Michael Coburn

Consensus statement on bladder injuries

The consensus on genitourinary trauma continues this month with the statement on bladder trauma from several internationally recognised experts on the subject. They describe blunt, penetrating and iatrogenic injuries and their management, considering paediatric injuries separately. They underline the importance of prompt diagnosis and treatment, stressing that problems raised when the diagnosis is delayed.

Recurrent thyroid cancer. Role of surgery versus radioactive iodine (I131)

ObjectiveThis retrospective study compared treatment and survival of patients with recurrent well-differentiated thyroid cancer that was diagnosed exclusively by I131 scanning, or by clinical examination. Summary Background DataDespite the usual excellent prognosis of differentiated thyroid cancer, approximately half of patients who develop a recurrence eventually succumb to the disease. It has been speculated, but not proven, that recurrent disease detected solely by I131 scanning may offer a better prognosis than recurrences detected clinically and be amendable to I131 ablative therapy without the addition of surgical resection. MethodsSeventy-four cases of recurrent differentiated thyroid cancer were identified retrospectively and examined regarding the location of recurrence, mode of detection of recurrent disease, treatment of recurrence, and outcome of patients. Using Fischer exact testing, outcome results for recurrences detected exclusively by I131 scan was compared to that of clinically diagnosed recurrences; among clinically detected recurrent cases, treatment with surgery only was compared to surgery/I131 ablation. Kaplan-Meier actuarial survival curves were generated for clinically detected recurrent cancer treated by surgery only and compared to those treated by surgery and I131 ablation using Gehan-Wilcoxon and log-rank analysis. ResultsRecurrences located most commonly were regional (53%), followed by local (28%), distant metastasis (13%), and combined locoregional (6%). Among patients whose recurrence was detected scintigraphically, only 9.5% had persistence of disease or were dead of disease compared to 54.0% of patients with clinically detected recurrences. Radioactive iodine ablation in scintigraphically detected recurrences salvaged 18 of 20 patients (90%). Among clinically detected recurrences, surgery alone salvaged 12 of 21 patients (57%), whereas the addition of I131 ablation to surgery salvaged only 3 of 15 patients (20%, p = 0.05).ConclusionThe probability of dying or living with persistent disease after treatment of recurrent thyroid cancer is less for I131 detected recurrences compared to clinically diagnosed recurrences; I131 ablation

Total thyroidectomy does not enhance disease control or survival even in high-risk patients with differentiated thyroid cancer.

SUMMARY BACKGROUND DATA The extent of primary thyroidectomy for differentiated thyroid cancer is controversial. There are strong proponents for total thyroidectomy based on its presumed and theoretical disease control benefits. In contrast, there are equally strong advocates of less aggressive thyroidectomy with its lower hazard of parathyroid and recurrent nerve injury. The authors have addressed whether total thyroidectomy has a survival benefit justifying its use in patients with high-risk primary cancer. The major risk factors include age and the following the pathologic determinants follicular histology, vascular invasion, and extracapsular extension. MATERIALS AND METHODS The clinical pathologic, therapeutic, prognostic, and outcome data were reviewed in 347 patients with well-differentiated thyroid cancer. Seventy-five percent were women, 216 patients were in the younger age group (low-risk) (21-50 years), 103 were in the intermediate-risk group (51-70 years), and 28 were in the high-risk group (>70 years). Included in the high-risk pathologic category were 158 patients who had follicular histology (55), extracapsular extension (107), or vascular invasion (119). Total thyroidectomy was performed in 56 patients, near or subtotal thyroidectomy in 47 patients and lobectomy in 55 patients. The 10-year disease specific survival in the overall patient group was 82% in patients with total thyroidectomy, 78% in patients with subtotal thyroidectomy, and 89% in patients with lobectomy (p = 0.30). There was no significant survival difference according to extent of thyroidectomy in the intermediate or high-risk groups either by age or in patients who had high-risk pathologic feature. CONCLUSIONS Total thyroidectomy in high-risk patients with differentiated thyroid cancer (containing follicular histology, vascular invasion, or extracapsular extension) showed no benefit over partial thyroidectomy. This suggests that the general use of total thyroidectomy is not indicated, except in highly selected patients.

Unilateral testicular injury from external trauma: evaluation of semen quality and endocrine parameters.

