Casey Seideman

Eye metrics as an objective assessment of surgical skill.

Objective:Currently, surgical skills assessment relies almost exclusively on subjective measures, which are susceptible to multiple biases. We investigate the use of eye metrics as an objective tool for assessment of surgical skill. Summary Background Data:Eye tracking has helped elucidate relationships between eye movements, visual attention, and insight, all of which are employed during complex task performance (Kowler and Martins, Science. 1982;215:997–999; Tanenhaus et al, Science. 1995;268:1632–1634; Thomas and Lleras, Psychon Bull Rev. 2007;14:663–668; Thomas and Lleras, Cognition. 2009;111:168–174; Schriver et al, Hum Factors. 2008;50:864–878; Kahneman, Attention and Effort. 1973). Discovery of associations between characteristic eye movements and degree of cognitive effort have also enhanced our appreciation of the learning process. Methods:Using linear discriminate analysis (LDA) and nonlinear neural network analyses (NNA) to classify surgeons into expert and nonexpert cohorts, we examine the relationship between complex eye and pupillary movements, collectively referred to as eye metrics, and surgical skill level. Results:Twenty-one surgeons participated in the simulated and live surgical environments. In the simulated surgical setting, LDA and NNA were able to correctly classify surgeons as expert or nonexpert with 91.9% and 92.9% accuracy, respectively. In the live operating room setting, LDA and NNA were able to correctly classify surgeons as expert or nonexpert with 81.0% and 90.7% accuracy, respectively. Conclusions:We demonstrate, in simulated and live-operating environments, that eye metrics can reliably distinguish nonexpert from expert surgeons. As current medical educators rely on subjective measures of surgical skill, eye metrics may serve as the basis for objective assessment in surgical education and credentialing in the future. Further development of this potential educational tool is warranted to assess its ability to both reliably classify larger groups of surgeons and follow progression of surgical skill during postgraduate training.

Conversion During Laparoscopic Surgery: Frequency, Indications and Risk Factors

PURPOSE There are limited data on the indications for open conversion during laparoscopic surgery. The frequency of conversion for various procedures is poorly quantified and the degree to which this changes with time is not well understood. Risk factors for conversion are not defined. We addressed these issues in a large series of laparoscopic operations. MATERIALS AND METHODS We reviewed our database of 2,128 laparoscopic operations performed between 1993 and 2005, including radical nephrectomy in 549 patients, simple nephrectomy in 186, partial nephrectomy in 347, donor nephrectomy in 553, pyeloplasty in 301, nephroureterectomy in 106 and retroperitoneal lymph node dissection in 86. Open conversions were identified and the frequency of conversion for the total cohort and specific procedures was determined. Trends in conversion with time were assessed and indications analyzed. Clinicopathological features between patients requiring conversion and those who did not were compared. RESULTS We identified 68 patients (3.3%) who underwent conversion to open surgery (group 1) and 2,011 (96.7%) who did not (group 2). The frequency of conversion was greatest during nephroureterectomy (8.49%), followed by simple nephrectomy (5.91%), retroperitoneal lymph node dissection (4.65%), partial nephrectomy (4.32%), radical nephrectomy (2.91%), donor nephrectomy (2.53%) and pyeloplasty (0.33%). The absolute number of conversions and conversions/cases performed per year decreased significantly with time, reaching a nadir of less than 1% per year. Conversion was inversely related to case volume and cumulative experience. Indications included vascular injury in 38.5% of cases, concern with margins in 13.5%, bowel injury in 13.5%, failure to progress in 11.5%, adhesions in 9.6%, diaphragmatic injury in 1.9% and other in 11.5%. The distribution of indications remained similar with time. There were no differences in patient age, gender, surgical history, American Society of Anesthesiologists score or tumor stage between groups 1 and 2. In groups 1 and 2 mean operative time was 304 vs 219 minutes and estimated blood loss was 904 vs 255 cc (each p <0.0001). CONCLUSIONS The rate of conversion during laparoscopic surgery is not uniform across procedures and it is important for patient counseling. The most common indication for conversion is vascular injury. Importantly the frequency of conversion is dynamic and likely related to case volume and cumulative experience.

Delayed haemorrhage after laparoscopic partial nephrectomy: frequency and angiographic findings.

