Understanding Options for the Unmatched Urology Applicant.

PURPOSE OF REVIEW: To evaluate recent literature regarding the pathways and options for unmatched urology applicants. RECENT FINDINGS: Urology remains a competitive surgical sub-specialty with a match process independent of the National Resident Matching Program. Each year a cohort of competitive applicants go unmatched and are faced with the decision to reapply the following cycle while doing a research fellowship or a preliminary internship in the interim or choose a different specialty altogether. In this review, we sought to evaluate the current match process and literature regarding outcomes and options for unmatched applicants as well as to provide future directions for research and improvements to support unmatched urology applicants. Presently, data regarding outcomes for unmatched applicants is relatively limited. Going forward it is imperative for national urology organizations to create centralized resources for applicants to provide the best possible information for applicants and mentors alike.

The Fate of the Unmatched Urology Applicant.

OBJECTIVE: To determine the outcomes and eventual career paths for unmatched applicants by evaluating a historical cohort of unmatched applicants in the Urology Match. METHODS: The 2008-2014 AUA Match lists were obtained from the Society of Academic Urologists and 730 unique applicants were identified with at least one unmatched result. Additional information such as preliminary training and eventual specialty choice were obtained from publicly available sources. Comparative analysis with univariable and multivariable analysis was performed between eventual urologists and those who chose alternative career paths. RESULTS: Overall, 43.5% (318/730) of unmatched urology applicants subsequently continued their interest in Urology and 77.4% (246/317) of initially unsuccessful applicants eventually became urologists. Males (80.9%, P = .01), Doctor of Osteopathy (DO) degree (62.5%, P = <.001), and those undergoing a research year compared to a preliminary surgery year (85.2% vs 72.0% respectively, P = .047) had an increased likelihood of successfully becoming a urologist. The most common alternative specialty choices were Internal Medicine (13.8%), General Surgery (12.9%) and Anesthesiology (11.9%). CONCLUSION: Urology is a competitive surgical sub-specialty. Surprisingly, approximately 3 in 4 unmatched urology applicants who continue their interest in urology will eventually obtain a residency position. However, only 33.7% of initially unmatched students ultimately became urologists. Unmatched applicants have several viable pathways to obtain a urological residency position. Male gender, a DO degree, and a research year are associated with successfully obtaining a urology residency position.

Heterogeneity in stone culture protocols and endourologist practice patterns: a multi-institutional survey.

Kidney stone cultures can be beneficial in identifying bacteria not detected in urine, yet how stone cultures are performed among endourologists, under what conditions, and by what laboratory methods remain largely unknown. Stone cultures are not addressed by current clinical guidelines. A comprehensive REDCap electronic survey sought responses from directed (n = 20) and listserv elicited (n = 108) endourologists specializing in kidney stone disease. Questions included which clinical scenarios prompt a stone culture order, how results influence post-operative antibiotics, and what microbiology lab protocols exist at each institution with respect to processing and resulting stone cultures. Logistic regression statistical analysis determined what factors were associated with performing stone cultures. Of 128 unique responses, 11% identified as female and the mean years of practicing was 16 (range 1-46). A specific 'stone culture' order was available to only 50% (64/128) of those surveyed, while 32% (41/128) reported culturing stone by placing a urine culture order. The duration of antibiotics given for a positive stone culture varied, with 4-7 days (46%) and 8-14 days (21%) the most reported. More years in practice was associated with fewer stone cultures ordered, while higher annual volume of percutaneous nephrolithotomy was associated with ordering more stone cultures (p < 0.01). Endourologists have differing practice patterns with respect to ordering stone cultures and utilizing the results to guide post-operative antibiotics. With inconsistent microbiology lab stone culture protocols across multiple institutions, more uniform processing is needed for future studies to assess the clinical benefit of stone cultures and direct future guidelines.

Management of the aortic arch in patients with Loeys-Dietz syndrome.

