Surgical Satisfaction Research Articles

Achalasia symptom response after Heller myotomy segregated by high-resolution manometry subtypes.

Achalasia is classified into three HRM subtypes that predict outcomes from diverse management strategies. We assessed if symptomatic response varied when a single management strategy-Heller myotomy (HM)-is employed. Treatment-naive subjects with achalasia referred for HM were followed in this observational cohort study. Chicago criteria designated achalasia subtypes (subtype I: no esophageal pressurization; subtype II: panesophageal pressurization in ≥20% swallows; subtype III: premature contractions in ≥20% swallows). Symptom questionnaires assessed symptom burden before and after HM on five-point Likert scales (0=no symptoms, 4=severe symptoms) and on 10-cm visual analog scales (global symptom severity, GSS); satisfaction with HM was recorded similarly. Data were analyzed to determine predictors of GSS change across subtypes. Sixty achalasia subjects (56.1±2.4years, 55% female) fulfilled inclusion criteria, 15% with subtype I, 58% with subtype II, and 27% with subtype III achalasia. Baseline symptoms included dysphagia (solids: 85%, liquids: 73%), regurgitation (84%), and chest pain (35%); mean GSS was 7.1±0.3. Upon follow-up 2.1±0.2years after HM, GSS declined to 1.9±0.4 (p<0.001), with surgical satisfaction score of 8.7±0.3 out of 10; these were similar across achalasia subtypes. On univariate analysis, female gender, Eckardt score, severity of transit symptoms, and maximal IRP predicted linear GSS improvement; female gender (p=0.003) and dysphagia for liquids (p=0.043) remained predictive on multivariate analysis. When a uniform surgical approach is utilized, symptomatic outcome and satisfaction with therapy are similar across achalasia subtypes. Female gender and severity of dysphagia for solids may predict better HM outcome.

Does pre-existing L5-S1 degeneration affect outcomes after isolated L4-5 fusion for spondylolisthesis?

BackgroundConcerns have been raised regarding residual symptoms of caudal segment (L5-S1) degeneration that may affect clinical outcomes or require additional surgery after isolated L4-5 fusion, especially if there is pre-existing L5-S1 degeneration. This study aimed to evaluate the L5-S1 segment after minimally invasive lumbar interbody fusion at the L4-5 segment, as well as the influence of pre-existing L5-S1 degeneration on radiologic and clinical outcomes.MethodsThis retrospective study evaluated patients with isthmic spondylolisthesis and degenerative spondylolisthesis who underwent mini-open anterior lumbar interbody fusion with percutaneous pedicle screw fixation (PSF) or minimally invasive transforaminal interbody fusion with PSF at the L4-5 segment. The minimum follow-up period was 7 years, and radiographic evaluations were conducted via magnetic resonance imaging, computed tomography, and plain radiography at the 5-year follow-up. Clinical outcomes were assessed using the Visual Analog Score, Oswestry Disability Index, and surgical satisfaction rate. Patients were divided into two groups, those with and without pre-existing L5-S1 degeneration, and their final outcomes and incidence of radiographic and clinical adjacent segment disease (ASD) were compared.ResultsAmong 70 patients who underwent the procedures at our institution, 12 (17.1%) were lost to follow-up. Therefore, this study evaluated 58 patients, with a mean follow-up period of 9.4 ± 2.1 years. Among these patients, 22 patients had pre-existing L5-S1 degeneration, while 36 patients did not have pre-existing L5-S1 segmental degeneration. There were no significant differences in the clinical outcomes at the final follow-up when the two groups were compared. However, radiographic ASD at L5-S1 occurred in seven patients (12.1%), clinical ASD at L5-S1 occurred in three patients (5.2%), and one patient (1.7%) required surgery. In the group with pre-existing degeneration, L5-S1 degeneration was radiographically accelerated in four patients (18.2%) and clinical ASD developed in one patient (4.5%). In the group without pre-existing degeneration, L5-S1 degeneration was radiographically accelerated in three patients (8.3%) and clinical ASD developed in two patients (5.7%). There were no differences in the incidence of ASD when we compared the two groups.ConclusionsPre-existing L5-S1 degeneration does not affect clinical and radiographical outcomes after isolated L4-5 fusion.