PURPOSE Because few studies have described the impact of unilateral testicular trauma on fertility parameters, we review the experience at the Ben Taub General Hospital during a 16-year period. Semen and endocrine profiles were analyzed to evaluate the influence on the outcomes of orchiectomy versus testicular salvage. MATERIALS AND METHODS From 1979 to 1995, 67 patients were identified who sustained unilateral testicular trauma. Of these patients 12 were located and 10 agreed to be evaluated. Injuries included gunshot wounds, stab wounds and blunt trauma, and treatment consisted of unilateral orchiectomy or testicular repair. The study protocol comprised a history and physical examination, routine semen analysis, determination of semen and serum antisperm antibody titers (Immunobead* assay) and a modified gonadotropin stimulation test. Results were compared with a group of semen donors with proved fertility. RESULTS In the 7 patients who underwent unilateral orchiectomy mean sperm density was normal but significantly decreased compared with that of the fertile controls (81.6 versus 132.6 x 10(6)/ml., p = 0.04). Sperm motility was not significantly affected. Baseline follicle-stimulating hormone (FSH) and luteinizing hormone (LH), and post-stimulation LH were significantly increased in this group compared with controls (p < 0.01). In the group that underwent testicular repair sperm density, motility, and baseline and post-stimulation FSH and LH levels were not significantly different from controls. In all patients in both groups testosterone levels and contralateral testicular size were normal. Only 1 patient in the repair group had an elevated serum and semen antisperm titer. CONCLUSIONS While the testicular salvage group had no significant seminal or endocrine abnormality, the orchiectomy group had a significant decrease in sperm density and elevation of baseline FSH and LH. These preliminary data suggest that testicular salvage is more protective of overall testicular function than orchiectomy.

Age correlates with increased frequency of high risk factors in elderly patients with thyroid cancer

BACKGROUND Age and certain pathologic features (ie, follicular histology, vascular invasion, and extracapsular extension) are reported to impact on prognosis in thyroid cancer, but the relationship between these two factors remains incompletely defined. PATIENTS AND METHODS Clinical, pathologic, therapeutic, prognostic, and outcome data were retrospectively collected and compared among three groups of patients with thyroid cancer: group 1 (age 21 to 50), group 2 (age 51 to 70), and group 3 (age greater than 70). RESULTS There was a statistically significant age-related decrement in survival: 10-year survival was 92% in group 1, 77% in group 2, and 48% in group 3. Follicular histology, vascular invasion, and extracapsular extension were more frequently observed in group 3 versus group 2 and in group 2 versus group 1 (all differences statistically significant except for vascular invasion). Although survival was significantly less for group 3 versus group 2 versus group 1, only vascular invasion and extracapsular extension independently predicted outcome by multivariate analysis. CONCLUSIONS The prognostic importance of age in thyroid cancer may be due to the greater prevalence of pathologic risk factors in older patients.

Ureteral Injury After Anterior Lumbar Interbody Fusion: A Case Report

Study Design This case report presents a patient with ureter injury after anterior spinal fusion and its management. Objectives To present possible causes, symptoms, diagnostic approach, and management of this rare complication. Summary of Background Data The reported complications of anterior surgical approaches to the lumbar sqine have been predominantly vascular or neurologic. The susceptibility of the ureter to injury is emphasized by the description of an as‐yet‐unreported case of ureter laceration after anterior lumbar fusion. Methods Ureter injury was diagnosed using computed axial tomography, ultrasonography‐guided aspiration, and chemical analysis of the aspirate after anterior spinal fusion. Results Early diagnosis of this injury prompted a ureter stent placement and prevented additional deterioration of renal function and infection. Conclusions The ureter is prone to injury if not identified and protected when sharp and pointed instruments are used for retraction. Abdominal mass, low‐grade fever, and leukocytosis should prompt use of computed tomography or ultrasonography‐guided aspiration.

Barriers to effective teaching

Medical school faculty members are charged with the critical responsibility of preparing the future physician and medical scientist workforce. Recent reports suggest that medical school curricula have not kept pace with societal needs and that medical schools are graduating students who lack the knowledge and skills needed to practice effectively in the 21st century. The majority of faculty members want to be effective teachers and graduate well-prepared medical students, but multiple and complex factors-curricular, cultural, environmental, and financial-impede their efforts. Curricular impediments to effective teaching include unclear definitions of and disagreement on learning needs, misunderstood or unstated goals and objectives, and curriculum sequencing challenges. Student and faculty attitudes, too few faculty development opportunities, and the lack of an award system for teaching all are major culture-based barriers. Environmental barriers, such as time limitations, the setting, and the physical space in which medical education takes place, and financial barriers, such as limited education budgets, also pose serious challenges to even the most committed teachers. This article delineates the barriers to effective teaching as noted in the literature and recommends action items, some of which are incremental whereas others represent major change. Physicians-in-training, medical faculty, and society are depending on medical education leaders to address these barriers to effect the changes needed to enhance teaching and learning.

SIU/ICUD Consultation on Urethral Strictures: Posterior urethral stenosis after treatment of prostate cancer.

