Joph Steckel

PREPERITONEAL PROSTHETIC MESH HERNIOPLASTY DURING RADICAL RETROPUBIC PROSTATECTOMY

PURPOSE The number of radical retropubic prostatectomies performed in the United States has increased during the last decade. There are 5 to 10% of candidates for radical retropubic prostatectomy who have a detectable inguinal hernia on physical examination. Furthermore, recent data suggest that there is an increased incidence of inguinal hernia after radical retropubic prostatectomy. We evaluated the role of simultaneous inguinal hernioplasty during radical prostatectomy. MATERIALS AND METHODS During 575 radical prostatectomy procedures from June 1991 to June 1997, 70 hernioplasties were performed in 48 patients. Retrospective chart review was performed for all men who underwent simultaneous hernia repair. Mean patient age was 60.9 years (range 43 to 73). Polypropylene or polyester fiber prostheses were used for mesh hernioplasty. All repairs were performed using a preperitoneal approach during radical retropubic prostatectomy. RESULTS There were 35 hernioplasties performed without and 35 with mesh. Mean postoperative followup was 24 months (range 6 to 66). Of the hernias 71% were indirect and 29% were direct. No recurrence was detected after mesh hernioplasty, whereas 5 hernias (14%) recurred in the nonmesh group. In this group 2 men (4%) also had de novo hernias on the contralateral side during followup. All recurrent hernias were diagnosed within 1 year of the initial operation. No patient had wound infection, persistent neuralgia or ischemic orchitis. CONCLUSIONS Simultaneous repair of inguinal hernias during radical retropubic prostatectomy is effective and technically feasible. There is convenient access to the preperitoneal space during radical retropubic prostatectomy and hernia repair adds only 5 to 10 minutes of operative time. Mesh repair appears to offer optimized results compared to the nonmesh technique. Despite the use of prosthetic material, no complications were attributable to its application during these genitourinary procedures.

Histological and Bacteriological Findings in Long-Term Ileocystoplasty and Colocystoplasty in The Rat

The long-term effects of bladder reconstruction using bowel were studied in rats. Bladder surgery consisted of cystotomy and closure, ileo- or colocystoplasty, or placement of a reverse serosal (Thal) patch of ileum. At least one-third of all groups received prophylactic cefaclor, postoperatively. Monthly urine cultures were obtained, and survivors were sacrificed at 1 year. Antimicrobial therapy markedly reduced the incidence of chronic colonization after cystoplasty. However, the majority of rats in the Thal patch group remained colonized because of acquired vesicoileal fistulae. Vesical stones were often present in this group and were also seen in 6 of 43 (14%) and 3 of 33 (9%) in the ileocystoplasty and colocystoplasty groups, respectively. Transitional cell papillomas and/or hyperplasia was seen at 20 of 42 (48%) uroileal and 20 of 31 (64%) urocolonic anastomoses (p = .15). Hyperplastic lesions could not be correlated with bacteriuria. Focal nonpapillary transitional cell carcinoma was seen once in the colocystoplasty group, and low grade papillary transitional cell tumors were noted once in each of the cystostomy and ileocystoplasty groups and twice in Thal patch rats with ileovesical fistulae. These findings suggest that the rat uroenteric anastomosis is susceptible to proliferative change which is rarely malignant in nature and occurs in the presence or absence of bacteriuria.

Uretero-Fallopian Tube Fistula Secondary to Laparoscopic Fulguration of Pelvic Endometriosis

Ureteral injuries during laparoscopic surgery have been documented. We present a case of the diagnosis and management of a uretero-fallopian tube fistula after laparoscopic laser fulguration of pelvic endometriosis.

PD17-02 THE USE OF CYTOLOGY DURING THE WORKUP OF PATIENTS WITH PRIMARY MICROSCOPIC HEMATURIA: GUIDELINE COMPLIANCE PATTERNS AMONG A COHORT OF ACADEMIC UROLOGISTS

INTRODUCTION AND OBJECTIVES: In an effort to improve patient autonomy, several organizations publish online data on surgeon performance. One such organization is Pro-Publica, an independent nonprofit newsroom that publishes an online 0surgeon scorecard.0 This scorecard reports calculated death and complication rates for surgeons performing elective procedures including radical prostatectomy in Medicare patients. We wanted to understand how the general public would interpret this data and how it would impact patients’ selection of surgeon. METHODS: 265 adults at the Minnesota State Fair were asked to interpret a representative image from the Pro-Publica surgeon scorecard. Participants were told that a loved one had already scheduled cancer surgery with a surgeon they trusted. They were then shown a graphic with a dot representing the point estimate complication rate and a bar representing the 95% confidence interval (CI) of their surgeon. They were also shown a graphic with 13 other surgeons’ point estimate complication rates, all of which fell within the CI of the index surgeon’s complication rate. Another surgeon with a 0.5% lower point estimate but statistically equivalent complication rate to the first surgeon was indicated on the graphic. Participants were then asked if they would recommend switching surgeons after seeing this graphic. RESULTS: The surveyed population was educated with 89% having attended or graduated from college (n1⁄4235). Median age of participants was 50 years (range 20-74) with 68% females (n1⁄4179). Participants were from 136 different zip codes predominantly in the upper Midwest. When presented with the graphic representing two surgeons with different point estimate complication rates falling within the same confidence interval, 124 or 46.8% (95% CI 41-53) of respondents would recommend switching surgeons based on this single graphic. CONCLUSIONS: Nearly half of adults surveyed would recommend switching cancer surgeons for genitourinary malignancies based on a graphical representation of surgeons’ complication rates even though there was no statistically significant difference between the two surgeons. This suggests that simplistic displays of complicated statistical data may lead to changes in medical decision-making based on random error of measurement instead of true differences in surgeon quality.