OBJECTIVES: We sought to develop strategies for management of the aortic arch in patients with Loeys-Dietz syndrome (LDS) through a review of our clinical experience with these patients and a comparison with our experience in patients with Marfan syndrome (MFS). METHODS: We reviewed hospital and follow-up records of 79 patients with LDS and compared them with 256 patients with MFS who served as reference controls. RESULTS: In the LDS group, 16% of patients presented initially with acute aortic dissection (AAD) (67% type A, 33% type B) or developed AAD during follow-up, compared with 10% of patients with MFS (95% type A, 5% type B). There was no difference between patients with LDS or MFS in need for subsequent arch interventions after aortic root surgery (46% vs 50%, P = 1.0). Among the patients who never had AAD, the need for arch repair at initial root surgery was greater in patients with LDS (5% vs 0.4%, P = .04), as was the need for any subsequent aortic surgery (12% vs 1.3%, P = .0004). Late mortality in patients with LDS after arch repair was greater than in those patients who had no arch intervention (33% vs 6%, P = .007). CONCLUSIONS: In the absence of dissection, patients with LDS have a greater rate of arch intervention after root surgery than patients with MFS. After a dissection, arch reintervention rates are similar in the 2 groups. Arch intervention portends greater late mortality in LDS.

Valve-sparing aortic root replacement in children: Outcomes from 100 consecutive cases.

OBJECTIVE: Valve-sparing root replacement is an attractive alternative to composite mechanical or biologic prostheses for aortic root aneurysms in children. Data on outcomes in pediatric patients are limited. We present our institutional experience with 100 consecutive pediatric valve-sparing aortic root procedures. METHODS: All children who underwent valve-sparing root replacement at our institution from May 1997 to August 2017 were identified, and echocardiographic and clinical data were reviewed. The primary end point was mortality, and secondary end points included complications, further interventions, and subsequent valvular dysfunction. RESULTS: Median age at operation was 13.6 years (interquartile range, 9.42-15.9); 51 patients (51%) had Marfan syndrome, and 39 patients (39%) had Loeys-Dietz syndrome. Mean preoperative maximum sinus diameter was 4.4 ± 0.71 cm (z score 7.3 [5.7-9.3]). Most patients (n = 80, 80%) underwent reimplantation procedures with a Valsalva graft. Four patients (4%) underwent David I reimplantation with a straight-tube graft, 13 patients (13%) underwent a Yacoub remodeling procedure, and 3 patients (3%) underwent a Florida sleeve procedure. Perioperative valve-sparing root replacement mortality was 2% (n = 2). Six patients required late reintervention for development of pseudoaneurysms. Eight patients underwent additional aortic surgery. Average time to reoperation was 7.23 ± 4.56 years. Of the 84 patients undergoing a reimplantation procedure, 5 (5.9%) underwent late valve replacement versus 5 (33.3%) of the 15 patients who received a remodeling procedure (P = .001). CONCLUSIONS: Valve-sparing root replacement is a safe and effective option for children with aortic root aneurysms in children. The reimplantation procedure is preferred. Late aortic insufficiency and pseudoaneurysm formation remain late concerns.

CT-Based Diagnosis of Low Vertebral Bone Mineral Density Is Associated with Hypercalciuria and Hypocitraturia on Opportunistic Imaging.