OCD Lesions Of The Patella And Trochlea In Children

Objectives:The purpose of this report is to evaluate the functional outcomes of surgical management of OCD lesions of the patella and trochlea in children. Secondary aims include elucidating predictors for higher functional outcomes, determining complication rates, surgical satisfaction and ability to return to sports.Methods:Patients age ≤ 18 years who were surgically treated for OCD of the patellar or trochlea were identified. Charts were queried to record patient/lesion data, surgical procedure, results and complications. Pre- and postoperative imaging was reviewed. Patients were asked to complete a follow-up athletic questionnaire and a Pediatric International Knee Documentation Committee (Pedi-IKDC) score. Statistical analysis was conducted to look for predictors for reoperation, residual pain, ability to return to sports and lower Pedi-IKDC scores.Results:Twenty-six children (9 female, 17 male, 3 bilateral) were identified. Mean age was 14.7 (range: 9-18), 21/29 (72%) had open physes, and median follow-up was 3.8 years (range: 1-9 years). The most common location was the trochlea (17/29, 59%). Twenty-two lesions (76%) underwent transarticular drilling (n=14) or drilling with fixation (8), while 7 underwent excision and marrow stimulation. Four patients (14%) required unplanned re-operation. Internal fixation was predictive of reoperation (OR= 8.7, 95% CI= 2.8-26.9, P=0.04). At final follow up, 14 knees (48%) were pain-free, 14 (48%) had mild residual pain. Female gender was predictive of residual pain (OR= 9, 95% CI= 2-56, P=0.02). Twenty-two patients (85%) returned to sports. Longer duration of preoperative pain negatively impacted return to sports (OR= 0.32, 95% CI= 0.05-0.97, P=0.04). On postoperative imaging, the lesion appeared completely healed in 5 cases (42%) and partially healed in 12 cases (58%). All 15 survey respondents were satisfied with surgery. The mean Pedi-IKDC score was 82.4 ± 17.8 (range: 40.2 -100).Conclusion:Surgical treatment of patellofemoral OCD in children produces a high rate of satisfaction and return to sports. Female gender, prolonged duration of symptoms and internal fixation may be associated with worse outcomes.

Surgical Management of Osteochondritis Dissecans Lesions of the Patella and Trochlea in the Pediatric and Adolescent Population

Background: There is a paucity of published data regarding the management of osteochondritis dissecans (OCD) lesions of the patellofemoral joint in children and adolescents. Purpose: To evaluate the functional outcomes of surgical management of OCD lesions of the patella and trochlea in children and adolescents. Secondary aims included elucidating predictors for higher functional outcomes and determining complication rates, surgical satisfaction, and ability to return to sports. Study Design: Case series; Level of evidence, 4. Methods: Patients aged 18 years and younger who were surgically treated for OCD of the patella or trochlea were identified. Charts were queried to record patient/lesion data, surgical procedure, results, and complications. Pre- and postoperative imaging was reviewed. Patients were asked to complete a follow-up athletic questionnaire and a Pediatric International Knee Documentation Committee (Pedi-IKDC) questionnaire. Statistical analysis was conducted to look for predictors for reoperation, residual pain, ability to return to sports, and lower Pedi-IKDC scores. Results: A total of 26 children (9 females, 17 males, 3 with bilateral lesions; thus, 29 lesions) were identified. The mean age was 14.7 years (range, 9-18, years), 21 of the 29 knees with lesions (72%) had open physes, and median follow-up was 3.8 years (range, 1-9 years). The most common location was the trochlea (17/29 lesions; 59%). Twenty-two lesions (76%) underwent transarticular drilling (n = 14) or drilling with fixation (n = 8), while 7 underwent excision and marrow stimulation. Four patients (14%) required unplanned reoperation. Internal fixation was predictive of reoperation (odds ratio [OR] = 8.7; 95% CI, 2.8-26.9; P = .04). At final follow-up, 14 knees (48%) were pain free, and 14 (48%) had mild residual pain. Female sex was predictive of residual pain (OR, 9; 95% CI, 2-56; P = .02). Twenty-two patients (85%) returned to sports. Longer duration of preoperative pain negatively affected return to sports (OR, 0.32; 95% CI, 0.05-0.97; P = .04). On postoperative MRI, the lesion appeared completely healed in 2 cases (18%) and partially healed in 9 cases (82%). All 15 survey respondents were satisfied with surgery. The mean Pedi-IKDC score was 82.4 ± 17.8 (range, 40.2-100). Conclusion: Surgical treatment of patellofemoral OCD in children and adolescents produces a high rate of satisfaction and return to sports. Female sex, prolonged duration of symptoms, and internal fixation may be associated with worse outcomes.

Subtotal versus total laparoscopic hysterectomy: could women sexual function recovery overcome the surgical outcomes in pre-operatory decision making?

