Nithin Theckumparampil

Continuing aspirin therapy during percutaneous nephrolithotomy: unsafe or under-utilized?

INTRODUCTION Aspirin, as an inhibitor of platelets, is traditionally discontinued prior to percutaneous nephrolithotomy (PCNL) given the concern for increased surgical hemorrhage. However, this practice is based on expert opinion only, and mounting evidence suggests holding aspirin perioperatively can be more harmful than once thought. We sought to compared PCNL outcomes and complications in patients continuing aspirin to those stopping aspirin perioperatively. METHODS A retrospective review was performed of 321 consecutive PCNLs done between July 2012 and March 2014. Patients were separated into two groups. The on-aspirin group consisted of patients continuing aspirin throughout the perioperative period. The off-aspirin group had aspirin held temporarily pre- and postoperatively. Surgical outcomes and complications were compared between groups. RESULTS Of the 321 PCNLs, 60 (18.7%) occurred in patients chronically taking aspirin. The on-aspirin group included 17 PCNLs (5.2%), while the off-aspirin group included 43 PCNLs (13.4%). There were no differences between groups in terms of operative time (77 minutes vs 74 minutes, p=0.212), hemoglobin change (p=0.522), stone size (21 mm vs 22 mm, p=1.0), stone-free rate (p=0.314), median length of hospitalization (p=0.642), transfusion rate (p=0.703), or total complications (p=1.0). No patient experienced a thromboembolic event. CONCLUSIONS PCNL is safe in patients continuing aspirin perioperatively and does not result in more blood transfusions, angioembolization procedures, or complications. Patients with large stone burdens who are at high risk for thromboembolic events appear to be able to safely undergo PCNL without discontinuing aspirin.

Improving time to continence after robot-assisted laparoscopic prostatectomy: augmentation of the total anatomic reconstruction technique by adding dynamic detrusor cuff trigonoplasty and suprapubic tube placement.

After robot-assisted laparoscopic prostatectomy, total anatomic reconstruction (TR) with the additions of a circumapical urethral dissection, a dynamic detrusor cuff trigonoplasty, and placement of a suprapubic catheter was performed in 49 patients from June to July 2012. Continence at 6 weeks after catheter removal was assessed for an initial group of 23 patients, and also at 2 weeks in an additional 26 patients who most recently had undergone surgery. Follow-up appointments and telephone interviews were used to assess pad use and continence. Of the initial 23 patients receiving the modified TR, 60.9% had 0 pad use at 6 weeks. By 2 weeks, 65.4% of the most recent 26 patients operated on achieved continence with 0-1 pad use. Preservation and reconstruction of the pelvic floor and supporting bladder structures leads to an earlier return of continence. These key steps need to be validated and confirmed in larger and randomized trials.

Surgical Complications and Their Repercussions

PURPOSE Surgical complications have a significant impact on intended quality of care. The aim of our study was to identify factors that contribute to the propagation of additional postoperative complications. MATERIALS AND METHODS Over a 1-year period, we prospectively identified and retrospectively reviewed data on all patients who experienced a surgical complication within 30 days of their procedure. A complication was defined as any deviation from the expected postoperative course and was described using the Clavien-Dindo classification. Data reviewed included length of stay (LOS), Clavien grade, readmission status, and management of the complication. Surgeries were stratified into retroperitoneal, pelvic, and endoscopic procedures. The association between complications and Clavien grade was measured using Spearman rank-order correlation. The probability of subsequent complications and readmission was measured using exact logistic regression. RESULTS Of the 4414 patients who underwent a urologic procedure, 191 (4.3%) had at least one complication. One hundred thirty-four (70%) of these patients had more than one complication, 84 (44%) had more than three complications, and 12 (6.3%) had up to a seventh complication. LOS was affected by the severity of the initial complication. Patients with initial Clavien grades 1, 2, 3a, 3b, and 4 had an LOS of 3.75, 4.17, 4.21, 4.94, and 8.58 days, respectively. Variables associated with the risk of developing a second complication included diabetes mellitus, longer operative times (OR 1.83), and greater estimated blood loss (OR 1.32). CONCLUSIONS Surgical patients with an initial complication are at higher risk for multiple subsequent postoperative complications. Complications are associated with an extended LOS and higher readmission rates. Diabetes, longer operative time, and greater blood loss were identified as risk factors for multiple complications.

