopher WallisChristopher Wallis More articles by this author , Michael JewettMichael Jewett More articles by this author , Mark Soloway Aventura, FlMark Soloway Aventura, Fl More articles by this author , Neil FleshnerNeil Fleshner More articles by this author , Girish KulkarniGirish Kulkarni More articles by this author , and Alexandre ZlottaAlexandre Zlotta More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003260.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Sixty percent of non-muscle-invasive bladder tumors initially present as low grade (LG), which have a high recurrence rate but low risk of progression. Transurethral resection of bladder tumor (TURBT) is standard for the diagnosis, staging, and treatment of bladder cancer (BC). Office-based fulguration under local anesthesia for small, recurrent, apparent Ta LG tumors is an alternative to TURBT. It is convenient for both patients and physicians, avoiding the costs and risks of a hospital-based procedure requiring general or spinal anesthesia. However, despite being part of some guidelines, it has not become the primary management approach in part due to the paucity of large studies with long term follow-up. METHODS: We retrospectively reviewed our experience with 270 patients with a history of Ta LG BC who underwent office-based fulguration for subsequent small recurrent papillary bladder tumors between 1991 and 2021 at the Toronto General Hospital/Princess Margaret Cancer Center, University Health Network, Toronto, Canada. We report the cancer specific survival (CSS) and progression free survival (PFS, defined as muscle invasive disease or metastases). RESULTS: 270 patients with recurrent Ta LG NMIBC treated with office fulguration were included. Mean age was 64.9 (SD 13.3) years, 70.8% were men and 60.3% had single tumors. The mean number of fulgurations per patient was 3.1 (SD 3.2) with a range from 1 to 22. Median follow up was 10.1 years (IQR 5.8−16.2). Patients also underwent a mean of 3.6 (SD 3.0) TURBTs during follow-up. 44.4% of patients never received intravesical therapy during follow-up. At 10 years, the CSS was 100% and PFS was 97.3 (93.8-98.8)%, respectively. CONCLUSIONS: Our results are based on a large patient experience with long follow-up (10 years) and demonstrate that select patients with recurrent apparent Ta LG BC can be safely managed with office-based fulguration under local anesthesia, without compromising long-term oncological outcomes. This approach reduces surgical and anesthetic associated morbidity and may generate cost-savings to healthcare systems. Office-based fulguration for recurrent small tumors after Ta LG NMIBC should be more widely used. Source of Funding: N/A © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e407 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Christian Vitug More articles by this author Katherine Lajkosz More articles by this author Julian Chavarriaga More articles by this author Andres Llano More articles by this author Shayan Din More articles by this author Eunice Villegas More articles by this author Cynthia Kuk More articles by this author Bruce Gao More articles by this author Otto Hemminiki More articles by this author Dhiral Kot More articles by this author Jimmy Misurka More articles by this author Theodorus Van Der Kwast More articles by this author Christopher Wallis More articles by this author Michael Jewett More articles by this author Mark Soloway Aventura, Fl More articles by this author Neil Fleshner More articles by this author Girish Kulkarni More articles by this author Alexandre Zlotta More articles by this author Expand All Advertisement PDF downloadLoading ...

669 Is Outpatient Spine Surgery at an Ambulatory Surgical Center Better Than at a Hospital? A MSSIC Study

INTRODUCTION: The number of outpatient surgeries have quadrupled over the past several decades. Although studies have shown increased efficacy and cost-effectiveness of surgery done in an outpatient setting, few studies have compared outpatient surgeries performed at a hospital versus an ambulatory surgery facility (ASF) METHODS: The Michigan Spine Surgery Improvement Collaborative was queried for patients undergoing cervical and/or lumbar spine surgery between 1/1/2021 to 12/31/2021 performed at an ASF or hospital with same day discharge. A 4-to-1 propensity score matching using BMI, location (lumbar, cervical), ASA &gt; 2, fusion procedure and number of levels as the matching variables for lumbar and cervical surgeries. Primary outcomes included: achieving MCID for PROMIS physical function, EQ-5D, Return-to-Work and NASS patient satisfaction. Complications were a secondary outcome and included: Surgical site Infection (SSI), urinary retention, hospital readmission/ED visit, return-to-OR, Axial pain, new radicular findings, weakness, Ileus (lumbar only), and Dysphagia (cervical only). RESULTS: A total of 2,763 patients were identified prior to matching. Of the 1,665 patients that were matched, 1,332 had surgery at a hospital and 333 in an ASF. There were no statistically significant differences for patient satisfaction, PROMIS-PF MCID, or Return-to-Work at 90-days. Patients who had surgery at an ASF had higher rates of axial pain (10% vs 5%, p = 0.002) and new radicular findings(19% vs 12%, p &lt; .001) compared to surgery at a hospital. Dysphagia was also higher in the ASF group (5% vs 0%, p = .006). There were no differences in SSI, readmission, urinary retention, return-to-OR or ED visits between sites CONCLUSIONS: Outpatient spine surgery at an ASF demonstrated no significantly increased surgical morbidity compared to hospitals. Although ASFs had a higher rate of new radicular findings and axial pain, there were no differences in patient satisfaction and PROs after surgery.

