Tertiary Care Referral Center Research Articles

Clinical atlas of rectal cancer highlights the barriers and insufficient interventions underlying the unfavorable outcomes in older patients

BackgroundAging confers an increased risk of developing cancer, and the global burden of cancer is cumulating as human longevity increases. Providing adequate care for old patients with rectal cancer is challenging and complex. MethodA total of 428 and 44,788 patients diagnosed with non-metastatic rectal cancer from a referral tertiary care center (SYSU cohort) and the Surveillance Epidemiology and End Results database (SEER cohort) were included. Patients were categorized into old (over 65 years) and young (aged 50–65 years) groups. An age-specific clinical atlas of rectal cancer was generated, including the demographic and clinicopathological features, molecular profiles, treatment strategies, and clinical outcomes. ResultsOld and young patients were similar in clinicopathological risk factors and molecular features, including TNM stage, tumor location, tumor differentiation, tumor morphology, lymphovascular invasion, and perineural invasion. However, old patients had significantly worse nutritional status and more comorbidities than young patients. In addition, old age was independently associated with less systemic cancer treatment (adjusted odds ratio 0.294 [95% CI 0.184–0.463, P < 0.001]). We found that old patients had significantly worse overall survival (OS) outcomes in both SYSU (P < 0.001) and SEER (P < 0.001) cohorts. Moreover, the death and recurrence risk of old patients in the subgroup not receiving chemo/radiotherapy (P < 0.001 for OS, and P = 0.046 for time to recurrence [TTR]) reverted into no significant risk in the subgroup receiving chemo/radiotherapy. ConclusionsAlthough old patients had similar tumor features to young patients, they had unfavorable survival outcomes associated with insufficient cancer care from old age. Specific trials with comprehensive geriatric assessment for old patients are needed to identify the optimal treatment regimens and improve unmet cancer care. Study registrationThe study was registered on the research registry with the identifier of researchregistry 7635.

Determinants of Patient No-Shows in a Multisite Urogynecology Clinic [ID: 1376316

INTRODUCTION: The objective of this study was to describe sociodemographic and clinical characteristics of patients who “no-show” urogynecology appointments and identify risk factors for “no-show” appointments. METHODS: We conducted an IRB-approved prospective chart review study of women aged 18 years or older scheduled for a urogynecology appointment at four outpatient clinical sites associated with an urban academic tertiary care referral center over 4 months. Patients were included in the no-show group if they did not show up for their appointment or cancelled their appointment the same day. For a comparison group, the patient immediately prior to or after the one who “no-showed” with the same visit type was included. Logistic regression was used to identify risk factors for “no-show” appointments. RESULTS: Four hundred twenty-six women were included, 213 in both the no-show and show groups. Women who “no-showed” were younger (median age 60 [interquartile range (IQR) 47–72] versus 69 [IQR 59–78], P&lt;.001). More women in the no-show group were Hispanic (24.4% versus 13.1%) and non-Hispanic Black (7.51% versus 3.76%, P=.0093), had Medicaid (17.4% versus 6.57%, P=.0006), no-showed a previous appointment (24.9% versus 11.7% P=.0005), had to wait longer for an appointment (median 39 days [IQR 23.5–55.5] versus 30.5 days [IQR 12.8–47.0], P=.002), and made appointments for urinary incontinence (44.1% versus 26.8%, P=.0002). On multivariate logistic regression, women with Medicaid had significantly higher odds of “no-showing” their appointment (adjusted odds ratio, 2.11 [1.04–4.48], P=.0440). CONCLUSION: Women with Medicaid are particularly likely to “no-show” urogynecology appointments. Further research is needed to identify and address potential barriers this group faces when accessing care.

PO-03-058 S-ICD GENERATOR EXCHANGE AND PERFORMANCE: A SINGLE TERTIARY CARE EXPERIENCE

Limited data exist on outcomes of subcutaneous implantable cardiac defibrillators (S-ICDs) generator exchange. Few studies have found that shock impedance increases after S-ICD Gen exchange which correlates with increase in DFT and possibly reduction in S-ICD effectiveness. We describe the performance of S-ICDs after generator exchange in a cohort of patients implanted and followed in a single tertiary-care referral center. We reviewed the device clinic interrogation reports of 525 patients who received S-ICDs between 2012 and 2022 and compared device parameters before and after generator exchanges specifically high-voltage impedance and shock efficacy during follow-up using the paired sample t-test with a 95% CI and p-value of 0.05. A total of 525 S-ICDs were implanted at our facility with an average age at implant of 51±16 years, predominantly males (n=348, 66.3%). The majority of S-ICDs were implanted for primary prevention (413, 79%), and ischemic cardiomyopathy (CM) was the most common type of CM (127, 24%). The average ejection fraction (EF) was 30±12%, and comorbidities were prevalent: 56% hypertension, 29% diabetes, 38% with history of coronary artery disease (CAD), and 33% end-stage renal disease (ESRD). Of those, 76 (15%) underwent generator battery exchange at a median time of 4.5± 2 years. Before generator exchange, a total of 114 shocks (22%) were delivered with an impedance of 68± 23Ω. Of those, 89 (78%) were appropriate shocks. Efficacy of the appropriate shocks was 95%. [F1] [IR2] After generator exchange (n=76), 10 appropriate shocks (13%) were administered with an impedance of 82± 29 Ω, and a shock efficacy of 100%. High voltage impedance and shock efficacy were not statistically different before and after Gen exchange (p=0.178 and p=0.158 respectively). The S-ICD generator exchange demonstrates high safety profile with relatively no change in device impedance or shock efficacy pre- and post- Gen exchange.

