Evaluating the Differences of Wound Related Complications in Robotically Assisted Radical Cystectomy vs Open Radical Cystectomy.

OBJECTIVE: To determine whether robotic-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) compared to open radical cystectomy (ORC) or RARC with extracorporeal urinary diversion (ECUD) would result in a decreased rate of surgical site complications. RARC has been shown to be non-inferior to ORC. Both RARC and ORC are complicated by a high rate of perioperative morbidity, including wound-related complications, which may be decreased by a robotic approach with intracorporeal diversion. METHODS: A retrospective review of our bladder cancer database for patients undergoing radical cystectomy from 2013-2021. Patients were stratified by surgical technique as RARC with ICUD vs ORC vs RARC with ECUD. Surgical site complications were measured at both 30- and 90-day intervals. RESULTS: Of the 269 patients, 127 (47.2%) had RARC with ICUD, 118 (43.7%) had ORC, and 24 (8.9%) had RARC with ECUD (mean ages 71.0, 69.5, and 67.5, respectively). A comparison of the 3 groups demonstrated statistical significance at both the 30-day (P <.001) and 90-day (P <.001) timeframes for total surgical site complications, with RARC with ICUD having the fewest amount of patients experiencing a surgical site complication (0.8%) followed by ORC (25.4%) and RARC with ECUD (29.2%). CONCLUSION: Overall, we observed lower surgical site complication rates among patients undergoing RARC with ICUD compared to patients who underwent ORC or RARC with ECUD. This study suggests that decreased surgical site complications may be one benefit of the minimally invasive approach, particularly in patients at high risk for surgical site complications after radical cystectomy.

Impact of multimodal therapy on margin status on overall survival for patients undergoing adrenalectomy for localized adrenocortical carcinoma.

Introduction: Adrenocortical carcinoma is a rare malignancy that typically presents with advanced features and carries a poor prognosis. Complete surgical resection offers patients the best survival outcomes, but this is not always achievable and many require additional therapy for advanced features. Some literature has explored the role of chemotherapy and radiation, but little has been conducted to explore the effects of multimodal therapy. Methods: We retrospectively reviewed the National Cancer Database for adults with primary nonmetastatic adrenocortical carcinoma (ACC) who underwent either partial or radical adrenalectomy. Excluded patients included those with metastatic disease and those with primary tumor >30 cm. Patients were categorized based on adjuvant treatment; chemotherapy, radiation therapy (RT), RT + chemotherapy, or no adjuvant therapy. Overall survival (OS) was compared using survival curves, log rank tests, and multivariate survival analysis. Results: We identified 1644 patients with localized ACC treated with adrenalectomy. The median tumor size was 10.6 cm. A total of 278 patients had positive margin status (R1), and 416 patients had nodal (pN+) disease. Out of all patients, a minority (39.4%) received adjuvant therapy, which was most commonly given as chemotherapy only. Statistically significant increase in OS was noted with the use of RT + chemotherapy in the node-negative, margins-positive (pN0/pNx; R1) subgroup versus patients who did not receive adjuvant therapy (5-year OS 60.5% and 28.2%, respectively [P = 0.002]). This held true on multivariate analysis with significant improvement in OS in the pN0/pNx; R1 population with RT + chemotherapy compared to those who received no treatment (hazard ratio: 0.40 [95% confidence interval: 0.2-0.9], P = 0.02). Conclusions: Our findings support the use of adjuvant chemotherapy plus RT in patients with positive surgical margins and no nodal disease. Additional studies are required to confirm these findings, clarify the objective benefit of multimodal therapy, and to determine the optimal chemotherapy/RT combination.

Informing the Management of Asymptomatic Nephrolithiasis: Markov Decision Analysis for the 1 cm Renal Stone.

INTRODUCTION: The management of an incidentally discovered, asymptomatic renal stone includes watchful waiting, shock wave lithotripsy, ureteroscopy with basket extraction of fragmented stones (URS-B) or ureteroscopy with laser "dusting" (URS-D). Each intervention has varying stone-free rates, requirements for ureteral stenting, and variable impact on a patient's quality of life. Decision analysis was used to assess the optimal quality adjusted life-years associated with each treatment option. METHODS: A Markov model was constructed to represent potential outcomes for a single 1 cm renal stone after treatment. The cohort was followed for 1-month cycles over 3 years and toll penalties for receiving a stent and undergoing surgery were standardized and incorporated into each subtree. Probabilities, utilities and toll penalties were derived from existing literature or clinical extrapolation when no published data were available. One-way sensitivity analyses were performed to determine threshold probabilities/utilities that may alter preferred options. RESULTS: Watchful waiting was the preferred intervention, preserving 2.82 quality adjusted life-years over 3 years. The remaining options had similar but decreasing quality adjusted life-years: URS-B provided 2.78 quality adjusted life-years; shock wave lithotripsy provided 2.72 quality adjusted life-years, and URS-D provided 2.67 quality adjusted life-years. One-way sensitivity analysis showed that URS-D was preferred when stone-free rates from URS-B dropped below 37%. Shock wave lithotripsy was preferred over URS-B when stone-free rates from URS-B dropped below 62%. As stents became progressively less bothersome, watchful waiting is preferred, followed by URS-B, shock wave lithotripsy and URS-D. CONCLUSIONS: Watchful waiting is the preferred management decision for asymptomatic renal stones. However, these results are sensitive to both actual stone-free rate and individual stent tolerance.

Monitoring ventilation with capnography.

Capnography, the graphic display of the exhaled and inhaled carbon dioxide concentration plotted against time, is used to monitor ventilation. This video reviews the principles of capnography and explains how to interpret the information it provides.

Roles of the respiratory syncytial virus trailer region: effects of mutations on genome production and stress granule formation.

The 5' extragenic trailer region of respiratory syncytial virus (RSV) is known to be necessary for genome replication, but is more than three times the length of the 3' leader replication promoter, raising the possibility that trailer might play an additional role in viral replication. To examine this, mutant recombinant viruses were constructed in which the trailer region was truncated or substituted with leader-complement sequence. This analysis showed that the complete trailer increased promoter activity, facilitating genome production and viral multiplication. In addition, trailer-containing viruses did not induce stress granules, whereas the leader-complement virus mutant did, resulting in poor multi-cycle viral growth. These data demonstrate that although the RSV trailer does not contain a unique essential sequence, it augments virus growth by enabling optimal genome production. In addition, a sequence at the 5' terminal end of the trailer region allows RSV to subvert stress granule formation.