Hysterectomy is the most common surgical procedure performed in gynecology and, in over 95% of the cases, does not necessarily require the removal of the uterine cervix to be completed successfully. In clinical practice, however, less than 20% of gynecologists offer patients the possibility to express a personal preference concerning the choice between total laparoscopic hysterectomy (TLH) and laparoscopic subtotal hysterectomy (LSH). The aim of this study is to compare patients who have undergone TLH versus LSH for benign uterine diseases in terms of intra-operative/peri-operative surgical outcomes and short-term recovery of sexual function. We performed an observational, retrospective study on 478 women who underwent hysterectomy for benign uterine disease at Gyn/Ob Clinic, Department of Women's and Children's Health of Padua University between January 2003 and December 2012. Surgical data were recorded. We investigated and compared outcomes between the two groups of patients (TLH vs LSH) in terms of the following: surgical complications rate, post-operative therapy, women satisfaction and sexual activity recovery. We found that operating time and length of hospital stay were significantly lower in patients who underwent LSH. A higher rate of post-operative fever was reported in the TLH treatment group although antibiotic prophylaxis was implemented in a similar fashion for both groups. At 60-70 days following surgery, women of LSH group reported a greater ease in recovery of sexual function as opposed to those who underwent TLH. The advantages and potential drawbacks of both procedures need to be discussed with women presenting with benign disease. LSH is a reasonable option for women, representing both an excellent minimally invasive approach in a proper clinical setting and an appropriate procedure for those women who prefer conservative surgery.

Dexmedetomidine could enhance surgical satisfaction in Trans-sphenoidal resection of pituitary adenoma.

Excessive bleeding is an unwanted complication of trans-sphenoidal resection of pituitary adenoma due to increases in intracranial pressure (ICP) and hemodynamic instability. Dexmedetomidine (Dex) anα2-agonists is the drug of choice in intensive care units (ICU) and cardiac surgeries to control abrupt changes in hemodynamic. Severe cardiovascular responses occur during trans-sphenoidal resection (TSR) of the pituitary adenoma despite adequate depth of anesthesia. The aim of this paper was to determine the effect of Dexmedetomidine on bleeding as primary outcome, and surgeon's satisfaction and hemodynamic stability as secondary outcomes in patients undergoing trans-sphenoidal resection of pituitary adenoma. Total numbers of 60 patients between 18-65 years old and candidate for elective trans-sphenoidal resection of pituitary adenoma were randomLy allocated to two groups; Dexmedetomidine infusion (0.6µg/kg/hour) or normal saline infusion. Mean arterial pressure (MAP), heart rate (HR), dose of hypnotics and narcotics during surgery, bleeding, and surgeon's satisfaction were recorded. Propofol maintenance dose (µg/kg/min) and total Fentanyl use (µg) were significantly lower in Dex group compare to control group (P=0.01 and 0.003, respectively). Total bleeding amount during operation in Dex group was significantly lower than control group (P=0.012). Surgeon's satisfaction was significantly higher in Dex group at the end of surgery. MAP and heart rate throughout surgery were significantly lower in Dex group compare to control group (P=0.001). Dexmedetomidine infusion (0.6µg/kg/hour) could reduce bleeding and provide surgeon's satisfaction during trans-sphenoidal resection of pituitary adenoma.

Prediction of Successful Surgery Outcome in Lumbar Disc Herniation Based on Artificial Neural Networks