Benign Karaciğer Hastalıklarında Endoskopik Ultrason Eşliğinde İnce İğne Aspirasyonu: Tek Merkez Deneyimi

Background and Aim: To report the efficacy and safety results of our initial experience with the endoscopic ultrasound-guided liver biopsy (EUS-LB).&#x0D; &#x0D; Materials and Method: Retrospective analysis of a prospectively maintained database in a tertiary care referral center. Consecutive patients who had EUS-LB for benign parenchymal diseases, using a 19 gauge fine needle with single-pass, three actuations, and wet suction technique between June 2022 and December 2022 were included. Patient demographics, procedure-related parameters, and the quality of specimens were investigated&#x0D; &#x0D; Results: The technical success was 100%. Of the 16 patients, four had a second procedure due to inadequate sampling. The median total sample length, the median number of pieces and the median length of the longest piece in fragmented samples, and the median number of complete portal tracts were 11mm (range, 0.2-2.5), 9.6 (range 0-20), 0.2mm (range 0.2-1.5) and 3.5 (range 0-19) respectively. None of the patients had any adverse events following the procedure.&#x0D; &#x0D; Conclusion: EUS-LB may be an alternative to other liver biopsy procedures but further studies are needed to determine the ideal needle type and technique.

Sinonasal Malignancies Involving the Frontal Sinus: A Mono-Institutional Experience of 84 Cases and Systematic Literature Review.

Frontal sinus involvement by malignant tumors is a rare finding. Therefore, a systematic literature review along with a personal case series may contribute to defining more accurately the epidemiology, treatment options, and outcomes of these neoplasms. This is a retrospective review of patients affected by frontal sinus malignancies surgically treated in a tertiary-care referral center over a period of 20 years. Moreover, a systematic literature review of studies describing frontal sinus cancers from 2000 to date was performed according to PRISMA guidelines in order to analyze current evidence about the treatment and outcomes of such a rare disease. Our retrospective review was basedon 84 cases, treated with an exclusive endoscopic approach in 43 cases (51.2%), endoscopic approach with frontal osteoplastic flap in 6 cases (7.1%), and transfacial or transcranial approaches in 35 cases (41.7%). The five-year overall, disease-specific, disease-free, and recurrence-free survivals were 54.6%, 62.6%, 33.1%, and 59.1%, respectively. Age, dural involvement, type of surgical resection, and surgical margin status were significantly associated with the survival endpoints. In conclusion, the involvement of the frontal sinus is associated with a poor prognosis. Multidisciplinary management, including specific histology-driven treatments, represents the gold standard for improving outcomes and minimizing morbidity.

Barriers and facilitators to seeking care for persons with acute brain infections: a cross sectional study

Background: Acute brain infections including encephalitis are less common but serious conditions characterized by the inflammation of the brain requiring immediate accurate diagnosis and management. For many infections appropriate therapies exist, but the outcome is often less desirable because of failure to receive appropriate treatment on time due to multiple factors. The aim of the study was to understand the barriers and facilitators towards receiving care for persons with acute brain infections in a low resource setting. Methods: The study design was cross sectional exploratory study. Consecutive patients presenting to neurology department of a tertiary referral care center for Neuropsychiatry in South India from July 2020 to September 2020 with the diagnosis of acute brain infections were assessed using the modified Kuppuswamy scale, Glasgow coma scale, the pathway scale: encounter form, patient centered health services in India and client socio-demographic and service receipt inventory. Results: A total of 110 participants, both male and female, were recruited for the study. The average age was 39.64±16.5 years, with more female (65.45%) representation. 29% of individuals reported continued use of traditional practices while seeking care for the brain infections. Costs associated with care increased with the increase in duration of infection. There are major barriers and facilitators which either prohibit or facilitate care for persons with acute brain infections. Conclusions: Acute brain infections continuing to be a public health challenge in developing country context, and the recognition that the delay in treatment causes significant disability, it becomes imperative to focus on the social, cultural, economic, environmental factors to understand the barriers and facilitators to health seeking among this population.

Laparoscopic management of hydatid cysts using long ribbon gauze: An initial experience of 37 consecutive cases

