Joseph Song

The second “time-out”: a surgical safety checklist for lengthy robotic surgeries

Robotic surgeries of long duration are associated with both increased risks to patients as well as distinct challenges for care providers. We propose a surgical checklist, to be completed during a second “time-out”, aimed at reducing peri-operative complications and addressing obstacles presented by lengthy robotic surgeries. A review of the literature was performed to identify the most common complications of robotic surgeries with extended operative times. A surgical checklist was developed with the goal of addressing these issues and maximizing patient safety. Extended operative times during robotic surgery increase patient risk for position-related complications and other adverse events. These cases also raise concerns for surgical, anesthesia, and nursing staff which are less common in shorter, non-robotic operations. Key elements of the checklist were designed to coordinate operative staff in verifying patient safety while addressing the unique concerns within each specialty. As robotic surgery is increasingly utilized, operations with long surgical times may become more common due to increased case complexity and surgeons overcoming the learning curve. A standardized surgical checklist, conducted three to four hours after the start of surgery, may enhance perioperative patient safety and quality of care.

Camera-Port Site Metastasis of a Renal-Cell Carcinoma After Robot-Assisted Partial Nephrectomy

BACKGROUND AND PURPOSE Port-site metastasis (PSM) is a rare complication of laparoscopic intervention in urologic malignancies. Of the greater than 50 reported cases of PSM in the urologic oncology literature, only 9 have occurred after surgery for renal-cell carcinoma (RCC). We report a 10th instance of RCC metastasis-in this case to the camera-port site after robot-assisted partial nephrectomy (RAPN). To our knowledge, this case is the first reported PSM of RCC after RAPN. PATIENT AND METHODS A 68-year-old man underwent an uncomplicated right RAPN for a 4-cm right renal mass (stage T1aN0M0). Five months later, he was found to have metastatic disease with an isolated peritoneal recurrence at the camera-port site. Biopsy of the lesion confirmed RCC, and the lesion was surgically resected. A comprehensive MEDLINE search for all published studies of port-site recurrences after laparoscopic renal surgery for RCC was performed. RESULTS Nine cases of PSM after successful laparoscopic radical or partial nephrectomy for locally confined RCC have been reported. Proposed etiologic factors for port-site recurrence include biologic aggressiveness of the tumor, patient immunosuppression, local wound factors, and technique-related factors. We report an unusual case of PSM to a camera port that was not used for specimen manipulation or extraction. CONCLUSION PSM after laparoscopic renal surgery for RCC is a rare occurrence. Our case, in which PSM occurred without specimen bag rupture or extraction through the port in question, highlights the importance of local and systemic factors in contributing to PSM occurrence. We also demonstrate that when PSM is the only site of disease recurrence, it can be successfully managed with minimally invasive surgical resection.

Cell Type Specific Changes in BMP-7 Expression Contribute to the Progression of Kidney Disease in Patients with Obstructive Uropathy

PURPOSE Congenital urinary tract obstruction is a leading cause of renal maldevelopment and pediatric kidney disease. Nonetheless, few groups have examined its molecular pathogenesis in humans. We evaluated the role of BMP-7, a protein required for renal injury repair and nephrogenesis, in disease progression in patients with obstructive uropathy. MATERIALS AND METHODS Whole kidney and cell specific BMP-7 expression was examined in a murine model of unilateral ureteral obstruction and in patients with congenital ureteropelvic junction obstruction. Findings were correlated with molecular markers of renal injury and clinical parameters. RESULTS Unilateral ureteral obstruction led to a dramatic decrease in BMP-7 expression in the proximal and distal tubules before the onset of significant loss of renal architecture and fibrosis, suggesting that this is a critical molecular event that drives early stage disease progression. Loss of BMP-7 expression then extended to the collecting ducts and glomeruli in end stage kidney disease. When translating these findings to patients with ureteropelvic junction obstruction, global loss of BMP-7 expression correlated with a decreased number of nephrons, loss of renal architecture, severe renal fibrosis and loss of kidney function. CONCLUSIONS Given that BMP-7 has a critical role in renal injury repair and nephrogenesis, these findings show that cell specific changes in BMP-7 expression contribute to the onset of irreversible renal injury and impaired kidney development secondary to congenital urinary tract obstruction. Accordingly therapies that target these cell populations to restore BMP-7 activity may limit disease progression in patients with obstructive uropathy.

Postprostatectomy Anastomosis Stenosis: A Systematic Review

Anastomotic strictures (AS) are uncommon but a vexing problem after radical prostatectomy. We reviewed the literature for AS treatment modalities to summarize the best management strategies for AS, as supported by current evidence. Twenty studies fit the inclusion and exclusion criteria. Weighted success rates and incontinence rates were calculated and used to create a treatment algorithm. Repeat attempts of minimally invasive methods seem to improve the success rate. Repeat procedures and more invasive techniques, however, may lead to higher incontinence rates.