INTRODUCTION AND OBJECTIVES: Studies have demonstrated associations between nephrolithiasis and systemic conditions, including low bone mineral density (BMD), which may correlate with hypercalciuria in kidney stone formers (KSFs). Traditionally, low BMD is diagnosed with dual-energy X-ray absorptiometry. As a noncontrast CT (NCCT) scan is typically part of a stone evaluation, our objective was to evaluate the association of NCCT-based vertebral BMD with 24-hour urine parameters in KSF. MATERIALS AND METHODS: This is a retrospective analysis of 99 KSFs who had CT imaging and 24-hour urine studies. For each patient, BMD was estimated at the L1 vertebral body and CT attenuation measured in HU. A threshold of 160 HU was chosen to distinguish normal from low BMD. Univariate and multivariate logistic regression analysis was performed to compare patients with low and normal BMD. Multivariate linear regression was performed to assess for variables associated with 24-hour urine parameters. RESULTS: Patients with low BMD had higher 24-hour urine calcium (219 vs 147 mg/day, p < 0.0001) and larger stone volume (259 vs 78.4 mm3, p = 0.009). Multivariate analysis demonstrated age >60 years (odds ratio [OR] 9.3, p < 0.0001) and hypercalciuria (OR 4.34, p = 0.004) correlated with low BMD. Linear regression demonstrated that lower BMD was associated with higher urinary calcium (ß-coefficient -0.268, p = 0.009) and lower urinary citrate (ß-coefficient 0.332, p = 0.01). CONCLUSIONS: CT-based diagnosis of low mineral bone density is associated with derangement in 24-hour urine calcium and citrate in KSFs, as well as larger stone volumes.

Optimization of urinary dipstick pH: Are multiple dipstick pH readings reliably comparable to commercial 24-hour urinary pH?

PURPOSE: Accurate measurement of pH is necessary to guide medical management of nephrolithiasis. Urinary dipsticks offer a convenient method to measure pH, but prior studies have only assessed the accuracy of a single, spot dipstick. Given the known diurnal variation in pH, a single dipstick pH is unlikely to reflect the average daily urinary pH. Our goal was to determine whether multiple dipstick pH readings would be reliably comparable to pH from a 24-hour urine analysis. MATERIALS AND METHODS: Kidney stone patients undergoing a 24-hour urine collection were enrolled and took images of dipsticks from their first 3 voids concurrently with the 24-hour collection. Images were sent to and read by a study investigator. The individual and mean pH from the dipsticks were compared to the 24-hour urine pH and considered to be accurate if the dipstick readings were within 0.5 of the 24-hour urine pH. The Bland-Altman test of agreement was used to further compare dipstick pH relative to 24-hour urine pH. RESULTS: Fifty-nine percent of patients had mean urinary pH values within 0.5 pH units of their 24-hour urine pH. Bland-Altman analysis showed a mean difference between dipstick pH and 24-hour urine pH of -0.22, with an upper limit of agreement of 1.02 (95% confidence interval [CI], 0.45-1.59) and a lower limit of agreement of -1.47 (95% CI, -2.04 to -0.90). CONCLUSIONS: We concluded that urinary dipstick based pH measurement lacks the precision required to guide medical management of nephrolithiasis and physicians should use 24-hour urine analysis to base their metabolic therapy.

Vascular Disease and Kidney Stones: Abdominal Aortic Calcifications Are Associated with Low Urine pH and Hypocitraturia.

OBJECTIVE: Vascular calcifications are associated with nephrolithiasis. Although studies have demonstrated correlations with vascular disease and calcium stones in kidney stone formers (KSF), an etiologic link has remained elusive. As a noncontrast CT (NCCT) scan is typically part of a stone evaluation, our objective was to evaluate the association of NCCT-based assessment of abdominal aortic calcifications (AACs) with 24-hour urine parameters and stone composition. MATERIALS AND METHODS: Ninety-seven KSF were included with CT imaging and 24-hour urine studies. For each patient, semi-automated CT software was utilized to provide an AAC Agatston score from the celiac axis to the aortic bifurcation. Univariate analysis was performed to compare patients with or without AAC. Multivariate logistic regression was performed to assess for variables associated with 24-hour urine parameters and stone composition. RESULTS: The presence of AAC was associated with hypertension, diabetes, peripheral vascular disease, and coronary artery disease. Patients with any AAC showed lower 24-hour urine citrate (399 vs 593 mg/day, p < 0.001) and lower 24-hour urine pH (5.862 vs 6.328, p = 0.003). When controlling for age, system comorbidities, the presence of AAC was associated with low urine pH <6 (odds ratio [OR] 2.86, p = 0.032) and hypocitraturia <320 mg/day (OR 4.37, p = 0.005). The receiver operating characteristic curve showed that increasing AAC was associated with low urine pH (area under the curve [AUC] 0.683, p = 0.002) and uric acid stone formation (AUC 0.698, p = 0.045). CONCLUSIONS: NCCT-based diagnosis of AAC is associated with low urine pH, hypocitraturia, and uric acid stone formation. The presence of AAC could be considered an additional prognosticator for the utility of alkalinization therapy.