Introduction The aim of this study, was to develop an artificial neural networks (ANNs) model for predicting successful surgery outcome in lumbar disc herniation (LDH). Materials and Methods An ANN model and a logistic regression (LR) model were used to predict outcomes. The age, gender, duration of symptoms, smoking status, surgical level, visual analog scale of leg/back pain, the Zung depression scale, and the Japanese Orthopaedic Association score, were determined as the input variables for the established ANN model. The Macnab classification was used for outcome assessment. ANNs on data from LDH patients, who had surgery, were trained to predict 2-year successful discectomy using several input variables. Sensitivity analysis to the established ANN model was used to identify the relevant variables. For evaluating the two models, the area under a receiver operating characteristic curve, accuracy rate of predicting, and Hosmer-Lemeshow (H-L) statistics were considered. Results A total of 203 (96 male, 107 female, mean age 48.3 ± 9.8 years) patients were categorized into training, testing, and validation datasets consisting of 101, 51, and 51 cases, respectively. Surgical successful outcome was categorized as: excellent, 32.0%; good, 40.9%; fair, 20.7%; and poor, 6.4% at 2-year follow-up. Compared with the LR model, the ANN model showed better results: accuracy rate, 95.8%; H-L statistic, 41.5%; and AUC, 0.82% of patients, respectively. Conclusion The findings show that ANNs can predict successful surgery outcome with a high level of accuracy in LDH patients. Such information is of use in the clinical decision-making process. Disclosure of Interest None declared References Fardon DF, Milette PC; Combined Task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology. Nomenclature and classification of lumbar disc pathology. Recommendations of the Combined task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology. Spine 2001;26(5):E93-E113 Li YC, Liu L, Chiu WT, Jian WS. Neural network modeling for surgical decisions on traumatic brain injury patients. Int J Med Inform 2PO.069;57(1):1–9 Bishop CM. Neural Networks for Pattern Recognition. Oxford, UK: Clarendon; 1995 Azimi P, Benzel EC, Shahzadi S, Azhari S, Mohammadi HR. Use of artificial neural networks to predict surgical satisfaction in patients with lumbar spinal canal stenosis. J Neurosurg Spine 2014;20(3):300–305 Price DD, McGrath PA, Rafii A, Buckingham B. The validation of visual analogue scales as ratio scale measures for chronic and experimental pain. Pain 1983;17(1):45–56 Azimi P, Mohammadi HR, Montazeri A. An outcome measure of functionality and pain in patients with lumbar disc herniation: a validation study of the Japanese Orthopedic Association (JOA) score. J Orthop Sci 2012;17(4):341–345 Zung WW, Richards CB, Short MJ. Self-rating depression scale in an outpatient clinic. Further validation of the SDS. Arch Gen Psychiatry 1965;13(6):508–515 Macnab I. Chapter 14. Pain and disability in degenerative disc disease. Clin Neurosurg 1973;20:193–196 Cross SS, Harrison RF, Kennedy RL. Introduction to neural networks. Lancet 1995;346(8982):1075–1079 Rughani AI, Dumont TM, Lu Z, et al. Use of an artificial neural network to predict head injury outcome. J Neurosurg 2010;113(3):585–590 Finneson BE. A lumbar disc surgery predictive score card. Spine 1978;3(2):186–188

Use of artificial neural networks to predict surgical satisfaction in patients with lumbar spinal canal stenosis

Object The purpose of this study was to develop an artificial neural network (ANN) model for predicting 2-year surgical satisfaction, and to compare the new model with traditional predictive tools in patients with lumbar spinal canal stenosis. Methods The 2 prediction models included an ANN and a logistic regression (LR) model. The patient age, sex, duration of symptoms, walking distance, visual analog scale scores of leg pain or numbness, the Japanese Orthopaedic Association score, the Neurogenic Claudication Outcome Score, and the stenosis ratio values were determined as the input variables for the ANN and LR models that were developed. Patient surgical satisfaction was recorded using a standardized measure. The ANNs were fed patient data to predict 2-year surgical satisfaction based on several input variables. Sensitivity analysis was applied to the ANN model to identify the important variables. The receiver operating characteristic–area under curve (ROC-AUC), Hosmer-Lemeshow statistics, and accuracy rate were calculated for evaluating the 2 models. Results A total of 168 patients (59 male, 109 female; mean age 59.8 ± 11.6 years) were divided into training (n = 84), testing (n = 42), and validation (n = 42) data sets. Postsurgical satisfaction was 88.7% at 2-year follow-up. The stenosis ratio was the important variable selected by the ANN. The ANN model displayed a better accuracy rate in 96.9% of patients, a better Hosmer-Lemeshow statistic in 42.4% of patients, and a better ROC-AUC in 80% of patients, compared with the LR model. Conclusions The findings show that an ANN can predict 2-year surgical satisfaction for use in clinical application and is more accurate compared with an LR model.