ObjectiveThe laparoscopic approach is becoming the standard of care for many surgical disorders. However, in the case of hydatid cysts, laparoscopic management is challenging due to the risk of spillage of hydatid fluid, which can cause an anaphylactic reaction and recurrence. Here, we report our initial experience with laparoscopic partial pericystectomy of hydatid cysts using long ribbon gauze to decrease intra-operative spillage. MethodThis was a retrospective study (between January 2010 and December 2021) in the Department of Surgical Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Science, a tertiary care referral center in northern India. Here, we have included 37 consecutive patients with hydatid cysts of the liver and spleen. Diagnosis was made by laboratory and imaging findings (abdominal sonography or contrast enhanced CT scans). All patients were managed with laparoscopic partial pericystectomy. Intraoperatively, a betadine-soaked long ribbon gauze, high-pressure suction canula, and an endo-bag were used in all patients. The collected data included patient demography, location, size, and number of cysts, WHO type, operative time, blood loss, postoperative complications, hospital stay and follow-up. ResultIn our series, the mean age was 38.4 ± 13.6 years, 15 (40.5%) were men and 22 (59.5%) were women. The right lobe of the liver was the most commonly affected site (21, 56.8%). The mean operative time was 80.0 ± 32.0 min, and intraoperative blood loss was 23.6 ± 11.5 mL. Bile leak was present in 6 (16.2%) patients. There was no mortality. The hospital stay was 5 (3, 9) days, and no recurrence was observed at a median follow-up of 36 months. ConclusionLaparoscopic partial pericystectomy using this technique is safe in the management of hydatid cysts. Simply, proper packing and safe removal of soaked gauzes can minimize the incidence of postoperative complications and recurrence.

The Outcome of Surgically Treated Proximal Femur Fractures Managed by Ortho-anesthetic Geriatric Care Pathway: A Prospective Observational Study with 2-Year Follow-Up.

Evaluation of the ortho-anesthetic geriatric care pathway for patients with proximal femur fracture in a tertiary care referral center was done by reporting the peri-operative morbidity and mortality. Clinical and demographic predictors of mortality were also identified in this cohort. This prospective observational study was conducted between August 2017 and November 2018. Demographic, anesthetic and surgical characteristics were recorded. Telephonic post-discharge follow-up was done for a period of 2years. Factors predicting mortality were estimated using multivariate logistic regression. The cohort was characterized by frailty, high ASA physical status, NYHA class and Charlson co-morbidity index. The delay in presentation to hospital and subsequent surgical fixation was 7 (1-8) and 8 (5-13) days, respectively. The 30, 60, 90-day, 1-year and 2-year mortality was 13.6%, 21.8%, 25.45%, 36.5% and 44%, respectively. Intra-operative blood transfusion was a predictor of 30-day mortality (OR 9.2, 95% CI 1.02-83.17; p = 0.048). Pre-operative respiratory dysfunction predicted 60-day (OR 11.245, 95% CI 1.38-91.58; p = 0.024) and 90-day (OR 11.654, 95% CI 1.91-71.1; p = 0.008) mortality. Post-operative morbidity was reported in 31 (28.1%) patients; incidence of pneumonia (n = 9), sepsis (n = 8), MI (n = 6), PTE (n = 5) and ARF (n = 3) were 8.18%, 7.27%, 5.45%, 4.54% and 2.72%, respectively. Existing pathway facilitated surgical fixation with median delay of 8days which should be shortened to 48h. High mortality in our cohort needs to be decreased by preventing admission delays and aggressively managing co-morbidities. Acceptable benchmark goals for pre-operative optimization of lung disease and decrease in intra-operative blood transfusion need to be incorporated in existing care pathway.

MP36-09 EXPERIENCE WITH EXTRATUNICAL GRAFTING (ETG) FOR CORRECTION OF INDENTATION DEFORMITY WITHOUT BUCKLING IN MEN WITH PEYRONIE’S DISEASE

You have accessJournal of UrologyCME1 Apr 2023MP36-09 EXPERIENCE WITH EXTRATUNICAL GRAFTING (ETG) FOR CORRECTION OF INDENTATION DEFORMITY WITHOUT BUCKLING IN MEN WITH PEYRONIE’S DISEASE Jose Quesada-Olarte, Spencer Mosack, Daniel Roadman, and Laurence Levine Jose Quesada-OlarteJose Quesada-Olarte More articles by this author , Spencer MosackSpencer Mosack More articles by this author , Daniel RoadmanDaniel Roadman More articles by this author , and Laurence LevineLaurence Levine More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003270.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Peyronie's Disease (PD) can be surgically challenging, especially in men with indentation deformity. Extratunical grafting (ETG) is a relatively new surgical option that be employed to treat corporal indentation in those without buckling or hinge effect. Objective: To report our experience with the ETG procedure, including different grafts or graft location (under or over Buck’s fascia) pre and post-operative patient characteristics, and patient satisfaction. METHODS: We performed a retrospective chart review of patients following ETG, collecting data including baseline demographics, prior treatments, pre-operative deformity, erectile function, type of graft, grafting location (under or over Buck’s), patient satisfaction, and clinical outcomes at our tertiary-care referral center. RESULTS: From December 2018 to July 2022, 33 patients presenting with PD underwent an ETG and TAP and/or PEG (partial plaque excision and grafting) for indentation deformity with a mean follow-up of 14.6 months. Overall, patient satisfaction, specifically for the correction of indentation was 94%. Grafting location under or over Buck's fascia showed no statistical difference in patient satisfaction with penile appearance (54.5% and 72.7%, respectively, p>=0.05). Patients undergoing ETG, with PEG had significantly lower satisfaction with their erect appearance than TAP and ETG (0% and 71.4%, respectively, p=0.003). Several different grafts were used, there was no difference in satisfaction between the grafts used. Palpable graft was reported in 30 patients (91%), but only two were bothered by the graft (6%). Statistical analysis showed no difference in patient satisfaction according to the size of the graft or degree of curve correction. CONCLUSIONS: ETG has emerged as a less invasive and less risky surgical option than PEG to correct indentation deformities which are not associated with buckling or axial instability. Our initial results demonstrate a high rate of satisfaction with correction of indentation, but multiple factors contributed to lower overall satisfaction with appearance of the penis including loss of length (9%), residual curvature (6%), sensory changes (9%), and erectile dysfunction (15.1%). Further studies are needed to determine the optimum approach. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e482 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jose Quesada-Olarte More articles by this author Spencer Mosack More articles by this author Daniel Roadman More articles by this author Laurence Levine More articles by this author Expand All Advertisement PDF downloadLoading ...

