Percutaneous ablation of renal tumors versus surgical ablation and partial nephrectomy: Medicare trends and reimbursement cost comparison from 2010 to 2018.

PURPOSE: The purpose of this study is to analyze trends in Medicare volume and reimbursement for percutaneous and surgical ablation as well as laparoscopic and open partial nephrectomy for treatment of small renal tumors from 2010 to 2018. METHODS: Claims from the Medicare Part B Physician/Supplier Procedure Summary from 2010 to 2018 were extracted using CPT codes for percutaneous and surgical renal ablation and surgical and laparoscopic partial nephrectomy. Facility reimbursement and relative value units (RVUs) were obtained using the Centers for Medicare & Medicaid Services physician fee schedule look-up tool. RESULTS: Volume of percutaneous ablation increased from 2539 to 4571 procedures (80.0%). Specifically, percutaneous cryoablation became the dominant technique, increasing from 1434 to 2981 procedures (107.9%). Overall, volume of partial nephrectomy also increased by 40.4%, driven by an increase in laparoscopic partial nephrectomy from 3227 to 7770 procedures (140.8%) with a decrease in open partial nephrectomy from 3489 to 1661 (- 52.4%). Volume of surgical ablations also decreased 72.7% from 1260 to 344 procedures. In 2018, reimbursement was $358.56 for percutaneous radiofrequency ablation, $481.32 for percutaneous cryoablation, $1216.43 for surgical radiofrequency ablation, $1269.35 for surgical cryoablation, $1381.67 for open partial nephrectomy, and $1552.66 for laparoscopic partial nephrectomy. CONCLUSION: There has been a trend toward minimally invasive techniques for treatment of small renal tumors among Medicare patients. Laparoscopic partial nephrectomy has become the dominant treatment. In the setting of evidence showing comparable outcomes with surgery as well as lower costs to insurers, the volume of percutaneous ablation has also markedly increased.

A novel technique for removing a fibrin sheath from a mediport catheter in the pediatric population.

Mediport (also known as port, portacath or Infusaport) is a commonly placed central venous access in pediatric patients. Fibrin sheath formation around the central venous catheter is a common biological response leading to port malfunction in the form of inability to aspirate but preserved capacity for infusion of fluids. If fibrinolytic therapy fails, percutaneous fibrin sheath stripping via transfemoral route or replacement with a new mediport are routine/conventional treatments for a fibrin sheath. We describe a novel technique for removing a fibrin sheath by exteriorizing the catheter through the neck entry site, stripping the fibrin sheath from the catheter manually under sterile conditions and replacing the catheter via a peel-away sheath introduced through the same skin incision as an alternative to complete port replacement or attempted catheter stripping.

Combined Surgical and Transhepatic Rendezvous Procedure for Relieving Anastomotic Biliary Obstruction in Children with Liver Transplants.

Four children (3 boys and 1 girl, age 1.4-9.4 y) presented 2-70 months after liver transplantation (mean 26 months) with high-grade narrowing at the surgical anastomosis that could not be crossed at percutaneous transhepatic cholangiography. Each patient was treated with a combined surgical and interventional radiology "rendezvous" procedure. Biliary drainage catheters were left in place for an average of 6 months after the procedure. At a mean 7.5 months after biliary drainage catheter removal, all children were catheter-free without clinical or biochemical evidence of biliary stricture recurrence.

Pediatric Necrotizing Pneumonia: A Case Report and Review of the Literature.

Necrotizing pneumonias occur infrequently in children but may be associated with significant morbidity. If not adequately treated, necrotizing pneumonia may lead to complications including bronchopleural fistula, empyema, respiratory failure, and septic shock. Staphylococcus aureus is the most commonly implicated agent, followed by Streptococcus pneumoniae. Antimicrobial treatment is the cornerstone of management, although surgical drainage may be required in some cases. We present the case of a 14-month-old child with fever and cough that persisted despite treatment with typical first-line oral antimicrobial therapy. An initial plain radiograph of the chest demonstrated lobar pneumonia. Ultimately, computed tomography of the chest revealed a cavitary lesion in the left upper lobe of the lung. We review the literature and describe the clinical presentation, diagnosis, microbiological etiology, and management of necrotizing pneumonia in children.

A case-based approach to common embolization agents used in vascular interventional radiology.

