Surgical Site Infections During the Pandemic: The Impact of the "COVID Bundle".

BACKGROUND: A reduction in surgical site infections (SSIs) has been reported in several discrete patient populations during the COVID-19 pandemic. Herein, this study evaluates the impact of the COVID-19 pandemic on SSI in a large patient cohort incorporating multiple surgical disciplines. We hypothesize that enhanced infection control and heightened awareness of such measures is analogous to an SSI care bundle, the hypothetical "COVID bundle", and may impact SSI rates. METHOD: Data collected for the American College of Surgeons National Surgical Quality Improvement Program between January 1, 2015, and April 1, 2021, were retrospectively analyzed. SSI rates were compared among time-dependent patient cohorts: Cohort A (pre-pandemic, N = 24,060, 87%) and Cohort B (pandemic, N = 3698, 13%). Time series and multivariable analyses predicted pre-pandemic and pandemic SSI trends and tested for association with timing of surgery. RESULTS: The overall SSI incidence was reduced in Cohort B versus Cohort A (2.8% vs. 4.5%, p < 0.001). Multivariable analysis indicated a downward SSI trend before pandemic onset (IRR 0.997, 95% CI 0.994, 1). At pandemic onset, the trend reduced by a relative factor of 39% (IRR 0.601, 95% CI 0.338, 1.069). SSI then trended upward during the pandemic (IRR 1.035, 95% CI 0.965, 1.111). SSI rates significantly trended downward in general surgical patients at pandemic onset (IRR 0.572, 95% CI 0.353, 0.928). CONCLUSION: Although overall SSI incidence was reduced during the pandemic, a statistically significant decrease in the predicted SSI rate only occurred in general surgical patients at pandemic onset. This trend may suggest a positive impact of the "COVID bundle" on SSI rates in these patients.

Obesity and Complication Risk From Radical Cystectomy: Identifying a Body Mass Index Threshold.

PURPOSE: There are conflicting reports regarding radical cystectomy complication risk from obesity subcategories, and a BMI threshold below which complication risk is notably reduced is undefined. A BMI threshold may be helpful in prehabilitation to aid patient counseling and inform weight loss strategies to potentially mitigate obesity-associated complication risk. This study aims to identify such a threshold and further investigate the association between BMI subcategories and perioperative complications from radical cystectomy. MATERIALS AND METHODS: Data were extracted from the Canadian Bladder Cancer Information System, a prospective registry across 14 academic centers. Five hundred and eighty-nine patients were analyzed. Perioperative (≤90 days) complications were compared between BMI subcategories. Unconditional multivariable logistic regression and cubic spline analysis were performed to determine the association between BMI and complication risk and identify a BMI threshold. RESULTS: Perioperative complications were reported in 51 (30%), 97 (43%), and 85 (43%) normal, overweight, and obese patients (P = .02). BMI was independently associated with developing any complication (OR 1.04 95% CI 1.01, 1.07). Predicted complication risk began to rise consistently above a BMI threshold of 34 kg/m2. Both overweight (OR 2.00 95% CI 1.26-3.17) and obese (OR 1.98 95% CI 1.24-3.18) patients had increased risk of complications compared to normal BMI patients. CONCLUSIONS: Complication risk from radical cystectomy is independently associated with BMI. Both overweight and obese patients are at increased risk compared to normal BMI patients. A BMI threshold of 34 kg/m2 has been identified, which may inform prehabilitation treatment strategies.

The prognostic value of urinary cytology after trimodal therapy (TMT) for muscle-invasive bladder cancer.

