The primary determinants of radiation use during fixation of proximal femur fractures

Objectives

To establish the primary determinants of operative radiation use during fixation of proximal femur fractures.

Design

Retrospective cohort study.

Setting

Level I trauma centre.

Cohort

205 patients treated surgically for subtrochanteric and intertrochanteric femoral fractures.

Main outcome measures

Fluoroscopy time, dose-area-product (DAP).

Results

Longer fluoroscopy time was correlated with higher body mass index (p = 0.04), subtrochanteric fracture (p < 0.001), attending surgeon (p = 0.001), and implant type (p < 0.001). Increased DAP was associated with higher body mass index (p < 0.001), subtrochanteric fracture (p = 0.002), attending surgeon (p = 0.003), lateral body position (p < 0.001), and implant type (p = 0.05).

Conclusion

The strongest determinants of radiation use during surgical fixation of intertrochanteric and subtrochanteric femur fractures were location of fracture, patient body position, patient body mass index, and the use of cephalomedullary devices. Surgeon style, presumably as it relates to teaching efforts, seems to strongly influence radiation use.     

Comparison of outcomes after triceps split versus sparing surgery for extra-articular distal humerus fractures

Objectives

To compare elbow range of motion (ROM), triceps extension strength, and functional outcome of AO/OTA type A distal humerus fractures treated with a triceps-split or -sparing approach.

Design

Retrospective review.

Setting

Two level one trauma centres.

Patients

Sixty adult distal humerus fractures (AO/OTA 13A2, 13A3) presenting between 2008 and 2012 were reviewed. Exclusion criteria removed 18 total patients from analysis and three patients died before final follow-up.

Intervention

Patients were divided into two surgical approach groups chosen by the treating surgeon: triceps split (16 patients) or triceps sparing (23 patients).

Main outcome measurements

Elbow ROM and triceps extension strength testing were completed in patients after fractures had healed. All patients were also given the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire.

Results

Compared to the triceps-split cohort, the triceps-sparing cohort had greater elbow flexion (sparing 143 ± 7° compared to split 130 ± 12°, p = 0.03) and less extension contracture (sparing 6 ± 8° compared to split 23 ± 4°, p < 0.0001). Triceps strength compared to the uninjured arm also favoured the triceps-sparing cohort (sparing 88.9 ± 28.3% compared to split 49.4 ± 17.0%, p = 0.007). DASH scores were not statistically significant between the two cohorts (sparing 14.5 ± 12.2 compared to split 23.6 ± 22.3, p = 0.333).

Conclusions

A triceps-sparing approach for surgical treatment of extra-articular distal humerus fractures can result in better elbow ROM and triceps strength than a triceps-splitting approach. Both approaches, however, result in reliable union and similar functional outcome.

Level of evidence

Level III.     

A comprehensive update on current fixation options for two-part proximal humerus fractures: A biomechanical investigation

Background

Recent advancements in implant technology offer updated options for surgical management that have been rapidly adopted into clinical practice. The objective of this study is to biomechanically test and compare the current fixation options available for surgical fixation of two-part proximal humerus fractures and establish load to failure and stiffness values.

Methods

Sixteen match-paired (32 total) fresh-frozen, cadaveric specimens were randomized to receive 1 of 4 fixation constructs following creation of an AO/OTA Type 11A3 (two-part) proximal humerus fractures. Fixation constructs tested consisted of 3.5 mm fixed angle plate (3.5-FAP), 4.5 mm fixed angle plate (4.5-FAP), humeral intramedullary nail (IMN), and a humeral intramedullary nail with a fixed angle blade (IMN-FAB). Specimen bone density was measured to ensure no adequate, non-osteoporotic bone. Constructs were tested for stiffness and ultimate load to failure and compared via one-way ANOVA analysis with subsequent post hoc Tukey HSD multiple group comparison statistical analysis.

Results

The IMN-FAB construct was significantly stiffer than the 3.5-FAP construct (123.8 vs. 23.9, p < 0.0001), the 4.5-FAP construct (123.8 vs. 33.3, p < 0.0001) and the IMN construct (123.8 vs. 60.1, p = 0.005). The IMN-FAB construct reported a significantly higher load to failure than the 3.5-FAB construct (4667.3 N vs. 1756.9 N, p < 0.0001), and the 4.5-FAP construct (4667.3 N vs. 2829.4 N, p = 0.019, Table 2). The IMN construct had a significantly higher load to failure than the 3.5-FAP construct (3946.8 vs. 1756.9, p = 0.001, Table 2).