OBJECTIVE: The objective of this article is to familiarize the reader with the most commonly used embolic agents in interventional radiology and discuss an approach for selecting among the different embolic agents. This article reviews their properties and uses a case-based approach to explain how to select one. CONCLUSION: A wide variety of embolic agents are available. Familiarity with the available embolic agents and selection of the most appropriate embolic agent is critical in interventional radiology to achieve optimum therapeutic response and avoid undesired, potentially disastrous complications such as nontarget embolization.

Computed tomography characteristics of unresectable primary renal cell carcinoma treated with neoadjuvant sunitinib.

UNLABELLED: Neoadjuvant sunitinib might downsize unresectable renal cell carcinoma (RCC) and enable nephrectomy in a subset of patients. After neoadjuvant sunitinib in 27 RCC patients, tumors were resected in 13 patients. Higher attenuation using computed tomography (CT) scans and favorable response according to Morphology, Attenuation, Size, and Structure (MASS) criteria after 2 cycles of sunitinib were independent predictors of subsequent tumor resection. INTRODUCTION: In patients with locally advanced and metastatic RCC, selection criteria for nephrectomy are imprecise. Neoadjuvant sunitinib might downsize unresectable tumors and enable nephrectomy. CT scans of unresectable primary RCCs before and after neoadjuvant sunitinib were retrospectively reviewed to identify radiographic features associated with patient selection for surgery. PATIENTS AND METHODS: CT scans of 27 patients with RCC (31 tumors) treated with neoadjuvant sunitinib were performed as part of a prospective clinical trial. After neoadjuvant sunitinib, tumors were surgically resected in 13 patients (17 tumors) and not resected in 14 patients (14 tumors). Response to treatment with sunitinib was assessed with Response Evaluation Criteria in Solid Tumors and MASS criteria. RESULTS: On the contrast-enhanced CT scan before nephrectomy compared with the baseline CT scan, 88% of resected tumors demonstrated decreased size (median decrease 26%; -2.0 cm; P < .001), 88% had decreased attenuation (median decrease 30%; -27 Hounsfield units; P = .004), and 76% had increased necrosis (P < .001). Response to sunitinib was significantly more favorable (according to MASS criteria) in resected than in nonresected tumors (P = .005). In addition, the degree of baseline necrosis was less in tumors subsequently resected than in nonresected tumors (P = .05). Multivariate analysis showed that higher tumor attenuation after 2 cycles of sunitinib therapy and a favorable response (MASS criteria) after 2 cycles of sunitinib therapy were independent predictors of subsequent tumor resection. CONCLUSION: In unresectable primary RCC tumors, changes in select CT parameters after 2 cycles of neoadjuvant sunitinib might be associated with the potential for surgical resection.

Wireless Connection between Guide Wires and Bone Cement: Extravasated Methyl Methacrylate Mimicking a Retained Guide Wire.

We present the case of a 56-year-old double lung transplant recipient with chest pain who underwent an attempted endovascular retrieval of what was described as a retained guide wire in the azygos vein. After successfully grasping the tip, the object further migrated to the right pulmonary artery complicating the retrieval. It was realized that the "wire" was extravasated methyl methacrylate from a recent percutaneous kyphoplasty. This is believed to be the first report of attempted endovascular retrieval of extravasated methyl methacrylate in the azygos system. We include the details of this case and briefly review the current literature on the management of extravasated methyl methacrylate from vertebral augmentation procedures. Extravasated methyl methacrylate in the venous system is a common finding after vertebral augmentation procedures and any radiopaque stripe arising from a cemented vertebral body should be first described as probable cement leakage.

Isolated intramuscular fibrous band masquerading antral web in a premature neonate. A case report.

Isolated fibrous gastric antral band in a neonate causing partial gastric obstruction and mimicking prepyloric antral web is not reported in the English literature, and we would like to report the first case. A premature neonate with feeding difficulties and bilious aspirate underwent upper gastrointestinal contrast examination. The upper gastrointestinal series showed a thin, radiolucent, circumferential band in the antrum with delayed gastric emptying. Radiographic diagnosis of prepyloric antral web with partial gastric obstruction was made. Intraoperatively, a circumferential fibrous cord was found in the muscle layer (tunica muscularis) of the antrum, which was completely divided. Clinically and radiographically, the 2 conditions could not be differentiated but require 2 separate surgical techniques for their management.