Quality and Safety of Minimally Invasive Surgery: Past, Present, and Future

Adverse events because of medical errors are a leading cause of death in the United States (US) exceeding the mortality rates of motor vehicle accidents, breast cancer, and AIDS. Improvements can and should be made to reduce the rates of preventable surgical errors because they account for nearly half of all adverse events within hospitals. Although minimally invasive surgery (MIS) has proven patient benefits such as reduced postoperative pain and hospital stay, its operative environment imposes substantial physical and cognitive strain on the surgeon increasing the risk of error. To mitigate errors and protect patients, a multidisciplinary approach is needed to improve MIS. Clinical human factors, and biomedical engineering principles and methodologies can be used to develop and assess laparoscopic surgery instrumentation, practices, and procedures. First, the foundational understanding and the imperative to transform health care into a high-quality and safe system is discussed. Next, a generalized perspective is presented on the impact of the design and redesign of surgical technologies and processes on human performance. Finally, the future of this field and the research needed to further improve the quality and safety of MIS is discussed

The Financial Burden of the Urology Match: Room for improvement

Abstract Introduction/ Background – The Urology match remains highly competitive, but there is limited published data on the costs of the application process for contemporary applicants. This study aims to determine the financial burden of the Urological match and the effect it has on applicants. Methods/ Materials – All applicants to the University of Nebraska Medical Center (UNMC) Urology Residency in the 2019 Urology match were invited to complete an anonymous, IRB approved online survey containing 16 questions on interview travel and costs, financial aid, and debt burden. Results – Thirty-nine out of 183 (21%) applicants responded to the survey. The median number of programs applied to was 87 (range 26 - 100). The median number of interviews offered was 17 (range 0 - 51) and the median number of interviews attended was 14 (range 0 - 27). The median interview expense was $6,0000 (range 0 – 10,000). Applicants reported the money came from a combination of medical student loans (43$57,500. Conclusions – At UNMC, applicants for the 2019 Urology interview cycle incurred a median monetary cost of $6,000. With 18Abstract Introduction/ Background – The Urology match remains highly competitive, but there is limited published data on the costs of the application process for contemporary applicants. This study aims to determine the financial burden of the U[A1] rological match and the effect it has on applicants. Methods/ Materials – All applicants to the University of Nebraska Medical Center (UNMC) Urology Residency in the 2019 Urology match were invited to complete an anonymous, IRB approved online survey containing 16 questions on interview travel and costs, financial aid, and debt burden. Results – Thirty-nine out of 183 (21$6,0000 (range 0 – 10,000). Applicants reported the money came from a combination of medical student loans (43%), family and friends (43%), or from personal savings (41%). To save money, 64% of applicants reported staying with family and friends on at least 1 interview and about 43% [A2] of applicants reported sharing a room with another applicant. Notably, 18%[A3] of applicants surveyed stated that they declined interviews due to cost. The median medical school debt of those surveyed was $57,500[A4] . Conclusions – At UNMC, applicants for the 2019 Urology interview cycle incurred a median monetary cost of$6,000 . With 18% of applicants stating that they declined interviews due to financial cost, there should be reform to the interview process to help lower costs to applicants and promote a successful match. Limiting total applications or coordinating same city interviews are two[A5] options to reduce cost. [A1]Check throughout – sometimes you capitalize Urology or Urological and other times you do not. Be consistent throughout entire paper. Either way is fine. [A2]Don’t start a sentence with a numeral – either spell it out or add to the previous sentence. [A3]Change – you can also start a sentence with a transition like “Notably, 18%...” [A4]This seems low. Double check [A5]Typically spell out numbers one-nine and then use numerals for 10 and up (except for measurements, dollar amounts, and others)

Preoperative frailty predicts postoperative complications and mortality in urology patients