Open, Laparoscopic, and Robotic Ureteroneocystotomy for Benign and Malignant Ureteral Lesions: A Comparison of Over 100 Minimally Invasive Cases

INTRODUCTION Laparoscopic (LAP) and robot-assisted laparoscopic (RAL) approaches have been applied to ureteroneocystostomies (UNC) although such experience has been limited to a small number of patients and limited follow-up. Herein, we detail our experience with over 100 minimally invasive UNC, the largest such series to date. METHODS All minimally invasive UNC performed at our institution between 1997 and 2013 and all open UNC performed between 2008 and 2013 were identified. Perioperative parameters of relevance were identified and recorded. Chi-squared and ANOVA with post hoc Tukey analysis were performed for all categorical and continuous variables, respectively. RESULTS A total of 130 patients met our study criteria. One hundred five underwent the minimally invasive approach (20 RAL and 85 LAP). Mean follow-up duration was 504 days. Patients in the RAL, LAP, and open cohorts were of similar age, gender and laterality distribution, American Society of Anesthesiologists (ASA) score, body-mass index, history of previous abdominal surgery, history of prior treatment for the ureteral lesion, and surgical indication ( Table 1 ). Operative time was similar across all cohorts (235-257 minutes, p=0.123). Estimated blood loss (EBL) was significantly lower in the RAL and LAP cohorts (100 and 150 mL) compared to their open counterparts (300 mL, p=0.001) although a decrease in hematocrit was similar across all groups. Only four intraoperative complications (4.7%) and two (2.4%) conversions to open were identified in the LAP group, without statistical significance. No intraoperative complications or conversions were identified in the RAL or open cohorts. Median length of stay (LOS) was significantly shorter in the minimally invasive cohorts compared to open (p<0.002). Ninety-day readmission rates (18.8-20%), major complications (10-20%), and failure rates (5.9-16%) were highest in the open cohort although without statistical significance. CONCLUSION RAL or LAP UNC is feasible, safe, and comparable to the open technique with some perioperative benefit in EBL, LOS, and stent duration.

V1272 ENHANCEMENT OF TOTAL ANATOMIC RECONSTRUCTION BY ADDING DYNAMIC DETRUSOR CUFF TRIGONOPLASTY AND SUPRA PUBIC TUBE PLACEMENT

INTRODUCTION AND OBJECTIVES: With the basic principle of restoring a patient’s anatomy to its original state postoperatively, we attempted to identify technical aspects of total anatomical reconstruction that led to early return of urinary continence after robot-assisted laparoscopic prostatectomy (RALP). METHODS: An analysis was performed in 107 consecutive men who underwent RALP as well as total anatomic reconstruction (TR) with the additions of a circum-apical urethral dissection, a dynamic detrusor cuff trigonoplasty, and placement of a suprapubic catheter by a single surgeon at a tertiary care center between June 2012 and September 2012. Patient demographics and post-operative urinary control was recorded at interval follow-up visits. Additionally, telephone interviews and follow-up questionnaires were used to assess pad usage and continence. RESULTS: Of the 107 patients operated between June 2012 and September 2012, 14 patients were lost to follow-up. Therefore, data is reported on 93 patients. We defined early continence as patients using zero pads at 6 weeks or less. 39.8% of men who underwent the modified TR achieved early continence. 65.5% of the patients operated achieved continence with the use of 0-1 pad at 6 weeks. CONCLUSIONS: Reconstructing the pelvic anatomy and supporting bladder structures leads to an earlier return to continence. Larger randomized trials will need to confirm these key steps.