Robotic Partial Nephrectomy Using Robotic Bulldog Clamps

Robotically applying bulldog clamps was found to be a safe and feasible method of hilar occlusion during robotic partial nephrectomy

Disparities in selective referral for cancer surgeries: implications for the current healthcare delivery system

Objectives: Among considerable efforts to improve quality of surgical care, expedited measures such as a selective referral to high-volume institutions have been advocated. Our objective was to examine whether racial, insurance and/or socioeconomic disparities exist in the use of high-volume hospitals for complex surgical oncological procedures within the USA. Design, setting and participants Patients undergoing colectomy, cystectomy, oesophagectomy, gastrectomy, hysterectomy, lung resection, pancreatectomy or prostatectomy were identified retrospectively, using the Nationwide Inpatient Sample, between years 1999 and 2009. This resulted in a weighted estimate of 2 508 916 patients. Primary outcome measures Distribution of patients according to race, insurance and income characteristics was examined according to low-volume and high-volume hospitals (highest 20% of patients according to the procedure-specific mean annual volume). Generalised linear regression models for prediction of access to high-volume hospitals were performed. Results: Insurance providers and county income levels varied differently according to patients’ race. Most Caucasians resided in wealthier counties, regardless of insurance types (private/Medicare), while most African Americans resided in less wealthy counties (≤$24 999), despite being privately insured. In general, Caucasians, privately insured, and those residing in wealthier counties (≥$45 000) were more likely to receive surgery at high-volume hospitals, even after adjustment for all other patient-specific characteristics. Depending on the procedure, some disparities were more prominent, but the overall trend suggests a collinear effect for race, insurance type and county income levels. Conclusions: Prevailing disparities exist according to several patient and sociodemographic characteristics for utilisation of high-volume hospitals. Efforts should be made to directly reduce such disparities and ensure equal healthcare delivery

Prospective multi-center study of oncologic outcomes of robot-assisted partial nephrectomy for pT1 renal cell carcinoma

BACKGROUND: Partial nephrectomy has been increasingly recommended over radical nephrectomy for the management of small renal masses based on improved renal functional outcomes without sacrifice of oncologic effectiveness. Robot-assisted partial nephrectomy (RAPN) has been introduced in an effort to offer another minimally invasive option for nephron-sparing surgery. However, reports of RAPN have been limited to short-term perioperative outcomes. The goal of this study is to report and evaluate the initial oncologic outcomes of RAPN. Utilizing prospectively obtained data on RAPN performed by four surgeons at four separate tertiary care centers, we selected patients with unilateral, localized, non-familial, pathologically-confirmed pT1 renal cell carcinoma and a minimum post-operative follow-up of 12 months. METHODS: Utilizing prospectively obtained data on RAPN performed by four surgeons at four separate tertiary care centers, we selected patients with unilateral, localized, non-familial, pathologically-confirmed pT1 renal cell carcinoma and a minimum post-operative follow-up of 12 months. Survival analysis (disease-free, cancer-specific, and overall survival) was performed, and Kaplan-Meier curves were generated. RESULTS: RAPN was performed in 124 patients with a median tumor size of 3.0 cm (IQR 2.2-4.2 cm). Median follow-up was 29 months (range 12-46 months). Positive parenchymal surgical margins occurred in two patients (1.6 %), both of whom were recurrence-free at 30 and 34 months after surgery. The three-year Kaplan-Meier estimated disease-free survival was 94.9 %, cancer-specific survival was 99.1 %, and overall survival was 97.3 %. CONCLUSIONS: In our cohort of patients with small renal carcinomas who were followed for a median of 29 months, recurrence and survival outcomes were similar to those reported for open and laparoscopic partial nephrectomy. Further long-term outcomes will be needed to definitively claim that RAPN is oncologically equivalent to other surgical approaches

National trends in hospital-acquired preventable adverse events after major cancer surgery in the USA

Objectives: While multiple studies have demonstrated variations in the quality of cancer care in the USA, payers are increasingly assessing structure-level and process-level measures to promote quality improvement. Hospital-acquired adverse events are one such measure and we examine their national trends after major cancer surgery. Design: Retrospective, cross-sectional analysis of a weighted-national estimate from the Nationwide Inpatient Sample (NIS) undergoing major oncological procedures (colectomy, cystectomy, oesophagectomy, gastrectomy, hysterectomy, lung resection, pancreatectomy and prostatectomy). The Agency for Healthcare Research and Quality Patient Safety Indicators (PSIs) were utilised to identify trends in hospital-acquired adverse events. Setting: Secondary and tertiary care, US hospitals in NIS Participants: A weighted-national estimate of 2 508 917 patients (>18 years, 1999–2009) from NIS. Primary outcome measures Hospital-acquired adverse events. Results: 324 852 patients experienced ≥1-PSI event (12.9%). Patients with ≥1-PSI experienced higher rates of in-hospital mortality (OR 19.38, 95% CI 18.44 to 20.37), prolonged length of stay (OR 4.43, 95% CI 4.31 to 4.54) and excessive hospital-charges (OR 5.21, 95% CI 5.10 to 5.32). Patients treated at lower volume hospitals experienced both higher PSI events and failure-to-rescue rates. While a steady increase in the frequency of PSI events after major cancer surgery has occurred over the last 10 years (estimated annual % change (EAPC): 3.5%, p<0.001), a concomitant decrease in failure-to-rescue rates (EAPC −3.01%) and overall mortality (EAPC −2.30%) was noted (all p<0.001). Conclusions: Over the past decade, there has been a substantial increase in the national frequency of potentially avoidable adverse events after major cancer surgery, with a detrimental effect on numerous outcome-level measures. However, there was a concomitant reduction in failure-to-rescue rates and overall mortality rates. Policy changes to improve the increasing burden of specific adverse events, such as postoperative sepsis, pressure ulcers and respiratory failure, are required