V03-02 ORTHOTOPIC ROBOT-ASSISTED KIDNEY TRANSPLANTATION: STEP-BY-STEP

You have accessJournal of UrologyCME1 Apr 2023V03-02 ORTHOTOPIC ROBOT-ASSISTED KIDNEY TRANSPLANTATION: STEP-BY-STEP Francesc Vigués Julià, Begoña Etcheverry Giadrosich, Arnau Abella Serra, José Ignacio Pérez Reggeti, Maria Fiol Riera, Pol Sanz Serra, José Francisco Suárez Novo, Manel Castells Esteve, and Lluis Riera Canals Francesc Vigués JuliàFrancesc Vigués Julià More articles by this author , Begoña Etcheverry GiadrosichBegoña Etcheverry Giadrosich More articles by this author , Arnau Abella SerraArnau Abella Serra More articles by this author , José Ignacio Pérez ReggetiJosé Ignacio Pérez Reggeti More articles by this author , Maria Fiol RieraMaria Fiol Riera More articles by this author , Pol Sanz SerraPol Sanz Serra More articles by this author , José Francisco Suárez NovoJosé Francisco Suárez Novo More articles by this author , Manel Castells EsteveManel Castells Esteve More articles by this author , and Lluis Riera CanalsLluis Riera Canals More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003241.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Orthotopic kidney transplant is an alternative for patients with an end-stage renal disease non-suitable for a heterotopic kidney transplant (KT) due to severe iliac atherosclerosis or occupation of iliac fossa by previous grafts. This approach is performed through a left lumbotomy, using the splenic or renal artery, the renal vein and the native urinary tract. However, it is technically challenging and is associated with a higher rate of complications compared to conventional KT. Recently, robot-assisted kidney transplant (RAKT) has been shown to achieve excellent patient and graft outcomes, while reducing surgical morbidity. From the experience in RAKT, we have developed this technique in orthotopic transplantation. The aim of this video is to describe the technique of orthotopic robotic assisted kidney (ORAKT) step by step, and our series of cases. METHODS: We present the ORAKT technique from different cases using splenic or renal artery. Some strategies to vessel dissection and preparation are also described. RESULTS: 5 ORAKT were done: 4 cases from cadaveric donor and 1 case from living donor. 1 arterial anastomosis was performed to the renal artery, 4 to the splenic artery. Surgical and functional data are shown in Table 1. 24 hour ultrasound is done in all cases, and the ureteral stent is removed at 4 week. CONCLUSIONS: ORAKT provides a minimally invasive alternative for some selected patients non-suitable for a heterotopic KT and is technically feasible in centers with robotics kidney transplant expertise. The potential advantages of the robotic approach are related to the reduction of lumbotomy morbidity, the better and precise dissection of the native renal vessels and splenic artery and the more precise vascular anastomosis. Source of Funding: None. © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e246 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Francesc Vigués Julià More articles by this author Begoña Etcheverry Giadrosich More articles by this author Arnau Abella Serra More articles by this author José Ignacio Pérez Reggeti More articles by this author Maria Fiol Riera More articles by this author Pol Sanz Serra More articles by this author José Francisco Suárez Novo More articles by this author Manel Castells Esteve More articles by this author Lluis Riera Canals More articles by this author Expand All Advertisement PDF downloadLoading ...