Purpose Our objective was to determine the impact of preoperative frailty, as measured by validated Risk Analysis Index (RAI), on the occurrence of postoperative complications after urologic surgeries in a national database comprised of diverse practice groups and cases. Study design The National Surgical Quality Improvement Program (NSQIP) database was queried from 2005 to 2011 for a list of abdominal, vaginal, transurethral and scrotal urological surgeries using Current Procedural Terminology codes. The study population was subdivided into two groups based on the nature of procedures performed: complex procedures (inpatient) and simple procedures (outpatient). Risk Analysis Index score was calculated using preoperative NSQIP variables to determine preoperative frailty. Major postoperative morbidities (pulmonary, cardiovascular, renal and infectious), mortality, return to operating room, discharge destination and readmission to the hospital were examined. Results The study identified 42,715 patients who underwent urological procedures, 25,693 complex and 17,022 simple procedures. Mean RAI score (range) was 7.75 (0–53). The majority of patients scored low on the RAI (90.57 % with RAI \u3c 10). As the RAI score increased, there was a significant increase in postoperative complication and mortality rate (both p \u3c 0.0001). Similarly, the rate of return to operating room and hospital readmission rate increased as RAI increased (both p \u3c 0.0001). Additionally, rate of discharge to home decreased. Interestingly, mortality rate in patients with high RAI did not differ comparing simple to complex procedures (p = 0.90), whereas complications were significantly greater in the complex operation (p = 0.01). Conclusions Increase in frailty, as measured by RAI score, is associated with increased postoperative complications and mortality. RAI may allow for rapid identification and counseling of patients who are at high risk of adverse perioperative outcomes

Clinical Features of Sarcomatoid Carcinoma (Carcinosarcoma) of the Urinary Bladder: Analysis of 221 Cases

Background. Urinary bladder sarcomatoid carcinoma (carcinosarcoma) is rare. The objective of this study was to examine the epidemiology, natural history, and prognostic factors of urinary bladder carcinosarcoma using population-based registry. Methods. The Surveillance, Epidemiology, and End Results (SEER) Program database was used to identify cases by tumor site and histology codes. The association between clinical and demographic characteristics and long-term survival was examined. Results. A total of 221 histology confirmed cases were identified between 1973 and 2004, this accounted for approximately 0.11% of all primary bladder tumors during the study period. Median age of the patients was 75 years (range 41–96). Of the patients with a known tumor stage (N = 204), 72.5% had a regional or distant stage; 98.4% of patients with known histology grade (N = 127), had poorly or undifferentiated histology. Multiple primary tumors were indentified in about 40% of study subjects. The majority of patients (95.9%) received cancer directed surgery, 35.8% had radical or partial cystectomy, 15.8% of patients received radiation therapy combination with surgery. The median overall survival was 14 months (95% CI 7–21 months). 1-, 5-, and 10-year cancer specific survival rate were 53.9%, 28.4% and 25.8%. In a multivariate analysis, only tumor stage was found to be a significant prognostic factor for disease-specific survival. Conclusions. Urinary bladder carcinosarcoma commonly presented as high grade, advanced stage and aggressive behavior with a poor prognosis. Emphasis on early detection, including identification of risk factors is needed to improve the outcome for patients with this malignancy

Clinically Undiagnosed Prostate Carcinoma Metastatic to Renal Oncocytoma

Tumors-to-tumor metastasis is an uncommon occurrence and can be a source of great diagnostic difficulty, especially when the donor tumor is undiagnosed. Here we report a case of a kidney resected for a primary neoplasm (oncocytoma) that harbored metastases from a clinically undiagnosed prostatic adenocarcinoma. The presence of the poorly differentiated metastasis within an otherwise typical oncocytoma in the absence of metastases in the surrounding nonneoplastic renal parenchyma resulted in a diagnostic dilemma. To our knowledge, this is the first report of a case in the English literature of a clinically undiagnosed prostatic adenocarcinoma metastatic to a renal oncocytoma identified on examination of the resected renal neoplasm

Human prostatic Acid phosphatase: structure, function and regulation.

