Catherine deVries

250 consecutive unilateral extravesical ureteral reimplantations in an outpatient setting.

PURPOSE Unilateral extravesical ureteral reimplantation is comparable to intravesical procedures and more effective than subureteral injection to resolve vesicoureteral reflux. Initial reports showed that the procedure could be feasibly done on an outpatient basis. We present further data on a large series of consecutive, planned, outpatient unilateral extravesical ureteral reimplantations. MATERIALS AND METHODS A total of 250 consecutive patients underwent scheduled outpatient unilateral extravesical ureteral reimplantation. We retrospectively reviewed their records. Patient data were collected on reflux laterality and grade, operative time, hospital stay, complications, need for rehospitalization and resolution rate on radiography 1 month postoperatively. RESULTS A total of 209 females (84%) and 41 males (16%) underwent planned outpatient extravesical ureteral reimplantation, including on the left side in 158 (63%) and on the right side in 92 (37%). Mean reflux grade was 3.2 with grades II to V in 64 (26%), 96 (38%), 74 (30%) and 16 cases (7%), respectively. Average operative time was 63 minutes and average length of stay, defined as time from initial admission in to discharge home, was 6.2 hours (range 3 to 10 hours). Short-term and late complications occurred in 9 (3.6%) and 8 patients (3.2%), respectively. CONCLUSIONS Extravesical ureteral reimplantation for unilateral vesicoureteral reflux may be consistently done on an outpatient basis with a reasonable complication rate and a low postoperative hospital admission rate.

Endoscopic Subureteral Injection is Not Less Expensive Than Outpatient Open Reimplantation for Unilateral Vesicoureteral Reflux

PURPOSE Extravesical ureteral reimplantation and subureteral Deflux injection are used to correct vesicoureteral reflux with success rates of 94% to 99% and up to 89%, respectively. It was reported that unilateral extravesical reimplantation may be performed safely in an outpatient setting. Given that, we analyzed total system reimbursement to compare planned outpatient unilateral extravesical reimplantation to subureteral Deflux injection in patients with unilateral vesicoureteral reflux. MATERIALS AND METHODS Data were collected on consecutive patients undergoing outpatient procedures for unilateral vesicoureteral reflux. Assessment of total system reimbursement was made using a payer mix adjusted calculation of surgery plus anesthesia plus hospital reimbursement. This was compared per procedure and in terms of total system reimbursement for each approach to obtain a similar resolution rate. RESULTS A total of 209 consecutive patients were identified, of whom 26 underwent subureteral Deflux injection and 183 underwent unilateral extravesical reimplantation. Mean operative time was 93 minutes for reimplantation and 45 minutes for injection. The mean volume of dextranomer-hyaluronic acid was 1.2 ml. Total initial system reimbursement per patient was

Parameatal urethral cysts in prepubertal males.

3,813 for reimplantation and

Expansion of laparoscopic cholecystectomy in a resource limited setting, Mongolia: a 9-year cross-sectional retrospective review.

4,259 for injection. A 3% hospital admission rate for reimplantation increased the total to

Fundamentals for establishing and maintaining an academic centre for global surgery: the University of Utah experience

3,945. Higher reimbursement for injection depended largely on the material expense for dextranomer-hyaluronic acid. CONCLUSIONS In terms of total system reimbursement it is less expensive in our system to treat unilateral vesicoureteral reflux with unilateral extravesical reimplantation than with subureteral Deflux injection using dextranomer-hyaluronic acid. The ability to perform unilateral reimplantation as an outpatient procedure has shifted this relationship.

Perspectives on International Urological Volunteerism: A Survey of IVUmed Resident Scholar Alumni