Computerized Tomography Based Diagnosis of Visceral Obesity and Hepatic Steatosis is Associated with Low Urine pH.

PURPOSE: Uric acid nephrolithiasis is associated with an elevated visceral fat area in kidney stone formers. Hepatic steatosis has also been linked to visceral obesity and nephrolithiasis. We evaluated the association of noncontrast computerized tomography based diagnosis of visceral obesity and hepatic steatosis with 24-hour urine parameters and stone composition in kidney stone formers. MATERIALS AND METHODS: A total of 98 kidney stone formers were included in study who had computerized tomography imaging and 24-hour urine studies available. For each patient a single computerized tomography axial area measurement was obtained of the visceral fat area. Hepatic steatosis was diagnosed by comparing the HU of regions from the liver and spleen. Univariate analysis was performed to compare patients with or without an elevated visceral fat area and hepatic steatosis. Multivariate linear and logistic regression was done to assess for variables associated with 24-hour urine parameters and stone composition. RESULTS: An elevated visceral fat area was associated with higher 24-hour urine sodium (175 vs 157 mg per day, p <0.036) and lower 24-hour urine pH (5.724 vs 6.478, <0.0001). Urine pH less than 6 (OR 2.52) was associated with hepatic steatosis. Low urine pH less than 6 (OR 11.1, p = 0.004) and stone volume greater than 65 mm3 (OR 5.12, p = 0.023) were associated with an elevated visceral fat area. Low urine pH less than 6 (OR 5.87) and visceral fat area greater than 48% (OR 5.33) were associated with uric acid stones. Linear regression demonstrated that the percent of visceral fat area was associated with lower 24-hour urine pH (ß-coefficient -0.438, p <0.0001). CONCLUSIONS: Noncontrast computerized tomography based diagnosis of visceral obesity is associated with low urine pH, high urinary sodium and uric acid stone formation. Hepatic steatosis is associated with low urine pH.

Comparison of retroperitoneal and transperitoneal robotic partial nephrectomy for Pentafecta perioperative and renal functional outcomes.

BACKGROUND: We compared quality outcomes between transperitoneal (TRPN) and retroperitoneal robotic partial nephrectomy (RRPN). METHODS: Two-center retrospective analysis of TRPN and RRPN from 10/2009 to 10/2015. Perioperative/renal function outcomes were analyzed. Primary endpoint was Pentafecta, a composite measure of quality [negative margin, no 30-day complication, ischemia time ≤25 min, return of glomerular filtration rate (eGFR) to >90% from baseline at last follow-up, and no chronic kidney disease upstaging]. Multivariable analysis (MVA) for factors associated with lack of optimal outcome was performed. RESULTS: 404 patients (TRPN 263, RRPN 141) were analyzed. Comparing TRPN vs. RRPN, mean tumor size (3.1 vs. 2.9 cm, p = 0.122) and RENAL score (7.4 vs. 7.2, p = 0.503) were similar. Most TRPN were anterior (65.0%) and most RRPN posterior (65.3%, p < 0.001). Operative time (p = 0.001) was less for RRPN. No significant differences between TRPN vs. RRPN were noted for ischemia time (23.1 vs. 22.8 min, p = 0.313), blood loss (p = 0.772), positive margins (p = 0.590), complications (p = 0.537), length of stay (p = 0.296), ΔeGFR (p = 0.246), eGFR recovery to >90% (55.9 vs. 57.4%, p = 0.833), and lack of CKD upstaging (84.0 vs. 87.2%, p = 0.464). Pentafecta rates were not significantly different (TRPN 33.9 vs. RRPN 43.3%, p = 0.526). MVA revealed increasing RENAL score (OR 1.5, p < 0.001) and decreasing baseline eGFR (OR 2.4, p = 0.017) as predictive for lack of Pentafecta. CONCLUSIONS: TRPN and RRPN have similar quality outcomes, though RRPN may offer modest benefit for operative time and have utility in posterior tumors. Association of increasing RENAL score and decreased baseline eGFR with lack of Pentafecta suggests dominant role of non-modifiable factors.

