Early apical release versus En-bloc no touch technique for holmium laser enucleation of the prostate: a high-volume single-surgeon cohort study.

PURPOSE: To determine whether the early apical release (EAR) technique for holmium laser enucleation of the prostate (HOLEP) is associated with improved perioperative outcomes compared to the En-bloc no touch (EBNT) technique. METHODS: Consecutive men treated with HOLEP by a single surgeon from August 2018 to March 2021 were identified. Beginning in June 2021 all procedures were performed using the EAR technique, and these were compared to the preceding cases done with the EBNT technique. Intraoperative outcomes included operative time, need for open conversion, enucleation efficiency (tissue removed per minute of OR time), and enucleation ratio (tissue removed relative to preoperative gland size on imaging). Postoperative outcomes included catheter reinsertion, blood transfusion, and complications classified by the Clavien-Dindo scale. RESULTS: We identified 801 men, including 571 (71%) treated with EBNT and 230 (29%) with EAR. Median preoperative characteristics were similar between groups. The EAR approach was associated with significantly longer mean operating room time, 100.5 min versus 91.9 min, p = 0.003. However, EAR patients had a much lower rate of conversion to open cystotomy (0.43% versus 3.0%). There were no significant differences in rate of catheter reinsertion or perioperative complications between groups (p > 0.05). CONCLUSION: EAR technique by an experienced HoLEP surgeon resulted in longer operative times, potentially reflecting an initial learning curve, but essentially eliminated the need for open cystotomy. Perioperative results including catheter reinsertion rate and bleeding complications were similar between the two cohorts. These data support continued use of the EAR technique for HOLEP to minimize risk of open conversion.

Etiology, urine metabolic risk factors, and urine oxalate patterns in patients with significant hyperoxaluria and recurrent nephrolithiasis.

PURPOSE: American Urology Association guidelines recommend genetic testing for patients with recurrent stones and urine oxalate > 75 mg/day. The goal of this study was to examine the treatment of patients in this category in a large multidisciplinary adult stone clinic. METHODS: Patients were evaluated from a single institution between 2006 and 2019. Those with at least one level of urinary oxalate excretion (uOx) above 75 mg/day were identified. A chart review identified enteric risk factors and genetic testing results. Patients without an identifiable enteric cause were considered idiopathic. RESULTS: A total of 4229 separate 24-h urine collections in 1302 patients were reviewed. At least one measurement of uOx above 75 mg/day was found in 103 (7.9%) patients. Enteric hyperoxaluria (EH) was seen in 28 (27%) and idiopathic hyperoxaluria (IH) in 76 (74%). 20 (71%) patients in the EH group had undergone gastric bypass. The median uOx was significantly higher level in the EH group (121.0 vs. 93.0 mg/day). For the entire cohort, there was a drop in uOx (- 33.8 mg/day) with medical and dietary therapy after a follow-up of 46.6 months. The final oxalate was higher in EH (88.9 vs. 60.1 mg/day). Only one patient had referral for genetic testing and was found to have primary hyperoxaluria type 2. CONCLUSIONS: The most common cause of significant hyperoxaluria in patients with recurrent nephrolithiasis remains idiopathic. Patients with IH have more significant improvement in uOx compared to EH; however, both groups had hyperoxaluria at last follow-up. Rate of genetic testing is low despite guideline recommendations.

Utilizing Preoperative Magnetic Resonance Imaging to Self-assess Enucleation Ratio in Holmium Laser Enucleation of the Prostate.

OBJECTIVE: To determine if transition zone (TZ) volume as measured by magnetic resonance imaging (MRI) correlates closely with specimen weight and postoperative prostate-specific antigen (PSA) and to determine if this correlation improved with increased experience. We hypothesize that information from a preoperative MRI can be leveraged to self-assess competency in holmium laser enucleation of the prostate (HoLEP). METHODS: From August 2018 to June 2021 567 men were identified who underwent HoLEP by a single surgeon and had their data entered into a database. Ninety-seven men were identified who had an MRI in our image archives. A radiologist blinded to the specimen weight measured the transition zone (TZ) using image analysis software. TZ volume was then correlated with specimen weight for the entire study period and subdivided into four consecutive periods. Preoperative and Postoperative PSA data was analyzed. RESULTS: Seventeen percent of men who underwent HoLEP at our institution had an MRI preoperatively. The TZ to total prostate volume ratio was 70%. The overall correlation coefficient between TZ volume and specimen weight was 0.914 (P-value <.001). There was no statistically significant improvement in correlation coefficient over time when divided into four equal subgroups. Median PSA reduction was 91% (7.9-0.7 ng/dL). CONCLUSION: Preoperative MRI derived TZ volume correlates closely with specimen weight. We present a reference cohort from a high volume HoLEP center to facilitate HoLEP learners to self-assess competency. Lack of increased correlation over time is likely due to an experienced HoLEP surgeon who is on the flatter portion of his learning curve.

