Jessica T. Casey

Communication failure in the operating room

BACKGROUND Communication errors contribute to the occurrence of adverse events in various domains of health care. Recent studies surveying perceptions of communication in the operating room have found disparities in the perceived quality of communication among members of the operating room team. Our aim was to characterize the nature of communication failures observed in the operating room and to assess whether a Team Training curriculum had any impact on observed communication errors. METHODS Intraoperative observation was performed and communication errors were identified according to predetermined criteria. Observed errors were classified according to the type of error, subject matter, and observed effect. RESULTS Seventy-six communication failures were observed over 150 hours of observation. Overall, communication errors relating to equipment and keeping team members informed of the progress of an operation comprised 36% and 24% of all observed communication errors, respectively. Prior to the introduction of a Team Training curriculum, 56 errors were observed over 76 hours (rate,737 errors per hour; standard error, 0.098). After Team Training, 20 errors over 74 hours were observed (rate .270 errors per hour; standard error, 0.060; P < .001). CONCLUSION Communication failures related most frequently to equipment and keeping team members updated as to the progress of an operation. These failures can lead to procedural delay and inefficiencies. A program that teaches teamwork and communication skills is one strategy that may improve communication among members of the operating room team.

Contemporary national comparison of open, laparoscopic, and robotic-assisted laparoscopic pediatric pyeloplasty.

OBJECTIVE We sought to determine current and longitudinal trends in the usage of open (OP), laparoscopic (LP), and robotic pyeloplasties. (RALP) Furthermore, we aimed to describe patient and hospital level characteristics associated with the use of minimally invasive pyeloplasties (MIP) and to compare basic utilization metrics for each approach. MATERIALS/METHODS The 2000, 2003, 2006, and 2009 Kids Inpatient Databases (KID) were used to determine current and longitudinal trends. As a result of a specific billing code for robotic surgery introduced in 2008, the 2009 KID database was used for analysis of RALP. Patient and hospital characteristics examined included: age, gender, race, insurance status, hospital location, and academic status. Utilization metrics of length of stay (LOS) and cost were determined from each modality. RESULTS In 2009, there were 3354 pediatric pyeloplasties performed in the USA (85% OP, 3% LP, 12% RP). Compared with 2000, this represents an 11.7% decrease in the overall number of pyeloplasties but a progressive increase in MIP from 0.34% in 2000 to 11.7%. Mean patient age was 3.7 years for OP, 9.3 years for LP and 9.9 years for RALP. MIP was more commonly performed in females, Caucasians, patients with private insurance, at urban hospitals and at teaching hospitals. Although length of stay (LOS) in days was statistically lower for MIP (3.46 OP, 2.86 LP, 1.96 RP, p < 0.001), total cost between the groups was not statistically different. On multivariable logistic regression analysis, age (OR 1.17, p < 0.001) increased the odds of MIP whereas lack of private insurance decreased the odds of MIP (OR 0.62, p = 0.002). CONCLUSION Although utilization of MIP is increasing in the USA, especially in older children, OP remains predominant. MIP was associated with a decrease in LOS. The odds of MIP were higher in older children, whereas the lack of private insurance decreased the odds of MIP.

Outcomes of locally advanced (T3 or greater) prostate cancer in men undergoing robot-assisted laparoscopic prostatectomy.