BACKGROUND: Urine cytology and cystoscopy are routinely employed during follow-up of patients after trimodal therapy (TMT) for muscle-invasive bladder cancer (MIBC). The significance of positive or equivocal cytology without visible disease recurrence on cystoscopy during follow-up is unknown, and studies informing outcomes in this scenario are lacking. This study aims to investigate the temporal trends of positive/equivocal cytology in the absence of visible disease recurrence and the association with bladder cancer recurrence and survival outcomes. METHODS: One hundred and twenty-nine patients with available post-TMT cytology data and negative cystoscopy from a single academic institution between 2002 and 2017 with a median follow-up of 3.4 (range 0.1-14.2) years were analyzed. Cytology results, first post-TMT cytology positive/equivocal (CP) and negative (CN), were evaluated for association with disease recurrence and survival. Kaplan. Meier and competing risks methods were used to assess time-to-negative cytology in CP patients with ≥2 interval post-TMT cytology results (n = 33), time-to-recurrence, and disease-specific mortality (DSM) stratified by first post-TMT cytology result. RESULTS: At first follow-up (6-8 weeks post-TMT completion), CP was observed in 41 (32%) and CN in 88 (68%) of patients. With further follow-up of CP patients with ≥2 interval post-TMT cytology results, the probability of developing negative cytology was 57% (95% CI 42, 77) at 6 months post-TMT, and the median time-to-negative cytology was 3.2 months (95% CI 2.99, 5.80). The median time-to-recurrence was reduced in CP patients compared to CN (24.3 vs. 78.1 months, p = 0.1), corresponding with an apparent increase in the cumulative incidence of recurrence rate at 3 years in the CP vs. CN group (62% vs. 42%, p = 0.1). No significant difference was observed in the 3-year DSM rates. On univariable analysis, the hazards of recurrence and DSM for patients with CP were 1.5 (95% CI 0.9, 2.5, p = 0.1) and 2.1 (95% CI 0.9, 4.7, p = 0.07) respectively. CONCLUSION: This is the first study to investigate the significance of a positive/equivocal cytology without visible disease following TMT for MIBC. Positive cytology is common and does not preclude subsequent negative cytology supporting a watchful waiting approach rather than proceeding immediately to biopsy. However, cytology that remains positive at subsequent follow-up may be associated with adverse recurrence and survival outcomes.

Standardized Reporting of Machine Learning Applications in Urology: The STREAM-URO Framework.

The Standardized Reporting of Machine Learning Applications in Urology (STREAM-URO) framework was developed to provide a set of recommendations to help standardize how machine learning studies in urology are reported. This framework serves three purposes: (1) to promote high-quality studies and streamline the peer review process; (2) to enhance reproducibility, comparability, and interpretability of results; and (3) to improve engagement and literacy of machine learning within the urological community.

Long-Term Outcomes of Renal Transplant in Patients With End-Stage Renal Failure Due to Systemic Lupus Erythematosus and Granulomatosis With Polyangiitis.

OBJECTIVES: Systemic lupus erythematosus and granulomatosis with polyangiitis are systemic inflammatory conditions associated with renalfailure that can recur after renal transplant. Patients with these conditions are treated with chronic immunosuppression, potentially increasing risk of secondary malignancies. Here, we investigated long-term outcomes in renal transplant recipients with these conditions. MATERIALS AND METHODS: Transplant recipients with end-stage kidney disease due to systemic lupus erythematosus and granulomatosis with polyangiitis seen between 1982 and 2016 at a national kidney transplant center were included. Primary outcome variables were long-term allograft survival and incidence of secondary malignancy. Secondary outcome measures were incidence of delayed graft function, primary disease recurrence, and serum creatinine at follow-up. RESULTS: Ninety-eight transplant procedures (90 from deceased donors) in 92 consecutive patients (mean age 42.3 ± 14.4 y) were included: 55 with systemic lupus erythematosus and 37 with granulomatosis with polyangiitis. Follow-up duration was 110.53 ± 81.95 months (range, 1-393 mo). Overall renal allograft survival was 94.7% at 1 year, 85.4% at 5 years, and 75.4% at 10 years posttransplant. Patientswith systemic lupus erythematosus showed overall allograft survival of 91.6% at 1 year, 84.3% at 5 years, and 74.4% at 10 years. There was 1 allograft failure due to recurrence of primary disease in this group. Patients with granulomatosis with polyangiitis showed overall allograft survival of 100% at 1 year, 92.4% at 5 years, and 92.4% at 10 years. There were 21 mortalities, with 5 (23.8%) due to secondary malignancy. In total, 46 malignancies were diagnosed in 31 patients. CONCLUSIONS: We found excellent long-term renal allograft survival rates in patients with systemic lupus erythematosus and granulomatosis with polyangiitis, with secondary malignancy rates similar to those shown in recipients without autoimmune diseases. These findings provide clinicians with long-term data on transplant recipients with end-stage renal failure due to systemic inflammatory conditions.