Hospital use following anterior cervical discectomy and fusion.

Most existing anterior cervical discectomy and fusion (ACDF) outcome studies omit emergency department (ED) use. To our knowledge, this study on ED use following ACDF surgery is the first to use a direct patient chart review and the first to include revision patients, 1-5 levels of ACDFs, and performance of corpectomy in the analysis. This study examines the frequency and basis of hospital service use within 30 days of ACDF surgery, specifically ED visits, hospital readmissions, and returns to the operating room. A retrospective chart review was performed for 1273 consecutive patients who underwent ACDF surgery at one institution from July 2013 to June 2016. Of the 1273 patients with ACDF, 97 (7.6%) presented to the ED within 30 days after surgery. Of 43 patients with revision ACDF, 9 (20.9%) returned to the ED, compared with 88 (7.2%) of 1230 patients with primary ACDF (P = 0.001). Of the 111 ED visits by 97 patients, 40 (36%) were for cervicalgia, 13 (12%) were for dysphagia, 8 (7%) were for trauma, 7 (6%) were for nausea, 4 (4%) were for medication refill, 3 (3%) were for dehiscence, 3 (3%) were for pneumonia, and 3 (3%) were for urinary tract infection. Of the ED presentations, 8 (7%) occurred during the first 2 days after surgery, and 46 (41%) occurred within the first postoperative week.

Perioperative and swallowing outcomes in patients undergoing 4- and 5-level anterior cervical discectomy and fusion.

OBJECTIVE: Anterior cervical discectomy and fusion (ACDF) is a common and robust procedure performed on the cervical spine. Literature on ACDF for 4 or more segments is sparse. Increasing the number of operative levels increases surgical complexity, tissue retraction, and risks of complications, particularly dysphagia. The overall risks of these complications and rates of dysphagia are not well studied for surgery on 4 or more segments. In this study, the authors evaluated their institution's perioperative experience with 4- and 5-level ACDFs. METHODS: The authors retrospectively reviewed patients who underwent 4- or 5-level ACDF at their institution over a 6-year period (May 2013-May 2019). Patient demographics, perioperative complications, readmission rates, and swallowing outcomes were recorded. Outcomes were analyzed with a multivariate linear regression. RESULTS: A total of 174 patients were included (167 had 4-level and 7 had 5-level ACDFs). The average age was 60.6 years, and 54.0% of patients (n = 94) were men. A corpectomy was performed in 12.6% of patients (n = 22). After surgery, 56.9% of patients (n = 99) experienced dysphagia. The percentage of patients with dysphagia decreased to 22.8% (37/162) at 30 days, 12.9% (17/132) at 90 days, and 6.3% (5/79) and 2.8% (1/36) at 1 and 2 years, respectively. Dysphagia was more likely at 90 days postoperatively in patients with gastroesophageal reflux (OR 4.4 [95% CI 1.5-12.8], p = 0.008), and the mean (± SD) lordosis change was greater in patients with dysphagia than those without at 90 days (19.8° ± 13.3° vs 9.1° ± 10.2°, p = 0.003). Dysphagia occurrence did not differ with operative implants, including graft and interbody type. The mean length of time to solid food intake was 2.4 ± 2.1 days. Patients treated with dexamethasone were more likely to achieve solid food intake prior to discharge (OR 4.0 [95% CI 1.5-10.6], p = 0.004). Postsurgery, 5.2% of patients (n = 9) required a feeding tube due to severe approach-related dysphagia. Other perioperative complication rates were uniformly low. Overall, 8.6% of patients (n = 15) returned to the emergency department within 30 days and 2.9% (n = 5) required readmission, whereas 1.1% (n = 2) required unplanned return to surgery within 30 days. CONCLUSIONS: This is the largest series of patients undergoing 4- and 5-level ACDFs reported to date. This procedure was performed safely with minimal intraoperative complications. More than half of the patients experienced in-hospital dysphagia, which increased their overall length of stay, but dysphagia decreased over time.

Troubleshooting an unusual complication following intrathecal chemotherapy delivered via Ommaya catheter: A case report.

The authors report the case of a 39-year-old woman with leukemic meningitis. A right frontal Ommaya reservoir was placed for intrathecal chemotherapy. During and immediately following the first injection of chemotherapy, the patient developed an episode of nausea, emesis, frontal headache and diarrhea. These same symptoms were later elicited during a second and third administration of chemotherapy. Post-placement head computed tomography showed the tip of the catheter projecting approximately 1.5 cm inferior to the floor of the left frontal ventricle. After a revision of the Ommaya catheter due to suboptimal positioning, subsequent intrathecal chemotherapy administration was tolerated without any of the adverse symptoms previously encountered. The case documents an unusual complication arising from catheter migration in the setting of intrathecal chemotherapy and also demonstrates the value in troubleshooting Ommaya reservoir complications rather than prematurely abandoning its use in favor of lumbar puncture.