Restaging MRI of Rectal Adenocarcinoma after Neoadjuvant Chemoradiotherapy: Imaging Findings and Potential Pitfalls

Rectal adenocarcinoma constitutes about one-third of all colorectal adenocarcinoma cases. Rectal MRI has become mandatory for evaluation of patients newly diagnosed with rectal cancer because it can help accurately stage the disease, impact the choice to give neoadjuvant therapy or proceed with up-front surgery, and even direct surgical dissection planes. Better understanding of neoadjuvant chemoradiotherapy effects on rectal tumors and recognition that up to 30% of patients can have a pathologic complete response have opened the door for the nonsurgical "watch-and-wait" management approach for rectal adenocarcinoma. Candidates for this organ-preserving approach should have no evidence of malignancy on all three components of response assessment after neoadjuvant therapy (ie, digital rectal examination, endoscopy, and rectal MRI). Hence, rectal MRI again has a major role in directing patient management and possibly sparing patients from unnecessary surgical morbidity. In this article, the authors discuss the indications for neoadjuvant therapy in management of patients with rectal adenocarcinoma, describe expected imaging appearances of rectal adenocarcinoma after completion of neoadjuvant therapy, and outline the MRI tumor regression grading system. Since pelvic sidewall lymph node dissection is associated with a high risk of permanent genitourinary dysfunction, it is performed for only selected patients who have radiologic evidence of sidewall lymph node involvement. Therefore, the authors review the relevant lymphatic compartments of the pelvis and describe lymph node criteria for determining locoregional nodal spread. Finally, the authors discuss limitations of rectal MRI, describe several potential interpretation pitfalls after neoadjuvant therapy, and emphasize how these pitfalls may be avoided. © RSNA, 2023 Quiz questions for this article are available in the supplemental material.

V03-01 SINGLE-PORT KIDNEY AUTO-TRANSPLANTATION (SP-KAT) WITH BOARI FLAP URETERAL REIMPLANT: DESCRIPTION OF OUR NOVEL APPROACH

You have accessJournal of UrologyCME1 Apr 2023V03-01 SINGLE-PORT KIDNEY AUTO-TRANSPLANTATION (SP-KAT) WITH BOARI FLAP URETERAL REIMPLANT: DESCRIPTION OF OUR NOVEL APPROACH Jaya Sai Chavali, Jihad Kaouk, Ethan Ferguson, Roxana Ramos, Albert Geskin, Alvin Wee, and Mohamed Eltemamy Jaya Sai ChavaliJaya Sai Chavali More articles by this author , Jihad KaoukJihad Kaouk More articles by this author , Ethan FergusonEthan Ferguson More articles by this author , Roxana RamosRoxana Ramos More articles by this author , Albert GeskinAlbert Geskin More articles by this author , Alvin WeeAlvin Wee More articles by this author , and Mohamed EltemamyMohamed Eltemamy More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003241.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: We aim to demonstrate the feasibility and safety of the novel minimally invasive technique for efficient, multiquadrant robotic kidney transplantation using da Vinci single-port robot platform (SP-KAT). The study patient had a good split renal function and complete ureter avulsion. METHODS: Eight consecutive patients underwent SP KAT using the DaVinci SP platform. Overall patient clinicopathologic variables were recorded in Table 1. We demonstrate our technique in 58 year old male that presented after complete avulsion of the ureter during ureteroscopy. He had good split renal function on imaging. Technical steps of the surgery included (1). Robotic nephrectomy; (2) Kidney benching; (3) Dissection of Iliac vessels and Kidney placement; (4) Vascular anastomosis; (5) Ureteral reimplant. Extra corporeal kidney benching performed at the same time while the iliac vessels are being exposed robotically for subsequent transplant. This patient in addition required Boari flap ureteroneocystostomy due to insufficient length of ureter. RESULTS: All SP KAT cases were successfully performed without repositioning or conversion to open. Total operative time was 701 minutes. Estimated blood loss was 500cc. The Foley and stent removed at 2 and 6 weeks postoperatively. Patient had complete preservation of renal function. No documented postoperative complications up to latest follow up at 1 year. CONCLUSIONS: We demonstrate our single-port efficient, multiquadrant robotic kidney transplantation technique performed though a single incision further reducing surgical morbidity. All the cases were completed successfully without conversion or loss of graft function. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e246 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jaya Sai Chavali More articles by this author Jihad Kaouk More articles by this author Ethan Ferguson More articles by this author Roxana Ramos More articles by this author Albert Geskin More articles by this author Alvin Wee More articles by this author Mohamed Eltemamy More articles by this author Expand All Advertisement PDF downloadLoading ...

