Patients with hemispatial neglect are more prone to limb spasticity, but this does not prolong their hospital stay.

OBJECTIVE: To determine whether stroke patients who suffer from hemispatial neglect tend to stay in hospitals longer because they are prone to limb spasticity. DESIGN: Retrospective analysis of inpatient medical notes. SETTING: Inpatient neurorehabilitation unit of a regional UK teaching hospital. PARTICIPANTS: All patients (N=106) admitted to the neurorehabilitation unit between 2008 and 2010 who had suffered a stroke, as confirmed by computed tomography or magnetic resonance imaging. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Statistical coincidence of hemispatial neglect and spasticity; length of hospital stay. RESULTS: Chi-square analyses indicated that individuals with left neglect were nearly one third more likely to develop spasticity than those without neglect (87% vs 57%), while nearly one half of those with left-sided spasticity showed neglect (44% vs 13%). Individuals with neglect stayed in the hospital 45 days longer than those without neglect, but the presence or absence of spasticity did not affect length of stay. CONCLUSIONS: The results provide the first statistical evidence, to the best of our knowledge, that neglect and limb spasticity tend to co-occur poststroke, though it is only the former that significantly prolongs stay. Diagnostic value aside, these results are important because they tell us that the treatment of neglect should not be overshadowed by efforts to reduce comorbid spasticity. Despite its poor prognosis, hemispatial neglect continues to receive little targeted therapy in some units.

Laparoscopic pyelolithotomy: indications and technique.

BACKGROUND AND PURPOSE: Laparoscopic pyelolithotomy, although uncommonly performed, may be considered in patients who have renal anomalies, are poorly compliant, and have a large single renal-pelvic calculus. We present our experience with this procedure in five patients. PATIENTS AND METHODS: Three patients underwent laparoscopic pyelolithotomy because of a horseshoe kidney, one for a pelvic kidney, and one for a large renal-pelvic calculus. All stones were solitary with a mean size of 2280 mm2 (range 540-8200 mm2). All were approached transperitoneally with passage of a flexible cystoscope through a laparoscopic port to aid in stone extraction. RESULTS: All cases were completed laparoscopically. The length of surgery was 74, 92, 134, 158, and 159 minutes. There were no minor or major complications, and the estimated blood loss was <50 mL in all cases. All patients were discharged on postoperative day 1 with the drains removed. Four patients were stented for 4 to 6 weeks. The remaining patient was not stented because of poor compliance. The stents were removed with office cystoscopy. All patients were stone free on follow-up imaging. CONCLUSIONS: Laparoscopic pyelolithotomy can be done safely, effectively, and efficiently with proper patient selection and adherence to standard laparoscopic surgical principles.

Pure laparoscopic radical nephrectomy for stage T(3b) renal-cell carcinoma: more than 2-year follow-up.

BACKGROUND AND PURPOSE: Renal-vein tumor thrombus associated with renal malignancy has traditionally been approached with open surgery, and preoperative diagnosis of stage T(3b) renal tumors often mandates open surgery. However, early arterial division and "milking" of the thrombus away from the inferior vena cava may facilitate laparoscopic surgery. We describe our single-surgeon experience with laparoscopic nephrectomy in patients with tumor extension into the renal vein. PATIENTS AND METHODS: Among 240 laparoscopic nephrectomies performed by a single surgeon from 2002 to 2005, six patients (2.6%) were found to have renal-vein tumor thrombus. These patients included three men and three women with a mean age of 55.8 years (range 43-78 years). Data collected prospectively were evaluated to characterize this cohort. RESULTS: All six tumors were right-sided, stage T(3b), and all were managed laparoscopically without major complications. Three tumors were suspected to have renal-vein thrombus on preoperative imaging; the other three tumor thrombi were discovered on pathologic examination. The mean tumor size was 9.5 cm (range 7.5-11.5 cm). Two tumors were grade 2, three were grade 3, and one patient had a grade 4 rhabdoid cell-type tumor. At a mean follow-up of 27 months, all patients were without evidence of disease with the exception of the patient with grade 4 disease, who developed recurrence in the chest. CONCLUSION: Laparoscopic nephrectomy for tumor with renal-vein thrombus can be accomplished safely with adherence to proper oncologic techniques.

Accreditation council on graduate medical education technical skills competency compliance: urologic surgical skills.

BACKGROUND: In accordance with new mandates implemented by the Accreditation Council on Graduate Medical Education, reliance on operative case logs as demonstration of residents' surgical competence will no longer be adequate. We describe the implementation of a comprehensive, year-round, mandatory skills laboratory curriculum as an integral component of our urology residency training program. STUDY DESIGN: We developed eight laboratory practicums using primarily nonhuman models: basic endoscopy, advanced endoscopy, ureteroscopy, percutaneous renal surgery, basic laparoscopy, advanced laparoscopy, urologic use of the gastrointestinal tract, and cadaveric pelvic dissection. RESULTS: Anonymous evaluations submitted by all training session participants indicate that acquisition of surgical skills is facilitated through participation in laboratory practicums. An incremental progression in proficiency was observed by all of the instructors and students who participated. There was a high degree of satisfaction with model fidelity and the value of technical experience gained. CONCLUSIONS: Our urologic surgery skills laboratory curriculum is an effective means of skills acquisition and maintenance for a wide variety of urologic techniques, including complex endourologic procedures. Patient care can safely be of secondary importance with respect to trainee experience in a low-stress environment that provides an opportunity for supervised repetitive performance of essential technical skills. We describe effective models, with high fidelity-to-cost ratio, that incorporate laboratory-based surgical skills training and evaluation into urology residency programs, with the aim of Accreditation Council on Graduate Medical Education competency guideline compliance.

A new approach to urology training: a laboratory model for percutaneous nephrolithotomy.

PURPOSE: The efficacy of traditional operating room based training of urology residents is being reevaluated. The development of hands-on laboratory practicums to facilitate the acquisition of skills by surgical residents lessens learning curves and hastens familiarity with tissue and instrument handling. We describe an innovative model for simulated percutaneous renal access and nephrolithotomy. MATERIALS AND METHODS: Porcine kidneys pre-implanted with artificial stone material were placed within intact chicken carcasses as a model for percutaneous nephrolithotomy. Urology residents were taught needle access, tract dilation and renal access sheath insertion using fluoroscopy. Training in percutaneous nephrolithotomy with the nephroscope, graspers and stone fragmentation methods followed. RESULTS: This simple, cost-effective model closely simulates percutaneous nephrolithotomy. Anonymous evaluations submitted by training session participants revealed a high degree of satisfaction with model effectiveness in the application of percutaneous renal access and nephrolithotomy techniques. CONCLUSIONS: Our percutaneous nephrolithotomy laboratory model is an effective means of skills acquisition for a complex endourological procedure. Patient care can safely be of secondary importance with respect to trainee experience in a low stress environment that provides an opportunity for supervised, repetitive performance of essential technical skills. We describe an effective percutaneous renal access and nephrolithotomy surgical training model of original design.