MP26-07 ARTIFICIAL INTELLIGENCE-ENABLED AUTOMATED IDENTIFICATION OF KEY STEPS IN ROBOTIC-ASSISTED RADICAL PROSTATECTOMY

You have accessJournal of UrologyCME1 Apr 2023MP26-07 ARTIFICIAL INTELLIGENCE-ENABLED AUTOMATED IDENTIFICATION OF KEY STEPS IN ROBOTIC-ASSISTED RADICAL PROSTATECTOMY Abhinav Khanna, Alenka Antolin, Maya Zohar, Figure Bar, Danielle Ben-Ayoun, Stephen A. Boorjian, Igor Frank, Paras Shah, Vidit Sharma, R. Houston Thompson, Tamir Wolf, Dotan Asselmann, and Matthew Tollefson Abhinav KhannaAbhinav Khanna More articles by this author , Alenka AntolinAlenka Antolin More articles by this author , Maya ZoharMaya Zohar More articles by this author , Figure BarFigure Bar More articles by this author , Danielle Ben-AyounDanielle Ben-Ayoun More articles by this author , Stephen A. BoorjianStephen A. Boorjian More articles by this author , Igor FrankIgor Frank More articles by this author , Paras ShahParas Shah More articles by this author , Vidit SharmaVidit Sharma More articles by this author , R. Houston ThompsonR. Houston Thompson More articles by this author , Tamir WolfTamir Wolf More articles by this author , Dotan AsselmannDotan Asselmann More articles by this author , and Matthew TollefsonMatthew Tollefson More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003254.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Analysis of surgical video allows surgeons to gain valuable insights into their practice. Opportunities include developing best practices, identifying key pitfalls, facilitating situational awareness, and revisiting intraoperative decision-making. However, surgical video review is laborious and time-intensive, thus limiting its routine and widespread use. We aim to develop a computer vision algorithm for automated identification of key surgical steps during robotic-assisted radical prostatectomy (RARP). METHODS: Retrospective surgical videos from RARP performed at a tertiary-care academic referral center were manually annotated by a team of medical image annotators under the supervision of two fellowship-trained urologic oncologists. Full-length surgical videos were annotated with the following steps of surgery: preparation, adhesiolysis, lymph node dissection, Retzius space dissection, anterior bladder neck transection, posterior bladder neck transection, seminal vesicle and posterior dissection, lateral (including neurovascular bundle) and apical dissection, urethral transection, urethrovesical anastomosis, specimen retrieval and final inspection. Manually annotated videos were then utilized to train a computer vision algorithm to perform automated video annotation of RARP surgical video. Accuracy of automated video annotation was determined by comparing to manual human annotations as the reference standard. RESULTS: A total of 107 full-length RARP videos [average 117±40 minutes] were manually annotated with sequential steps of surgery. Of these, 70 cases served as a training dataset for algorithm development, 14 cases were used for internal validation, and 23 were used as a separate testing cohort for evaluating algorithm accuracy. Concordance between AI-enabled automated video analysis and manual human video annotation was 87.6%. Algorithm accuracy was highest for the vesicourethral anastomosis step (98.6%) and lowest for the final inspection and extraction step (63.0%). CONCLUSIONS: We present results of an AI-enabled computer vision algorithm for automated annotation of full-length RARP surgical video. Automated surgical video analysis has practical applications in retrospective video review by surgeons, surgical training, quality assessment, and for the development of future algorithms to associate perioperative and long-term outcomes with intraoperative surgical events. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e354 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Abhinav Khanna More articles by this author Alenka Antolin More articles by this author Maya Zohar More articles by this author Figure Bar More articles by this author Danielle Ben-Ayoun More articles by this author Stephen A. Boorjian More articles by this author Igor Frank More articles by this author Paras Shah More articles by this author Vidit Sharma More articles by this author R. Houston Thompson More articles by this author Tamir Wolf More articles by this author Dotan Asselmann More articles by this author Matthew Tollefson More articles by this author Expand All Advertisement PDF downloadLoading ...