OBJECTIVES Despite nearly equivalent outcomes between open and robot-assisted laparoscopic prostatectomy (RALP) for organ-confined prostate cancer (PCa), the role of primary treatment with RALP in men with locally advanced (T3 or greater) PCa has not been described in detail. We report our experience with RALP for pathologically advanced disease. PATIENTS AND METHODS From October 2005 to November 2008, 220 RALPs were performed by a single surgeon (R.B.N.). Outcomes were assessed prospectively in an institutional review board-approved database. RESULTS Of 220 RALPs, 35 (15.9%) were performed for pT3 PCa; none of them were identified preoperatively. There was no difference in operative time compared with patients with pT2 disease (271 vs. 295 minutes, p = 0.09). The positive surgical margin (PSM) rate was 20% compared with 4.9% for pT2 (p = 0.004). Sural nerve grafts were performed in 20%, and 57% had bilateral nerve sparing. The use of bilateral or unilateral nerve sparing was not associated with increased PSM (p = 0.85). Biochemical recurrence occurred in 28.6% of men with pT3 disease over an average of 13 months of follow-up time, 30% of which occurred in men with a PSM. At 6 months, an 85% continence rate was achieved, and at 1 year continence was 100% for pT3. Compared with pT2, men with advanced disease had similar recovery after RALP based on postsurgery questionnaires. CONCLUSIONS RALP is a feasible approach to patients with pathologically advanced PCa as 71% were without evidence of disease at 13 months postoperatively. PSM rate (20%) is comparable to previously reported open PSM rates (24-66%).

Magnetic Resonance Arteriography/Venography is Not Accurate to Structure Management of the Impalpable Testis

PURPOSE Recent studies have shown that magnetic resonance arteriography/venography is a highly sensitive tool to identify impalpable testes in young boys. Due to this and the low risk of cancer in testicular nubbins observation has been proposed after the identification of nubbins by magnetic resonance arteriography/venography. We prospectively examined the accuracy of magnetic resonance imaging and magnetic resonance imaging with magnetic resonance arteriography/venography for identifying impalpable testes in a younger cohort of patients typically seen at a pediatric institution in the United States. MATERIALS AND METHODS We prospectively studied 26 infants and boys with impalpable testes. Conventional magnetic resonance imaging or magnetic resonance imaging with magnetic resonance arteriography/venography was performed in all patients. All patients subsequently underwent surgical exploration. Surgical and radiological findings were then evaluated for concordance. RESULTS A total of 26 boys (29 impalpable testes) with a median age of 13 months were evaluated. A subset of 14 boys (14 impalpable testes) also underwent magnetic resonance arteriography/venography. Standard magnetic resonance imaging correctly identified 10 of 12 intra-abdominal testes, 4 of 6 intracanalicular testes, 4 of 10 testicular nubbins and 0 of 1 scrotal testis. Magnetic resonance arteriography/venography correctly identified 4 of 5 intra-abdominal testes, 2 of 3 intracanalicular testes, 2 of 5 testicular nubbins and 0 of 1 scrotal testis. The overall accuracy of magnetic resonance imaging alone and magnetic resonance arteriography/venography for identifying a viable testis or testicular nubbin was 62% and 57%, respectively. The accuracy of magnetic resonance imaging and magnetic resonance arteriography/venography for identifying a viable testis was 74% and 67%, respectively. CONCLUSIONS Preoperative magnetic resonance imaging or magnetic resonance arteriography/venography does not accurately identify or localize impalpable testes in the age group typically presenting to pediatric urologists. Accuracy at our institution is discrepant with that in previous studies. We do not recommend using magnetic resonance imaging or magnetic resonance arteriography/venography for the possible observation of vanishing testes or nubbins and we recommend surgical exploration in all individuals.

Simple Modifications in Operating Room Processes to Reduce the Times and Costs Associated with Robot-Assisted Laparoscopic Radical Prostatectomy

BACKGROUND AND PURPOSE Robot-assisted laparoscopic radical prostatectomy (RALRP) is the most expensive, yet most common, surgical treatment for patients with prostate cancer. Furthermore, its popularity continues to grow despite the lack of evidence for functional and oncologic superiority over other treatments. As a result, we modified operating room (OR) processes to determine if the times and costs that are associated with RALRP in an academic setting could be reduced. PATIENTS AND METHODS Four modifications in OR processes were implemented: Trainee adherence to time-oriented surgical goals; use of a dedicated anesthesia team; simultaneous processing by nursing and urology house staff during case turnover; and identification and elimination of unused disposable instruments. Total surgical, anesthesia, and OR turnover times were measured. Payroll, surgical supply, OR time, and anesthesia costs were also measured. One hundred RALRP cases before and after the modifications were implemented were compared. RESULTS Patients undergoing RALRP were similar both before and after the modifications were implemented. Total surgical, anesthesia, and turnover times were reduced by 17.4 (6.8%, P=0.041), 4.5 (19.1%, P=0.006), and 12.1 (28.1%, P=0.005) minutes, respectively. Payroll, surgical supply, and OR costs were reduced by