Aortic Root Replacement for Children With Loeys-Dietz Syndrome.

BACKGROUND: Loeys-Dietz syndrome (LDS) is an aggressive aortopathy with a proclivity for aortic aneurysm rupture and dissection at smaller diameters than other connective tissue disorders. We reviewed our surgical experience of children with LDS to validate our guidelines for prophylactic aortic root replacement (ARR). METHODS: We reviewed all children (younger than 18 years) with a diagnosis of LDS who underwent ARR at our institution. The primary endpoint was mortality, and secondary endpoints included complications and the need for further interventions. RESULTS: Thirty-four children with LDS underwent ARR. Mean age at operation was 10 years, and 15 (44%) were female. Mean preoperative root diameter was 4 cm. Three children (9%) had composite ARR with a mechanical prosthesis, and 31 (91%) underwent valve-sparing ARR. Concomitant procedures included arch replacement in 2 (6%), aortic valve repair in 1 (3%), and patent foramen ovale closure in 16 (47%). There was no operative mortality. Two children (6%) required late replacement of the ascending aorta, 5 (15%) required arch replacement, 1 (3%) required mitral valve replacement, and 2 (6%) had coronary button aneurysms/pseudoaneurysms requiring repair. Three children required redo valve-sparing ARR after a Florida sleeve procedure, and 2 had progressive aortic insufficiency requiring aortic valve replacement after a valve-sparing procedure. There were 2 late deaths (6%). CONCLUSIONS: These data confirm the aggressive aortopathy of LDS. Valve-sparing ARR should be performed when feasible to avoid the risks of prostheses. Serial imaging of the arterial tree is critical, given the rate of subsequent intervention.

Intra-Aortic Missile After Gunshot Wound to Chest: An Interesting Case of Traumatic Cardiac Injury.

Missile embolus to the heart, although uncommon, is one of the most challenging scenarios in trauma. We describe a 36-year-old man who presented with a gunshot wound to the left chest and a chest x-ray revealing a foreign body in the mediastinum. A median sternotomy was performed and an injury to the left ventricle was identified. After intraoperative echocardiography and fluoroscopy confirmed a foreign body in the aortic root, cardiopulmonary bypass was implemented. A bullet was retrieved from the noncoronary sinus of the aortic valve. Injuries to the anterior leaflet of the mitral valve and left ventricle were repaired.

Cardiovascular operations for Loeys-Dietz syndrome: Intermediate-term results.

OBJECTIVES: Early experience with Loeys-Dietz syndrome (LDS) suggested an aggressive aortopathy with high risk of aneurysm dissection and rupture at young ages and at smaller aortic diameters than in other connective tissue disorders. We reviewed our experience with LDS to re-examine our indications and outcomes of surgical management. METHODS: We reviewed all patients with a diagnosis of LDS who underwent cardiovascular surgery at our institution. The primary endpoint was mortality, and secondary endpoints included postoperative complications and need for reintervention. RESULTS: Seventy-nine operated patients with LDS were identified. Mean age at first operation was 25 years, 39 (49%) were female, and 38 (48%) were children (age <18 years). Six (8%) patients presented with acute dissection. Five (6%) patients had a bicuspid aortic valve, and all presented with an ascending aortic aneurysm with a mean root diameter of 3.5cm. Twenty (25%) patients had a previous sternotomy. Sixty-five (82%) patients underwent aortic root replacement, of whom 52 underwent a valve-sparing operation and 4 had concomitant arch replacement. Mean aortic root diameter in this group was 4.2 cm. Nine (11%) patients underwent aortic arch replacement, 2 (3%) had isolated ascending aorta replacement, and 3 (4%) underwent open thoracoabdominal repair. There were 2 (3%) operative and 8 late deaths. Nineteen patients underwent subsequent operations for late aneurysm and/or dissection. Mean follow-up was 6 years (range 0-24 years). Kaplan-Meier survival was 88% at 10 years. CONCLUSIONS: Growing experience with LDS has confirmed early impressions of its aggressive nature and proclivity toward aortic catastrophe. Surgical outcomes are favorable, but reintervention rates are high. Meticulous follow-up with cardiovascular surveillance imaging remain important for management, particularly as clinical LDS subtypes are characterized and more tailored treatment is developed.