PURPOSE Parameatal urethral cyst in boys is an uncommon and often poorly understood condition. We describe the largest known series of 18 prepubertal boys with parameatal cysts. MATERIALS AND METHODS We retrospectively reviewed the charts of all pediatric patients at our institution diagnosed with a penile cyst according to our office database between 1992 and 2010. Charts were reviewed to determine patient demographics, symptomatology, pathology, cyst characteristics and treatment. RESULTS We identified 18 patients during the last 18 years who were diagnosed with a parameatal cyst. Most patients (66%) were asymptomatic. All cysts were less than 1 cm in diameter. Of the patients 50% were circumcised before presentation and 78% underwent surgical excision. There have been no recurrences in patients who underwent excision. One patient had spontaneous resolution of the cyst during the first few weeks of life. Pathology results were available for 6 patients. Three specimens contained a single type of epithelium and 3 contained a combination of transitional, cuboidal and/or columnar epithelia. The transitional and cuboidal epithelia were the most common components. There was no evidence of malignancy in any of the specimens and only 1 specimen contained an inflammatory infiltrate. CONCLUSIONS Parameatal cysts are a benign, usually asymptomatic condition that may contain a variety of epithelial types. The cysts may resolve spontaneously in neonates but are also easily excised with minimal risk of recurrence.

Geospatial Mapping of Surgical Capacity in Zambia

BACKGROUND The benefits of laparoscopic cholecystectomy have been largely unavailable to most people in developing countries. Mongolia has an extremely high incidence of gallbladder disease. In 2005, only 2% of cholecystectomies were being done laparoscopically. Open cholecystectomies were associated with high rates of wound infections, complications, and increased recovery time. Because of the unacceptable complications associated with open cholecystectomies, and nearly 50% of the nomadic population needing faster post-operative recovery times, a national project for the development of laparoscopic surgery was organised. Multi-institutional collaboration between the Mongolia Health Sciences University, the Dr W C Swanson Family Foundation (SFF), the University of Utah, Intermountain Healthcare, and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) led to the promulgation of a formalised countrywide laparoscopic training programme during the past 9 years. This is a retrospective review of the transition from open to laparoscopic cholecystectomy throughout Mongolia. METHODS Demographic patient data, diagnosis, and operation preformed-laparoscopic versus open cholecystectomy, between January, 2005, and September, 2013, were collected and trends were analysed from seven regional diagnostic referral and treatment centres, and two tertiary academic medical centres from six of the 21 provinces (Aimags) throughout Mongolia. Data were analysed by individual training centre, by year, and then compared between rural and urban centres. FINDINGS Nearly 16 000 cholecystectomies were analysed and compared (4417 [28·2%] men; 11 244 [71·8%] women). Men and women underwent laparoscopic cholecystectomy with the same frequency (41·2% men, 43·2% women) and had similar age (men, mean 52·2 years [SD 14·8]; women, mean 49·4 years [SD 15·7]). By 2013, 62% of gallbladders were removed laparoscopically countrywide as opposed to only 2% in 2005. More than 315 Mongolian practitioners have received laparoscopic training in 19 of 21 Aimags. On average 60% of cholecystectomies are done laparoscopically in urban surgical centres, up from 2%, versus 55% in rural surgical centres, up from 0%, in 2005. Laparoscopic cholecystectomy surpassed open cholecystectomy as the primary method for gallbladder removal countrywide in 2011. INTERPRETATION By 2013, 62% of cholecystectomies countrywide were done laparoscopically, a great increase from 9 years ago. Despite being a resource limited country, the expansion of laparoscopic cholecystectomy has transformed the care of biliary tract disease in Mongolia. FUNDING The University of Utah Center for Global Surgery.

The Conundrum of Training in Global Surgery: Are We There Yet?

Abstract Background Although departments of surgery and surgical specialties are well established components of all medical schools, these departments generally focus on the teaching of technical aspects of surgery and clinical and basic science aspects of perioperative care. Few departments have dedicated resources to the study of surgical systems or ecosystems within health care as a whole. The Center for Global Surgery at the University of Utah was founded on the mission to develop the next generation of global surgical and anaesthesia leaders able to design innovative, affordable surgical care, locally and abroad, that is accessible to all through education, research, development, and advocacy. Methods The following were established as priorities: overcoming misconceptions about the scope of global surgery and its potential as an academic endeavour; improving public and academic awareness of disparities in surgical care as a public health problem; advocating for improved access for underserved populations worldwide; and extending expertise in global surgery by training undergraduate students, graduate students, medical students, residents, fellows, and faculty in research methods pertinent to the field. Findings Initially approved as a programme within the Department of Surgery in 2009, the Center for Global Surgery has grown to include participation of other departments within the health sciences programmes (anaesthesia, ophthalmology, orthopaedics, family practice, preventive medicine, and telehealth) and the main campus (engineering and anthropology) to serve a broad community within the University of Utah and worldwide. The centre provides a forum for collaboration and intersection of many disciplines that affect surgical care. Since its inception, the centre has supported engagement in advocacy at the World Health Assembly; education, including courses in global surgery; the University of Utahs Extreme Affordability Conferences; and international collaborative research. Interpretation Global surgery is now recognised in foundational surgical textbooks and publications on disease control priorities. Similar academic programmes in global surgery could benefit universities at many levels and should be integrated into dynamic and robust health education. Funding University of Utah School Department of Surgery, Adele Parkinson Endowment.