Editorial: Predicting surgical satisfaction using artificial neural networks

In this issue of the Journal of Neurosurgery: Spine, the clinical article titled “Use of artificial neural networks to predict surgical satisfaction in patients with lumbar spinal canal stenosis” by Azimi and colleagues1 represents the first application of an artificial neural network (ANN) in predicting outcomes from spinal surgery. Although ANNs have been used in the biomechanical assessments of spine disease, to date the literature lacks any examples of the clinical applications of ANNs in patients with spine disease. The authors undertook this initiative by identifying 168 patients who had undergone surgery for lumbar stenosis and who had completed a series of preoperative grading instruments. Along with age, sex, and symptom duration, scores on these instruments were collectively taken as the inputs for the ANN. The network was trained on half of the patients by pairing the inputs with known outputs. When a novel cohort of patients was then used to test the model, it statistically outperformed a standard logistic regression (LR) model in terms of accuracy in predicting surgical satisfaction. Notably, the authors incorporated only preoperative data points in an effort to predict long-term outcome. One could reasonably expect that the most important factors in predicting this include biomechanical and surgical factors such as sagittal balance, the number of levels decompressed, and whether or not the interspinous ligaments are preserved during decompression, just to name a few. Accurate prediction of longer-term outcomes would probably need such variables incorporated. It would not only be simple to model an end point such as whether or not a patient receives a spinal fusion, but this would have practical implications if such a model were ever to be used in clinical practice. One of the popular criticisms of ANN modeling is that the variables exist as a “black box,” with the exact relationships and interaction between them remaining somewhat abstract. Although this is true, what can still be gleaned easily from the model is which of the variables is most salient in predicting outcome. A simple visual representation of the model in the authors’ Fig. 3 readily reveals that the stenosis ratio has the greatest impact in predicting patient satisfaction. We remain quite a distance from seeing the use of ANNs in practice. To date there are well under a dozen examples of ANN models applied to neurosurgical diseases. The few examples that exist, however, illustrate the power of this form of modeling over traditional linear models, and also over clinical intuition alone. To date ANNs have been shown to outperform LR models at predicting 1-year survival in patients with brain metastases,4 have been shown to be more accurate than LR models at predicting in-hospital survival in patients with traumatic brain injury,6 more accurate than either LR models or clinicians in predicting in-hospital survival from traumatic brain injury,5 more accurate than LR models in predicting survival from intracerebral hemorrhage,3 and more accurate at predicting which patients with subarachnoid hemorrhage are likely to suffer from cerebral vasospasm.2 That the demonstrated accomplishments of ANNs in neurosurgery can be listed so briefly hints at their unexplored potential. It is worth emphasizing that the authors used a commercially available software package to generate their ANN model. This nicely highlights the ease with which such models can be developed. As clinical decision making becomes increasingly complex, clinical decision support tools will perhaps play an increasingly useful role in clinical practice. At the present time, however, such clinical informatics remain widely underdeveloped and underutilized, especially in the realm of neurosurgical diseases. To this end, the authors have contributed a simple proof of concept of the application of ANNs to neurosurgical decision making. (http://thejns.org/doi/abs/10.3171/2013.10.SPINE13851)

Renal transplantation through a modified non-muscle-cutting Pfannenstiel incision

To assess the feasibility of performing a renal transplant operation through a modified non-muscle-cutting Pfannenstiel incision (MFI). Renal transplantation with MFI was performed in 20 men with a body mass index (BMI) of less than 25 and five women with a BMI of less than 27. The parameters assessed were incision length, operative time, postoperative pain score by visual analogue score, wound complication, graft-related complications, eGFR at 3 months, and surgical scar satisfaction score. The results were compared with a BMI-matched cohort of patients who had a conventional hockey stick incision. Statistical analyses were done by Chi-square test and Student's t test. There was a significant decrease in mean bed preparation time, mean time for closure, and mean incision length in patients with MFI. In MFI group, the mean surgical satisfaction score was significantly more. There was no significant difference between the groups on all other aspects. In the era of minimally invasive surgery, MFI technique could challenge the role of laparoscopic and robotic surgery in renal transplantation. Our study shows that the technique is successful in carefully selected patients with low BMI.

Subjective and objective results 1 year after robotic sacrocolpopexy using a lightweight Y-mesh

Introduction and hypothesisThe objective of this study was to assess outcomes following robotic sacrocolpopexy using a lightweight polypropylene Y-mesh.MethodsDuring our study period, all patients who underwent robotic sacrocolpopexy were enrolled in this single-arm prospective trial. Endpoints included Pelvic Organ Prolapse Quantification (POP-Q) values; Pelvic Floor Distress Inventory, short form 20 (PFDI-20); Pelvic Floor Impact Questionnaire, short form 7 (PFIQ-7); Surgical Satisfaction scores; and the Sandvik Incontinence Severity Index. All surgeries were performed with a pre-configured monofilament type 1 polypropylene Y-mesh (Alyte©, C.R. Bard, Covington, GA, USA). Cure rates at 12 months were calculated using two separate definitions: (1) “clinical cure”: no POP-Q points > 0, point C ≤ −5, no prolapse symptoms on the PFDI-20, and no reoperations for prolapse and (2) “objective anatomic cure”: POP-Q stage 0 or 1, point C of ≤ −5, and no reoperations for prolapse.ResultsA total of 150 patients underwent robotic sacrocolpopexy and 143 (95 %) were available for 12-month follow-up. Mean age was 58.6 ± 9.8 and mean body mass index was 26.3 ± 4.5. Mean operative time and blood loss were 148 ± 27.6 min (range 75–250 min) and 51.2 ± 32, respectively. There were no mesh erosions or exposures, and mesh edges were not palpable in any patient. At 12 months the clinical cure rate was 95 %, and the objective anatomic cure rate was 84 %. The PFDI-20 mean score improved from 98 at baseline to 17 at 12 months (p < 0.0001); PFIQ-7 scores improved from 59 to 6.5 (p < 0.0001).ConclusionsRobotic sacrocolpopexy using this lightweight polypropylene Y-mesh offers excellent subjective and objective results at 1 year.

