Feasibility of same-day discharge of robotic-assisted laparoscopic radical prostatectomy with pelvic lymph node dissection.

PURPOSE: Prostate cancer is one of the most common oncologic diseases. Outpatient robotic-assisted laparoscopic radical prostatectomy (RALP) has gained popularity due to its ability to minimize patient costs while maintaining low complication rates. Few studies have analyzed the possibility of performing outpatient RALP specifically in patients undergoing concurrent pelvic lymph node dissections (PLND). METHODS: Using the National Surgical Quality Improvement Program Database (NSQIP), we identified total number of RALP, stratified into inpatient and outpatient groups including those with and without PLND from 2016 to 2021. Baseline characteristics, intraoperative and postoperative complications, and unplanned readmission rates were summarized. Proportions of outpatient procedures were calculated to assess adoption of outpatient protocol. RESULTS: Between 2016 and 2021, a total of 58,527 RALP were performed, 3.7% (2142) outpatient and 96.3% inpatient. Altogether, patients undergoing outpatient RALP without PLND were more likely to have hypertension (52.6% vs. 46.3%, p < 0.01). Patients undergoing outpatient RALP without PLND were more likely to have sepsis or urinary tract infections (3.4% vs. 1.9%, p = 0.04) when compared to outpatient RALP with PLND. Cardiopulmonary, renal, thromboembolic complications, and 30-day events such as unplanned readmission, reoperation rates, and mortality were similar in both groups. However, among multivariate analysis regarding 30-day readmission and complications, there were no significant differences between outpatient RALP with or without PLND. CONCLUSION: Patients undergoing outpatient RALP without PLND were more likely to have baseline hypertension and higher rates of postoperative infection, when compared to outpatient RALP with PLND. No significant differences were seen regarding 30-day readmission or complications on multivariate analysis.

Recent trends in the prescription of opioids in the emergency department in patients with urolithiasis.

PURPOSE: Pain management is central in the treatment of urolithiasis. We aimed to estimate the impact of the 2017 Department of Health and Human Services declaration of an opioid crisis on prescribing patterns of opioids and NSAIDs in emergency department visits for urolithiasis. METHODS: The National Health Ambulatory Medical Care Survey (NHAMCS) was queried for emergency department visits of adults with a diagnosis of urolithiasis. The association between urolithiasis and narcotic and NSAIDs prescription patterns was evaluated and compared at pre-declaration (2014-2016) to post-declaration (2017-2018) periods. RESULTS: Opioids were prescribed in about 211 million (41.1%) out of 513 million emergency department visits, over a 5-year period. Diagnosis of urolithiasis accounted for 1.9% of the visits (6.0 million). The use of opioids was higher in urolithiasis (82.7%) compared to non-urolithiasis diagnosis (40.3%), as well as the use of multiple opioids per visit (p < 0.01 for all). There was an overall decrease in opioid prescriptions in the post-declaration period, - 4.3% for urolithiasis (p = 0.254) and - 5.6% for non-urolithiasis visits (p < 0.05). A decrease in the use of hydromorphone (- 47.5%. p < 0.001), an increase in the use of morphine (+ 59.7% p = 0.006), and an increase of 'other' opioids (+ 98.8%, p < 0.041), were observed. Opioids combined with NSAIDs comprised 72.6% of the opioid prescriptions and 62.3% of all analgesic prescriptions in visits with urolithiasis diagnosis. CONCLUSIONS: The use of opioids when managing urolithiasis decreased 4.3% after the crisis declaration; however, statistically are not different from pre-declaration numbers. Most often, opioids were prescribed with NSAIDs in urolithiasis patients.

Bullseye Technique to Optimize S3 Foramen Access: Applying a Trusted Endourology Technique to Pelvic Medicine.