Posterior urethral stenosis can result from radical prostatectomy in approximately 5%-10% of patients (range 1.4%-29%). Similarly, 4%-9% of men after brachytherapy and 1%-13% after external beam radiotherapy will develop stenosis. The rate will be greater after combination therapy and can exceed 40% after salvage radical prostatectomy. Although postradical prostatectomy stenoses mostly develop within 2 years, postradiotherapy stenoses take longer to appear. Many result in storage and voiding symptoms and can be associated with incontinence. The evaluation consists of a workup similar to that for lower urinary tract symptoms, with additional testing to rule out recurrent or persistent prostate cancer. Treatment is usually initiated with an endoscopic approach commonly involving dilation, visual urethrotomy with or without laser treatment, and, possibly, UroLume stent placement. Open surgical urethroplasty has been reported, as well as urinary diversion for recalcitrant stenosis. A proposed algorithm illustrating a graded approach has been provided.

The Impact of Proximal Stone Burden on the Management of Encrusted and Retained Ureteral Stents

PURPOSE Managing the encrusted and retained ureteral stent is a potentially complex challenge. To improve surgical planning, we hypothesized that proximal stone burden is the most important factor associated with complicated removal, and that computerized tomography more accurately estimates stone burden than plain film x-ray of the kidneys, ureters and bladder. MATERIALS AND METHODS Records were reviewed of patients undergoing surgical removal of an encrusted and retained ureteral stent or nephrostomy at Ben Taub General Hospital from 2007 to 2009. Preoperative imaging consisted of a plain x-ray of the kidneys, ureters and bladder and/or computerized tomography of the abdomen/pelvis. Each encrusted tube was assessed using the FECal (forgotten, encrusted, calcified) grading system and associated stone burden was calculated. Univariate and multivariate analyses were performed to determine factors associated with the need for multiple surgeries. RESULTS A total of 55 encrusted and retained ureteral stents and 1 nephrostomy were removed from 52 patients. Mean tube duration was 24.9 months. Most tubes were removed endoscopically (94.2%). Of the patients 21.2% required multiple surgical procedures to remove each tube. Computerized tomography graded stone burden more accurately than plain x-ray of the kidneys, ureters and bladder (94.9% vs 64.4%, p = 0.01). Plain x-ray of the kidneys, ureters and bladder underestimated proximal stone burden in 44.4% of patients who underwent multiple surgeries. When dividing stone burden into 3 categories (0 to 100, 101 to 400 and greater than 401 mm(2)) only proximal stone burden correlated with multiple surgeries and surgical complications (p = 0.01 for both). On multivariate analysis only proximal stone burden was associated with multiple surgeries to remove each tube (OR 12.1, 95% CI 1.5-95.9, p = 0.02 for 101 to 400 mm(2) and OR 18.1, 95% CI 1.7-192.8, p = 0.02 for greater than 401 mm(2)). CONCLUSIONS In patients with encrusted and retained ureteral stents accurate determination of the proximal stone burden, preferably by computerized tomography, is important for surgical counseling and planning.

Multidisciplinary team learning in the management of the morbidly adherent placenta: outcome improvements over time

BACKGROUND: Morbidly adherent placenta (MAP) is a serious obstetric complication causing mortality and morbidity. OBJECTIVE: To evaluate whether outcomes of patients with MAP improve with increasing experience within a well‐established multidisciplinary team at a single referral center. STUDY DESIGN: All singleton pregnancies with pathology‐confirmed MAP (including placenta accreta, increta, or percreta) managed by a multidisciplinary team between January 2011 and August 2016 were included in this retrospective study. Turnover of team members was minimal, and cases were divided into 2 time periods so as to compare 2 similarly sized groups: T1 = January 2011 to April 2014 and T2 = May 2014 to August 2016. Outcome variables were estimated blood loss, units of red blood cell transfused, volume of crystalloid transfused, massive transfusion protocol activation, ureter and bowel injury, and neonatal birth weight. Comparisons and adjustments were made by use of the Student t test, Mann‐Whitney U test, χ2 test, analysis of covariance, and multinomial logistic regression. RESULTS: A total of 118 singleton pregnancies, 59 in T1 and 59 in T2, were managed during the study period. Baseline patient characteristics were not statistically significant. Forty‐eight of 59 (81.4%) patients in T1 and 42 of 59 (71.2%) patients in T2 were diagnosed with placenta increta/percreta. The median [interquartile range] estimated blood loss (T1: 2000 [1475‐3000] vs T2: 1500 [1000‐2700], P = .04), median red blood cell transfusion units (T1: 2.5 [0‐7] vs T2: 1 [0‐4], P = .02), and median crystalloid transfusion volume (T1: 4200 [3600‐5000] vs T2: 3400 [3000‐4000], P < .01) were significantly less in T2. Also, a massive transfusion protocol was instituted more frequently in T1: 15/59 (25.4%) vs 3/59 (5.1%); P < .01. Neonatal outcomes and surgical complications were similar between the 2 groups. CONCLUSION: Our study shows that patient outcomes are improved over time with increasing experience within a well‐established multidisciplinary team performing 2−3 cases per month. This suggests that small, collective changes in team dynamics lead to continuous improvement of clinical outcomes. These findings support the development of centers of excellence for MAP staffed by stable, core multidisciplinary teams, which should perform a significant number of these procedures on an ongoing basis.