Conclusion

Biomechanical testing of modern fixation options for two-part proximal humerus fracture exhibited that the stiffest and highest load to failure construct was the IMN-FAB followed by the IMN, 3.5-FAP and then the 4.5-FAP constructs. However, prospective clinical trials with longer-term follow-up are required for definitive assessment of the ideal fixation construct for surgical management of two-part proximal humerus fractures.     

Mid-term results in relation to age and analysis of predictive factors after fixation of acetabular fractures using the modified Stoppa approach

Introduction

Data concerning outcome after management of acetabular fractures by anterior approaches with focus on age and fractures associated with roof impaction, central dislocation and/or quadrilateral plate displacement are rare.

Methods

Between October 2005 and April 2009 a series of 59 patients (mean age 57 years, range 13–91) with fractures involving the anterior column was treated using the modified Stoppa approach alone or for reduction of displaced iliac wing or low anterior column fractures in combination with the 1st window of the ilioinguinal approach or the modified Smith-Petersen approach, respectively. Surgical data, accuracy of reduction, clinical and radiographic outcome at mid-term and the need for endoprosthetic replacement in the postoperative course (defined as failure) were assessed; uni- and multivariate regression analysis were performed to identify independent predictive factors (e.g. age, nonanatomical reduction, acetabular roof impaction, central dislocation, quadrilateral plate displacement) for a failure. Outcome was assessed for all patients in general and in accordance to age in particular; patients were subdivided into two groups according to their age (group “<60 yrs”, group “≥60 yrs”).

Results

Forty-three of 59 patients (mean age 54 yrs, 13–89) were available for evaluation. Of these, anatomic reduction was achieved in 72% of cases. Nonanatomical reduction was identified as being the only multivariate predictor for subsequent total hip replacement (Adjusted Hazard Ratio 23.5; p < 0.01). A statistically significant higher rate of nonanatomical reduction was observed in the presence of acetabular roof impaction (p = 0.01). In 16% of all patients, total hip replacement was performed and in 69% of patients with preserved hips the clinical results were excellent or good at a mean follow up of 35 ± 10 months (range: 24–55). No statistical significant differences were observed between both groups.

Conclusion

Nonanatomical reconstruction of the articular surfaces is at risk for failure of joint-preserving management of acetabular fractures through an isolated or combined modified Stoppa approach resulting in total joint replacement at mid-term. In the elderly, joint-preserving surgery is worth considering as promising clinical and radiographic results might be obtained at mid-term.     

Physician-based emergency medical service deployment characteristics in severe traumatic brain injury: A Dutch multicenter study

Introduction

Prehospital guidelines advise advanced life support in all patients with severe traumatic brain injury (TBI). In the Netherlands, it is recommended that prehospital advanced life support is particularly provided by a physician-based helicopter emergency medical service (P-HEMS) in addition to paramedic care (EMS). Previous studies have however shown that a substantial part of severe TBI patients is exclusively treated by an EMS team. In order to better understand this phenomenon, we evaluated P-HEMS deployment characteristics in severe TBI in a multicenter setting.

Methods

The database included patient demographics, prehospital and injury severity parameters and determinants of EMS or EMS/P-HEMS dispatch in 334 patients with severe TBI admitted to level 1 trauma centres in the Netherlands.

Results

P-HEMS was deployed in 62% of patients with severe TBI. Patients treated by the P-HEMS had a higher injury severity score (29 (20–38)) vs. (25 (16–30); P < 0.001), more frequently required blood product transfusions (41% vs. 29%; P = 0.03) and recurrently suffered from TBI with extracranial injuries (33% vs. 6%; P < 0.001) than patients solely treated by an EMS. The prehospital endotracheal intubation rate was higher in the P-HEMS group in isolated TBI (93% vs. 19%; P < 0.001) or TBI with extracranial injuries (96% vs. 43%; P < 0.001) compared to the EMS group. In the EMS group, more patients were secondary referred to a level 1 trauma centre (32% vs. 4%; P < 0.001 vs. P-HEMS). Despite higher injury severity levels in P-HEMS patients, 6-month mortality rates were similar among groups, irrespective of the presence of extracranial injuries in addition to TBI. Deployment of P-HEMS estimated 52% and 72% (P < 0.001) in urban and rural regions, respectively, with comparable endotracheal intubation rates among regions.

Conclusions

This study shows that a physician-based HEMS was more frequently deployed in patients with severe TBI in the presence of extracranial injuries, and in rural trauma regions. Treatment of severe TBI patients by a paramedic EMS only was associated with a higher incidence of secondary referrals to a level I trauma centre. Our data support adjustment of local prehospital guidelines for patients with severe TBI to the geographical context.     