BACKGROUND: Sacral neuromodulation (SNM) is an advanced therapy that stimulates sacral spinal nerves to modulate bladder or bowel dysfunction and is approved for the treatment of overactive bladder, fecal incontinence, and non-obstructive urinary retention. Prior to implantation, a successful trial period must be performed via percutaneous nerve evaluation (PNE) or a staged trial to assess treatment efficacy. Ideal lead placement in the S3 foramen is imperative to produce an adequate response and successful outcome. Traditional lead placement with fluoroscopic guidance utilizes the anteroposterior (AP) and lateral views. In this abstract we describe an additional modification which may aid lead placement. OBJECTIVE: This video demonstrates the bullseye technique to obtain S3 foramen access for optimal lead placement in SNM. METHODS/MATERIAL: Begin the procedure by placing the patient in the prone position. The medial edges of the S3 foramen are marked bilaterally in the AP view followed by a horizontal marking at the level of S3. The pelvis is imaged with live fluoroscopy starting at 0 degrees and then rotating the C-arm to 30 degrees. This rotation allows the "opening up" of the S3 foramen from an ellipsoid to an oval. The surgeon grasps the needle with a Kelly clamp, placing it at the level of the skin approximately 2 cm cephalad from the horizontal marking. Live fluoroscopy is performed to align the needle with the image intensifier to form the bullseye. Once the correct angle is identified, the needle is advanced. The procedure is repeated on the contralateral foramen. RESULTS: The bullseye technique allows quick and predictable access into S3. It can potentially decrease operating time, minimize needle entries in PNE, and allows the surgeon to access S3 while maintaining proper medial orientation. CONCLUSION: The bullseye technique can assist surgeons in obtaining optimal access in SNM and can quickly be integrated into current practices.

Federated learning enables big data for rare cancer boundary detection.

Although machine learning (ML) has shown promise across disciplines, out-of-sample generalizability is concerning. This is currently addressed by sharing multi-site data, but such centralization is challenging/infeasible to scale due to various limitations. Federated ML (FL) provides an alternative paradigm for accurate and generalizable ML, by only sharing numerical model updates. Here we present the largest FL study to-date, involving data from 71 sites across 6 continents, to generate an automatic tumor boundary detector for the rare disease of glioblastoma, reporting the largest such dataset in the literature (n = 6, 314). We demonstrate a 33% delineation improvement for the surgically targetable tumor, and 23% for the complete tumor extent, over a publicly trained model. We anticipate our study to: 1) enable more healthcare studies informed by large diverse data, ensuring meaningful results for rare diseases and underrepresented populations, 2) facilitate further analyses for glioblastoma by releasing our consensus model, and 3) demonstrate the FL effectiveness at such scale and task-complexity as a paradigm shift for multi-site collaborations, alleviating the need for data-sharing.

The "Tri-Glide" Technique: A Case Report on a Novel Intraoperative Approach for Removal of Retained and Encrusted Ureteral Stents.

BACKGROUND: Retained ureteral stents can result in significant morbidity and can be surgically challenging to urologists. A multimodal approach is often necessary for removal, potentially including retrograde and antegrade procedures performed over multiple anesthetic sessions. We describe the novel "Tri-Glide" technique for treating retained stents, particularly those with stent shaft encrustation prohibiting safe removal. Case Presentation. Two patients with nephrolithiasis and retained, encrusted ureteral stents were managed with the "Tri-Glide" technique. Patient #1 was a 58-year-old man with a severely calcified ureteral stent, retained for 14 years. After undergoing simultaneous cystolitholapaxy and percutaneous nephrolithotomy to treat proximal and distal encrustations, the stent shaft remained trapped in the ureter due to heavy calcifications. Three hydrophilic guidewires were passed alongside the stent, allowing it to easily slide out of the ureter intact. Patient #2 was a 74-year-old man who after only 3-months of stent dwell time developed severe stent shaft encrustation preventing removal. After multiple maneuvers failed, the "Tri-Glide" technique was used to create a smooth track for stent to slide out intact with gentle traction. Both patients did well postoperatively with no complications. CONCLUSION: The "Tri-Glide" technique can aid in the management of complex encrusted stent extractions, especially when there is significant shaft encrustation.

High-Dose-Rate Brachytherapy for the Treatment of Basal and Squamous Cell Carcinomas on Sensitive Areas of the Face: A Report of Clinical Outcomes and Acute and Subacute Toxicities.