Long-term outcomes of aortic root operations for Marfan syndrome: A comparison of Bentall versus aortic valve-sparing procedures.

OBJECTIVES: Prophylactic aortic root replacement improves survival in patients with Marfan syndrome with aortic root aneurysms, but the optimal procedure remains undefined. METHODS: Adult patients with Marfan syndrome who had Bentall or aortic valve-sparing root replacement (VSRR) procedures between 1997 and 2013 were identified. Comprehensive follow-up information was obtained from hospital charts and telephone contact. RESULTS: One hundred sixty-five adult patients with Marfan syndrome (aged > 20 years) had either VSRR (n = 98; 69 reimplantation, 29 remodeling) or Bentall (n = 67) procedures. Patients undergoing Bentall procedure were older (median, 37 vs 36 years; P = .03), had larger median preoperative sinus diameter (5.5 cm vs 5.0 cm; P = .003), more aortic dissections (25.4% vs 4.1%; P < .001), higher incidence of moderate or severe aortic insufficiency (49.3% vs 14.4%; P < .001) and more urgent or emergent operations (24.6% vs 3.3%; P < .001). There were no hospital deaths and 9 late deaths in more than 17 years of follow-up (median, 7.8 deaths). Ten-year survival was 90.5% in patients undergoing Bentall procedure and 96.3% in patients undergoing VSRR (P = .10). Multivariable analysis revealed that VSRR was associated with fewer thromboembolic or hemorrhagic events (hazard ratio, 0.16; 95% confidence interval, 0.03-0.85; P = .03). There was no independent difference in long-term survival, freedom from reoperation, or freedom from endocarditis between the 2 procedures. CONCLUSIONS: After prophylactic root replacement in patients with Marfan syndrome, patients undergoing Bentall and valve-sparing procedures have similar late survival, freedom from root reoperation, and freedom from endocarditis. However, valve-sparing procedures result in significantly fewer thromboembolic and hemorrhagic events.

Parenchymal Volumetric Assessment as a Predictive Tool to Determine Renal Function Benefit of Nephron-Sparing Surgery Compared with Radical Nephrectomy.

PURPOSE: To develop a preoperative prediction model using a computer-assisted volumetric assessment of potential spared parenchyma to estimate the probability of chronic kidney disease (CKD, estimated glomerular filtration rate [eGFR] <60 mL/min/1.73 m(2)) 6 months from extirpative renal surgery (nephron-sparing surgery [NSS] or radical nephrectomy [RN]). PATIENTS AND METHODS: Retrospective analysis of patients who underwent NSS or RN at our institution from January 2000 to June 2013 with a compatible CT scan 6-month renal function follow-up was performed. Primary outcome was defined as the accuracy of 6-month postoperative eGFR compared with actual postoperative eGFR based on root mean square error (RMSE). Models were constructed using renal volumes and externally validated. A clinical tool was developed on the best model after a given surgical procedure using area under the curve (AUC). RESULTS: We identified 130 (51 radical, 79 partial) patients with a median age of 58 years (interquartile range [IQR] 48-67) and preoperative eGFR of 82.1 (IQR 65.9-104.3); postoperative CKD (eGFR <60) developed in 42% (55/130). We performed various linear regression models to predict postoperative eGFR. The Quadratic model was the highest performing model, which relied only on preoperative GFR and the volumetric data for a RMSE of 15.3 on external validation corresponding to a clinical tool with an AUC of 0.89. CONCLUSION: Volumetric-based assessment provides information to predict postoperative eGFR. A tool based on this equation may assist surgical counseling regarding renal functional outcomes before renal tumor surgical procedures.