Mayo Adhesive Probability Score: An Accurate Image-based Scoring System to Predict Adherent Perinephric Fat in Partial Nephrectomy

Background

Image-based renal morphometry scoring systems are used to predict the potential difficulty of partial nephrectomy (PN), but they are centered entirely on tumor-specific factors and neglect other patient-specific factors that may complicate the technical aspects of PN. Adherent perinephric fat (APF) is one such factor known to make PN difficult.

Objective

To develop an accurate image-based nephrometry scoring system to predict the presence of APF encountered during robot-assisted partial nephrectomy (RAPN).

Design, setting, and participants

We prospectively analyzed 100 consecutive RAPNs performed by one surgeon and defined APF as the need for subcapsular renal dissection to isolate the renal tumor for RAPN.

Outcome measurements and statistical analysis

The scoring algorithm to predict the presence of APF was developed with a multivariable logistic regression model using a forward selection approach with a focus on improvement in the area under the receiver operating characteristic curve.

Results and limitations

Thirty patients (30%; 95% confidence interval, 21–40) had APF. Single-variable analysis noted an increased likelihood of APF in male patients (p < 0.001), higher body mass index (p = 0.003), greater posterior perinephric fat thickness (p < 0.001), greater lateral perinephric fat thickness (p < 0.001), and those with perirenal fat stranding (p < 0.001). Two of these variables, posterior perinephric fat thickness and stranding, were most highly predictive of APF in multivariable analysis and were therefore used to create a risk score, termed Mayo Adhesive Probability (MAP) and ranging from 0 to 5, to predict the presence of APF. We observed APF in 6% of patients with a MAP score of 0, 16% with a score of 1, 31% with a score of 2, 73% with a score of 3–4, and 100% of patients with a score of 5.

Conclusions

MAP score accurately predicts the presence of APF in patients undergoing RAPN. Prospective validation of the MAP score is required.

Patient summary

The Mayo Adhesive Probability score that we we developed is an accurate system that predicts whether or not adherent perinephric, or “sticky,” fat is present around the kidney that would make partial nephrectomy difficult.     

Incidence and prediction of inadequate preoxygenation before induction of anaesthesia

Background

Preoxygenation aims to obtain an expired oxygen fraction (FEO₂) ≥ 90%. Little is known about the incidence and predictors of inadequate preoxygenation in the clinical setting.

Patients and methods

Over a 12-month period, 1050 consecutive preoperative patients were prospectively included. Preoxygenation was performed for 3 minutes with a facial mask using a machine circuit and 12-L/min oxygen flow. Inadequate preoxygenation was defined as an FEO₂ < 90%. A logistic regression was performed to identify incidence and independent predictors.

Results

The patient characteristics were: age 51 ± 20 years, 47% male, BMI of 26 ± 5 kg/m², and ASA score (median [extremes]) of 2 [1–4]. Inadequate preoxygenation was observed in 589 patients (56%). The effective FiO₂ delivered was lower in the patients with inadequate preoxygenation than in those with adequate preoxygenation, 95 ± 3% vs. 98 ± 2%, P < 0.001. The difference between the FiO₂ and the FEO₂ was higher (12 ± 6% vs. 6 ± 3%, P < 0.0001) in patients with inadequate preoxygenation compared with those with adequate preoxygenation. The independent risk factors for inadequate preoxygenation were: firstly, bearded male (odds ratio [OR] of 9.1 [2.7–31.4] P < 0.001); secondly, beardless male (OR 2.4 [1.6–3.4] P < 0.001), thirdly, ASA score of 4 (OR 9.1 [2.6–31.2] P < 0.015); fourthly, ASA score of 2–3 (OR 2.4 [1.6–3.4] P < 0.015); fifthly, lack of teeth (OR 2.4 [1.2–4.5] P < 0.006), and lastly age > 55 years (OR 1.8 [1.2–2.7] P < 0.005).

Conclusion

Inadequate preoxygenation, defined as an FEO₂ < 90% despite 3-min tidal volume breathing, was a common occurrence. The predictive factors share an overlap with those previously identified for difficult mask ventilation.     

Surgical complications after immediate nephrectomy versus preoperative chemotherapy in non-metastatic Wilms' tumour: Findings from the 1991–2001 United Kingdom Children's Cancer Study Group UKW3 Trial

Purpose

To compare surgical complication rates after immediate nephrectomy versus delayed nephrectomy following preoperative chemotherapy in children with non-metastatic Wilms’ tumour enrolled in UKW3, both in randomised patients and in those for whom the treatment approach was defined by parental or physician choice.

Methods

Records for all patients enrolled into UKW3 were reviewed. Any record of tumour rupture or surgical complication was extracted and comparisons made between the two treatment strategies in both populations of randomised and non-randomised patients.