Bladder neck placement of a synthetic polypropylene sling for the treatment of stress urinary incontinence.

INTRODUCTION: Pubo-vaginal sling placed at the bladder neck is the gold standard treatment for stress urinary incontinence (SUI). The synthetic mid-urethral sling (MUS) is now widely used, as morbidity rates with this technique are substantially reduced. This is an initial report on long-term outcomes of a polypropylene sling (PPS) placed in the traditional bladder neck location. METHODS: A retrospective analysis of all patients who underwent PPS insertion at our institution between 2006 and 2014 was conducted. Patient and urodynamic demographics were recorded. Subjective and objective measures of success were determined by postoperative pad usage and validated incontinence questionnaires. RESULTS: A total of 170 patients were followed for a median of four years (range 1-8). The mean age was 51 years (±10). Subjective response was assessed in 57% of patients; the overall subjective cure rate was 85.3% (n=145), subjective improvement rate was 4.1% (n=7), and the subjective failure rate was 10.6% (n=18). The mean Urogenital Distress Inventory (UDI)-6 score was 6.5 (±5.6) out of a maximum score of 24 and the Incontinence Impact Questionnaire (IIQ)-7 score was 5.5 (±6.3) out of a maximum score of 28. There was no significant difference in objective outcome measures in those with an abdominal leak-point pressure (ALPP) < or >60 cmH2O. CONCLUSIONS: Bladder neck placement of a PPS resulted in cure rates of 85% in this series. SUI secondary to intrinsic sphincter deficiency (ISD) and urethral hypermobility were treated with equal success. Bladder neck PPS placement has a role in the treatment of SUI. Our data may well reassure rectus fascia sling (RFS) surgeons who wish to take advantage of faster postoperative recovery using the less invasive PPS placed at the bladder neck.

Retrospective Multicenter Analysis of the Accuracy of Clinical Examination by Community Physicians in Diagnosing Developmental Dysplasia of the Hip.

OBJECTIVES: To determine among general practitioners (GPs) the most common clinical findings that raised concern for developmental dysplasia of the hip (DDH) and necessitated an orthopedic outpatient referral. In addition, we assessed the sensitivity and specificity of the most common of these clinical findings. STUDY DESIGN: We performed a multicenter retrospective review of all referrals by GPs to local orthopedic outpatient departments for DDH over a 12-month period. All patients had undergone pelvic radiographs, and the acetabular index (AI) was measured. The AI was used as a reference test to assess the accuracy of the clinical examination in diagnosing DDH. Sensitivity and specificity of each clinical sign was calculated. RESULTS: Twenty-six of 174 (14.9%) referred patients were diagnosed with DDH, defined as an AI score > 30. The most common indication for referral, per the GP letter was asymmetrical skin folds (97 patients, 45.8%), followed by hip click (42 patients, 19.8%), and limb shortening (34 patients, 16%). Sensitivities and specificities, respectively, among findings were asymmetric skin folds 46.2% (95% CI 26.6%-66.6%) and 42.6% (95% CI 34.5%-51.0%), hip click 23.1% (95% CI 9.0%-43.6%) and 75.7% (95% CI 67.9%-82.3%), limb shortening 30.8% (95% CI 14.3%-51.8%) and 82.4% (75.3%-88.2%), and reduced abduction 19.2% (95% CI 6.6%-39.4%) and 91.9% (95% CI 86.3%-95.7%). Using logistic regression analysis, no clinical sign was found to be a statistically significant indicator of an abnormal AI. CONCLUSIONS: Clinical examination by GPs does not reliably detect radiographically-defined DDH. None of the clinical findings by the GP showed an acceptable level of sensitivity. Absence of reduced abduction and limb shortening are relevant negatives given the high level of specificity of these signs.

Radical prostatectomy in the presence of ongoing refractory ESBL Escherichia coli bacterial prostatitis.

A 44-year-old Indian national with a prostate-specific antigen of 5.4 ng/mL underwent 12-core transrectal ultrasound-guided prostate biopsies. Following this, he had three hospital admissions with severe urosepsis secondary to extended spectrum ß lactamase (ESBL) producing Escherichia coli. He had recurrent sepsis immediately after discontinuation of intravenous meropenem to which the ESBL was sensitive. He proceeded to radical prostatectomy for intermediate-high risk Gleason 7 prostate cancer, while still on intravenous meropenem, 2 months after his biopsy. His prostatectomy involved a difficult dissection due to inflammatory changes and fibrosis after multiple septic episodes. He had complete resolution of infection after surgery with discontinuation of antibiotics on the third postoperative day, without any recurrence of sepsis.