Étude préliminaire sur la faisabilité de la double promontofixation robotique comparée à la voie cœlioscopique

The aim of our study was to demonstrate the feasibility of the laparoscopic robot-assisted anterior and posterior mesh sacrocolpopexy compared to the laparoscopic approach. Between November 2009 and August 2011, 36 women underwent sacrocolpopexy with anterior and posterior mesh, 16 by a robot-assisted approach and 20 by laparoscopy. The cases were systematically evaluated at 1 and 12 months postoperatively. All cases were contacted 6 months later to evaluate the functional results. Both groups were comparable in terms of age, ASA score, Body Mass Index, surgical history and grades of pelvic organ prolapse preoperatively. There was no difference in terms of hospital stay, per- and postoperative complications, especially concerning the rate of postoperative constipation. The mean operating time was significantly more important in the Robot group (P=0.001) with 318 min for the Robot group versus 260 min for the laparoscopic group. With a mean follow-up of 12 months, the anatomic result was satisfactory without recurrence in 97.2% of the cases. The urinary and sexual results, the restart of a sexual activity postoperatively, the surgical satisfaction and the return to daily activities were comparable between both groups. Robot-assisted laparoscopic sacrocolpopexy seems to be a reliable technique with morbidity, anatomic and functional outcomes comparable to that of laparoscopy.

Sacral Colpopexy Versus Transvaginal Mesh Colpopexy in Obese Patients

ObjectivesObesity can predispose women to pelvic organ prolapse and can also affect the success of pelvic organ prolapse surgery. The purpose of this study was to compare the postoperative anatomical outcomes following sacral colpopexy (SC) and transvaginal mesh colpopexy in a group of obese women with pelvic organ prolapse. MethodsWe conducted a retrospective cohort study of obese women who underwent SC (n = 56) or transvaginal mesh colpopexy (n = 35). Follow-up ranged from 6 to 12 months. Preoperative, perioperative, and postoperative variables were compared using Student t, Mann−Whitney U, and Fisher exact tests, and by analysis of covariance. ResultsThe women in the SC group had significantly higher mean apical vaginal measurements (P < 0.05), and significantly fewer stage II recurrences than women in the transvaginal mesh colpopexy group. There were no significant differences between the groups for other postoperative outcomes, including mesh erosion, recurrent prolapse symptoms, dyspareunia, and surgical satisfaction (P > 0.05). ConclusionIn these 91 obese patients with pelvic organ prolapse, SC resulted in better anatomical outcomes than transvaginal mesh colpopexy. However, the two procedures had similar outcomes with regard to recurrent symptoms and surgical satisfaction.

2121 RANDOMIZED CONTROLLED TRIAL OF LAPAROENDOSCOPIC SINGLE SITE DONOR NEPHRECTOMY VERSUS. CONVENTIONAL LAPAROSCOPIC DONOR NEPHRECTOMY FOR LIVING KIDNEY DONORS

INTRODUCTION AND OBJECTIVES: Laparoendoscopic single site (LESS) surgery has been increasingly used to perform donor nephrectomies. However it remains unclear if the benefits of LESS are limited to improved cosmesis. We performed a randomized controlled trial of LESS versus conventional laparoscopic donor nephrectomy (LDN) to assess potential benefits in clinical outcomes. METHODS: After IRB approval, 100 consecutive patients were randomized to a donor nephrectomy utilizing either the LESS or LDN technique starting January 2011 at a single center. Donors were stratified by laterality, single or multiple arteries, and body mass index (BMI). All LESS procedures utilized the GelPoint system (Applied Medical, RanchoSanta Margarita, CA). Subjects are followed postdonation for complications and satisfaction with validated questionnaires at 2-, 6-, and 12-months. Ninety-three patients had follow-up data for at least 2 months postoperatively. RESULTS: Baseline characteristics were similar between the two treatment arms. There were no significant differences in the overall operative time, warm ischemia time, estimated blood loss, and conversion to hand-assisted laparoscopy rates (p 0.05). There were similarly no differences in the 30and 90-day postoperative complication rates (p 0.05). Of those with follow up of at least 2 months (n 93), 97% of those who underwent LESS reported full recovery at two months, compared to 80% of LDN (p 0.03). There were no significant differences in surgical scar rating or overall satisfaction between LESS and LDN (p 0.05). All allografts had immediate graft function, and donor and graft survival are 100% to date. CONCLUSIONS: In this randomized controlled trial, we found that LESS donor nephrectomies could be performed with similar operative outcomes and postoperative complication rates. LESS donor nephrectomies have a significantly faster recovery time compared to LDN, with no impact on allograft function. Table 1: Outcomes in LDN vs LESS