Morbidity and Mortality After Benign Prostatic Hyperplasia Surgery: Data from the American College of Surgeons National Surgical Quality Improvement Program

Background and Purpose: With the aging population, it is becoming increasingly important to identify patients at risk for postsurgical complications who might be more suited for conservative treatment. We sought to identify predictors of morbidity after surgical treatment of benign prostatic hyperplasia (BPH) using a large national contemporary population-based cohort. Methods: Relying on the American College of Surgeons National Surgical-Quality Improvement Program (ACS-NSQIP; 2006?2011) database, we evaluated outcomes after transurethral resection of the prostate (TURP), laser vaporization of the prostate (LVP), and laser enucleation of the prostate (LEP). Outcomes included blood-transfusion rates, length of stay, complications, reintervention rates, and perioperative mortality. Multivariable logistic-regression analysis evaluated the predictors of perioperative morbidity and mortality. Results: Overall, 4794 (65.2%), 2439 (33.1%), and 126 (1.7%) patients underwent TURP, LVP, and LEP, respectively. No significant difference in overall complications (P=0.3) or perioperative mortality (P=0.5) between the three surgical groups was found. LVP was found to be associated with decreased blood transfusions (odds ratio [OR]=0.21; P=0.001), length of stay (OR=0.12; P30%) levels were the only predictors of lower overall complications and perioperative mortality. Conclusions: All three surgical modalities for BPH management were found to be safe. Advanced age and non-Caucasian race were independent predictors of adverse outcomes after BPH surgery. In patients with these attributes, conservative treatment might be a reasonable alternative. Also, preoperative hematocrit and albumin levels represent reliable predictors of adverse outcomes, suggesting that these markers should be evaluated before BPH surgery.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140378/1/end.2013.0805.pd

Current Challenges and Opportunities in Microstructure-Related Properties of Advanced High-Strength Steels

This is a viewpoint paper on recent progress in the understanding of the microstructure–property relations of advanced high-strength steels (AHSS). These alloys constitute a class of high-strength, formable steels that are designed mainly as sheet products for the transportation sector. AHSS have often very complex and hierarchical microstructures consisting of ferrite, austenite, bainite, or martensite matrix or of duplex or even multiphase mixtures of these constituents, sometimes enriched with precipitates. This complexity makes it challenging to establish reliable and mechanism-based microstructure–property relationships. A number of excellent studies already exist about the different types of AHSS (such as dual-phase steels, complex phase steels, transformation-induced plasticity steels, twinning-induced plasticity steels, bainitic steels, quenching and partitioning steels, press hardening steels, etc.) and several overviews appeared in which their engineering features related to mechanical properties and forming were discussed. This article reviews recent progress in the understanding of microstructures and alloy design in this field, placing particular attention on the deformation and strain hardening mechanisms of Mn-containing steels that utilize complex dislocation substructures, nanoscale precipitation patterns, deformation-driven transformation, and twinning effects. Recent developments on microalloyed nanoprecipitation hardened and press hardening steels are also reviewed. Besides providing a critical discussion of their microstructures and properties, vital features such as their resistance to hydrogen embrittlement and damage formation are also evaluated. We also present latest progress in advanced characterization and modeling techniques applied to AHSS. Finally, emerging topics such as machine learning, through-process simulation, and additive manufacturing of AHSS are discussed. The aim of this viewpoint is to identify similarities in the deformation and damage mechanisms among these various types of advanced steels and to use these observations for their further development and maturation

Effects of treating subclinical hypothyroidism in pregnancy in India: Are we treating too many for little gain? A retrospective cohort study

Objective: To assess the impact of treatment of subclinical hypothyroidism (SCH) on short‐term pregnancy outcomes.Method: Data from 4526 consecutive women with singleton pregnancies who delivered between January 2015 and December 2017 were analyzed. SCH was defined as a thyroid‐stimulating hormone (TSH) level between 2.5 and 10 mU/mL with normal free thyroxine. Of those with SCH, some were treated but others were not. These two groups were compared using χ2 and Student t tests for categorical and continuous variables, respectively. Multiple logistic regression models, adjusted for maternal age, body mass index, parity, gestation at TSH measurement, and gestational diabetes mellitus status, were used to investigate the effect of treatment on pregnancy and neonatal outcomes.Results: In all, 1227 (27.1%) of 4526 women had SCH, of whom 393 (32.0%) were treated. The mean age and body mass index were similar in both groups. The mean gestation at measuring of TSH was 11.7 ± 6.5 weeks. There was no significant difference in pregnancy or neonatal outcomes between the two groups. A sub‐group analysis when SCH was defined as TSH 4.0 mU/mL or greater showed a higher rate of large for gestational age and lower rates of low birth weight and small for gestational age in the treated group.Conclusions: The prevalence of SCH based on the international guidelines threshold is high in India. Treatment of SCH did not show any difference in pregnancy and neonatal outcomes in this study