Ex vivo reconstruction of the donor renal artery in renal transplantation: a case-control study.

Transplantation of renal allografts with anatomic variability or injured vasculature poses a challenge to the transplanting surgeon but can be salvaged for transplantation with ex vivo bench reconstruction of the vasculature. We investigated whether renal allograft function is impaired in these reconstructed allografts; compared to the donor-matched, un-reconstructed allograft. Reconstructed allografts were transplanted into 60 patients at our institution between 1986 and 2012. A control group was selected from the matched pair of the recipient in deceased donor transplantation. We found no significant difference in the overall graft and patient survival rates (P = 1.0, P = 0.178). Serum creatinine levels were not significantly higher in the study group at 1, 3 and 12 months postoperatively. There were two cases of vascular thrombosis in the study group that were not related to the ex vivo reconstruction. A significantly greater proportion of reconstructed patients were investigated with a colour duplex ultrasound postoperatively (0.007). Although we have demonstrated a higher index of suspicion of transplant failure in patients with a reconstructed allograft, this practice has proven to be a safe and useful technique with equivocal outcome when compared to normal grafts; increasing the organ pool available for transplantation.

Outcome of deceased donor renal transplantation in patients with an ileal conduit.

Renal transplantation in recipients with an ileal conduit is uncommon and occasionally controversial as it has been associated with high morbidity and mortality rates. We report on 17 patients with an ileal conduit who received a deceased donor renal transplant at our institution between January 1986 and December 2012. We retrospectively reviewed their allograft and surgical outcome. There were four mortalities at five, five, 39, and 66 months post-transplant. Sixteen of 17 grafts functioned immediately; one patient had primary non-function secondary to vascular thrombosis. Thirteen of 17 (76.5%) grafts were functioning at a mean follow-up period of 105 months. The mean serum creatinine at follow-up was 111 µM (±38.62). Five patients had seven episodes of urosepsis requiring hospital admission, and five patients received treatment for renal stone disease. We conclude that given improvements in immunosuppression, surgical technique, infection treatment, and selection criteria, we believe that renal transplantation in the patient with an ileal conduit yields excellent graft survival, although there is a high morbidity rate in this cohort of patients in the long term.

Severe sprains of the sub-axial cervical spine in adolescents: a diagnostic and therapeutic challenge: a report of three cases.

BACKGROUND: Sub-axial cervical spine(C spine) distraction flexion injuries, known as cervical sprains, have been divided into either "benign" or "severe" sprains depending on the integrity of the posterior longitudinal ligament (PLL) of the spinal column. It is a very uncommon injury and rarely reported in the literature. Most of the reports in the literature discuss this injury in the adult age group and so the adolescent age group was also considered to follow the same model of progression of mechanical instability depending on the degree and extent of structures injured, including the PLL as a cutoff factor between a "stable" and an "unstable" injury. PATIENTS AND METHODS: We report three cases of adolescents with severe cervical sprains at the C2-C3 level and argue the integrity of PLL as a determinant factor in the sagittal stability of the C spine in this age group.

Ureteral diverticulum: a review of the current literature.

INTRODUCTION: Ureteral diverticulum is a rare urological condition with only 45 cases described in the literature. These previously reported cases vary in their presentation, diagnosis and management and there is no consensus in the literature on the best diagnostic tool available. We describe our experience on diagnosing and managing this condition in two patients and provide a descriptive review of the current literature on ureteral diverticulum. MATERIALS AND METHODS: A Medline search was performed to identify all reported cases of ureteral diverticulum. Key words used were: ureteral diverticulum; abortive bifid ureter; congenital diverticulum; acquired diverticulum. We also reviewed the records of two patients who presented consecutively to our institution with a ureteral diverticulum. The clinical and radiological characteristics of this entity were then evaluated. RESULTS: Forty-one manuscripts were identified, encompassing single case reports and case series, the largest of which contained seven patients. Two additional cases were diagnosed in our institution; a true congenital diverticulum and an abortive bifid ureter which is synonymous with a true ureteral diverticulum. Both were uncomplicated cases and were managed conservatively. Retrograde pyelography was used for definitive diagnosis of this lesion. CONCLUSION: Ureteral diverticulum may present as an incidental finding or with a secondary complication. Conservative management is advocated in the literature for non-complicated cases. Retrograde pyelography is our diagnostic tool of choice.

