Predictors of surgical approach for the management of renal cell carcinoma: a population-based study from New South Wales.

BACKGROUND: The simultaneous adoption of laparoscopy and partial nephrectomy (PN) has been reported to result in unintended consequences. We aim to examine the contemporary (2001-2009) trends in use of PN and laparoscopy within a population-wide database. METHODS: All renal cell carcinomas diagnosed between 2001 and 2009 in New South Wales, Australia, were identified from the Central Cancer Registry. Records of treatment were electronically linked. All patients with localized renal cell carcinoma who underwent surgical treatment were selected for this study (3771 patients). Follow-up was to the end of 2010. Multivariable logistic regression analysis was used to determine predictors of PN and laparoscopy. RESULTS: In the entire cohort, 150 (4%), 495 (13%), 1516 (40%) and 1610 (43%) received laparoscopic PN, open PN, laparoscopic radical nephrectomy (RN) and open RN, respectively. Between the years 2001 and 2009, there was a gradual increase in the use of PN except between 2005 and 2007. Between 2001 and 2009, a rapid uptake of laparoscopy was observed. Multivariable analysis demonstrated that age (OR: 0.99 (0.98-0.99)), year of surgery (OR: 1.15 (1.11-1.19)), comorbidity (OR: 1.40 (1.12-1.76)) and hospital case load >8/year (OR: 2.39 (1.49-3.81)) predicted use of PN. Year of surgery (OR: 1.19 (1.15-1.21)), comorbidity (OR: 0.70 (0.58-0.85)), non-teaching hospital (OR: 0.70 (0.53-0.93)), private hospital (OR: 1.86 (1.45-2.38)) and hospital case load > 8/year (OR: 3.36 (2.22-5.09)) predicted use of laparoscopy. CONCLUSION: The unintended decrease in PN associated with increased use of laparoscopic RN had reversed by 2009. Hospital case load predicts the use of PN and laparoscopy.

Spontaneous ureteric rupture secondary to an invasive desmoid tumour.

INTRODUCTION: Spontaneous ureteric rupture is a rare entity that presents as an extravasation of urine from the ureter without previous surgery, ureteric manipulation and external trauma of the ureter. We report the case of a desmoid tumour presenting as spontaneous ureteric rupture which was managed in our institution. PRESENTATION OF CASE: A 28 years old healthy male presented with a four day history of generalised abdominal pain secondary to spontaneous right ureteric rupture. Patient was initially managed via insertion of nephrostomy tube and antibiotics. After unsuccessful attempts of retrograde and antegrade ureteric stent insertion, patient was subsequently managed via elective surgical intervention. The excised specimen revealed desmoid tumour as cause of the ureteric rupture. DISCUSSION: Desmoid tumours are rare benign tumours arising from fascial or musculoaponeurotic structures that do not metastasise, but tend to invade locally. It is often initially managed medically prior to undertaking a definitive surgical intervention. To our knowledge this is the first reported case of ureteric perforation secondary to a desmoid tumour of the mesentery. CONCLUSION: Spontaneous rupture of the ureter is often misdiagnosed as other conditions. History taking and examination can be unreliable, hence a high level of suspicion and further investigations should be utilised. Once the diagnosis is made, treatment can be individualised based on aetiology.

Ureteric access sheath aided insertion of resonance metal ureteric stent.

Ureteral obstruction caused by malignancy is a challenging and often complicated problem for urologists. We present a novel technique of ureteric access sheath aided insertion of a Resonance metal ureteric stent in the setting of a difficult obstruction.

Diabetic control and coronary artery bypass: effect on short-term outcomes.

AIM: To evaluate the effect of preoperative glycemic control on hospital morbidity and mortality in diabetic patients undergoing primary coronary artery bypass grafting. METHODS: Data of 3857 patients undergoing primary coronary artery bypass grafting was prospectively collected and retrospectively analyzed. There were 1109 (29%) diabetic patients, of whom 712 (64%) had hemoglobin A1c levels recorded. They were categorized by diabetic treatment: diet (179), oral hypoglycemic agent, (718) or insulin (212); and by diabetic control: hemoglobin A1c < 7 (265) or ≥7 (447). Nondiabetic patients (2,748) were used as controls. RESULTS: The preoperative risk factors of hypertension (p < 0.001), hyperlipidemia (p < 0.001), renal failure (p < 0.04), peripheral vascular disease (p < 0.001), and chronic obstructive pulmonary disease (p < 0.04) were significantly more prevalent in diabetic patients. Major complications were not significantly different between the diabetic and control groups (p = 0.33), but minor complications were less frequent in diabetic patients (p = 0.03). Major and minor complications were not significantly different among the treatment subgroups of diabetic patients (p = 0.74 and p = 0.48) or in those with hemoglobin A1c < 7 and ≥7 (p = 0.23, p = 0.41). CONCLUSIONS: Short-term outcomes were not affected by the degree of preoperative glycemic control or type of treatment used in diabetic patients undergoing primary coronary artery bypass grafting. A plausible explanation is strict protocol-driven glycemic control in the perioperative period.

Contemporary results following surgical repair of acute type a aortic dissection (AAAD): a single centre experience.

OBJECTIVES: The study aims to define predictors of neurological dysfunction, 30-day mortality, long-term survival and quality of life following repair of acute type A aortic dissection (AAAD). METHODS: Between 2000 and 2008, 65 patients underwent repair of AAAD. Sixty-four pre-, intra- and post-operative variables were studied. Mean follow-up was 26.6 months. RESULTS: The mean age was 61years; 60% were male and five had Marfan's syndrome. At presentation, ischaemic ECG changes were seen in 45%, malperfusion syndrome in 59%, moderate-severe aortic regurgitation in 48% and tamponade in 16%. EF was <40% in 17%. There was a delay of >12hours between diagnosis and operation in 64%. Axillary cannulation was performed in 37%. Cerebral protection was by hypothermic arrest (HCA) alone (19%), HCA with retrograde cerebral perfusion (RCP) (11%), or HCA with antegrade cerebral perfusion (ACP) (46%). The procedure was performed on cross-clamp in 24%. Full arch replacement was performed in 14% and concomitant coronary artery grafting was performed in 11%. Post-operative neurological dysfunction was present in 33.8%. The only significant predictor of poor neurological outcome was full arch replacement (p=0.04) on univariate analysis. In-hospital OR 30 mortality was 23.53%. Significant predictors of mortality were low ejection fraction (p=0.017) and post-operative renal failure (p=0.012). Long-term survival was 70% at two years, 50% at five years and 25% at nine years. Functional outcomes and long-term quality of life were assessed in 69% of patients who were alive at last follow-up. Ninety percent of patients reported minimal limitation on functional scores. Quality of life was assessed using the EQ-5D questionnaire. Forty-eight percent of patients recorded full health with an overall mean index of 0.854 (where the best possible score is 1) using the US preference weighted index score. CONCLUSIONS: Discharged patients have reasonable long-term survival and good quality of life.