Results

Of 525 children enrolled, 205 patients were randomised to either immediate nephrectomy (n = 103) or pre-operative chemotherapy followed by delayed nephrectomy (n = 102). Of the 320 children not randomised, data were available on 189 cases treated with immediate nephrectomy and 103 treated with pre-operative chemotherapy. There were significantly fewer surgical complications in randomised children given pre-operative chemotherapy before surgery compared to children undergoing immediate nephrectomy (1% vs. 20.4%, P < 0.001); this difference was most marked for tumour rupture (0% vs. 14.6%, P < 0.001).

Conclusions

Delayed nephrectomy for Wilms’ tumour, preceded by pre-operative chemotherapy was associated with fewer surgical complications compared with immediate nephrectomy.     

Surgical results of concomitant treatment of deltoid contracture and rotator cuff tear

Background

Contracture of the deltoid muscle is an uncommon disorder. The symptoms usually are nonspecific and the diagnosis may be missed, especially when combined with other shoulder disorders, such as rotator cuff lesions. Few reports have described the surgical treatment of combined deltoid contracture and a torn rotator cuff. The purpose of this study was to share our experiences in the diagnosis and treatment of patients, who sustained deltoid contracture combined with rotator cuff tearing.

Materials and methods

Between April 2001 and December 2006, 18 consecutive patients underwent concomitant treatment for distal release of deltoid contracture and repair of a torn rotator cuff. The mean age at operation was 55.1 years. There were eight female and ten male patients. The acromial type, winging angle of the scapula and thickest diameter of the deltoid fibrotic band were measured using preoperative magnetic resonance imaging studies. The abduction-contracture angle, extension-contracture angle, horizontal-adduction angle and Constant and Murley scores were measured preoperatively and at the latest follow-up.

Results

There were nine complete rotator cuff tears and nine partial tears. At an average of 5 years and 3 months’ follow-up, the mean abduction-contracture angle significantly improved from 27° to 0° (p < 0.001), the mean extension-contracture angle improved from 13° to 0° (p < 0.001), and, the mean horizontal-adduction angle improved from 8° to 44° (p < 0.001). The mean Constant score also improved from 69 points to 95 points (p < 0.001).

Conclusions

If a symptomatic torn rotator cuff and deltoid contracture co-exist, simultaneous operative treatment of both conditions is highly recommended.     

Laparoscopy utilization and outcomes for appendicitis in small children

Purpose

To examine the trends in laparoscopic appendectomy (LA) utilization and outcomes for children 5 years or younger.

Methods

We studied 16,028 inpatient admissions for children 5 years of age or less undergoing an appendectomy for acute appendicitis in 2000, 2003, and 2006 using the Kids' Inpatient Database (KID). Laparoscopy frequency, hospital length of stay, and complications were reviewed.

Results

In 2000, 2003 and 2006 appendectomies were done laparoscopically 11.4%, 18.7% and 31.3% of the time, respectively. Children were more likely to undergo LA at a children's hospital (P < 0.001). LA complications were less likely overall (OR: 0.80, CI: 0.70–0.92, P = 0.002) and in perforated cases (OR: 0.78, CI: 0.67-0.91, P = 0.001). LA decreased hospital length of stay by 0.54 days for all patients and 0.70 days for perforated cases (P < 0.001).

Conclusions

Open appendectomy has historically been the standard in children 5 years of age and younger. Laparoscopic appendectomy has slowly gained acceptance for the treatment of appendicitis in smaller children. The use of laparoscopy has increased significantly at all facilities. Furthermore, laparoscopic appendectomy in this age group has a comparatively low complication rate and short hospital length of stay, and is safe in complicated perforated appendicitis cases.     

Health-related quality of life of hospitalized patients with burns—Comparison with general population and a 2-year follow-up

Objective

Health-related quality of life (HRQoL) has gained increasing interest as an important indicator of adaptation after a burn injury. Our objective was to compare HRQoL of medium severity hospitalized burn victims with no need for intensive care treatment with that of the general population.

Methods

The 15D HRQoL questionnaire at discharge, and 6, 12 and 24 months thereafter.

Results

44 patients filled in the baseline questionnaire between June 2007 and December 2009. At discharge the mean (SD) HRQoL score (on a scale of 0–1) of the patients was worse in comparison with that of the general population (0.839 (0.125) vs. 0.936 (0.071)), p < 0.001. The most striking differences (p < 0.001) were seen on the dimensions of sleeping, usual activities, discomfort and symptoms, and sexual activity. At the 2-year follow-up the mean HRQoL score had increased from 0.835 (0.121) to 0.856 (0.149), but the difference was not statistically significant. Of the dimensions, moving and usual activities improved statistically significantly.