Primary penile melanoma with an incidental renal oncocytoma.

A 57-year-old man presented with a pigmented lesion on the ventral aspect of his glans penis. A punch biopsy showed features consistent with malignant melanoma. Preoperative staging was initiated with CT of the thorax, abdomen and pelvis. A mass in the lower pole of the left kidney was found and given the presence of a primary melanoma, was highly suspicious for a metastatic deposit or a primary renal cell carcinoma. A biopsy of this mass failed to give a definitive diagnosis. The patient proceeded to have a partial penectomy and a left radical nephrectomy. The penile lesion was a 2.5 mm malignant melanoma with nodular and superficial spreading components. The renal mass turned out to be a benign oncocytoma. The final clinical stage of the penile melanoma was pT3a N0 M0. The patient received adjuvant interferon therapy. He is well and free of disease recurrence at 1-year postsurgery.

Acetabular revision arthroplasty: using the Hastings bipolar head to enable retention of a well-fixed monoblock stem.

UNLABELLED: We describe a novel technique of combining the Hastings bipolar head, matched in size to the acetabular cup liner, with a fixed, cemented monoblock stem allowing for isolated uncemented acetabular revision arthroplasty. AIM: To assess patient clinical and radiological outcomes after isolated uncemented acetabular revision arthroplasty using the Hastings bipolar head. METHODS: Clinical outcome was assessed with the Oxford and WOMAC hip scores.
Radiographs were assessed preoperatively for acetabular defects. Post operative osseointegration of the acetabular cup was then classified and the femoral stem was examined for signs of loosening. RESULTS: Nine acetabular components were revised in eight patients. Preoperative acetabular defects ranged from Paprosky type 1 to 3A. There were no significant intra or postoperative complications. At a mean final follow-up of 15 months, the Oxford hip score improved from an average of 17.5 preoperatively to 44.1, and the WOMAC score had improved from 44.1 to 90.9. Eight acetabular cups demonstrated three or more signs of osseointegration with the remaining cup showing two signs. There were no signs of loosening of the retained femoral stems. CONCLUSION: These short term results of the use of the Hastings bipolar head in isolated uncemented acetabular revision arthroplasty demonstrate good patient outcomes, reduced morbidity, decreased technical difficulties for the surgeon and reduced expense for the health service.

Atypical Mycobacterial infections in children: the case for early diagnosis.

BACKGROUND & AIMS: Atypical Mycobacteria (ATB) are a miscellaneous collection of Mycobacteriaceae which also includes M. tuberculosis, M. bovis and M. leprae. In the paediatric population, ATB infections present with non-tender unilateral lymphadenopathy in a systemically well child. Initially the disease may be mistaken for a staphylococcal or streptococcal abscess. Inappropriate surgical incision and drainage is often performed and specimens may be sent for routine histopathology and bacteriology analysis only without considering Mycobacterial infection. The simple incision and drainage procedures can complicate the management and may result in a poor cosmetic outcome. ATB can go undiagnosed until the initial medical management has failed, these surgical interventions performed and the child remains symptomatic. We wish to highlight the importance of considering ATB infection in the differential diagnosis of a child with painless lymphadenitis. METHODS: An illustrative case report is described. A review of the paediatric data from the Mycobacterial laboratories in Northern Ireland over the last 14 years was performed to ascertain disease trends and prevalence of species. RESULTS: Overall an upward trend in the number of cases of cervical lymphadenitis caused by ATB infections in children was demonstrated. Organisms isolated in our population were M avium intracellulare, M malmoense and M interjectum. CONCLUSIONS: We would like to present this data and a literature review, illustrated by case report, on the optimal management of these infections. We suggest that early definitive surgery is the management of choice, performed ideally by a surgeon with experience of this condition. A heightened awareness of these infections is essential to ensure appropriate early management.