Transition from open to robotic-assisted radical prostatectomy is associated with a reduction of positive surgical margins amongst private-practice-based urologists

Several recent studies have suggested that thought leaders in radical prostatectomy have decreased their own positive margin rates by switching from open to robot-assisted radical prostatectomy. Theoretically, this improvement is largely attributed to enhanced visualization of the deep pelvis and precision of dissection afforded by the instrumentation. To date, it has not been determined if this phenomenon exists amongst non-fellowship-trained urologists in private practice. Herein, we describe the positive margin rates of two non-fellowship-trained private-practice urologists who converted from open radical retropubic prostatectomy to robot-assisted radical prostatectomy. The margin positivity data from two non-fellowship-trained private-practice urologists (surgeon 1 and surgeon 2) were reviewed retrospectively. The last 50 cases of open radical retropubic prostatectomy from each surgeon were compared with the first 50 robotic prostatectomy cases of surgeons 1 and 2, respectively. A positive surgical margin was defined as tumor present at the inked margin of the prostate. There was a significant decrease in the overall and pT2 positive margin rates for both surgeons. The overall positive margin rate and pT2 positive margin rate for surgeon 1 dropped from 44 to 20% and from 37 to 5.7%, respectively, after changing from open to robotic prostatectomy. For surgeon 2, the overall positive margin rate changed from 26 to 18% and the pT2 positive margin rate changed from 27.5 to 7% after converting. Changing from open to robotic-assisted radical prostatectomy may improve the ability of urologists to obtain negative surgical margins. With proper training this phenomenon does seem to apply to non-fellowship-trained urologists in private practice and can be realized within the first 50 cases performed.     

Influence of intraluminal thrombus on structural and cellular composition of abdominal aortic aneurysm wall

INTRODUCTION: It has been suggested that the intraluminal thrombus of abdominal aortic aneurysm (AAA) affects the underlying vessel wall. Aneurysm enlargement has been associated with growth of thrombus, and rupture has been proposed to occur after bleeding into the thrombus. To examine how thrombus affects the vessel wall, we compared the morphology of aneurysm wall covered with thrombus with wall segments exposed to flowing blood.Material and methods Sixteen patients (14 men, 2 women; age range, 56-79 years) undergoing elective repair of AAA, where computed tomography scans showed thrombus and segments of the aneurysm wall exposed to flowing blood, were included in the study. Specimens from the aneurysm were taken for light and electron microscopy. Masson trichrome staining was performed for wall thickness determination and demonstration of collagen, and Weigert-van Gieson staining for elastin. The cellular composition was analyzed by immunohistochemistry with antibodies against CD3 for T cells, CD4 for T helper cells, CD8 for T cytotoxic cells, CD20 for B cells, CD68 for macrophages, and smooth muscle alpha-actin for smooth muscle cells (SMCs). Caspase-3 staining and TUNEL analysis were performed to evaluate apoptosis. RESULTS: The aneurysm wall covered with thrombus was thinner and contained fewer elastin fibers, and the few that were found were often fragmented. This part of the wall also contained fewer SMCs and more apoptotic nuclei than the wall exposed to flowing blood. Clusters of inflammatory cells were detected in the media of the aneurysm wall and in higher numbers in the parts covered with thrombus. Electron microscopy showed that the aneurysm wall without thrombus contained a dense collagenous matrix with differentiated SMCs. In the segment covered with thrombus, SMCs were more dedifferentiated (synthetic) and apoptotic or necrotic. There were also an increased number of inflammatory cells located in close contact with SMCs in various stages of apoptosis. CONCLUSION: The aneurysm wall covered with thrombus is thinner and shows more frequent signs of inflammation, apoptosis of SMCs, and degraded extracellular matrix. These findings suggest that thrombus formation and accumulation of inflammatory cells may perturb the structural integrity and stability of the vessel wall and thereby increase the risk for aneurysm rupture.     

Can fine-needle aspiration biopsy of thyroid nodule help in determining the extent of surgery in follicular and Hurthle cell neoplasm at a community teaching institution?

Fine-needle aspiration biopsy (FNAB) was used to evaluate cold thyroid nodules in 179 patients treated between 1990 and 1998. The purpose of this study was to see whether FNAB findings of follicular or Hurthle cells could help in planning the extent of thyroid surgery. Group I patients (47) had findings suggestive of follicular or Hurthle cell neoplasm. Group II patients (132) had inconclusive results. In group I FNAB was 100 per cent correct in diagnosing follicular or Hurthle cell neoplasm with a high percentage of malignant findings (malignancy 85 per cent and benign adenoma 15 per cent). In Group II malignancy was found in 16 per cent and benign pathology in 84 per cent. Women were more likely to have malignancy than men. The average age was over 50 years in patients with either malignant or benign nodules. In addition there was no significant difference in average size of benign or malignant nodules (2.9 vs 2.6 cm respectively). When an FNAB finding was suggestive of neoplasm malignancy was found in 85 per cent. On the other hand when an FNAB was inconclusive malignancy was present in 16 per cent. Thus we conclude that using FNAB finding can guide surgical resection and recommend performing total or subtotal thyroidectomy when FNAB is suggestive of neoplasm and lobectomy when FNAB is inconclusive.     

Optimal closure of surgical wounds in forefoot surgery: are adhesive strips beneficial?

A subcuticular suture is an ideal closure method of surgical wounds where the aim is healing by primary intention. The addition of adhesive strips over the subcuticular suture appears to be based on anecdotal, rather than experimental evidence. We performed a prospective study to compare the postoperative wound complications of combination closure with subcuticular closure alone. The wounds of 60 consecutive patients undergoing foot surgery were assessed clinically for wound complications at one week postoperatively. Patients who had a combined closure were more likely to develop wound complications. They were also twice as likely to return to clinic for a further wound check. The addition of adhesive strips to such a closure appears to offer no clinical benefit, and can be detrimental to wound healing. We recommend meticulous closure of surgical wounds with continuous, absorbable, subcuticular suture without adhesive strips, for an optimal outcome.     