Human prostatic acid phosphatase (PAcP) is a 100 kDa glycoprotein composed of two subunits. Recent advances demonstrate that cellular PAcP (cPAcP) functions as a protein tyrosine phosphatase by dephosphorylating ErbB-2/Neu/HER-2 at the phosphotyrosine residues in prostate cancer (PCa) cells, which results in reduced tumorigenicity. Further, the interaction of cPAcP and ErbB-2 regulates androgen sensitivity of PCa cells. Knockdown of cPAcP expression allows androgen-sensitive PCa cells to develop the castration-resistant phenotype, where cells proliferate under an androgen-reduced condition. Thus, cPAcP has a significant influence on PCa cell growth. Interestingly, promoter analysis suggests that PAcP expression can be regulated by NF-κB, via a novel binding sequence in an androgen-independent manner. Further understanding of PAcP function and regulation of expression will have a significant impact on understanding PCa progression and therapy

Quality and Safety of Minimally Invasive Surgery: Past, Present, and Future

Adverse events because of medical errors are a leading cause of death in the United States (US) exceeding the mortality rates of motor vehicle accidents, breast cancer, and AIDS. Improvements can and should be made to reduce the rates of preventable surgical errors because they account for nearly half of all adverse events within hospitals. Although minimally invasive surgery (MIS) has proven patient benefits such as reduced postoperative pain and hospital stay, its operative environment imposes substantial physical and cognitive strain on the surgeon increasing the risk of error. To mitigate errors and protect patients, a multidisciplinary approach is needed to improve MIS. Clinical human factors, and biomedical engineering principles and methodologies can be used to develop and assess laparoscopic surgery instrumentation, practices, and procedures. First, the foundational understanding and the imperative to transform health care into a high-quality and safe system is discussed. Next, a generalized perspective is presented on the impact of the design and redesign of surgical technologies and processes on human performance. Finally, the future of this field and the research needed to further improve the quality and safety of MIS is discussed

Preoperative frailty predicts postoperative complications and mortality in urology patients

Purpose Our objective was to determine the impact of preoperative frailty, as measured by validated Risk Analysis Index (RAI), on the occurrence of postoperative complications after urologic surgeries in a national database comprised of diverse practice groups and cases. Study design The National Surgical Quality Improvement Program (NSQIP) database was queried from 2005 to 2011 for a list of abdominal, vaginal, transurethral and scrotal urological surgeries using Current Procedural Terminology codes. The study population was subdivided into two groups based on the nature of procedures performed: complex procedures (inpatient) and simple procedures (outpatient). Risk Analysis Index score was calculated using preoperative NSQIP variables to determine preoperative frailty. Major postoperative morbidities (pulmonary, cardiovascular, renal and infectious), mortality, return to operating room, discharge destination and readmission to the hospital were examined. Results The study identified 42,715 patients who underwent urological procedures, 25,693 complex and 17,022 simple procedures. Mean RAI score (range) was 7.75 (0–53). The majority of patients scored low on the RAI (90.57 % with RAI \u3c 10). As the RAI score increased, there was a significant increase in postoperative complication and mortality rate (both p \u3c 0.0001). Similarly, the rate of return to operating room and hospital readmission rate increased as RAI increased (both p \u3c 0.0001). Additionally, rate of discharge to home decreased. Interestingly, mortality rate in patients with high RAI did not differ comparing simple to complex procedures (p = 0.90), whereas complications were significantly greater in the complex operation (p = 0.01). Conclusions Increase in frailty, as measured by RAI score, is associated with increased postoperative complications and mortality. RAI may allow for rapid identification and counseling of patients who are at high risk of adverse perioperative outcomes

Delayed severe anaphylactoid reaction following retrograde pyelogram: A case report

Retrograde pyelography is used to evaluate upper collecting system in patients with hematuria who have contrast allergy. Reported here is a patient who developed severe, late-onset anaphylactoid reaction after retrograde pyelography. Premedication is commonly used to reduce risk of allergic reaction but has limited evidence to support its efficacy. Caution should be used when evaluating microhematuria with retrograde pyelography in patients with prior anaphylactoid reaction to intravenous contrast