Ian D. McLaren

A comparison of superficial versus combined (superficial and deep) cervical plexus block for carotid endarterectomy: a prospective, randomized study.

Carotid endarterectomy may be performed by using cervical plexus blockade with local anesthetic supplementation by the surgeon during surgery. Most practitioners use either a superficial cervical plexus block or a combined (superficial and deep) block, but it is unclear which offers the best operative conditions or greatest patient satisfaction. We compared the two techniques in patients undergoing carotid endarterectomy. Forty patients undergoing carotid endarterectomy were randomized to receive either a superficial or a combined cervical plexus block. Bupivacaine 0.375% to a total dose of 1.4 mg/kg was used. The main outcome measure was the amount of supplemental lidocaine 1% used by the surgeon. Subsidiary outcome measures were postoperative pain score, sedative and analgesic requirements before and during surgery, and postoperative analgesic requirements. Median supplemental lidocaine requirements were 100 mg (range 30–180 mg) in the superficial block group and 115 mg (range 30–250 mg) in the combined block group. These differences were not statistically significant (Mann-Whitney U-test). There was no significant difference in the number of patients needing postoperative analgesia between the groups (11 of 20 in the deep block group versus 8 of 20 in the superficial block group) in the 24 h after surgery. The median time to first analgesia in the superficial block group was 150 min, more than in the combined block group (median time 45 min) but this difference, although large, was not statistically significant (Mann-Whitney U-test). We found no significant differences between the anesthetic techniques studied. All patients reported satisfaction with the techniques. Implications Carotid endarterectomy may be performed satisfactorily by using either superficial or combined block, and it is found that peroperative lidocaine requirements will be the same regardless of which block is used. The decision to use one block or the other might, therefore, reasonably be influenced by the relative safety of the superficial block compared with the combined block, because previous work suggests the deep injection is associated with a more frequent complication rate.

Technique and Outcomes of Robot-assisted Retroperitoneoscopic Partial Nephrectomy: A Multicenter Study

BACKGROUND Robot-assisted retroperitoneoscopic partial nephrectomy (RARPN) may be used for posterior renal masses or with prior abdominal surgery; however, there is relatively less familiarity with RARPN. OBJECTIVE To demonstrate RARPN technique and outcomes. DESIGN, SETTING, AND PARTICIPANTS A retrospective multicenter study of 227 consecutive RARPNs was performed at the Swedish Medical Center, the University of Michigan, and the University of California, Los Angeles, from 2006 to 2013. SURGICAL PROCEDURE RARPN. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS We assessed positive margins and cancer recurrence. Stepwise regression was used to examine factors associated with complications, estimated blood loss (EBL), warm ischemia time (WIT), operative time (OT), and length of stay (LOS). RESULTS AND LIMITATIONS The median age was 60 yr (interquartile range [IQR]: 52-66), and the median body mass index (BMI) was 28.2 kg/m(2) (IQR: 25.6-32.6). Median maximum tumor diameter was 2.3 cm (IQR: 1.7-3.1). Median OT and WIT were 165 min (IQR: 134-200) and 19 min (IQR: 16-24), respectively; median EBL was 75 ml (IQR: 50-150), and median LOS was 2 d (IQR: 1-3). Twenty-eight subjects (12.3%) experienced complications, three (1.3%) had urine leaks, and three (1.3%) had pseudoaneurysms that required reintervention. There was one conversion to radical nephrectomy and three transfusions. Overall, 143 clear cell carcinomas (62.6%) composed most of the histology with eight positive margins (3.5%) and two recurrences (0.9%) with a median follow-up of 2.7 yr. In adjusted analyses, intersurgeon variation was associated with complications (odds ratio [OR]: 3.66; 95% confidence interval, 1.31-10.27; p = 0.014) and WIT (parameter estimate [PE; plus or minus standard error]: 4.84 ± 2.14; p = 0.025). Higher surgeon volume was associated with shorter WIT (PE: -0.06 ± 0.02; p = 0.002). Higher BMI was associated with longer OT (PE: 2.09 ± 0.56; p < 0.001). Longer OT was associated with longer LOS (PE: 0.01 ± 0.01; p = 0.002). Finally, there was a trend for intersurgeon variation in OT (PE: 18.5 ± 10.3; p = 0.075). CONCLUSIONS RARPN has acceptable morbidity and oncologic outcomes, despite intersurgeon variation in WIT and complications. Greater experience is associated with shorter WIT. PATIENT SUMMARY Robot-assisted retroperitoneoscopic partial nephrectomy has acceptable morbidity and oncologic outcomes, and there is intersurgeon variation in warm ischemia time and complications.