Conclusions

HRQoL of patients hospitalized for treatment of burns is, at discharge, compromised compared with that of the general population. During follow-up HRQoL showed slight improvement but remained at a clearly lower level.     

Impact of Adjuvant Radiation Therapy on Urinary Continence Recovery After Radical Prostatectomy

Background

Little is known about the impact of adjuvant radiation therapy (aRT) after radical prostatectomy (RP) on urinary continence (UC).

Objective

To evaluate the impact of aRT on UC recovery in patients with unfavourable pathologic characteristics.

Design, setting, and participants

The study included 361 patients with either pT2 with positive surgical margin(s) or pT3a/pT3b node-negative disease treated with RP at a tertiary care referral centre.

Intervention

Patients were stratified according to the administration of aRT into two groups: group 1 (no aRT; n = 208; 57.8%) and group 2 (aRT; n = 153; 42.2%).

Outcome measurements and statistical analysis

Continence was defined as no use of protective pads. Log-rank test was used to compare the rate of UC recovery according to aRT status. The association between aRT and UC was also tested in Cox regression models after accounting for age, Cancer of the Prostate Risk Assessment (CAPRA) score, nerve-sparing (NS) status, Charlson Comorbidity Index, body mass index, and year of surgery.

Results and limitations

At a mean follow-up of 30 mo, 254 patients (70.4%) recovered complete UC. The 1- and 3-yr UC recovery was 51% and 59% for patients submitted to aRT versus 81% and 87% for patients not receiving aRT, respectively (p < 0.001). At univariable analysis, older age (p < 0.001), presence of non–organ-confined disease (p < 0.001), non-NS procedure (p < 0.001), and delivery of aRT (p < 0.001) were significantly associated with lower UC. At multivariable analysis, the delivery of aRT remained an independent predictor of worse UC recovery (hazard ratio: 0.57; p = 0.001). Patients treated with aRT had a 1.6-fold higher risk of incontinence. Younger age (p = 0.02), lower CAPRA score (p = 0.03), and NS approach (p < 0.001) also represented independent predictors of UC recovery. The main limitations of the study are related to the lack of validated questionnaires in the evaluation of UC and in the lack of information regarding UC status at aRT.

Conclusions

The delivery of aRT has a detrimental effect on UC. The oncologic benefits must be balanced with an impaired UC recovery. Patients should be informed of such impairment before adjuvant treatments are planned.     

Heterogeneity of the effects of combined nitric oxide synthase inhibition on organ perfusion in ovine sepsis

Introduction

Previous studies demonstrated beneficial effects of early neuronal nitric oxide synthase (nNOS) and subsequent inducible NOS (iNOS) inhibition on the development of multiple organ dysfunctions in septic sheep. However, the effects of NOS inhibition on regional blood flow remained undetermined. The current study was conducted to assess the effects of combined NOS inhibition on blood flow to various organs in an ovine sepsis model.

Methods

Eighteen adult, female sheep were randomly allocated to the following groups: (1) sham-injured, non-treated group, (2) injured (smoke inhalation and instillation of Pseudomonas aeruginosa into the lungs), non-treated group (control), and (3) injured, treated group (specific nNOS inhibition from 1 h to 12 h and iNOS inhibition from 12 h to 24 h post-injury). Fluorescent microspheres were injected at baseline and various time points post-injury. At the end of the 24-h experimental period, tissue from various organs was harvested.

Results

Blood flow to the ileum was significantly increased in the control group from 12 h to 24 h versus sham (P < 0.05). This increase was attenuated in the treatment group (P < 0.05). In contrast, blood flow to the pancreas was significantly increased in the treatment group after 12 h and 24 h versus both sham and control (P < 0.05). Blood flow to the spleen was significantly lower after 24 h in the control group versus sham and treatment (P < 0.05 both).

Conclusions

Combined NOS inhibition significantly influenced the pathologically altered organ perfusion during ovine sepsis. However, this treatment strategy showed heterogeneous effects on organ perfusion, perhaps dependent on the sepsis-related degree of NO production and ensuing changes in regional flow.     

Photographic assessment of burn wounds: A simple strategy in a resource-poor setting

Objective

To validate the use of photographic burn wound assessment in evaluation of burn size and wound characteristics.

Methods

Feasibility study of agreement between methods of measurement of burn size and characteristics, in patients admitted to the burn unit at Kamuzu Central Hospital (KCH), Malawi, over two months in 2011. Burn wounds were photographed and assessed clinically, concurrently, by an experienced clinician. Photographs reviewed by two blinded burn clinicians after 4–6 weeks. Correlation between clinical assessment and photographic evaluation was calculated using kappa score and Pearson's correlation coefficient.