PURPOSE: Basal cell and cutaneous squamous cell carcinoma are common malignancies (keratinocyte carcinomas [KCs]). Surgical resection is the standard of care. Radiation using high-dose rate brachytherapy (HDR-BT) may serve as a superior alternative where surgical scars may be of cosmetic concern or in elderly patients with significant comorbidity. We aim to describe the clinical and cosmetic outcomes as well as posttreatment radiation toxicities associated with HDR-BT in patients who were treated for KCs of the face. METHODS AND MATERIALS: Patients with KCs treated with HDR-BT from 2015 to 2018 were included in the study. Patient medical records and clinical photos were reviewed at multiple time points: start of treatment, end of treatment, short-term (2 week) follow-up, 3-month follow-up, and if needed at 6 months. Radiation toxicity was graded using the Radiation Therapy Oncology Grading (RTOG) acute toxicity scale. Median (range) toxicity grades at follow-up intervals were calculated. Clinical outcomes including local recurrence were evaluated for all patients. RESULTS: The study included 19 patients and 20 KCs. The median radiation dose was 42 Gy (39-42 Gy) over 6 fractions. The median toxicity at completion of treatment was RTOG grade 2 (85% of patients). At short-term follow-up, 50% of patients (n = 10) improved to RTOG grade 1 (0-2). At 3 months, 70% of patients (n = 14) had RTOG grade 0, and by 6 months, 100% of patients (n = 18) had RTOG grade 0. No RTOG grade 3 or higher skin toxicity was observed. With a median follow-up of 7.2 months (range, 1.3-54.4 months), the local recurrence-free survival was 95%. CONCLUSIONS: We demonstrate that HDR-BT can be used as definitive treatment of KCs of the face with excellent cosmetic outcomes and local control. Acute and subacute skin toxicities were most commonly RTOG grade 2 or less with resolution of patient's skin toxicity by 3 months.

Is the placement of jejunostomy tubes in patients with esophageal cancer undergoing esophagectomy associated with increased inpatient healthcare utilization? An analysis of the National Readmissions Database.

BACKGROUND: Patients undergoing esophagectomy often receive jejunostomy tubes (j-tubes) for nutritional supplementation. We hypothesized that j-tubes are associated with increased post-esophagectomy readmissions. STUDY DESIGN: We identified esophagectomies for malignancy with (EWJ) or without (EWOJ) j-tubes using the 2010-2015 Nationwide Readmissions Database. Outcomes include readmission, inpatient mortality, and complications. Outcomes were compared before and after propensity score matching (PSM). RESULTS: Of 22,429 patients undergoing esophagectomy, 16,829 (75.0%) received j-tubes. Patients were similar in age and gender but EWJ were more likely to receive chemotherapy (24.2% vs. 15.1%, p < 0.01). EWJ was associated with decreased 180-day inpatient mortality (HR 0.72 [0.52-0.99]) but not with higher readmissions at 30- (15.2% vs. 14.0%, p = 0.16; HR 0.9 [0.77-1.05]) or 180 days (25.2% vs. 24.3%, p = 0.37; HR 0.94 [0.79-1.10]) or increased complications (p = 0.37). These results were confirmed in the PSM cohort. CONCLUSION: J-tubes placed in the setting of esophagectomy do not increase inpatient readmissions or mortality.

Brain extraction on MRI scans in presence of diffuse glioma: Multi-institutional performance evaluation of deep learning methods and robust modality-agnostic training.

