A prospective, comparative study of the analgesic effect between the WALANT technique and local anesthesia associated with sedation for hand surgery.

PURPOSE: The primary objective of this study was to compare the WALANT (wide awake, local anesthesia, no tourniquet) technique with local anesthesia associated with sedation in relation to pain intensity for minor hand surgical procedures. The secondary objective was to evaluate the need for analgesic complementation. METHODS: A prospective, randomized, comparative, and clinical study was carried out. The sample size in each group was determined after statistical evaluation of the results of a pilot project. The participants were allocated to one of two groups; those in group 1 were submitted to the WALANT technique, and those in group 2, to local anesthesia associated with sedation, for elective surgery. The surgical procedures were carpal tunnel syndrome, De Quervain's tenosynovitis, synovial cyst, finger cyst, and trigger finger. Pain intensity, need for complementation and evolution to complex regional pain syndrome were evaluated. RESULTS: There was no difference between groups in pain intensity after WALANT and need for intraoperative complementation. There was no significant difference in the amount of opioid applied postoperatively between the groups. There was no difference between groups regarding comfort during surgery. There was no difference in adverse effects and complications between the groups. Hematoma was the most frequent adverse event. No severe adverse events were observed. CONCLUSIONS: The WALANT technique promoted an analgesic effect similar to that of local anesthesia associated with sedation, without increasing adverse effects.

A prospective, comparative study of the analgesic effect between the WALANT technique and local anesthesia associated with sedation for hand surgery

Purpose: The primary objective of this study was to compare the WALANT (wide awake, local anesthesia, no tourniquet) technique with local anesthesia associated with sedation in relation to pain intensity for minor hand surgical procedures. The secondary objective was to evaluate the need for analgesic complementation. Methods: A prospective, randomized, comparative, and clinical study was carried out. The sample size in each group was determined after statistical evaluation of the results of a pilot project. The participants were allocated to one of two groups; those in group 1 were submitted to the WALANT technique, and those in group 2, to local anesthesia associated with sedation, for elective surgery. The surgical procedures were carpal tunnel syndrome, De Quervain's tenosynovitis, synovial cyst, finger cyst, and trigger finger. Pain intensity, need for complementation and evolution to complex regional pain syndrome were evaluated. Results: There was no difference between groups in pain intensity after WALANT and need for intraoperative complementation. There was no significant difference in the amount of opioid applied postoperatively between the groups. There was no difference between groups regarding comfort during surgery. There was no difference in adverse effects and complications between the groups. Hematoma was the most frequent adverse event. No severe adverse events were observed. Conclusions: The WALANT technique promoted an analgesic effect similar to that of local anesthesia associated with sedation, without increasing adverse effects.

Quality management of a massive transfusion protocol.

BACKGROUND: Massive transfusion is a response to massive uncontrolled hemorrhage. To be effective, it must be timely and address the patient's needs for blood volume, oxygen transport, and hemostasis. STUDY DESIGN AND METHODS: A review was performed on all activations of the massive transfusion protocol (MTP) in a hospital with large emergency medicine, trauma, and vascular surgery programs. Indications, transfused amounts, and outcomes were determined for each MTP event to determine appropriateness of MTP use. Results are presented as descriptive statistics, categorical associations, and simple linear trend relationships. RESULTS: The MTP was activated 309 times in 2016. Of these episodes, 237 were for trauma, 29 for gastrointestinal bleeding, 16 for ruptured abdominal aortic aneurisms, and 25 for a variety of other causes. Trauma-related MTP activations had a mean injury severity score of 32. Blood use averaged 6.6 units of red blood cells (RBCs), 6.5 units of plasma, and 1.2 units of apheresis platelets. Fourteen activations ended without the administration of any blood products, and 45 (14%) did not meet the critical administration threshold of three components. Only 60 (19%) activations met the historic definition of massive with at least 10 units of RBCs administered. Mortality was 15% for the trauma-related activations. CONCLUSIONS: Massive transfusion protocol activations were frequent and conducted with high fidelity to the 1:1:1 unit ratio standard. Making blood components available quickly was associated with low rates of total component usage and low mortality for trauma patients and was not associated with overuse.

Building a New Transfusion Service.