Limited use of surveillance imaging following nephrectomy for renal cell carcinoma

OBJECTIVES To evaluate the utilization of follow-up imaging after nephrectomy for renal cell carcinoma (RCC) in nationally representative data. PATIENTS AND METHODS Using Surveillance, Epidemiology, End Results data linked to Medicare records, we identified patients with RCC who received nephrectomy from 1991 to 2007. Patients were stratified by tumor stage. Postoperative chest and abdominal imaging (including chest x-ray, computed tomography scan, and magnetic resonance imaging; abdominal ultrasound, computed tomography scan, and magnetic resonance imaging) was assessed. Observed surveillance imaging frequency was compared to published protocols. Predictors of initial and continued yearly surveillance imaging were identified. RESULTS Agreement between observed imaging frequency and evidence-based surveillance protocols was low, particularly for patients with T2-T4 disease. For patients who were not censored before 13 months, initial abdominal and chest surveillance imaging was obtained in 69% and 78% of patients, respectively. By year 5, 28% and 39% of patients with high-risk disease (T3 or T4), as compared to 21% and 25% of patients with low to moderate risk disease (T1 and T2), received yearly surveillance abdominal and chest imaging, respectively. High-risk disease was predictive of initial chest (odds ratio [OR] = 1.38) and abdominal (OR = 1.6) imaging, as well as continued yearly chest (hazard ratio [HR] = 0.73) and abdominal (HR = 0.74) imaging surveillance. For abdominal imaging, more contemporary year of surgery was predictive of initial (1997-2001, OR = 1.6; 2002-2007, OR = 2.4) and continued yearly surveillance (1997-2001, HR = 0.82; 2002-2007; HR = 0.67). CONCLUSIONS In the Medicare population, surveillance imaging is performed in a limited number of patients following nephrectomy for RCC. However, increasing tumor stage is predictive of both increased chest and abdominal imaging surveillance.

Epithelioid Angiomyolipoma in a Pediatric Patient: Case Report and Review of Literature

We report a case of a 17-year-old girl with tuberous sclerosis complex who underwent partial nephrectomy for a newly discovered 7.5-cm renal mass subsequently determined to be an epithelioid angiomyolipoma, a rare variant of angiomyolipoma that can be confused clinically, radiographically, and pathologically for renal cell carcinoma. Proper diagnosis and treatment are critical, especially in the pediatric patient. This case report and review of literature serve at increasing the awareness of this renal tumor, with its somewhat unpredictable outcome, reviewing the pertinent literature on the topic of epithelioid angiomyolipoma in the clinical setting of tuberous sclerosis complex.

Urethrography Interpretation Skills of Urology and Radiology Residents at Tertiary Care Medical Centers

OBJECTIVE To assess the ability of urology and radiology residents to interpret retrograde urethrograms (RUGs) and voiding cystourethrograms (VCUGs). METHODS A standardized examination of 10 combination RUGs and VCUGs of the male urethra was administered to urology and radiology residents from all levels of training at Washington University, Stanford University, and Northwestern University. Residents were asked to evaluate stricture location(s) and length, if present. RESULTS Sixty residents participated, consisting of 26 from Washington University, 15 from Stanford University, and 19 from Northwestern University. Average years of training for urology and radiology were 3.6 and 2.8 years, respectively (P=.01). Normal RUGs and VCUGs were recognized by 18 of 31 radiologists (58%) and 19 of 29 urologists (65.5%; P=.5). Anterior strictures were correctly identified in 145 of 403 (36%) and 165 of 377 (43.8%) responses by radiologists and urologists, respectively (P=.03). Posterior strictures were correctly identified in 20 of 62 (32.3%) and 10 of 58 (17.2%) responses by radiologists and urologists, respectively (P=.09). When both groups of residents were combined, anterior strictures were identified correctly more often than posterior strictures (39.7% vs 25%; P<.01). Overall accuracy was 24.2% (75 of 310) for the radiology group and 27.9% (81 of 290) for the urology group (P=.30). In the presence of multiple strictures, accuracy declined to 7.26% (9 of 124) for the radiology group and 9.48% (11 of 116) for the urology group (P=.5), with a combined accuracy of 8.33% (20 of 240). CONCLUSION Radiology and urology residents in the United States have poor skills at interpreting urethrography, especially when multiple strictures or posterior strictures are present. A formal educational program for RUG and VCUG interpretation should be designed and implemented into the radiology and urology resident curriculum.