UNILATERAL EXTRAVESICAL URETERAL REIMPLANTATION IN CHILDREN PERFORMED ON AN OUTPATIENT BASIS

Introduction: The primary intentions of international surgical programs are to directly benefit those receiving medical care, educate local physicians and staff, and improve care delivery models. IVUmed, a nonprofit organization dedicated to providing urological care to resource poor areas of the world, provides scholarship opportunities for urology trainees. We assessed the motivations and barriers of IVUmed traveling resident scholars regarding continuing international surgical work after completion of the program. Methods: An Internet based survey was sent to all previous IVUmed resident scholars assessing potential factors associated with repeat international service. Logistic regression was used to examine the association between survey responses and the likelihood of repeating an international service trip after completion of training. Results: Of 196 IVUmed resident scholar participants 100 (51%) responded to the survey. Of the 69 attending surgeons 17 (25%) had repeated an international service trip. Altruism (100%), personal fulfillment (99%) and practicing in a resource limited setting (94%) were the most frequently cited motivating factors for repeat participation, while lack of time (96%) was the most commonly reported barrier. Respondents in private practice were less likely to participate in a subsequent trip compared to those in an academic setting (OR 0.16, CI 0.03–0.80, p = 0.03). No other factors were associated with the likelihood of repeating an international service trip. Conclusions: Among urologists who participated in a funded international scholarship program during residency repeat participation during the subsequent 7 years was modest. Private practitioners were less likely to repeat international service compared to academic urologists.

New onset of hydroceles in boys over 1 year of age

Recent strides in advocacy, financial modeling, and reevaluation of the global burden of diseases that can be treated by surgery have led to the point that the World Health Assembly, World Bank, and ministries of health are now adopting resolutions and indicators for scaling up surgical care to meet the needs of the 5 billion people who currently lack access to it.1-4 There has been a burst of interdisciplinary creativity as the surgical community considers how to meet the needs of patients in underserved regions. The first problem has been to define the problem—namely, lack of timely access to safe and essential surgery. To surgeons and anesthetists this problem was self evident. To the public health community, however, it was not. The surgical community had not made the case that lack of timely access to safe and essential surgery was a problem. We lacked data. A current focus of research in global surgery involves geospatial mapping that improves our understanding of complex surgical ecosystems. Unlike calculating incidence or prevalence of individual diseases, assessing capacity for essential surgical care requires integrating maps of population, means of travel, and municipal and on-site infrastructure such as water systems and electricity, in addition to skilled, permanent human resources and surgical resources. These inventories, when combined with surgical indicators, provide the necessary information to create national plans for improving surgical care. In the last year, several groups have published articles on the use of geospatial mapping to assess access to surgical care.5-7 In Ghana, it was found that almost one-third of the population lacked access to essential surgery, as defined by the Lancet bellwether procedures, because they lived more than 2 hours from surgical facilities that could provide these procedures.6 In this issue of JAMA Surgery, Esquivel et al7 used multiple layers of population and sophisticated travel time data for geospatial mapping in Zambia, matching access to hospitals that met World Health Organization guidelines for safe surgical facilities. The list of essential surgical cases adopted by the Disease Control Priorities, 3rd edition,4 was used rather than the Lancet Commission’s 3 bellwether procedures, to determine a hospital’s capacity to provide essential surgery. Esquivel et al7 found that in Zambia, 65.9% of people live more than 2 hours from hospitals that meet standards of safe surgical care. Modern geospatial mapping technologies and data sets are providing tools to identify gaps and to match population needs with human resources and infrastructure development. These are new methods for the surgical community, but they provide a common language for the many skills necessary for building surgical capacity and transparency in resourcelimited settings.