MP61-15 SKILL-ASSESSMENT DURING ROBOT-ASSISTED RADIOGUIDED SURGERY - USING ARTIFICIAL INTELLIGENCE TO EXTRACT KINEMATIC METRICS OF DROP-IN GAMMA PROBE USE

You have accessJournal of UrologyCME1 Apr 2023MP61-15 SKILL-ASSESSMENT DURING ROBOT-ASSISTED RADIOGUIDED SURGERY - USING ARTIFICIAL INTELLIGENCE TO EXTRACT KINEMATIC METRICS OF DROP-IN GAMMA PROBE USE Samaneh Azargoshasb, Hilda A De Barros, Daphne D.D. Rietbergen, Paolo Dell'oglio, Pim J Van Leeuwen, Christian Wagner, Tobias Maurer, Henk G. Van der poel, Matthias N. Van Oosterom, and Fijs W. B. Van Leeuwen Samaneh AzargoshasbSamaneh Azargoshasb More articles by this author , Hilda A De BarrosHilda A De Barros More articles by this author , Daphne D.D. RietbergenDaphne D.D. Rietbergen More articles by this author , Paolo Dell'oglioPaolo Dell'oglio More articles by this author , Pim J Van LeeuwenPim J Van Leeuwen More articles by this author , Christian WagnerChristian Wagner More articles by this author , Tobias MaurerTobias Maurer More articles by this author , Henk G. Van der poelHenk G. Van der poel More articles by this author , Matthias N. Van OosteromMatthias N. Van Oosterom More articles by this author , and Fijs W. B. Van LeeuwenFijs W. B. Van Leeuwen More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003319.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Radioguided prostate cancer (PCa) surgery has been greatly facilitated by the introduction of the steerable DROP-IN gamma probe technology. Reported indications include sentinel node (SN) resections and prostate-specific membrane antigen (PSMA)-targeted resections. Both make use of 99mTc-labeled imaging vectors. As result of the targeting mechanisms used the signal- and background intensities in these procedures, however, differ substantially. To study how this reflects on the surgical decision-making process we used computer-vision strategies to compare DROP-IN gamma probe use during SN- and PSMA-targeted surgeries. METHODS: A DROP-IN gamma probe was applied during 45 robot-assisted PCa surgeries from 2018 to 2021 at single tertiary care referral centre: SN resections [n=25; primary surgery; intraprostatic injection of indocyanine green (ICG)-99mTc-nanocolloid (∼200MBq, 5-6h prior to surgery)], PSMA-targeted resections [n=20; salvage surgery; intravenous injection of 99mTc-PSMA I&S (∼550MBq, 16-22h prior to surgery)}. Preoperative imaging-roadmaps were created using SPECT/CT and PET/CT imaging. Using custom tracking algorithms, based on a neural network architecture, the DROP-IN probe trajectories were extracted from endoscopic videos. Trajectories were then processed to extract key kinematic performance metrics. To allow for skill-assessment, the metrics were incorporated in decision-making and dexterity scores. RESULTS: The nodal signal intensities in PSMA- vs SN-targeted resections were 550 vs. 1200 counts in preoperative SPECT-CT scans (p=0.098) and 150 vs 1050 counts/s with regard to intraoperative probe readouts (p<0.001). Due to the relatively high background signals observed during PSMA tracing a 2-fold reduction in the intraoperative signal to background ratio (SBR) (1.8 vs. 3.6; p<0.001) was observed in this setting. Kinematic analysis revealed significant differences in a number of metrics, e.g., target identification time (368 sec per PSMA lesion vs. 75 sec per SLN; p<0.001), number of probe pick-ups (5 vs. 1; p<0.001), and reduction in dexterity (281-fold; p<0.001) and decision-making scores (3.9-fold; p<0.001) during PSMA-targeted resections. CONCLUSIONS: DROP-IN technology facilitates robotic radioguided surgery in SN and PSMA-targeted resections. However, a profound performance difference was observed in favour of SN-targeted resections. In particular, the SBR<2 as found mostly in PSMA-targeted resections directly converted to a decline in dexterity and decision-making. These findings might be related to limited previously experience in PSMA-targeted surgery. Source of Funding: This research was supported by an NWO-TTW-VICI grant (TTW 16141) and with hardware by Eurorad S.A. and Intuitive Inc. © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e858 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Samaneh Azargoshasb More articles by this author Hilda A De Barros More articles by this author Daphne D.D. Rietbergen More articles by this author Paolo Dell'oglio More articles by this author Pim J Van Leeuwen More articles by this author Christian Wagner More articles by this author Tobias Maurer More articles by this author Henk G. Van der poel More articles by this author Matthias N. Van Oosterom More articles by this author Fijs W. B. Van Leeuwen More articles by this author Expand All Advertisement PDF downloadLoading ...

Parapneumonic effusion in children: Rapid pathogen detection in pleural fluid using multiplex bacterial PCR.

Parapneumonic effusion in children: Rapid pathogen detection in pleural fluid using multiplex bacterial PCR.

Fecal Microbiota Transfer for Clostridium difficile Infection and Its Effects on Recurrent Urinary Tract Infection.

Recurrent urinary tract infection (rUTI) poses a significant management challenge, and fecal microbiota transfer (FMT) has been shown in a limited manner to positively effect rUTI. The objective of this study was to compare UTI rates after FMT for Clostridium difficile infection (CDI) in patients with previously diagnosed rUTI and patients without a previous diagnosis of rUTI. This was a retrospective cohort study of female patients who underwent FMT between 2015 and 2020 and were identified from a database at a tertiary care referral center. The electronic medical record was queried for demographic and UTI characteristics in the 3 years before and 5 years after FMT, which were compared between patients with or without a preexisting history of rUTI. One hundred thirty-five patients were included, 17 of whom had a preexisting history of rUTI. The median number of culture-proven UTIs was 1 in the rUTI group versus 0 in the non-rUTI group both in the 1 year (P = 0.003) and 3 years (P < 0.001) before FMT. Most UTIs before and after FMT were Escherichia coli UTIs (53.8%) and carried some antibiotic resistance (54.6%). Comparatively, in the year after FMT, there were no differences between groups in UTI frequency or antibiotic administration (0 [0-1] vs 0.5 [0-1], P = 0.28). A trend toward decreased frequency of UTI in the 1 year after FMT was seen in the rUTI group. On survival analysis, there was a nonsignificant decrease in the 3-year UTI-free rate for the rUTI group compared with the non-rUTI group (76.5% vs 90.1%, P = 0.07). Patients with recurrent UTI undergoing FMT for recurrent CDI experienced a trend toward a decrease in frequency of UTI after FMT.