Coagulation Status During Aortic Aneurysm Surgery: Comparison of Thrombelastography with Standard Tests

A prospective comparison of thrombelastography to standard coagulation tests was undertaken in ten patients undergoing routine, uncomplicated abdominal aortic aneurysm surgery in order to explore potential clinical utility and establish normal patterns of change. Thrombelastograph k values increased (7.1 vs 5.4 min baseline, P < or = .01), and alpha angle (43 vs 52 degrees baseline, P < or = .001) and ma (39 vs 52 mm baseline, P < or = .01) values decreased following graft placement, while r values remained unaffected (6.4 vs 7.5 min baseline, P > .05). Weak correlations were observed between alpha angle and fibrinogen, prothrombin time, and partial thromboplastin time (aPTT), as well as between k and aPTT (0.70 < r < 0.79 for all). Systemic fibrinolysis was suggested by thrombelastography in 25% of samples, although euglobulin lysis times were abnormal in only 5% (chi 2 = 4.80, P < or = .05). Fibrin degradation product detection increased through the fifth postoperative day in all patients. Variations in thrombelastographic parameters and their correlation to standard coagulation tests in patients undergoing uncomplicated abdominal aortic aneurysm repair were documented. In such a setting, no clear advantages to thrombelastography were defined. Further observations will be necessary to establish the role for thrombelastography in the management of patients experiencing clinically significant perioperative coagulation disorders.

Iatrogenic lithotripsy failure: penetration of shock waves through tape.

Foam tape used to protect epidural catheters during immersion in a Dornier HM3 lithotriptor was identified retrospectively as the cause of poor stone fragmentation. Studies of shock wave penetration through various protective type materials indicate that a particular water repellant tape is least likely to impair shock wave penetration.

The Urology Applicant: An Analysis of Contemporary Urology Residency Candidates

OBJECTIVE To better understand todays urology applicant. METHODS All 2016 Urology Residency Match applicants to the study-participating institutions were provided a survey via email inquiring about their paths to urology, their career aspirations, how they evaluate a training program, and how they perceive residency programs evaluate them. RESULTS Of a possible 468 applicants registered for the match, 346 applicants completed the survey. Only 8.7% had a mandatory urology rotation, yet 58.4% believed that a mandatory urology rotation would influence their career decision. Most applicants (62.1%) spent more than 8 weeks on urology rotations, and 79.2% completed 2 or more away rotations. Applicants were attracted to urology by the diversity of procedures, prior exposure to the field, and the mix of medicine and surgery, with mean importance scores of 4.70, 4.52, and 4.45 of 5, respectively. Female applicants were more likely to be interested in pediatric urology, trauma or reconstructive urology, and female pelvic medicine and reconstructive surgery. Significant differences in survey results were noted when applicants were separated by gender. Three-fourths of respondents (75.7%) applied to more than 50 residency programs. Applicants ranked operative experience, interactions with current residents, and relationships between faculty and residents as the most important criteria when evaluating training programs. Of the subspecialties, 62.1% of applicants expressed most interest in urologic oncology. At this stage in their career, a significant majority (83.5%) expressed interest in becoming academic faculty. CONCLUSION This study provides new information that facilitates a more comprehensive understanding of todays urology applicants.

A comparison of superficial versus combined (superficial and deep) cervical plexus block for carotid endarterectomy: a prospective, randomized study. (University of Michigan Medical Center, Ann Arbor, MI) Anesth Analg 2000;91:781–786.

Carotid endarterectomy may be preformed by using cervical plexus blockade with local anesthetic supplementation by the surgeon during surgery. Most practitioners use either a superficial cervical plexus block or a combined (superficial and deep) block, but it is unclear which offers the best operative conditions or greatest patient satisfaction. This study compared the 2 techniques in 40 patients undergoing carotid endarterectomy. The patient randomly received either a superficial or a combined cervical plexus block. Bupivacaine 0.375% to a total dose of 1.4 mg/kg was used. The main outcome measure was the amount of supplemental lidocaine 1% used by the surgeon. Subsidiary outcome measures were postoperative pain score, sedative and analgesic requirements before and during surgery, and postoperative analgesic requirements. Median supplemental lidocaine requirements were 100 mg in the superficial block group and 115 mg in the combined block group. These differences were not statistically significant. There was no significant difference in the number of patients needing postoperative analgesia between the groups in the 24 h after surgery. The median time to first analgesia in the superficial block group was 150 min. more than in the combined block group, but this difference, although large, was not statistically significant. No significant differences were found between the anesthetic techniques studied. Comment by Alan Kaye, M.D. Carotid endarterectomy surgery can be performed with regional or general anesthesia. It is probable that a substantial majority of CEAs performed in North America are performed under general anesthesia. Debate over choice of regional versus general anesthesia persists because of various studies of risks and benefits. Each type of anesthesia has its own advantages and disadvantages, which must be considered when choosing the optimal anesthetic for patients. Regional anesthetic techniques available include local infiltration, superficial and deep cervical plexus block, a combination of these with or without contralateral superficial plexus, and cervical epidural anesthesia. This prospective, randomized, double-blinded study compared superficial versus combined (superficial and deep) cervical plexus block in 40 patients. Outcomes were measured by supplemental local anesthetic used by the surgeon, postoperative pain scores, and sedative and analgesic requirements before, during, and postoperatively. The results showed no significant difference in either study group. Therefore, this small study suggests that superficial block should be preferred in as much that it is relatively easy to do and the potential side-effects are far less than deep cervical block. Larger studies are warranted in this difficult population of patients.