1843 EVIDENCE-BASED PERIOPERATIVE MANAGEMENT OF WOMEN UNDERGOING PELVIC RECONSTRUCTIVE SURGERY

INTRODUCTION AND OBJECTIVES: Pelvic organ prolapse and female stress urinary incontinence are prevalent, costly, and significantly impact quality of life. The perioperative management of these conditions becomes increasingly important for optimizing outcomes and minimizing complications; however, perioperative regimens differ widely and may not be supported by evidence–based studies. The aim of this pilot study is to evaluate available literature regarding the perioperative management for female patients undergoing pelvic floor reconstructive surgery (PFRS) and to identify evidence gaps to guide development of evidence–based pathways. METHODS: After IRB approval, a PubMed review of the English–language literature using MeSH subheadings was conducted regarding multiple perioperative variables: bowel preparation, antibiotics, antiseptic skin preparation and hair removal, patient positioning, DVT prophylaxis, routes of anesthesia, postoperative analgesia, activity level, diet, and bowel regimen. Five representative operations were selected by approach: (1) sling only; (2) sling with prolapse repair, any route; (3) prolapse repair, vaginal; (4) prolapse repair, abdominal; and, (5) prolapse repair, robotic. Studies were graded using the Oxford Guidelines (Level 1–4), with Level 1 studies representing the highest level of evidence. Grades of recommendation (A–D) were assigned, with Grade A being the highest. RESULTS: Initial search yielded over 4000 potential manuscripts. Out of these, fewer than 150 usable manuscripts could be isolated regarding the chosen perioperative variables. AUA Best Practice Statements exist for prophylactic antibiotic use and DVT prophylaxis (Grade A). There is also Level 1 evidence supporting specific methods of antiseptic skin preparation and pubic/abdominal hair removal (Grade A). The quality of evidence regarding the remaining perioperative variables tends to be low (Grades C and D). The bulk of the information was found in the gynecological and general surgery literature, rather than in the urologic literature. CONCLUSIONS: At present, high–quality, evidence–based support for the way women undergoing PFRS are managed is lacking in several categories. Furthermore, the urologic literature is overall deficient in its content regarding perioperative management strategies. Based on the available literature, we present an evidence–based perioperative protocol for women undergoing PFRS with the future goal of prospective implementation. The ultimate goal is to optimize surgical satisfaction and minimize adverse events.

Another Option for Laparoscopic Living Donor Nephrectomy: A Single Center Experience Comparing Two-Port Versus Hand-Assisted Technique

To compare the clinical outcomes of two-port laparoscopic donor nephrectomy (TPLDN) vs hand-assisted laparoscopic donor nephrectomy (HALDN). Between November 2010 and March 2012, 100 kidney donors scheduled for left nephrectomy were alternatively assigned to HALDN or TPLDN in a 1:1 fashion. All procedures were performed by the same laparoscopic surgeon. Demographic data and intraoperative and early postoperative data were collected prospectively and analyzed. There was no difference in the operating time (133±12 vs 142±17 min, P=0.07), blood loss (55±46 vs 58±52 mL, P=0.84), complication rate (10% vs 12%, P=0.74), and length of hospital stay (3.8±0.8 vs 4.1±2.8 days, P=0.5) between the HALDN and TPLDN groups. The warm ischemia time was longer in the TPLDN group (2.2±0.7 vs 3.5±0.9 min, P<0.001). No statistically significant differences were found in the analgesic requirement and the visual analog pain scores. There was a trend toward quicker return to 100% recovery in the TPLDN group (60±46 vs 39±15 days, P=0.05). The TPLDN group had a significantly smaller surgical incision (8.2±0.6 vs 5.5±0.4 cm, P<0.001) and higher scar satisfaction score (7.8±1.5 vs 8.6±1.3, P=0.02) than the HALDN group. No differences were found in the recipient serum creatinine values or in the incidence of delayed graft function. In comparing TPLDN and HALDN, there was no significant difference in a majority of the operative and postoperative parameters. TPLDN might be associated with smaller surgical incision, improved cosmetic satisfaction, and equivalent recipient graft function.