Effect of sterile vs clean gloves for cervical checks in labor on maternal infection at term: a randomized trial

Intrapartum infection usually warrants immediate delivery and impacts 5-12% of term pregnancies, with the most commonly identified pathogenic organism being of the Ureaplasma genus. When performing cervical examinations during labor, providers in the United States commonly use sterile gloves, although there are no data currently to support that this practice reduces rates of infection. Furthermore, in nearly all other settings of Gynecologic care, aside from surgery in an operating room, nonsterile gloves are used. Even though the uterus could be sterile in normal pregnancies, the provider performing the cervical examination must traverse the milieu of vaginal bacteria in order to reach the cervix to perform the exam, introducing vaginal microbiota into the uterus regardless of the type of glove used. This prospective randomized controlled study examines whether the type of glove used (sterile vs clean) impacts the rates of intrapartum infection in patients receiving cervical examinations during labor or induction of labor at term.. This study aimed to evaluate if the glove type (sterile vs clean) used for cervical examinations during labor affects the rates of intrapartum and postpartum infection. This randomized controlled trial assigned eligible and consenting participants to receive cervical examinations during labor with either sterile powder-free polyvinyl chloride examination gloves (current routine practice, control group) or clean powder-free nitrile examination gloves (nonsterile, experimental group). The primary outcome was rates of intrapartum infection (chorioamnionitis). Sample size calculations estimated that 300 participants would be needed with a rate of infection of 10% in the control group and 20% in the experimental group to demonstrate difference between the groups; however, the rates of infection were much lower than expected, at 5.4% and 4.4% in the sterile and clean glove group, respectively. At this point, it was determined futile to continue the study because a sample size of >29,000 participants would be needed, which would not be achievable at a single tertiary care referral center with approximately 3500 deliveries per year. The study was approved by the Eastern Virginia Medical School Institutional Review Board (IRB 21-09-FB-0206), and was registered at ClinicalTrials.gov (identifier NCT05603624; https://clinicaltrials.gov/ct2/show/NCT05603624). A total of 163 participants with singleton pregnancies completed the study; 74 (45%) were randomized to the sterile glove group, and 89 (55%) were randomized to the clean glove group. In the sterile glove group, 4 (5.4%) developed intrapartum infection (chorioamnionitis) and 1 (1.3%) developed postpartum infection (endometritis). In the clean glove group, 4 (4.4%) developed intrapartum infection and 2 (2.2%) developed postpartum infection. There was no significant difference in rates of intrapartum infection (P=1.0) or postpartum infection (P=1.0), or combined rates of infection (including both chorioamnionitis and endometritis; P=.99) between the sterile and the clean glove group. When comparing the participants from both groups who had any intrapartum or postpartum infection (n=11) with those who had no infection (n=152), the former were more likely to be nulliparous (P=.01), have lower gravidity (P<.01) and parity (P<.01), have longer times from first cervical examination to delivery (P=.02), have longer times from rupture of membranes to delivery (P=.0001), undergo cesarean delivery (P=.0002), and experience postpartum hemorrhage (P=.001). Although participants who were in labor for a longer time also likely had more cervical examinations, these data could suggest that duration of labor (P=.02) is more closely associated with infectious morbidity compared with the number of cervical examinations (P=.15). Using clean gloves for cervical examinations during labor is unlikely to increase risk of infection, and could reduce cost by up to 92.4% at our institution, saving over $25,000 annually.

Recall patterns and risk of primary liver cancer for subcentimeter ultrasound liver observations: a multicenter study

Patients with cirrhosis and subcentimeter lesions on liver ultrasound are recommended to undergo short-interval follow-up ultrasound because of the presumed low risk of primary liver cancer (PLC). The aim of this study is to characterize recall patterns and risk of PLC in patients with subcentimeter liver lesions on ultrasound. We conducted a multicenter retrospective cohort study among patients with cirrhosis or chronic hepatitis B infection who had subcentimeter ultrasound lesions between January 2017 and December 2019. We excluded patients with a history of PLC or concomitant lesions ≥1cm in diameter. We used Kaplan Meier and multivariable Cox regression analyses to characterize time-to-PLC and factors associated with PLC, respectively. Of 746 eligible patients, most (66.0%) had a single observation, and the median diameter was 0.7cm (interquartile range: 0.5-0.8cm). Recall strategies varied, with only 27.8% of patients undergoing guideline-concordant ultrasound within 3-6 months. Over a median follow-up of 26 months, 42 patients developed PLC (39 HCC and 3 cholangiocarcinoma), yielding an incidence of 25.7 cases (95% CI, 6.2-47.0) per 1000 person-years, with 3.9% and 6.7% developing PLC at 2 and 3 years, respectively. Factors associated with time-to-PLC were baseline alpha-fetoprotein >10ng/mL (HR: 4.01, 95% CI, 1.85-8.71), platelet count ≤150 (HR: 4.90, 95% CI, 1.95-12.28), and Child-Pugh B cirrhosis (vs. Child-Pugh A: HR: 2.54, 95% CI, 1.27-5.08). Recall patterns for patients with subcentimeter liver lesions on ultrasound varied widely. The low risk of PLC in these patients supports short-interval ultrasound in 3-6 months, although diagnostic CT/MRI may be warranted for high-risk subgroups such as those with elevated alpha-fetoprotein levels.

