Massive Leiomyomatous Uterine Proliferation Following Kidney Transplantation: A Case Report and Literature Review.

Uterine fibroids are the most common benign uterine tumors affecting > 50% of premenopausal women. The incidence, burden and symptoms from uterine fibroids are higher in women of African descent compared to Caucasians. Despite increasing number of African American females being evaluated for and undergoing kidney transplantation (KT), perioperative management guidelines for uterine fibroids currently do not exist. We present a case of a 40 y/o African American female with known symptomatic uterine fibroids preoperatively and medically managed, who underwent a successful KT and 4 years later progressively developed massive leiomyomatous uterine proliferation, causing a complete lateral displacement of the transplanted kidney with severe hydronephrosis, transplant ureteral obstruction and secondary urinary tract infections with bacteremia. This obstruction required a percutaneous nephrostomy tube placement followed by an interval transabdominal hysterectomy, which was complicated by transplant ureteral transection requiring ureteral reimplantation, resulting in prolonged hospitalization, follow-up and outpatient antibiotic regimen. There is a need for management guidelines for uterine fibroids incidentally encountered during the KT evaluation process to avoid similar preventable post-KT complications in patient populations most commonly affected. Literature review and perioperative management/surveillance strategies are provided.

Does residents' involvement in mastectomy cases increase operative cost? If so, who should bear the cost?

INTRODUCTION: It is a widely held belief that surgical residents' involvement in operative cases increases operative time and costs. However, there is little published data regarding the veracity of this belief, and there is poor documentation of the actual costs associated with involving surgical residents in operative cases. This report represents a retrospective analysis of the additional cost associated with involving surgical residents of all training years in mastectomy cases over a 6-y period. METHODS: A total of 1063 mastectomy cases (with and without reconstruction) were performed over a 6-y period (2004-2010) at the Saint Barnabas Medical Center, Livingston, NJ. Data relating to the type of mastectomy performed, operative times, training level of residents involved, and the surgical attendings' case volume were collected. Two major groups (attendings-only and attendings with residents) and 19 mastectomy subcategories were formed. Differences in operating room (OR) times between the attendings-only and attendings with residents groups were multiplied by the hospital OR charges per minute of time ($15/min after the initial 30 min) to determine the additional operative costs associated with residents' involvement. The impact of postgraduate training year and the attendings' case volume on operative time was analyzed separately. Statistical analysis was conducted using IBM SPSS 18.0.1 Windows version (PASW Statistics for Windows, SPSS Inc, Chicago). RESULTS: Twenty-six surgeons and 97 residents were involved in 1063 mastectomy cases. Eight hundred ninety-five cases involved residents, of which 405 cases had reconstruction and 490 cases did not. Among 168 cases involving residents, 107 cases had reconstruction and 61 cases did not. The mean OR time was increased in nearly all cases involving surgical residents but statistically significant in only nine of the 19 mastectomy subcategories. Postgraduate year (PGY) 1 or PGY2 residents increased OR time for unilateral mastectomy, whereas the involvement of PGY1 through PGY3 residents increased OR time for bilateral mastectomy+reconstruction (P<0.05). No significant difference was observed when PGY4 and PGY5 were involved in mastectomy cases. The additional calculated time required to perform mastectomies involving surgical residents was 41,366 min, which corresponded to an increase in OR costs of $620,340 over 6 y. CONCLUSION: The involvement of surgical residents in mastectomy cases significantly increases operative times and cost. This difference is most apparent when junior-level residents are involved and disappears by the PGY4-PGY5. Increased operative costs and the lost opportunity costs for surgical attendings are significant issues associated with residency education. Center for Medicare and Medicaid Services and Accreditation Council on Graduate Medical Education should consider such data when establishing appropriate reimbursements for graduate training programs.

Retroperitoneal extrarenal angiomyolipomas: an evidence-based approach to a rare clinical entity.

Extrarenal angiomyolipomas (ERAMLs) are rare tumors that present as incidentalomas upon imaging for other conditions. Retroperitoneal ERAMLs present a unique challenge from a diagnostic and treatment standpoint as they can mimic other benign and malignant retroperitoneal tumors. We present a case of a 39-year-old female with a 19.3 cm × 13.5 cm × 10.7 cm left extrarenal retroperitoneal mass. Histopathologic examination and HMB-45 staining revealed the mass to be a retroperitoneal ERAML. Our case report provides a comprehensive literature review and an evidence-based algorithm for taking care of patients with ERAMLs.