Results

Thirty-nine patients were included in evaluation of TBSA, and fifty wounds assessed for their characteristics. Pearson's correlation coefficient for agreement of TBSA between clinical exam and photograph review by expert#1, and #2, was 0.96, 0.93 (p < 0.001), respectively. Pearson's correlation coefficients comparing expert#1 and #2 to the gold standard were: proportion of full-thickness burn (0.88 and 0.81, p < 0.001), and epithelialized superficial burn (0.89 and 0.55, p < 0.001). Kappa scores were significant for wound evolution (expert#1 0.57, expert#2 0.64, p < 0.001), and prognosis (expert#1 0.80, expert#2 0.80, p < 0.001).

Conclusions

Burn assessment with digital photography is a valid and affordable alternative to direct clinical exam, alleviating access issues to burn care in developing countries.     

Features Associated with Recurrence Beyond 5 Years After Nephrectomy and Nephron-Sparing Surgery for Renal Cell Carcinoma: Development and Internal Validation of a Risk Model (PRELANE score) to Predict Late Recurrence Based on a Large Multicenter Database (CORONA/SATURN Project)

Background

Approximately 10–20% of recurrences in patients treated with nephrectomy for renal cell carcinoma (RCC) develop beyond 5 yr after surgery (late recurrence).

Objective

To determine features associated with late recurrence.

Design, setting, and participants

A total of 5009 patients from a multicenter database comprising 13 107 RCC patients treated surgically had a minimum recurrence-free survival of 60 mo (median follow-up [FU]: 105 mo [range: 78–135]); at last FU, 4699 were disease free (median FU: 103 mo [range: 78–134]), and 310 patients (6.2%) experienced disease recurrence (median FU: 120 mo [range: 93–149]).

Interventions

Patients underwent radical nephrectomy or nephron-sparing surgery.

Outcome measurements and statistical analysis

Multivariable regression analyses identified features associated with late recurrence. Cox regression analyses evaluated the association of features with cancer-specific mortality (CSM).

Results and limitations

Lymphovascular invasion (LVI) (odds ratio [OR]: 3.07; p < 0.001), Fuhrman grade 3–4 (OR: 1.60; p = 0.001), and pT stage >pT1 (OR: 2.28; p < 0.001) were significantly associated with late recurrence. Based on accordant regression coefficients, these parameters were weighted with point values (LVI: 2 points; Fuhrman grade 3–4: 1 point, pT stage >1: 2 points), and a risk score was developed for the prediction of late recurrences. The calculated values (0 points: late recurrence risk 3.1%; 1–3 points: 8.4%; 4–5 points: 22.1%) resulted in a good-, intermediate- and poor-prognosis group (area under the curve value for the model: 70%; 95% confidence interval, 67–73). Multivariable Cox regression analysis showed LVI (HR: 2.75; p < 0.001), pT stage (HR: 1.24; p < 0.001), Fuhrman grade (HR: 2.40; p < 0.001), age (HR: 1.01; p < 0.001), and gender (HR: 0.71; p = 0.027) to influence CSM significantly. Limitations are based on the multicenter and retrospective study design.

Conclusions

LVI, Fuhrman grade 3/4, and a tumor stage >pT1 are independent predictors of late recurrence after at least 5 yr from surgery in patients with RCC. We developed a risk score that allows for prognostic stratification and individualized aftercare of patients with regard to counseling, follow-up scheduling, and clinical trial design.     

Gender and Age Differences in the Perception of Bother and Health Care Seeking for Lower Urinary Tract Symptoms: Results from the Hospitalised and Outpatients’ Profile and Expectations Study

Background

Few comparisons have been made of health care seeking behaviour for lower urinary tract symptoms (LUTS) between men and women, as well as trends across age groups.

Objective

To investigate the bother from LUTS and effect on health care seeking in both men and women of different age groups and in comparison between the two genders.

Design, setting, and participants

A representative cross section of each of 13 clinics of a general academic hospital, with equal numbers of subjects recruited in each of six design cells that were defined by age (18–40, 41–60, 61–80 yr) and gender.

Intervention

A 2-h in-person interview, conducted by a trained psychologist/interviewer in a clinic office.

Measurements

Severity of LUTS was measured by the International Prostate Symptom Score (IPSS). Treatment seeking was measured by a single item. A bother question was modified to assess overall bother. Impact on quality of life (QoL) was measured by the IPSS QoL question.