Effects of Denosumab and Teriparatide Transitions on Bone Microarchitecture and Estimated Strength: the DATA‐Switch HR‐pQCT study

In postmenopausal osteoporosis, switching from teriparatide to denosumab results in continued bone mineral density (BMD) gains whereas switching from denosumab to teriparatide results in BMD loss. To assess the effects of these transitions on bone microarchitecture and strength, we performed high‐resolution peripheral QCT (HR‐pQCT) at the distal tibia and radius in postmenopausal osteoporotic women who received 24 months of teriparatide 20 μg daily followed by 24 months of denosumab 60 mg every 6 months, 24 months of denosumab followed by 24 months of teriparatide, or 24 months of both medications followed by 24 months of denosumab. The 77 women who completed at least one post‐switch visit are included in this analysis. Tibial cortical volumetric BMD (vBMD) increased between months 24 and 48 in the teriparatide‐to‐denosumab (net 48‐month change –0.8% ± 2.4%) and combination‐to‐denosumab groups (net 48‐month changes +2.4% ± 4.1%) but decreased in the denosumab‐to‐teriparatide group (net 48‐month change –3.4% ± 3.2%, p < 0.001 for all between‐group comparisons). Changes in total vBMD, cortical thickness, and estimated stiffness (by micro–finite element analysis [µFEA]) followed a similar pattern, as did changes at the radius. Conversely, tibial cortical porosity remained stable between months 24 and 48 in the teriparatide‐to‐denosumab and combination‐to‐denosumab groups (net 48‐month changes +7.2% ± 14.8% and –3.4% ± 12.1%, respectively) but increased in the denosumab‐to‐teriparatide group (net 48‐month change +16.2% ± 11.5%, p < 0.05 versus other groups). Trabecular vBMD changes did not differ among groups. Together, these findings demonstrate that in women treated with denosumab, switching to teriparatide is associated with a reduction in total and cortical vBMD, cortical thickness, and estimated strength, whereas switching to denosumab from teriparatide or combination therapy results in improvements in these parameters with the greatest improvements observed in women treated with combined therapy followed by denosumab. These findings strongly suggest that the use of teriparatide after denosumab should be avoided and that the use of combined teriparatide/denosumab followed by denosumab alone may be a useful treatment strategy in those with severe osteoporosis. © 2017 American Society for Bone and Mineral Research.     

Use of pelvic ultrasound in the diagnosis of megarectum in children with constipation

Purpose

It has not been possible so far to differentiate slow transit constipation from functional fecal retention because the existing medical literature lacks data on rectal dimensions for healthy children or children with chronic idiopathic constipation (CIC). We, for the first time, describe the use of pelvic ultrasound (US) to achieve this.

Methods

A pelvic US was carried out on 82 children with a full or partially full bladder and with no history of bowel problems and on 95 children with CIC. The rectal crescent seen behind the bladder was measured. All children also had documentation of their age, weight, and height.

Results

The median age, weight, and height for the healthy children were comparable with those of the children with CIC. The median rectal crescent size in children with constipation was 3.4 cm (range, 2.10-7.0; IQR, 1.0), as compared with 2.4 cm (range, 1.3-4.2; IQR, 0.72) in the healthy children, and this difference is statistically significant on multiple regressions of log for rectal diameter, adjusted for height, weight, and age (P value< .001).

Conclusion

Pelvic US is a quick child-friendly investigation, which can be used to document the presence of megarectum. It should be the first line investigation for all the children with CIC.     

Does Robotic Technology Make Minimally Invasive Cardiac Surgery Too Expensive? A Hospital Cost Analysis of Robotic and Conventional Techniques

BACKGROUND: While potential benefits of robotic technology include decreased morbidity and improved recovery, some have suggested a prohibitively high cost. This study was undertaken to compare actual hospital costs of robotically assisted cardiac procedures with conventional techniques. METHODS: We conducted a retrospective review of clinical and financial data of 20 patients who underwent atrial septal defect (ASD) closure and 20 patients who underwent mitral valve repair (MVr) using either robotic techniques or a conventional approach with a sternotomy. Total hospital cost (actual resource consumption) was subdivided into operative and postoperative costs. RESULTS: Robotic technology did not significantly increase total hospital cost for ASD closure or MVr (p = 0.518 and p = 0.539). However, when including the initial capital investment for the robot through amortization of institutional costs, total hospital cost was increased by $3,773 for robotic ASD closure and $3,444 for robotic MVr (p = 0.021 and p = 0.004). The major driver of cost for robotic cases (operating room time) decreased over time. CONCLUSIONS: Robotic technology did not significantly increase hospital cost. While the absolute cost for robotic surgery was higher than conventional techniques after taking into account the institutional cost of the robot, the major driver of cost for robotic procedures will likely continue to decrease, as the surgical team becomes increasingly familiar with robotic technology. Furthermore, other benefits, such as improvement in postoperative quality of life and more expeditious return to work may make a robotic approach cost-effective. Thus, it is possible that the benefits of robotic surgery may justify investment in this technology.     

Motivations,Barriers, and Outcomes of Patient-Reported Shared Decision Making in Eosinophilic Esophagitis

Digestive Diseases and Sciences - Little is known about patient choice in treatment of eosinophilic esophagitis (EoE). Determine motivators and barriers to using common EoE therapies and describe...