TVT-O in the treatment of stress urinary incontinence： long-term evaluation and urodynamic study

Objective To evaluate the long-term outcomes, complications and urodynamie parame- ters of using tension-free vaginal tape-obturator （TVT-O） in the treatment of patients with stress urinary in- continence. Methods Preoperative and postoperative evaluations including urodynamic data and quality of life were performed for 24 patients with stress urinary incontinence who were enrolled and treated with TVT-O between May 2007 and June 2011. Results Patients completed long-term postoperative follow-up from 12 to 60 months after surgery. Twenty-one （87.5%） patients achieved long-term subjective success and 22 （91.7%） achieved objective success. Surgical satisfaction and quality of life was high. Long-term postoperative abdominal leak point pressure of 23 patient was greater than 100 cm H20, and the remaining parameters preoperative and postoperative showed no significant differences. Voiding difficulty and external reflection voding desire were the main long-term complications. Conclusions TVT-O is with few compli- cations and high patient satisfaction. It is a simple, safe and effective procedure for treatment of patients with stress urinary incontinence. Long follow-up period is important for the comprehensive evaluation of TVT-O. Postoperative urodynamic study has significance in complications, diagnosis and evaluation. Key words: Urinary incontinence, stress; Tension-free vaginal tape-obturator; Urodynamics; Treatment outcome; Complications

The use of regional anesthetic techniques in pain management in patients undergoing primary knee replacement

During last 30 years orthopedic surgery dramatically improved. The most significant progress had place in joint surgery. Today in many orthopedic centers total hip and knee arthroplasties are made and may be counted in hundreds per year. Surgeons can choose among many different implant operation systems. Nevertheless this type of operations is connected with pain in immediate postoperative course. The aim of the paper was presentation of contemporary methods of pain management after big knee surgery, especially after total knee arthroplasty (TKA). Among presented methods of pain management the anesthetic techniques were discussed: epidural anesthesia (EA) and peripheral nerves blocks (PNB). They seem to be most interesting and evolutionary because of possibility of early ambulation and more effective postoperative rehabilitation. It directly corresponds to therapeutic effect of surgical procedure and patient's satisfaction. In the paper there are presented advantages and possible complications of regional techniques, particular block techniques and technical problems with possible modifications of pain management. This review is based on latest medical literature, especially on metaanalyses published during last few years comparing different modes of postoperative pain management.

Autologous dermal grafts for rectus sheath reconstruction and application in closure of ventral myofascial defects

Ventral abdominal hernias pose a reconstructive challenge, with recurrence rates after primary closure exceeding 50 % and synthetic options at high risk for infection. We describe our experience with using autologous dermis, sourced from the redundant overlying abdominal skin, for reconstruction of ventral abdominal wall defects. We describe the surgical technique, applied anatomy and an analysis of short- and long-term outcomes. Twelve consecutive patients undergoing repair of medium-large size, reducible abdominal wall defects were recruited. The dermal graft technique was used in each case, utilizing an autologous running strip of abdominal skin for reconstruction. Both short- and long-term outcomes were assessed prospectively. Scores were given on a scale of 1-10, with 1 = least/worst and 10 = most/best. The described technique was successfully undertaken in all patients. Long-term follow-up demonstrated a 100 % resumption of normal activities, with an improvement in quality of life and physical activity scores postoperatively, and no recurrences. Short-term complications were notable, with five patients requiring postoperative intensive care unit admission, and seven patients requiring respiratory support. In conclusion, the use of autologous rectus sheath reinforcement may achieve good surgical outcomes and high patient satisfaction. While early respiratory complications should be noted, the potential utility of this technique is worthy of future investigation.

Improving the quality of breast cancer surgical treatment decisions.

6024 Background: Ensuring breast cancer treatment decisions are high quality (i.e., informed and preference-concordant) is a key component of patient centered care. Methods: A web-based decision tool, including an interactive preference clarification exercise, was developed over a one-year period with input from health communication experts, clinicians, and women with breast cancer. Newly diagnosed early stage breast cancer patients from two cancer centers were recruited and randomized to view the tool before or after completing a survey. Mean scores for key outcome measures, including surgical treatment knowledge (4 true/false questions), decision satisfaction (12 questions each with a 5-point Likert scale from strongly agree to strongly disagree), and preference-concordant decisions, were compared between the groups using t-tests. Concordance between preferences and surgical choices was evaluated using the chi-square test. Results: 110 subjects were recruited and 105 completed the study. Their mean age was 57 years, 60% had a college degree or more, and 81% were white. Those viewing the website first had higher scores on several decision outcomes than those taking the survey first (Table). Knowledge scores were also higher among those viewing the website before the survey (3.0 vs. 2.61, p=.23). The risk of recurrence was the most important treatment attribute, followed by retaining the natural breast, in both groups. Concordance between treatment choice and computer generated treatment was 65% for website first and 61% for survey first groups. Conclusions: A tool focused on improving knowledge and preference-concordant decisions produced positive results on breast cancer surgical treatment decision making. Further work should assess the impact of the tool in larger and more diverse populations. [Table: see text]