Results and limitations

The final study sample comprised 415 patients. More women than men reported the presence of LUTS (85.5% vs 75.2%; p = 0.01). LUTS were more bothersome in women (25.4% of women vs 17.6% of men with bother “some” or “a lot”; p = 0.02). Severity of LUTS increased with age in both genders (men: p < 0.001; women: p = 0.03). Bother from LUTS increased as severity of symptoms increased in both genders (p < 0.001) but was associated with age only in men (p < 0.001). QoL showed similar results as bother. Although men and women had equal prevalence of treatment seeking (27.9% vs 23.7%; p = 0.40), men, but not women, were more likely to seek treatment as age (p < 0.01) and severity of LUTS (p < 0.001) increased. In multivariate logistic regressions, only bother from LUTS was associated with treatment seeking in women, compared with bother, age, and the presence of voiding symptoms in men.

Conclusions

In our hospital-based sample, differences in LUTS frequency, bother, and health care seeking profiles between men and women suggest a different perception and response to LUTS between the two genders.     

Bloqueio dos nervos ílio‐hipogástrico/ilioinguinal em correção de hérnia inguinal para tratamento da dor no pós‐operatório: comparação entre a técnica de marcos anatômicos e a guiada por ultrassom

Objectives

The purpose of this study is to compare the efficacy of iliohypogastric/ilioinguinal nerve blocks performed with the ultrasound guided and the anatomical landmark techniques for postoperative pain management in cases of adult inguinal herniorrhaphy.

Methods

40 patients, ASA I–II status were randomized into two groups equally: in Group AN (anatomical landmark technique) and in Group ultrasound (ultrasound guided technique), iliohypogastric/ilioinguinal nerve block was performed with 20 ml of 0.5% levobupivacaine prior to surgery with the specified techniques. Pain score in postoperative assessment, first mobilization time, duration of hospital stay, score of postoperative analgesia satisfaction, opioid induced side effects and complications related to block were assessed for 24 h postoperatively.

Results

VAS scores at rest in the recovery room and all the clinical follow‐up points were found significantly less in Group ultrasound (p < 0.01 or p < 0.001). VAS scores at movement in the recovery room and all the clinical follow‐up points were found significantly less in Group ultrasound (p < 0.001 in all time points). While duration of hospital stay and the first mobilization time were being found significantly shorter, analgesia satisfaction scores were found significantly higher in ultrasound Group (p < 0.05, p < 0.001, p < 0.001 respectively).

Conclusion

According to our study, US guided iliohypogastric/ilioinguinal nerve block in adult inguinal herniorrhaphies provides a more effective analgesia and higher satisfaction of analgesia than iliohypogastric/ilioinguinal nerve block with the anatomical landmark technique. Moreover, it may be suggested that the observation of anatomical structures with the US may increase the success of the block, and minimize the block‐related complications.     

Complete Continence after Botulinum Neurotoxin Type A Injections for Refractory Idiopathic Detrusor Overactivity Incontinence: Patient-Reported Outcome at 4 Weeks

Background

Objective improvement following intradetrusor injections of botulinum neurotoxin type A (BoNTA) is well documented. Although patient-related outcome measures are highly recommended for monitoring overactive bladder symptoms, no study before has dealt with the question of patient-reported complete continence after BoNTA treatment using validated questionnaires.

Objective

To investigate the change in patient-reported continence rate after intradetrusor injections of BoNTA for treatment of refractory idiopathic detrusor overactivity (IDO) incontinence.

Design, setting, and participants

Seventy-four patients (51 women, 23 men) with refractory IDO incontinence treated for the first time with intradetrusor injections of 200 U BoNTA were evaluated in this nonrandomised, open-label, cohort study.

Measurements

Changes in patient-reported urinary frequency, urgency incontinence, and stress incontinence were assessed using the condition-specific validated short form of the Urogenital Distress Inventory (UDI 6) before and 4 wk after BoNTA treatment.

Results and limitations

The patient-reported outcome of complete continence (defined as a score of 0 in both the urgency and stress incontinence subscales of the UDI 6) was 51% (38 of 74) 4 wk after intradetrusor injections of BoNTA. In patients who were not completely continent, median urgency incontinence scores reduced significantly from 100 to 0 (p < 0.001), stress incontinence scores from 33 to 0 (p < 0.001), and median urinary frequency scores from 100 to 33 (p < 0.001), respectively. The inclusion of patients with mixed incontinence may have resulted in underestimation of the complete continence rate.

Conclusions

An excellent response with >50% of patients reporting complete continence 4 wk after BoNTA treatment reveals the efficacy of this emerging treatment for patients with refractory IDO incontinence. Furthermore, in those in whom complete continence was not achieved, there was a notable and significant reduction in reported urgency incontinence, stress incontinence, and urinary frequency.     

Long-term Cancer-specific Outcomes of TaG1 Urothelial Carcinoma of the Bladder

Background

Few studies have investigated the natural history of TaG1 urothelial carcinoma of the bladder (UCB).

