Quality of care: partial cystectomy for bladder cancer--a case of inappropriate use?

PURPOSE: Partial cystectomy is perceived to be a less morbid, less technically demanding procedure than radical cystectomy, although only select patients (approximately 6% to 10%) are appropriate candidates (solitary tumor in space/time, absence of carcinoma in situ). From a quality of care perspective, overuse of partial cystectomy may signify inappropriate delivery of health care. MATERIALS AND METHODS: Subjects who underwent extirpative treatment for bladder cancer between 1988 and 2000 were identified within the Surveillance, Epidemiology and End Results (SEER, 3,381) registry and the Nationwide Inpatient Sample (NIS, 22,088). Adjusted models were developed to identify clinical factors independently associated with the use of partial cystectomy for bladder cancer treatment within each sample. RESULTS: Among patients who underwent extirpative surgery for bladder cancer, 18% and 20% of those in SEER and NIS, respectively, underwent partial cystectomy. Significant decreases in use between early and later years were noted in both samples (SEER-22% to 13%, NIS-24% to 17%, both p <0.0001). Partial cystectomy was preferentially used in the elderly, those with stage I disease, females and black patients. Furthermore, partial cystectomy was more commonly provided in rural, nonteaching, low volume hospitals. CONCLUSIONS: Trends in national use of partial cystectomy are consistent between the NIS and SEER with 13% to 17% of patients currently being treated with partial in lieu of radical cystectomy. Partial cystectomy is disproportionately used in certain medical centers (nonteaching, rural, low volume) and patient populations (elderly, black, females, stage I disease) reflecting selective referral or overuse.     

Pelvic floor exercises for erectile dysfunction

OBJECTIVE: To examine the role of pelvic floor exercises as a way of restoring erectile function in men with erectile dysfunction. PATIENTS AND METHODS: In all, 55 men aged > 20 years who had experienced erectile dysfunction for > or = 6 months were recruited for a randomized controlled study with a cross-over arm. The men were treated with either pelvic floor muscle exercises (taught by a physiotherapist) with biofeedback and lifestyle changes (intervention group) or they were advised on lifestyle changes only (control group). Control patients who did not respond after 3 months were treated with the intervention. All men were given home exercises for a further 3 months. Outcomes were measured using the International Index of Erectile Function (IIEF), anal pressure measurements and independent (blinded) assessments. RESULTS: After 3 months, the erectile function of men in the intervention group was significantly better than in the control group (P < 0.001). Control patients who were given the intervention also significantly improved 3 months later (P < 0.001). After 6 months, blind assessment showed that 40% of men had regained normal erectile function, 35.5% improved but 24.5% failed to improve. CONCLUSION: This study suggests that pelvic floor exercises should be considered as a first-line approach for men seeking long-term resolution of their erectile dysfunction.     

Radiological findings and healing patterns of incomplete stress fractures of the pars interarticularis

Objective The objective was to retrospectively record the CT and MRI features and healing patterns of acute, incomplete stress fractures of the pars interarticularis. Method The CT scans of 156 adolescents referred with suspected pars interarticularis stress fractures were reviewed. Patients with incomplete (grade 2) pars fractures were included in the study. Fractures were assessed on CT according to vertebral level, location of cortical involvement and direction of fracture propagation. MRI was also performed in 72 of the 156 cases. MRI images of incomplete fractures were assessed for the presence of marrow oedema and cortical integrity. Fracture healing patterns were characterised on follow-up CT imaging. Results Twenty-five incomplete fractures were identified in 23 patients on CT. All fractures involved the inferior or infero-medial cortex of the pars and propagated superiorly or superolaterally. Ninety-two percent of incomplete fractures demonstrated either complete or partial healing on follow-up imaging. Two (8%) cases progressed to complete fractures. Thirteen incomplete fractures in 11 patients confirmed on CT also had MRI, and 92% demonstrated oedema in the pars. Ten out of thirteen fractures (77%) showed a break in the infero-medial cortex with intact supero-lateral cortex, which correlated with the CT findings. MRI incorrectly graded one case as a complete (grade 3) fracture, and 2 cases as (grade 1) stress reaction. Six fractures had follow-up MRI, 67% showed partial or complete cortical healing, and the same number showed persistent marrow oedema. Conclusions Incomplete fracture of the pars interarticularis represents a stage of the evolution of a complete stress fracture. The direction of fracture propagation is consistent, and complete healing can be achieved in most cases with appropriate clinical management. CT best demonstrates fracture size and extent, and is the most appropriate modality for follow-up. MRI is limited in its ability to fully depict the cortical integrity of incomplete fractures of the pars, but the presence of marrow oedema on fat-saturated T2-weighted sequences is a useful means of detecting acute spondylolysis.     

To thin or not to thin: the use of the anterolateral thigh flap in the reconstruction of intraoral defects.