Study Type – Therapy (case series) 
Level of Evidence 4

PATHOLOGIC FINDINGS IN PATIENTS WITH URETEROPELVIC JUNCTION OBSTRUCTION AND CROSSING VESSELS

OBJECTIVES To define the role of crossing vessels in the pathophysiology of ureteropelvic junction (UPJ) obstruction, we analyzed the relationship between the presence of crossing vessels and UPJ pathologic findings in patients undergoing laparoscopic pyeloplasty. The significance of crossing renal vessels in patients with UPJ obstruction is unclear. METHODS We performed a retrospective analysis of 155 consecutive patients undergoing laparoscopic pyeloplasty. Pathologic specimens from the UPJ were evaluated in 95 patients. The presence or absence of crossing vessels was documented intraoperatively. The histopathologic findings allowed for categorization into 5 groups: group 1, normal ureteral tissue; group 2, chronic inflammation; group 3, smooth muscle hypertrophy, group 4, fibrosis; and group 5, smooth muscle atrophy. The pathologic findings between patients with and without crossing vessels were compared. RESULTS Overall, crossing vessels were identified in 98 patients (63.2%). Of the 95 cases with specimens retrieved for histologic analysis, 65 had crossing vessels and 30 did not. The most common UPJ histologic finding in patients with crossing vessels was no intrinsic abnormality (43%). In contrast, this was seen in only 10% of patients without a crossing vessel. In the group without crossing vessels, chronic inflammation (40%) was the predominant histologic findings. Patients with a crossing vessel were less likely to have intrinsic histologic pathologic findings (P < .0003). CONCLUSIONS Patients with crossing vessels and UPJ obstruction had no histologic abnormalities identified in 43% of cases. This finding implicates crossing vessels in the pathogenesis of select cases of UPJ obstruction and direct mechanical compression as the etiology of obstruction in these individuals.

Laparoscopic ureteral reimplantation: technique and outcomes.

PURPOSE We describe our experience with laparoscopic ureteral reimplantation in 45 adults, and report success rates and complications at intermediate term followup. MATERIALS AND METHODS We performed a retrospective chart review of 45 patients who underwent laparoscopic ureteral reimplantation between 1997 and 2007. Demographics, clinicopathological parameters, perioperative course, complications and followup studies were analyzed. RESULTS Elective laparoscopic ureteral reimplantation was performed in 35 female and 10 male patients with a mean followup of 24.1 months (range 1 to 76). All patients presented with distal ureteral stricture with a mean stricture length of 3 cm and a mean +/- SD preoperative serum creatinine of 0.91 +/- 0.04 mg/dl. Mean patient age was 47.8 +/- 2.2 years (range 17 to 87). Mean American Society of Anesthesiologists score was 2 (range 1 to 3). Median estimated blood loss was 150 ml. The overall success rate, defined as radiographic evidence of no residual obstruction, symptoms, renal deterioration or need for subsequent procedures, was 96%. Two patients had recurrent strictures and 1 underwent nephrectomy for flank pain and preexisting chronic pyelonephritis. CONCLUSIONS According to intermediate followup data laparoscopic ureteral reimplantation can be performed with an excellent success rate and low morbidity. Our data substantiate this technique as an effective method for managing distal ureteral stricture.

Long-Term Follow-Up for Salvage Laparoscopic Pyeloplasty After Failed Open Pyeloplasty

OBJECTIVES To report our long-term experience with salvage laparoscopic pyeloplasty after a failed open procedure. Laparoscopic repair of a primary ureteropelvic junction obstruction (UPJO) is associated with very high long-term success. However, there are limited data on patients who have failed previous open pyeloplasty. We have determined that salvage laparoscopic pyeloplasty is an excellent option for these patients. METHODS We queried our laparoscopic pyeloplasty database of 367 patients from July 1994 to May 2007 for patients who had undergone prior open pyeloplasty. We analyzed demographic data, perioperative course, complications, and follow-up studies on identified subjects. We assessed clinical status by verbal pain scale and diagnostic studies. Radiologic follow-up consisted of diuretic renal scan, intravenous pyelography, or both. RESULTS We identified 9 patients (2.5%) who underwent salvage laparoscopic pyeloplasty for persistent obstruction after open pyeloplasty. The mean age of our cohort was 30.5 years (range, 19-50 years). Mean operative time was 204 minutes (range, 80-264 minutes), estimated blood loss was 105 mL (range, 20-300 mL), and mean length of stay was 2.1 days (range, 2-3 days). No intraoperative or postoperative complications were reported. All patients reported relief of symptoms in the immediate postoperative period. At a median follow-up of 66 months (range, 12-119 months), 8 of 9 patients (89%) had clinical and radiologic resolution of UPJO with stable renal function, pain free status, and a patent ureteropelvic junction. The remaining patient failed laparoscopic repair within the first year with evidence of persistent obstruction, necessitating endopyelotomy. CONCLUSIONS Our findings support the use of salvage laparoscopic pyeloplasty as an excellent option for patients who failed previous open pyeloplasty. This approach provides durable long-term outcomes.