MP31-01 SINGLE-PORT ROBOTIC KIDNEY AUTOTRANSPLANTATION (SP-KAT) - EARLY LEARNING CURVE

You have accessJournal of UrologyCME1 Apr 2023MP31-01 SINGLE-PORT ROBOTIC KIDNEY AUTOTRANSPLANTATION (SP-KAT) - EARLY LEARNING CURVE Jaya Sai Chavali, Ethan Ferguson, Sanjay Vallabhaneni, Albert Geskin, Zeyad Schwen, Roxana Ramos, Alp Tuna Beksac, Alvin Wee, Mohamed Eltemamy, and Jihad Kaouk Jaya Sai ChavaliJaya Sai Chavali More articles by this author , Ethan FergusonEthan Ferguson More articles by this author , Sanjay VallabhaneniSanjay Vallabhaneni More articles by this author , Albert GeskinAlbert Geskin More articles by this author , Zeyad SchwenZeyad Schwen More articles by this author , Roxana RamosRoxana Ramos More articles by this author , Alp Tuna BeksacAlp Tuna Beksac More articles by this author , Alvin WeeAlvin Wee More articles by this author , Mohamed EltemamyMohamed Eltemamy More articles by this author , and Jihad KaoukJihad Kaouk More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003264.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: We present our initial series of single-port (SP) robotic KAT, ideal for multi-quadrant surgeries, and aim to evaluate the feasibility and safety of the novel approach. METHODS: Ten consecutive patients underwent robotic SP KAT and indications include complex or recurrent ureteral stricture, ureteral avulsion, chronic visceral pain due to multiple etiologies and failed prior surgeries. Extra corporeal kidney benching performed at the same time while the iliac vessels are being exposed robotically for subsequent transplant. Overall patient clinicopathologic variables and perioperative outcomes were recorded in Tables 1, 2. RESULTS: All SP KATs were successfully performed without repositioning or conversion to open or loss of graft function. Operative times ranged from 366 to 701 mins with a warm and cold ischemia time between 4 to 10 mins and 86 to 209 mins, respectively. Median hospital length of stay was 4 days. The learning curve in our case series was hard to evaluate given each individual patient presents a unique challenge but overall ischemia and revascularization times showed progressive improvement (Figure 1). There was one Clavien-Dindo 3 complication, an unrecognized bowel injury that required re-operation in our series. At a median of 8 months follow-up, latest postoperative GFRs were stable, ranging from +23% to −14%, and the grafts were functioning well. Notably, all patients who had preoperative chronic visceral pain had complete resolution of pain postoperatively. CONCLUSIONS: We demonstrate our single-port multi quadrant robotic kidney auto transplantation technique performed through a single incision further reducing surgical morbidity. All the cases reported improvement in flank pain and no radiological evidence of urinary obstruction on follow up. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e429 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jaya Sai Chavali More articles by this author Ethan Ferguson More articles by this author Sanjay Vallabhaneni More articles by this author Albert Geskin More articles by this author Zeyad Schwen More articles by this author Roxana Ramos More articles by this author Alp Tuna Beksac More articles by this author Alvin Wee More articles by this author Mohamed Eltemamy More articles by this author Jihad Kaouk More articles by this author Expand All Advertisement PDF downloadLoading ...

Clinical efficacy of midline lumbar interbody fusion arthrodesis with neuronavigation-guided cortical bone trajectory screws in the treatment of degenerative lumbar spondylolisthesis:a prospective randomized controlled trial

Introduction. Currently, the standard treatment of degenerative spondylolisthesis involves pedicle screw fixation to enhance the success of intervertebral fusion. The traditional pedicle screw techniques require extensive lateral muscle dissection, resulting in significantly increased surgical-related morbidity. To address some of these shortcomings, the Midline Lumbar Interbody Fusion (MIDLIF®) technique has recently been developed. It involves the combination of the cortical bone trajectory screw fixation of the spine with intervertebral cage placement to achieve a solid interbody fusion. So far, the clinical efficacy of the MIDLIF technique in the treatment of low-grade degenerative spondylolisthesis is still unknown. All existing publications are studies with a low level of relevance or scientific evidence. Materials and methods. A prospective randomized controlled trial was conducted between 2017 and 2022. The study analyzed the clinical and radiological effectiveness of the MIDLIF arthrodesis technique compared to the traditional lumbar interbody fusion techniques, used exclusively in the treatment of degenerative lumbar spondylolisthesis. Results. The study enrolled 112 eligible patients with degenerative low-grade spondylolisthesis, randomly assigned into two groups. At 1 year post-operatively, MIDLIF provided a significantly better improvement in postoperative relief of low back pain and radiating pain, as well as a significantly better functional recovery. Additionally, MIDLIF resulted in lower surgical morbidity compared to traditional fusion techniques. Conclusions. The success rate of MIDLIF arthrodesis is similar to that associated with traditional fusion techniques. At the same time, MIDLIF offers all the specific benefits of a minimally invasive approach, such as less postoperative pain, faster functional recovery, less bleeding, and fewer blood transfusions. Thus, MIDLIF might be a good alternative to the traditional intervertebral fusion techniques in the treatment of degenerative low-grade spondylolisthesis.