Comparison of the Subcutaneous and Intramuscular Estradiol Regimens as Part of Gender-Affirming Hormone Therapy

ObjectiveGender-affirming hormone therapy guidelines describe the estradiol (E2) doses for intramuscular (IM), but not subcutaneous (SC), routes. The objective was to compare the SC and IM E2 doses and hormone levels in transgender and gender diverse individuals. MethodsThis is a retrospective cohort study at a single-site tertiary care referral center. Patients were transgender and gender diverse individuals who received injectable E2 with at least 2 E2 measurements. The main outcomes were the dose and serum hormone levels between the SC and IM routes. ResultsThere were no statistically significant differences in age, body mass index, or antiandrogen use between patients on SC (n = 74) and those on IM (n = 56). The weekly doses of SC E2, 3.75 mg (IQR, 3-4 mg), were statistically significantly lower than those of IM E2, 4 mg (IQR, 3-5.15 mg) (P =.005); however, the E2 levels achieved were not significantly different (P =.69), and the testosterone levels were in the cisgender female range and not significantly different between routes (P =.92). Subgroup analysis demonstrated significantly higher doses in the IM group when the E2 and testosterone levels were >100 pg/mL and <50 ng/dL, respectively, with the presence of the gonads or use of antiandrogens. Multiple regression analysis demonstrated that the dose was significantly associated with the E2 levels after adjusting for injection route, body mass index, antiandrogen use, and gonadectomy status. ConclusionBoth the SC and IM E2 achieve therapeutic E2 levels without a significant difference in the dose (3.75 vs 4 mg). SC may achieve therapeutic levels at lower doses than IM .

Radical nephrectomy in medically underserved patients: Selection bias and disparity in surgical health care delivery.

609 Background: Disparities in outcomes of renal cell carcinoma (RCC) exist with respect to survival outcomes between different ethnic, and socioeconomic groups. We sought to evaluate disparities in delivery of surgical care between medically underserved (MU) and non-medically underserved (NMU) patients. Methods: We conducted a single-center retrospective analysis of consecutive patients presenting with localized renal cortical neoplasms who underwent surgical excision [Radical (RN) or Partial Nephrectomy (PN)] at an academic tertiary-care referral center. The cohort was divided into MU and NMU groups and descriptive analyses were conducted for demographics and clinical disease characteristics, type of surgery, time to surgery, estimated blood loss, and 30-day total and major complications (Clavien-Dindo, ≥3). Cochran-Armitage trend analysis was conducted to evaluate for surgical trends, and logistic regression multivariable analyses (MVA) were conducted for type of surgery and major complications. Results: 1418 patients were analyzed (MU n=334/NMU n=1084). Comparing MU vs. NMU, no differences were noted for age (p=0.612), Charlson Comorbidity Index (p=0.803), tumor size (p=0.236), or time to surgery (p=0.482). Significantly greater proportions of white patients were noted in NMU (60.6% vs. MU=45.5%, p&lt;0.001) and higher proportion of RN in MU (47% vs. NMU=40.4%, p=0.028). Subgroup analyses of PN groups revealed no differences with respect to demographics, tumor size (p=0.33), major complications (p=0.66), or blood loss (p=0.583). Subgroup analysis of RN revealed significantly higher proportion of non-white patients (p=0.019) and patients with diabetes (p=0.019). MVA for predictors for receipt of RN were non-white (OR1.4, p=0.002), MU (OR=1.32, p=0.043), age (OR=1.01, p=0.009) and treatment year (OR=0.913, p&lt;0.001). MVA for predictors for 30 day major complications demonstrated RN (OR=0.913 p&lt;0.001). Cochran-Armitage trend analysis indicated that both MU and NMU had significant increases in PN between 2003 and 2021 (p&lt;0.0001). Conclusions: Despite overall similarities with respect to demographics and clinical disease characteristics and time to surgery, MU status was associated with a significantly higher odds of receiving a RN at a tertiary care referral center, which represents a disparity in care and possible selection bias. Nonetheless, RN was also associated with a decreased risk of complications. While trends have demonstrated an increase in proportion of PN for both NMU and MU groups, comparative underutilization of PN in MU patients may be associated with increased downstream risks to health. Further investigation is requisite.