High-Energy Transurethral Thermotherapy with CoreTherm Approaches Transurethral Prostate Resection in Outcome Efficacy: A Meta-Analysis

BACKGROUND AND PURPOSE Minimally invasive office-based treatments for benign prostatic hyperplasia (BPH) are challenging the traditional surgical and medical management options for symptomatic BPH. We conducted a meta-analysis of published randomized controlled trials that compared high-energy transurethral microwave thermotherapy (HE-TUMT) with transurethral resection of the prostate (TURP) to compare subjective and objective outcomes. MATERIALS AND METHODS A literature search using Pub-Med was conducted to obtain all published data on HE-TUMT and all randomized controlled trials that compared HE-TUMT with TURP. Data were analyzed focusing on the pretreatment and posttreatment end points of the International Prostate Symptom Score(IPSS), maximum flow rate (Q(max)), and postvoid residual (PVR). A meta-analysis was conducted, and data were stratified with respect to the type of HE-TUMT machinery used. RESULTS A total of 458 patients were studied. Differences in IPSS, Q(max), and PVR from current trials that compared TURP with HE-TUMT are best evaluated at 1-year follow-up. At this time point, changes in Q(max) (P < 0.001), IPSS (P = 0.01), and PVR (P = 0.02) are more significant if TURP is the management mode. HE-TUMT with the CoreTherm() device demonstrates the most significant improvements in subjective and objective criteria that approximate outcomes with TURP (Figs. 1-3). CONCLUSIONS A meta-analysis of current randomized controlled trials that compared TURP with HE-TUMT demonstrates more significant changes in Q(max), IPSS, and PVR when TURP is used to manage symptomatic BPH. Despite these statistical differences, stratified data demonstrate that current HE-TUMT machinery is more effective than previously used lower-energy machinery, especially at objective end points. This is most evident when the CoreTherm device is used. These findings, coupled with the decreased costs and morbidity associated with HE-TUMT, support this treatment as a reasonable alternative to TURP.

Predictors of Hemorrhage After Laparoscopic Partial Nephrectomy

OBJECTIVES To identify risk factors associated with hemorrhage during laparoscopic partial nephrectomy (LPN), and to determine the impact of hemorrhage on hospital course. METHODS We retrospectively analyzed prospective data from 335 LPNs to identify clinicopathologic factors associated with hemorrhagic complications (blood loss requiring ≥ 1 U transfusion) and extended length of hospitalization (≥ 3 days). We excluded patients with a coagulopathy or perioperative vascular injuries. RESULTS We identified 23 patients (7%) undergoing LPN with hemorrhagic complications (group 1 and 312 patients (93%) without complications (group 2). Mean age was 64.1 ± 14.4 vs 57.6 ± 12.7(P = .006), American Society of Anesthesiologists (ASA) score ≥ 3 seen in 61% vs 37% (P = .02), mean tumor size (cm) was 2.90 ± 2.02 vs 2.59 ± 1.15 (P = .93), mean total operative time (min) was 250.1 ± 116.1 vs 191.8 ± 69.2 (P = 0.006), and mean hospital stay (days) was 4.7 ± 3.4 vs 3.1 ± 3.0 (P = .0002), for groups 1 and 2, respectively. Hypertension, diabetes mellitus, chronic renal insufficiency, obesity, smoking, and coronary artery disease-congestive heart failure were present in group 1 vs group 2: 39.1% vs 31.4% (P = .4), 17.4% vs 8% (P = .12), 8.7% vs 1.9% (P = .09), 4.3% vs 3.5% (P = .57), 17.4% vs 5.4% (P = .04), and 8.7% vs 2.2% (P = .11), respectively. On multivariate analysis, smoking (P < .0437) and ASA score ≥ 3 (P < .0233) were associated with hemorrhagic complications. Hemorrhagic complications were 3.5 times more likely in smokers than nonsmokers (95% confidence interval, 1.0-11.7), and 2.9 times more likely with an ASA class ≥ 3. Only age (P < .0002) and operative time (P < .0001) were associated with longer hospitalization. CONCLUSIONS High ASA scores and smoking are risk factors for hemorrhagic complications during LPN. Hemorrhagic complications did not significantly affect hospitalization length.

DELAYED HEMORRHAGE AFTER LAPAROSCOPIC PARTIAL NEPHRECTOMY: CHARACTERIZATION OF ANGIOGRAPHIC FINDINGS

Doppler Probe Results RNx/NU PNx RALP Patients 16 22 7 Mean Doppler Time (seconds) 111 98 171 Total AV on CT 1 7 N/A Total AV on Doppler 5 11 N/A Patients with AV 5 9 N/A Patients with Crossing Vessel N/A N/A 6 (85.7%) Patients with changed management 4 (25%) 5 (22.7%) 3 (42.9%) Patients with time saved 12 (75%) 17 (77.3%) 5 (71.4%) Use Score “very easy” 16 (100%) 22 (100%) 7 (100%) Complications 0 0 0 Technical Failure 1 (6.3%) 1 (4.5%) 0

T-Shaped Shunt with Intracavernosal Tunneling, for a Pediatric Case of Refractory Ischemic Priapism

We present the first reported case of refractory pediatric priapism treated by intracavernosal tunneling T shunt. A 12-year-old male, with sickle cell disease, presented with 72 hours of painful erection. The patient failed conservative measures including aspiration, injection of phenylephrine, as well as distal shunt procedure. A T-T shunt was performed, as previously described in the adult literature. There was immediate resolution of the erection with no complications. At 1-year follow-up, he reports no subsequent episodes of priapism and normal erections. T shunt with tunneling can be performed in select cases of severe pediatric refractory ischemic priapism.