Surgical management of traumatic penile amputation: a case report and review of the world literature.

INTRODUCTION: There is paucity of case reports that describe the successful reimplantation of a penis after amputation. We sought to report on self-inflicted penile amputation and comment on its surgical management and review current literature. AIM: To report on self-inflicted penile amputation and comment on its surgical management and review current literature. METHODS: A 19-year-old male with no prior medical history presented to our university-affiliated trauma center following sustaining a self-inflicted amputation of shaft penis secondary to severe methamphetamine-induced psychosis. He immediately underwent extensive reconstructive reimplantation of the penis performed jointly by plastics and urology teams reattaching all visible neurovascular bundles, urethra, and corporal and fascial layers. The patient was discharged with a suprapubic tube in place and a Foley catheter in place with well-healing tissue. MAIN OUTCOME MEASURES: To review the current published literature and case reports on the management of penile amputation with particular emphasis its etiology, surgical repairs, potential complications and functional outcomes. RESULTS: We report herein a case of a traumatic penile amputation and successful outcome of microscopic reimplantation and review of the published literature with particular comments on surgical managements. CONCLUSION: We review the literature and case reports on penile amputation and its etiology, surgical management, variables effecting outcomes, and its complications. Raheem OA, Mirheydar HS, Patel ND, Patel SH, Suliman A, and Buckley JC. Surgical management of traumatic penile amputation: A case report and review of the world literature. Sex Med 2015;3:49-53.

Efficacy of education followed by computerized provider order entry with clinician decision support to reduce red blood cell utilization.

BACKGROUND: Two necessary components of a patient blood management program are education regarding evidence-based transfusion guidelines and computerized provider order entry (CPOE) with clinician decision support (CDS). This study examines changes in red blood cell (RBC) utilization associated with each of these two interventions. STUDY DESIGN AND METHODS: We reviewed 5 years of blood utilization data (2009-2013) for 70,118 surgical patients from 10 different specialty services at a tertiary care academic medical center. Three distinct periods were compared: 1) before blood management, 2) education alone, and 3) education plus CPOE. Changes in RBC unit utilization were assessed over the three periods stratified by surgical service. Cost savings were estimated based on RBC acquisition costs. RESULTS: For all surgical services combined, RBC utilization decreased by 16.4% with education alone (p = 0.001) and then changed very little (2.5% increase) after subsequent addition of CPOE (p = 0.64). When we compared the period of education plus CPOE to the pre-blood management period, the overall decrease was 14.3% (p = 0.008; 2102 fewer RBC units/year, or a cost avoidance of $462,440/year). Services with the highest massive transfusion rates (≥10 RBC units) exhibited the least reduction in RBC utilization. CONCLUSIONS: Adding CPOE with CDS after a successful education effort to promote evidence-based transfusion practice did not further reduce RBC utilization. These findings suggest that education is an important and effective component of a patient blood management program and that CPOE algorithms may serve to maintain compliance with evidence-based transfusion guidelines.

Does Listening to Music During Office-Based Flexible Cystoscopy Decrease Anxiety in Patients: A Prospective Randomized Trial.