OBJECTIVES: For over 60 years, Harborview Medical Center (HMC) in Seattle has received its blood components and pretransfusion testing from a centralized transfusion service operated by the regional blood supplier. In 2011, a hospital-based transfusion service (HBTS) was activated. METHODS: After 5 years of operation, we evaluated the effects of the HBTS by reviewing records of hospital blood use, quality system events, blood product delivery times, and costs. Furthermore, the effects of in-house expertise on laboratory medicine resident and medical laboratory scientist student training, as well as regulatory and accrediting agency concerns, were reviewed. RESULTS: Blood use records from 2003 to 2015 demonstrated large reductions in blood component procurement, allocation, transfusion, and wastage with decreases in costs temporally related to the change in service. The turnaround time for thawed plasma for trauma patients decreased from 90 to 3 minutes. Transfusion medicine education metrics for residents and laboratory technology students improved significantly. HMC researchers brought in $2 million in transfusion research funding. CONCLUSIONS: HMC successfully transitioned to an HBTS, providing world-class primary transfusion support to a level 1 trauma center. Near-term benefits in patient care, education, and research resulted. Blood support became faster, safer, and cheaper.

Image-guided robot-assisted prostate ablation using water jet-hydrodissection: initial study of a novel technology for benign prostatic hyperplasia.

PURPOSE: To evaluate the safety and efficacy of a novel robotic tissue ablation system (PROCEPT Aquablation(™) System), in performing prostate ablation in a survival canine model. MATERIALS AND METHODS: This novel technology uses a high-velocity saline stream that aims to selectively ablate prostatic glandular tissue while sparing collagenous structures such as blood vessels and capsule. Once the ablation is complete, a laser beam is captured by a low-pressure water jet to produce surface hemostasis. The extent and depth of ablation is predetermined by endoscopic and transrectal ultrasonography guidance. The procedure was performed in eight noncastrated male beagles aged 6 years or older (Acute 2, Chronic 6) through a previously created perineal urethrostomy. RESULTS: Aquablation time ranged from 40 to 84 seconds (mean 60.5 sec). There was no active bleeding in any of the dogs during or after Aquablation. Water jet-guided laser coagulation was used for purposes of monitoring its safety and efficacy. Five of the six dogs reached the predetermined 6-week mark. Complications included two dogs with infection successfully treated with antibiotics, a false passage created during catheter placement, and two bladder neck perforations (from mechanical insertion), one leading to euthanasia. Histologic evaluation at 6 weeks revealed a normal cellular architecture and full reepithelialization of the treatment cavity. CONCLUSIONS: We report the initial survival data in the animal model of a novel robotic device developed for managing symptomatic benign prostatic hyperplasia (BPH). Aquablation produces ablation of adenomatous elements while preserving collagenous structures and is a promising technology for surgical management of symptomatic BPH.

Transvesical robotic simple prostatectomy: initial clinical experience.

BACKGROUND: Despite significant developments in transurethral surgery for benign prostatic hyperplasia (BPH), simple prostatectomy remains an excellent option for patients with large glands. OBJECTIVE: To describe our technique of transvesical robotic simple prostatectomy (RSP). DESIGN, SETTING, AND PARTICIPANTS: From May 2011 to April 2013, 25 patients underwent RSP. SURGICAL PROCEDURE: We performed RSP using our technique. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Baseline demographics, pathology data, perioperative complications, 90-d complications, and functional outcomes were assessed. RESULTS AND LIMITATIONS: Mean patient age was 72.9 yr (range: 54-88), baseline International Prostate Symptom Score (IPSS) was 23.9 (range: 9-35), prostate volume was 149.6 ml (range: 91-260), postvoid residual (PVR) was 208.1 ml (range: 72-800), maximum flow rate (Qmax) was 11.3 ml/s, and preoperative prostate-specific antigen was 9.4 ng/ml (range: 1.9-56.3). Eight patients were catheter dependent before surgery. Mean operative time was 214 min (range: 165-345), estimated blood loss was 143 ml (range: 50-350), and the hospital stay was 4 d (range: 2-8). There were no intraoperative complications and no conversions to open surgery. Five patients had a concomitant robotic procedure performed. Early functional outcomes demonstrated significant improvement from baseline with an 85% reduction in mean IPSS (p<0.0001), an 82.2% reduction in mean PVR (p=0.014), and a 77% increase in mean Qmax (p=0.20). This study is limited by small sample size and short follow-up period. One patient had a urinary tract infection; two had recurrent hematuria, one requiring transfusion; one patient had clot retention and extravasation, requiring reoperation. CONCLUSIONS: Our technique of RSP is safe and effective. Good functional outcomes suggest it is a viable option for BPH and larger glands and can be used for patients requiring concomitant procedures. PATIENT SUMMARY: We describe the technique and report the initial results of a series of cases of transvesical robotic simple prostatectomy. The procedure is both feasible and safe and a good option for benign prostatic hyperplasia with larger glands.