Brain extraction, or skull-stripping, is an essential pre-processing step in neuro-imaging that has a direct impact on the quality of all subsequent processing and analyses steps. It is also a key requirement in multi-institutional collaborations to comply with privacy-preserving regulations. Existing automated methods, including Deep Learning (DL) based methods that have obtained state-of-the-art results in recent years, have primarily targeted brain extraction without considering pathologically-affected brains. Accordingly, they perform sub-optimally when applied on magnetic resonance imaging (MRI) brain scans with apparent pathologies such as brain tumors. Furthermore, existing methods focus on using only T1-weighted MRI scans, even though multi-parametric MRI (mpMRI) scans are routinely acquired for patients with suspected brain tumors. In this study, we present a comprehensive performance evaluation of recent deep learning architectures for brain extraction, training models on mpMRI scans of pathologically-affected brains, with a particular focus on seeking a practically-applicable, low computational footprint approach, generalizable across multiple institutions, further facilitating collaborations. We identified a large retrospective multi-institutional dataset of n=3340 mpMRI brain tumor scans, with manually-inspected and approved gold-standard segmentations, acquired during standard clinical practice under varying acquisition protocols, both from private institutional data and public (TCIA) collections. To facilitate optimal utilization of rich mpMRI data, we further introduce and evaluate a novel ''modality-agnostic training'' technique that can be applied using any available modality, without need for model retraining. Our results indicate that the modality-agnostic approach1 obtains accurate results, providing a generic and practical tool for brain extraction on scans with brain tumors.

Outcomes of out-of-hospital extracorporeal membrane oxygenation transfers: significance of initiation site and personnel.

BACKGROUND: Extracorporeal membrane oxygenation is an accepted therapy option for refractory cardiac or respiratory failure. The outcomes of cases initiated at non-extracorporeal membrane oxygenation centers and subsequently transported for management to an extracorporeal membrane oxygenation center require further investigation. METHODS: Retrospective institutional review board-approved database research and chart reviews were performed on referrals for extracorporeal membrane oxygenation initially admitted to an outside non-extracorporeal membrane oxygenation center hospital (OSH) then transferred to our extracorporeal membrane oxygenation center (Thomas Jefferson University Hospital (TJUH)). Unstable patients were placed on extracorporeal membrane oxygenation at OSH (Group A) before transport, while others were initiated at our certified extracorporeal membrane oxygenation center (Group B) upon arrival. Group A was further subdivided into patients cannulated by OSH personnel (Group AOSH) or TJUH transport team (Group ATJUH). Outcomes and complications were compared between the different initiation sites and personnel. RESULTS: A total of 108 patients were transferred from August 2010 to June 2018. The technical complication rate for all Group A patients was 33/49 (67%), while that of Group B was 24/59 (41%); p = 0.006. Within Group A, Group AOSH had a greater technical complication rate with 29/33 (88%) than Group ATJUH with 4/16 (25%); p < 0.001. extracorporeal membrane oxygenation survival rate was 34/49 (69%) in Group A and 43/59 (73%) in Group B; p = 0.690. The extracorporeal membrane oxygenation survival rate for Group AOSH and Group ATJUH was 21/33 (64%) and 13/16 (81%), respectively; p = 0.210. CONCLUSION: Promising extracorporeal membrane oxygenation survival rates were observed in transferred patients. The complication rates related to cannulation technique were significantly higher when patients were initiated at non-extracorporeal membrane oxygenation centers, especially when placed by personnel from non-extracorporeal membrane oxygenation centers.

Comparing in-patient extracorporeal cardiopulmonary resuscitation to standard cardiac treatment group of extracorporeal membrane oxygenation patients: 8 years of experience at a single institution.