Pediatric Genital Injury: An Analysis of the National Electronic Injury Surveillance System

330 (25%),

Surgical Reconstruction of the Male Urethral Diverticulum

609 (15.7%), and

Extracorporeal Shockwave Lithotripsy Versus Ureteroscopy: A Comparison of Intraoperative Radiation Exposure During the Management of Nephrolithiasis

1638 (27.7%), respectively. There was no fiscally significant change in anesthesia costs. CONCLUSIONS Using simple modifications, it is possible that RALRP efficiency can be improved by decreasing its associated times and costs. These modifications were implemented in an academic setting but may be used in any institution. These modifications represent an initial attempt to improve RALRP cost-competitiveness with other treatment modalities.

Urethral Reconstruction in Patients With Neurogenic Bladder Dysfunction

OBJECTIVE To describe the characteristics of pediatric genital injuries presenting to United States emergency departments (EDs). METHODS A retrospective cohort study utilizing the U.S. Consumer Product Safety Commission (CPSC) National Electronic Injury Surveillance System (NEISS) from 1991-2010 to evaluate pediatric genital injuries was performed. RESULTS Pediatric genital injuries represented 0.6% of all pediatric injuries with the incidence of injuries rising through the period studied, 1991-2010. The mean age at injury was 7.1 years old and was distributed 56.6% girls and 43.4% boys. A total of 43.3% had lacerations and 42.2% had contusions/abrasions. The majority of injuries occurred at home (65.9%), and the majority of patients (94.7%) were treated and released from the hospital. The most common consumer products associated with pediatric genital trauma were: bicycles (14.7% of all pediatric genital injuries), bathtubs (5.8%), daywear (5.6%), monkey bars (5.4%), and toilets (4.0%). CONCLUSION Although pediatric genital injuries represent a small proportion of overall injuries presenting to the emergency department, genital injuries continue to rise despite public health measures targeted to decrease childhood injury. Our results can be used to guide further prevention strategies for pediatric genital injury.

Quality of life related to urinary continence in adult spina bifida patients.

OBJECTIVES To describe the outcomes and reconstructive techniques used for men with symptomatic urethral diverticula in an attempt to standardize treatment based on the length of the urethral defect after diverticulum excision and the type of repair used. Urethral diverticula are rare in men and may be either congenital or acquired. METHODS Between 2003 and 2008, 13 men were treated surgically for symptomatic urethral diverticula at a single institution by a single surgeon (C.M.G.). A total of 6 (46.2%) patients had urethral defects of < 4 cm and underwent excision of the diverticulum with primary anastomosis. Substitution urethroplasty using either penile skin or buccal mucosa was used in 7 (53.8%) patients with urethral defects of >or= 4 cm. Demographic and preoperative characteristics were compared among patients according to the length of the urethral defect. RESULTS The mean age of men at the time of surgery was 38.4 years (+/- 13.0; range, 20.4-63.7), with a median follow-up time of 21.7 (+/- 29.0; range, 0.9-84.0) months. Neither age at the time of surgery, length of follow-up, or diverticulum volume was significantly different between men who underwent primary repair vs substitution urethroplasty. The overall success rate was 92% (12/13) with an overall complication rate of 42% at intermediate follow-up. CONCLUSIONS Outcomes after excision and primary anastomosis for diverticula associated with defects of < 4 cm were similar to outcomes after diverticulum excision and substitution urethroplasty for defect of >or= 4 cm.