Parkinsonism as a late presentation of lymphomatosis cerebri following high-dose chemotherapy with autologous stem cell transplantation for primary central nervous system lymphoma.

Primary central nervous system lymphoma is an aggressive form of non-Hodgkin lymphoma arising in the eyes, meninges, spinal cord, or brain. Treatment of primary CNS lymphoma with a combination of high-dose chemotherapy and autologous stem cell transplantation has been shown to have high rates of remission which is frequently sustained for multiple years. Recurrence of primary CNS lymphoma generally presents with one or multiple contrast enhancing lesions on MRI. In rare cases, lymphoma cells may proliferate diffusely within the brain parenchyma without mass formation, a pattern termed lymphomatosis cerebri. Lymphomatosis cerebri presents a significant diagnostic challenge, and has not been reported to present with parkinsonism. Here, we present a case of initially mass forming, contrast-enhancing primary CNS lymphoma which remitted following chemotherapy and autologous stem cell transplantation, and recurred 7 years post-transplant with symptoms of parkinsonism and a lack of typical lesions on imaging, with lymphomatosis cerebri confirmed at autopsy.

Effects of Negative Pressure Wound Therapy on Wound Dehiscence and Surgical Site Infection Following Instrumented Spinal Fusion Surgery-A Single Surgeon's Experience.

BACKGROUND: Incisional negative pressure wound therapy (NPWT) is used in many surgical specialties to prevent postoperative dehiscence and surgical site infections (SSIs). However, little is known about the role of incisional NPWT in spine fusion surgery. Therefore, we sought to report a single surgeon's experience using incisional NPWT and describe its effects on dehiscence and SSIs after instrumented spine surgery. METHODS: We compared rates of hospital readmission and return to the operating room for dehiscence and SSIs in a consecutive series of patients who underwent spinal fusion surgery with or without NPWT from 2015 to 2018. RESULTS: A total of 393 patients without and 76 patients with NPWT were included for analysis. Half way through the data collection period, all patients who underwent anterior lumbar fusion received NPWT. Three of 15 (20.0%) of non-NPWT patients who underwent anterior lumbar fusion had dehiscence or SSI compared with zero of 23 (0.0%) of NPWT patients (P = 0.01). NPWT for posterior surgeries was used on a case-by-case basis using risk factors that contribute to SSIs and dehiscence. NPWT patients had higher rates of spinal neoplasia (0.5% vs. 11.3%, P < 0.0001), osteomyelitis/diskitis (1.3% vs. 7.5%, P = 0.02), durotomy (14.9% vs. 28.6%, P = 0.007), revision surgery (32.2% vs. 59.6%, P = 0.0001), and longer fusion constructs (7 vs. 11 levels, P < 0.0001) but had similar rates of dehiscence and SSIs as non-NPWT patients (5.6% vs. 5.7%, P = 0.98). CONCLUSIONS: NPWT decreases dehiscence and SSIs in patients undergoing lumbar fusion through an anterior approach. When preferentially used in patients at high risk for postoperative wound complications, NPWT prevents increased rates of dehiscence and SSI.

Trends in Direct Hospital Payments to Anesthesia Groups: A Retrospective Cohort Study of Nonacademic Hospitals in California.

BACKGROUND: In addition to payments for services, anesthesia groups in the United States often receive revenue from direct hospital payments. Understanding the magnitude of these payments and their association with the hospitals' payer mixes has important policy implications. METHODS: Using a dataset of financial reports from 240 nonacademic California hospitals between 2002 and 2014, the authors characterized the prevalence and magnitude of direct hospital payments to anesthesia groups, and analyzed the association between these payments and the fraction of anesthesia revenue derived from public payers (e.g., Medicaid). RESULTS: Of hospitals analyzed, 69% (124 of 180) made direct payments to an anesthesia group in 2014, compared to 52% (76 of 147) in 2002; the median payment increased from $242,351 (mean, $578,322; interquartile range, $72,753 to $523,861; all dollar values in 2018 U.S. dollars) to $765,128 (mean, $1,295,369; interquartile range, $267,006 to $1,503,163) during this time period. After adjusting for relevant covariates, hospitals where public insurers accounted for a larger fraction of anesthesia revenues were more likely to make direct payments to anesthesia groups (ß = 0.45; 95% CI, 0.10 to 0.81; P = 0.013), so that a 10-percentage point increase in the fraction of anesthesia revenue derived from public payers would be associated with a 4.5-percentage point increase in the probability of receiving any payment. Among hospitals making payments, our results (ß = 2.10; 95% CI, 0.74 to 3.45; P = 0.003) suggest that a 1-percentage point increase in the fraction of anesthesia revenue derived from public payers would be associated with a 2% relative increase in the amount paid. CONCLUSIONS: Direct payments from hospitals are becoming a larger financial consideration for anesthesia groups in California serving nonacademic hospitals, and are larger for groups working at hospitals serving publicly insured patients.