Face, content, construct and concurrent validity of dry laboratory exercises for robotic training using a global assessment tool.

OBJECTIVES: To evaluate robotic dry laboratory (dry lab) exercises in terms of their face, content, construct and concurrent validities. To evaluate the applicability of the Global Evaluative Assessment of Robotic Skills (GEARS) tool to assess dry lab performance. MATERIALS AND METHODS: Participants were prospectively categorized into two groups: robotic novice (no cases as primary surgeon) and robotic expert (≥30 cases). Participants completed three virtual reality (VR) exercises using the da Vinci Skills Simulator (Intuitive Surgical, Sunnyvale, CA, USA), as well as corresponding dry lab versions of each exercise (Mimic Technologies, Seattle, WA, USA) on the da Vinci Surgical System. Simulator performance was assessed by metrics measured on the simulator. Dry lab performance was blindly video-evaluated by expert review using the six-metric GEARS tool. Participants completed a post-study questionnaire (to evaluate face and content validity). A Wilcoxon non-parametric test was used to compare performance between groups (construct validity) and Spearman's correlation coefficient was used to assess simulation to dry lab performance (concurrent validity). RESULTS: The mean number of robotic cases experienced for novices was 0 and for experts the mean (range) was 200 (30-2000) cases. Expert surgeons found the dry lab exercises both 'realistic' (median [range] score 8 [4-10] out of 10) and 'very useful' for training of residents (median [range] score 9 [5-10] out of 10). Overall, expert surgeons completed all dry lab tasks more efficiently (P < 0.001) and effectively (GEARS total score P < 0.001) than novices. In addition, experts outperformed novices in each individual GEARS metric (P < 0.001). Finally, in comparing dry lab with simulator performance, there was a moderate correlation overall (r = 0.54, P < 0.001). Most simulator metrics correlated moderately to strongly with corresponding GEARS metrics (r = 0.54, P < 0.001). CONCLUSIONS: The robotic dry lab exercises in the present study have face, content, construct and concurrent validity with the corresponding VR tasks. Until now, the assessment of dry lab exercises has been limited to basic metrics (i.e. time to completion and error avoidance). For the first time, we have shown it is feasibile to apply a global assessment tool (GEARS) to dry lab training.

The natural history of renal stone fragments following ureteroscopy.

OBJECTIVES: To describe the natural history of postureteroscopic renal stone fragments ≤4 mm based on computed tomography (CT) follow-up. The goal of ureteroscopy is to fragment stones, actively basket and remove fragments larger than 1 mm, and allow the remaining fragments to pass spontaneously. The reality is that smaller fragments may be difficult to extract or may be missed. METHODS: Patients treated with ureteroscopy and holmium laser lithotripsy for urolithiasis by a single surgeon from May 2001 to July 2008 at a tertiary referral center were identified. Patients with residual renal fragments measuring ≤4 mm on initial postoperative CT and at least one additional follow-up CT were included. Outcomes measured were fragment growth and location, stone event (emergency department visit, hospitalization, or additional intervention), and spontaneous fragment passage. RESULTS: Of 330 ureteroscopies, 51 met inclusion criteria. For these patients, the mean follow-up duration was 18.9 months (1.6 years). Among 46 ureteroscopies for calcium-based stones, 9 patients (19.6%) experienced a stone event, 10 patients (21.7%) spontaneously passed their fragments, and the remaining 27 patients (58.7%) retained asymptomatic residual fragments. Among this asymptomatic group, mean fragment sizes were similar at 2.7, 3.3, 3.5, and 3.0 mm at mean follow-up durations of 2.8, 10.2, 16.8, and 33.0 months, respectively. CONCLUSIONS: This study suggests that among patients with postureteroscopic renal stone fragments ≤4 mm, approximately one in five (or 19.6%) will experience a stone event over the following 1.6 years. The remaining patients will either become stone-free via spontaneous passage or retain asymptomatic stable-sized fragments.