The anterolateral thigh (ALT) flap has achieved popularity recently for free-flap reconstruction of intraoral defects following excision of squamous cell carcinoma. We have assessed the feasibility of the ALT flap as a free flap for oral lining and the potential use of the thinned ALT flap in a one-stage reconstruction. We used the ALT flap to reconstruct the oral cavity in 18 consecutive patients between December 2000 and December 2001 following intraoral resection of squamous cell carcinoma. Twelve patients underwent reconstruction using a standard ALT flap, four patients received a thinned ALT flap in a one-stage procedure, one patient received a standard ALT flap in combination with a fibula flap and one patient received a combination of a standard ALT flap and vascularised iliac bone. There were no complications in any of the 14 cases in which a standard ALT flap was used. Two of these flaps were thinned subsequently as secondary procedures. Of the four thinned ALT flaps, one flap failed completely and two flaps experienced partial necrosis. In all but one case the donor site was closed directly with minimal donor-site morbidity. The ALT flap is a versatile flap that can be used in combination with other flaps for more complex defects with minimal donor-site morbidity and is a useful alternative in the armamentarium of the head and neck surgeon. Thinning of the flap is best performed as a secondary procedure, should it be required.     

Titanium elastic nailing in femoral diaphyseal fractures of children in 6-16 years of age

Background:

Management of femoral diaphyseal fractures in the age group of 6-16 years is controversial. There has been a resurgence worldwide for operative fixation.

Materials and Methods:

Twenty-two children (18 boys, 4 girls) aged 6-16 years with recent (> 3 days) femoral diaphyseal fractures (20 closed, 2 open) were stabilized with Titanium Elastic Nail (TEN). These fractures were in proximal third (n=3), middle third (n=15) and in the distal third (n=4) 17 patients underwent surgery within seven days of their injury. The results were evaluated using Flynn''s scoring criteria. Statistical analysis was done using Fischer''s exact test.

Results:

All 22 patients were available for evaluation after a mean of 26 months (14-36 months) of followup. Radiological union in all cases were achieved in a mean time of 8.7 weeks. Full weight bearing was possible in a mean time of 8.8 weeks. Mean duration of hospital stay was 9.8 days. The results were excellent in 13 patients (59.0%), successful in six (27.2%) and poor in three patients (13.6%). All patients had early return to school.

Conclusion:

Intramedullary fixation titanium elastic nailing is an effective treatment of diaphyseal fractures of the femur in properly selected patients of the 6-16 years age group.     

Effect of apolipoprotein E genotype on hematoma volume after trauma.

OBJECT: The apolipoprotein E-epsilon4 (APOE-epsilon4) allele is associated with poor outcome after head injury and spontaneous intracerebral hemorrhage (SICH). The aims of this study were to determine if patients in whom one or more APOE-epsilon4 alleles are present are more likely to sustain intracranial mass lesions after head injury and to determine whether there is an isoform-specific effect on the size of the intracranial hematoma. METHODS: The authors performed a computerized volumetric analysis of 142 hematomas visible on computerized tomography (CT) scans obtained in 129 patients. The APOE genotype was determined by subjecting buccal smear samples to polymerase chain reaction and restriction enzyme digestion. Allele frequencies were similar in head-injured patients with and without intracranial hematomas (p = 0.36). Univariate analysis revealed that in those patients with one or more APOE-epsilon4 alleles hematoma volume was greater (cube root-transformed values) than that found in patients without the APOE-epsilon4 allele (3.1 cm compared with 2.5 cm, p = 0.0039). The results of univariate analysis also suggested significant effects of patient age, injury severity (mild, moderate, or severe according to admission Glasgow Coma Scale scores) and hematoma location (extraaxial, intraaxial, or both) on hematoma volume. The mechanism of injury (assault, fall, or other) was marginally associated with hematoma volume (p = 0.052). Time from injury to CT scan, hypoxia, and hypotension had no significant effect on hematoma volume. The results of multiple linear regression analysis showed that the presence of an APOE-epsilon4 allele and an extraaxial hematoma location were independent predictors of hematoma volume, after adjusting for patient age, hours between injury and CT scan, injury severity, and injury mechanism. CONCLUSIONS: Larger hematomas were found in head-injured patients with one or more APOE-epsilon4 alleles than in patients without the allele. This may contribute to the poorer outcomes observed in these patients.     