PURPOSE: To validate the effect of listening to music on perceived anxiety and pain during office-based flexible cystoscopy using the State-Trait Anxiety Inventory (STAI) and the Visual Analog Scale (VAS), in a well-matched North American veteran patient population in a prospective, randomized fashion. PATIENTS AND METHODS: A total of 137 veteran patients receiving routine urologic care in a North American Veterans Affairs (VA) healthcare system were recruited over a 2-year period (June 2011 to June 2013). All patients were prospectively randomized to undergo office-based flexible cystoscopy with or without music. The music group consisted of 73 patients who listened to the same excerpt of classical music at the time of flexible cystoscopy; the nonmusic group consisted of 64 patients. RESULTS: The median postprocedural STAI anxiety scores between the music and nonmusic groups were statistically significantly different: 30 (range 23-39) and 35 (range 28-49), respectively (P=0.0017). The median postprocedural pain VAS score between the music and nonmusic groups reached statistical significance: 0 (range 0-1) and 2 (range 1-2), respectively (P<0.0001). The median delta STAI anxiety score was statistically significantly different between the music and nonmusic groups: 0 (range -3-0) and 2 (range 0-4), respectively (P<0.0001). CONCLUSIONS: This study demonstrates that listening to music decreases anxiety and pain associated with flexible cystoscopy in a North American VA patient population. We recommend incorporating music as an effective adjunct to other maneuvers used at the time of flexible cystoscopy to reduce anxiety and pain.

The History of Heart Surgery at The Johns Hopkins Hospital.

Johns Hopkins has made many lasting contributions to cardiac surgery, including the discovery of heparin and the Blalock-Taussig Shunt, which represents the dawn of modern cardiac surgery. Equally important, Johns Hopkins has trained some of the world's leaders in academic cardiac surgery, and is committed to training the future leaders in our specialty.

Perioperative Outcomes of Robotic and Laparoscopic Simple Prostatectomy: A European-American Multi-institutional Analysis.

BACKGROUND: Laparoscopic and robotic simple prostatectomy (SP) have been introduced with the aim of reducing the morbidity of the standard open technique. OBJECTIVE: To report a large multi-institutional series of minimally invasive SP (MISP). DESIGN, SETTING, AND PARTICIPANTS: Consecutive cases of MISP done for the treatment of bladder outlet obstruction (BOO) due to benign prostatic enlargement (BPE) between 2000 and 2014 at 23 participating institutions in the Americas and Europe were included in this retrospective analysis. INTERVENTION: Laparoscopic or robotic SP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Demographic data and main perioperative outcomes were gathered and analyzed. A multivariable analysis was conducted to identify factors associated with a favorable trifecta outcome, arbitrarily defined as a combination of the following postoperative events: International Prostate Symptom Score <8, maximum flow rate >15ml/s, and no perioperative complications. RESULTS AND LIMITATIONS: Overall, 1330 consecutive cases were analyzed, including 487 robotic (36.6%) and 843 laparoscopic (63.4%) SP cases. Median overall prostate volume was 100ml (range: 89-128). Median estimated blood loss was 200ml (range: 150-300). An intraoperative transfusion was required in 3.5% of cases, an intraoperative complication was recorded in 2.2% of cases, and the conversion rate was 3%. Median length of stay was 4 d (range: 3-5). On pathology, prostate cancer was found in 4% of cases. Overall postoperative complication rate was 10.6%, mostly of low grade. At a median follow-up of 12 mo, a significant improvement was observed for subjective and objective indicators of BOO. Trifecta outcome was not significantly influenced by the type of procedure (robotic vs laparoscopic; p=0.136; odds ratio [OR]: 1.6; 95% confidence interval [CI], 0.8-2.9), whereas operative time (p=0.01; OR: 0.9; 95% CI, 0.9-1.0) and estimated blood loss (p=0.03; OR: 0.9; 95% CI, 0.9-1.0) were the only two significant factors. Retrospective study design, lack of a control arm, and limited follow-up represent major limitations of the present analysis. CONCLUSIONS: This study provides the largest outcome analysis reported for MISP for BOO/BPE. These findings confirm that SP can be safely and effectively performed in a minimally invasive fashion in a variety of healthcare settings in which specific surgical expertise and technology is available. MISP can be considered a viable surgical treatment in cases of large prostatic adenomas. The use of robotic technology for this indication can be considered in centers that have a robotic program in place for other urologic indications. PATIENT SUMMARY: Analysis of a large data set from multiple institutions shows that surgical removal of symptomatic large prostatic adenomas can be carried out with good outcomes by using robot-assisted laparoscopy.