Satisfaction among persons with epilepsy towards physical consultation versus online video consultation for follow-up

PurposeTelemedicine gained popularity in the setting of the COVID-19 pandemic. We aimed to study the satisfaction levels of persons with epilepsy (PWE) with online video consultation (OVC) and physical consultation (PC). MethodsThis was a cross-sectional questionnaire-based study conducted in a tertiary referral care center for epilepsy in India. All PWE who had availed of both OVC and PC were included. Those who did not give consent to a questionnaire were excluded. A questionnaire was given to assess patients’ satisfaction regarding OVC and PC. Scores for each question for both OVC and PC were compared. ResultsOne hundred and forty-one patients who had PC earlier and later availed of OVC from December 2020 to July 2021 formed the cohort. Seventy one patients who responded to the questionnaire were included. 49% and 51% of the patients belonged to urban and rural regions respectively. 8.5% of the patients were off anti-seizure medications (ASM), while 5.6% and 85.9% were on single and multiple ASMs respectively. There were no differences between PC and OVC regarding ease of getting the appointment, privacy during a consultation, patients’ perceived chances of missing consultations, and overall comfort and experience on either type of consultation. Physical consultation scored more than OVC in patients’ satisfaction with the time doctor spent with them, an opportunity to communicate their queries well, clarifications received from the doctor, and the likelihood of patients recommending the particular type of consultation to others(p < 0.05). ConclusionsOnline video consultation can be a satisfactory alternative to PC and can improve patient satisfaction if some of the issues in OVC are addressed properly.

Hertel Exophthalmometry Values in a Greek Adult Outpatient Clinic-Based Population: Association With Demographic Factors and Systemic Disease.

To investigate correlations of exophthalmometry values (EVs) with age, gender, and the presence of diabetes mellitus, arterial hypertension, and dyslipidemia. In a cross-sectional, clinic-based study, consecutive adult Greek patients presenting for evaluation at the outpatient general clinic on a scheduled appointment basis at a tertiary care referral center were submitted to Hertel exophthalmometry in both eyes by the same observer. Subjects with signs ofhistory or orbital pathology, including thyroid-associated ophthalmopathy, were excluded. Demographics, as well as a detailed systemic history report, were recorded. Mixed effect linear regression analysis was performed to account for the correlation between the eyes ofthe same participant. A total of 800 eyes (400 subjects) were included, 194 males and 206 females, with a mean age of 67.82 ± 12 years (range: 18-92 years). The mean exophthalmometry value was 15.7 ± 2.6 mm (range: 11-21 mm). Every one year of increase in age is associated with a decrease in EVs by 0.03 mm (95% CI -0.04, -0.02/p-value<0.001). Female gender was associated with lower EVs by 0.33mm (95% CI-0.56, -0.1/p-value=0.005). Patients with diabetes mellitus had higher EVs by 0.47 mm (95% CI 0.25, 0.70/p-value<0.001) compared to patients without diabetes, and patients with arterial hypertension had lower EVs by 0.26 mm (95% CI -0.5, -0.02/p-value=0.034) compared to patients without hypertension. No association was found between dyslipidemia and systemic history of thyroid dysfunction. Conclusions: A negative correlation of EVs was noted with increasing age, female gender, as well as history of arterial hypertension and a positive correlation with diabetes mellitus.

Understanding the Role of Ureteral Access Sheath in Preventing Post-Operative Infectious Complications in Stone Patients Treated with Ureteroscopy and Ho:YAG Laser Lithotripsy: Results from a Tertiary Care Referral Center.

The use of ureteral access sheaths (UAS) limits the irrigation-induced increase in intrarenal pressure during ureteroscopy (URS). We investigated the relationship between UAS and rates of postoperative infectious complications in stone patients treated with URS. Data from 369 stone patients treated with URS from September 2016 to December 2021 at a single institution were analyzed. UAS (10/12 Fr) placement was attempted in case of intrarenal surgery. The chi-square test was used to assess the relationship between the use of UAS and fever, sepsis, and septic shock. Univariable and multivariable logistic regression analyses tested the association of patients' characteristics and operative data and the rate of postoperative infectious complications. Full data collection of 451 URS procedures was available. Overall, UAS was used in 220 (48.8%) procedures. As for postoperative infectious sequalae, we recorded fever (n = 52; 11.5%), sepsis (n = 10; 2.2%), and septic shock (n = 6; 1.3%). Of those, UAS was not used in 29 (55.8%), 7 (70%), and 5 (83.3%) cases, respectively (all p > 0.05). At multivariable logistic regression analysis, performing URS without UAS was not associated with the risk of having fever and sepsis, but it increased the risk of septic shock (OR = 14.6; 95% CI = 1.08-197.1). Moreover, age-adjusted CCI score (for fever-OR = 1.23; 95% CI = 1.07-1.42, sepsis-OR = 1.47; 95% CI = 1.09-1.99, and septic shock-OR = 1.61; 95% CI = 1.08-2.42, respectively), history of fever secondary to stones (for fever-OR = 2.23; 95% CI = 1.02-4.90) and preoperative positive urine culture (for sepsis-OR = 4.87; 95% CI = 1.12-21.25) did emerge as further associated risk factors. The use of UAS emerged to prevent the onset of septic shock in patients treated with URS, with no clear benefit in terms of fever and sepsis. Further studies may help clarify whether the reduction in fluid reabsorption load mediated by UAS is protective against life-threatening conditions in case of infectious complications. The patients' baseline characteristics remain the main predictors of infectious sequelae in a clinical setting.