Ideal culture time for improvement in sperm motility from testicular sperm aspirates of men with azoospermia

PURPOSE: The motility of testicular derived spermatozoa reflects viability and predicts success during intracytoplasmic sperm injection. Although improvements in sperm motility are seen after incubation for extended periods, no guidelines suggest duration or media use for optimal improvement in motility. MATERIALS AND METHODS: Between July 1999 and February 2005 testicular aspirations were performed on 95 men with azoospermia, including 51 with obstructive azoospermia and 44 with nonobstructive azoospermia. Sperm motility was determined at initial collection and following incubation for 24 or 48 hours in processing media or Ham's F10 + protein. A mixed regression model controlling for testis side, media and baseline motility was created to analyze the change in motility between 24 and 48 hours. RESULTS: Mean motility improved from 3% to 20% at 24 hours and 25% at 48 hours for OA cases and from 0% to 5% at 24 hours and 11% at 48 hours for nonobstructive azoospermia cases. The improvement in motility from 24 to 48 hours was significant for obstructive azoospermia cases (p = 0.001). While media was a nonsignificant factor in regression models, when patients were grouped into categories of motility change there was a significantly better response to F10 compared to processing media (p = 0.03). CONCLUSIONS: Incubation in processing media or Ham's F10 + albumin media improves sperm motility with significant improvement noted between 24 and 48 hours for obstructive azoospermia cases. Ham's F10 + albumin media may provide extra benefit for cases of nonobstructive azoospermia or nerve injury. These results suggest the ideal timing of oocyte retrieval for intracytoplasmic sperm injection correlates with 48-hour sperm incubation for obstructive azoospermia cases, and 24 hours for nonobstructive azoospermia and nerve injury cases.     

Differential adoption of laparoscopy by treatment indication

PURPOSE: The diffusion of laparoscopic renal surgery has been gradual. While surgery for benign and malignant kidney disease is usually within the urological domain, donor nephrectomy is multidisciplinary. Therefore, we compared the use of laparoscopy by procedure indication (kidney donor, and benign and malignant kidney disease) to examine potential specialty specific associations with the slow uptake of this technology. MATERIALS AND METHODS: Data on 53,461 patients undergoing nephrectomy for all indications between 1998 and 2003 were abstracted from the Nationwide Inpatient Sample using International Classification of Diseases, 9th Revision, Clinical Modification procedure and diagnostic codes. Generalized estimating equations were fitted to measure the association between laparoscopy use and the procedure indication (kidney donor, benign kidney disease and kidney cancer). RESULTS: The use of laparoscopy varied by treatment indication. In 2003, 33% of kidney donors underwent a laparoscopic approach compared to 22% and 16% of patients with benign and malignant kidney disease, respectively (p <0.0001). After adjusting for patient and hospital differences patients with benign (adjusted OR 0.71, 95% CI 0.58-0.94) and malignant (adjusted OR 0.51, 95% CI 0.35-0.74) kidney disease were significantly less likely to undergo laparoscopic nephrectomy than kidney donors. CONCLUSIONS: These data highlight that the use of laparoscopic renal surgery varies by procedure indication with slower adoption of laparoscopy for malignant or benign indications than for donor nephrectomy. This variation was not readily explained by differences in measurable patient and hospital factors. Further characterization of provider and nonclinical characteristics may provide additional insight into differences in the adoption of this technology, which appears to be a specialty specific phenomenon.     

Comparative analysis of urinary incontinence severity after autologous fascia pubovaginal sling, pubovaginal sling and tension-free vaginal tape

PURPOSE: Autologous fascia, Pelvicol implant and polypropylene are common materials used in suburethral anti-incontinence procedures. We explored the relative effectiveness of the autologous fascia pubovaginal sling, Pelvicol pubovaginal sling and Gynecare TVT on self-reported postoperative urinary incontinence. MATERIALS AND METHODS: The study was a mailed cross-sectional survey of health related quality of life 1 to 3 years after suburethral anti-incontinence surgery performed at our institution. The Incontinence Symptom Index was used to assess the presence and severity of urinary incontinence symptoms and the Incontinence Impact Questionnaire-7 was used to assess impairment. Regression models were developed to identify factors with an independent effect on the presence, severity and impairment of urinary incontinence symptoms. RESULTS: The questionnaire was returned by 69% of eligible respondents (173 of 250). Those with previous incontinence surgery (OR 11.0, 95% CI 2.3-51.4) and medical comorbidities (OR 1.6, 95% CI 1.1-2.2) were more likely to report urinary incontinence symptoms, ie incontinence symptom index greater than 0. Symptom severity, which was analyzed only in respondents with urinary incontinence symptoms, was greater in the Pelvicol than in the autologous fascia pubovaginal sling and TVT groups (each p <0.01). No significant difference was observed between the TVT and autologous fascia pubovaginal sling groups (p = 0.15). Also associated with higher urinary incontinence symptom severity scores were body mass index (p = 0.03), a history of incontinence surgery (p = 0.01) and lower education (p <0.01). Impairment from urinary incontinence, as assessed by the Incontinence Impact Questionnaire-7, was associated with body mass index, severe depression and current smoking (each p = 0.01) but not with surgical treatment group. CONCLUSIONS: Women who received an autologous fascia pubovaginal sling or TVT reported lower symptom severity scores than those who had a Pelvicol pubovaginal sling. Impairment was not associated with procedure type. These findings suggest better outcomes with autologous fascia pubovaginal sling and TVT. Randomized, controlled trials are needed to confirm these findings.