INTRODUCTION: Post-cardiac arrest survivals remain low despite the effort of cardiopulmonary resuscitation. Utilization of extracorporeal membrane oxygenation during cardiopulmonary resuscitation (extracorporeal cardiopulmonary resuscitation) can provide immediate cardiovascular support and potentially improve outcomes of patients with cardiac arrest requiring cardiopulmonary resuscitation. There is renewed interest in the use of extracorporeal cardiopulmonary resuscitation due to improved outcomes over the years. METHODS: Extracorporeal membrane oxygenation data between 2010 and 2018 were reviewed. Patients with extracorporeal membrane oxygenation placed under cardiopulmonary resuscitation were identified, and demographics, extracorporeal membrane oxygenation survival, survival to discharge, and neurological recovery were retrospectively analyzed with institutional review board approval. RESULTS: Among 230 cases of extracorporeal membrane oxygenation, 34 (21 males and 13 females, age of 49 ± 13 years) underwent extracorporeal cardiopulmonary resuscitation. The mean duration of extracorporeal membrane oxygenation support after extracorporeal cardiopulmonary resuscitation was 8.3 ± 7.9 days. Extracorporeal membrane oxygenation mortality among extracorporeal cardiopulmonary resuscitation patients was 32% (11/34) and hospital survival was 38% (13/34), which are similar to standard cardiac extracorporeal membrane oxygenation (extracorporeal membrane oxygenation survival 62% and hospital survival 39% in cardiac extracorporeal membrane oxygenation). Among the extracorporeal membrane oxygenation death after extracorporeal cardiopulmonary resuscitation, the majority was due to neurological injury (73%, 8/11); 8/34 extracorporeal membrane oxygenation survival rate and 30-day survival rate were 63% and 25% in early half of study (2010-2014) and have improved to 70% and 60% in late half of study (2014-2018). CONCLUSION: Over years of experience with extracorporeal membrane oxygenation, the outcome of the extracorporeal cardiopulmonary resuscitation has been improving and appears to exceed those of traditional methods, despite limited sample size. Neurological complications still need to be addressed in order for survival and outcomes to improve.

Twitter and academic Urology in the United States and Canada: a comprehensive assessment of the Twitterverse in 2019.

OBJECTIVE: To provide the first comprehensive analysis of the Twitterverse amongst academic urologists and programmes in North America. METHODS: Using national accreditation and individual programme websites, all active urology residency programmes (USA and Canada) and academic Urology faculty at these programmes were identified. Demographic data for each programme American Urological Association [AUA] section, resident class size) and physician (title, fellowship training, Scopus Hirsch index [H-index] and citations) were documented. Twitter metrics (Twitter handle, date joined, # tweets, # followers, # following, likes) for programmes and physicians were catalogued (data capture: March-April 2019). Descriptive analyses and temporal trends in Twitter utilisation amongst programmes and physicians were assessed. Multivariable logistic regression was used to identify predictors of Twitter use. RESULTS: In all, 156 academic programmes (143 USA, 13 Canada) and 2214 academic faculty (2015 USA, 199 Canada) were identified. Twitter utilisation is currently 49.3% and 34.1% amongst programmes and physicians, respectively, and continues to increase. On multivariable analysis, programmes with 3-5 residents/year and programmes with a higher percentage of faculty Twitter engagement were more likely to have Twitter accounts. From a physician perspective, those with fellowship training, lower academic rank (Clinical Instructor, Assistant Professor, Associate Professor vs Professor) and higher H-indices were more likely to have individual Twitter accounts. CONCLUSION: There is a steady increase in Twitter engagement amongst Urology programmes and academic physicians. Faculty Twitter utilisation is an important driver of programme Twitter engagement. Twitter social media activity is strongly associated with academic productivity, and may in fact drive academic metrics. Within Urology, social media presence appears to be proportional to academic activity.

Cross-inhibition of pathogenic agents and the host proteins they exploit.

The major limitations of pathogen-directed therapies are the emergence of drug-resistance and their narrow spectrum of coverage. A recently applied approach directs therapies against host proteins exploited by pathogens in order to circumvent these limitations. However, host-oriented drugs leave the pathogens unaffected and may result in continued pathogen dissemination. In this study we aimed to discover drugs that could simultaneously cross-inhibit pathogenic agents, as well as the host proteins that mediate their lethality. We observed that many pathogenic and host-assisting proteins belong to the same functional class. In doing so we targeted a protease component of anthrax toxin as well as host proteases exploited by this toxin. We identified two approved drugs, ascorbic acid 6-palmitate and salmon sperm protamine, that effectively inhibited anthrax cytotoxic protease and demonstrated that they also block proteolytic activities of host furin, cathepsin B, and caspases that mediate toxin's lethality in cells. We demonstrated that these drugs are broad-spectrum and reduce cellular sensitivity to other bacterial toxins that require the same host proteases. This approach should be generally applicable to the discovery of simultaneous pathogen and host-targeting inhibitors of many additional pathogenic agents.