Objective

To assess the long-term outcomes of patients with TaG1 UCB and the impact of immediate postoperative instillation of chemotherapy (IPIC).

Design, setting, and participants

A retrospective analysis of 1447 patients with TaG1 UCB treated between 1996 and 2007 at eight centers. Median follow-up was 67.2 mo (interquartile range: 67.9). Patients were stratified into three European Association of Urology (EAU) guidelines risk categories; high-risk patients (n = 11) were excluded.

Intervention

Transurethral resection of the bladder with or without IPIC.

Outcome measurements and statistical analysis

Univariable and multivariable Cox regression models addressed factors associated with disease recurrence, disease progression, death of disease, and any-cause death.

Results and limitations

Of the 1436 patients, 601 (41.9%) and 835 (58.1%) were assigned to low- and intermediate-risk categories, respectively. The actuarial estimate of 5-yr recurrence-free survival was 56% (standard error: ±1). Advancing age (p = 0.04), tumor >3 cm (p = 0.001), multiple tumors (p < 0.001), and recurrent tumors (p < 0.001) were independently associated with increased risk of disease recurrence, whereas IPIC was associated with decreased risk (p = 0.001). The actuarial estimate of 5-yr progression-free survival was 95% ± 1. Advancing age (p < 0.001) and multiple tumors (p = 0.01) were independent risk factors for disease progression. Five-year cancer-specific survival was 98% ± 1. Advancing age (p = 0.001) and previous recurrence (p = 0.04) were associated with increased risk, whereas female gender (p = 0.02) was associated with decreased risk of cancer-specific mortality. Compared with low-risk patients, intermediate-risk patients were at significantly higher risk of disease recurrence, disease progression, and cancer-specific mortality (all p < 0.01). Limitations include the retrospective design of the study and the lack of a central pathology review.

Conclusions

TaG1 UCB patients experience heterogeneous risks of disease recurrence. We validated the EAU guidelines risk stratification in TaG1 UCB patients. IPIC was associated with a reduced risk of disease recurrence in patients with low- and intermediate-risk TaG1 UCB.     

Athermal Division and Selective Suture Ligation of the Dorsal Vein Complex During Robot-Assisted Laparoscopic Radical Prostatectomy: Description of Technique and Outcomes

Background

Apical dissection and control of the dorsal vein complex (DVC) affects blood loss, apical positive margins, and urinary control during robot-assisted laparoscopic radical prostatectomy (RALP).

Objective

To describe technique and outcomes for athermal DVC division followed by selective suture ligation (DVC-SSL) compared with DVC suture ligation followed by athermal division (SL-DVC).

Design, settings, and participants

Retrospective study of prospectively collected data from February 2008 to July 2010 for 303 SL-DVC and 240 DVC-SSL procedures.

Surgical procedure

RALP with comparison of DVC-SSL prior to anastomosis versus early SL-DVC prior to bladder-neck dissection.

Measurements

Blood loss, transfusions, operative time, apical and overall positive margins, urine leaks, catheterization duration, and urinary control at 5 and 12 mo evaluated using 1) the Expanded Prostate Cancer Index (EPIC) urinary function scale and 2) continence defined as zero pads per day.

Results and limitations

Men who underwent DVC-SSL versus SL-DVC were older (mean: 59.9 vs 57.8 yr, p < 0.001), and relatively fewer white men underwent DVC-SSL versus SL-DVC (87.5% vs 96.7%, p < 0.001). Operative times were also shorter for DVC-SSL versus SL-DVC (mean: 132 vs 147 min, p < 0.001). Men undergoing DVC-SSL versus SL-DVC experienced greater blood loss (mean: 184.3 vs 175.6 ml, p = 0.033), and one DVC-SSL versus zero SL-DVC were transfused (p = 0.442). Overall (12.2% vs 12.0%, p = 1.0) and apical (1.3% vs 2.7%, p = 0.361) positive surgical margins were similar for DVC-SSL versus SL-DVC. Although 5-mo postoperative urinary function (mean: 72.9 vs 55.4, p < 0.001) and continence (61.4% vs 39.6%, p < 0.001) were better for DVC-SSL versus SL-DVC, 12-mo urinary outcomes were similar. In adjusted analyses, DVC-SSL versus SL-DVC was associated with shorter operative times (parameter estimate [PE] ± standard error [SE]: 16.84 ± 2.56, p < 0.001), and better 5-mo urinary function (PE ± SE: 19.93 ± 3.09, p < 0.001) and continence (odds ratio 3.39, 95% confidence interval 2.07–5.57, p < 0.001).

Conclusions

DVC-SSL versus SL-DVC improves early urinary control and shortens operative times due to fewer instrument changes with late versus early DVC control.