Petar Bajic

Postoperative Atrial Fibrillation Predicts Long-Term Cardiovascular Events after Radical Cystectomy

PURPOSE Postoperative atrial fibrillation after radical cystectomy occurs in 2% to 8% of cases. Recent evidence suggests that transient postoperative atrial fibrillation leads to future cardiovascular events. The long-term cardiovascular implications of postoperative atrial fibrillation in patients undergoing radical cystectomy are largely unknown. MATERIALS AND METHODS The Healthcare Cost and Utilization Project State Inpatient Databases for California and Florida were used to identify patients who underwent radical cystectomy between 2007 and 2010. After excluding patients with a history of atrial fibrillation, coronary artery disease and/or stroke, patients were matched using propensity scoring on age, race, insurance status and preexisting comorbidities. Adjusted Kaplan-Meier time-to-event analysis and Cox proportional hazards models were used to assess the effect of postoperative atrial fibrillation on cardiovascular events (acute myocardial infarction and stroke) during postoperative year 1. RESULTS Radical cystectomy was performed in 4,345 patients who met the study inclusion criteria, of whom 210 (4.8%) had postoperative atrial fibrillation. There was a significantly higher cumulative incidence of cardiovascular events during the first postoperative year in patients in whom postoperative atrial fibrillation developed (24.8% vs 10.9%, adjusted log rank p=0.007). Cox proportional hazards regression demonstrated an increased risk of cardiovascular events in patients with postoperative atrial fibrillation (HR 10, p=0.02). CONCLUSIONS Our results demonstrate that patients undergoing radical cystectomy in whom transient postoperative atrial fibrillation develops are at significantly increased risk for cardiovascular events in the first postoperative year. Physicians should be vigilant in assessing postoperative atrial fibrillation, even when transient, and establish appropriate followup given the increased risk of cardiovascular morbidity.

A Simplified Technique for GreenLight Laser Enucleation of the Prostate

OBJECTIVE To present a simplified technique for GreenLight laser enucleation of the prostate (GreenLEP), designed to reduce the learning curve commonly associated with endoscopic prostate enucleation. MATERIALS AND METHODS GreenLEP is a novel endoscopic treatment for BPH which allows for durable resection of large glands with minimal energy use, minimal bleeding and has been shown to be non-inferior to holmium laser enucleation of the prostate (HoLEP). Furthermore, GreenLEP has been shown to be superior to GreenLight PVP For glands >80 g with respect to operative time, unplanned hospital readmission and decrease in post treatment PSA and prostate size. Unfortunately, a steep learning curve has remained a roadblock for adaptation by many urologists. Our technique for lobe-by-lobe GreenLEP is described and shown. RESULTS GreenLEP allows for removal of the entire transition zone in patients with large glands traditionally best treated with staged TURP or simple prostatectomy. A lobe-by-lobe approach allows the urologist to learn the procedure in a stepwise fashion as they become increasingly comfortable with the technique. During the learning process, some lobes may be addressed by enucleation while others by vaporization. CONCLUSION This simplified technique allows novice enucleators with GreenLight experience to feel more comfortable with GreenLEP, simplifying the learning curve.

Management of Renal Cell Carcinoma with Inferior Vena Caval Tumor Thrombus

Direct intraluminal extension of tumor into the renal vein and inferior vena cava may be seen in up to 10% of patients with renal cell carcinoma. Accurate preoperative assessment of the cephalad extent of the tumor thrombus allows for a planned controlled operative intervention. Adjunctive techniques drawn from vascular, hepatobiliary, and cardiac surgery may be necessary. Long-term survival is possible with an aggressive surgical approach.

Metabolic Syndrome Increases Risk of Postoperative Myocardial Infarction Following Percutaneous Nephrolithotomy

INTRODUCTION Percutaneous nephrolithotomy (PCNL) is the gold standard treatment for upper tract stone burdens greater than 2 cm. Metabolic syndrome (MetS) is a constellation of conditions (diabetes mellitus, hypertension, dyslipidemia, and obesity) and is a risk factor for nephrolithiasis. Our objective was to investigate adverse cardiovascular outcomes of PCNL in patients with comorbid MetS diagnoses. MATERIALS AND METHODS Data from the Healthcare Cost and Utilization Project State Inpatient Database for Florida and California were used to identify PCNL patients (ICD9: 55.03, 55.04) between 2007 and 2011. Patients were categorized having 0, 1-2, or 3-4 components of MetS. Postoperative myocardial infarction (MI) and inhospital mortality rate outcomes were identified. Multivariate logistic regression was used to control for patient characteristics (age, race, and primary insurance provider) and medical comorbidities. RESULTS PCNL was performed on 39,868 patients, of whom 17,932 (45.0%) had no MetS conditions, 19,268 (48.3%) had 1-2 MetS conditions, and 2668 (6.7%) had 3-4 MetS conditions. With increasing MetS conditions, patients had increased incidence of postoperative MI (0: 0.6%; 1-2: 1.0%; 3-4: 1.8%, p < 0.001). On multivariate analysis, the presence of 3-4 MetS comorbidities increased the odds of a postoperative MI (1-2: odds ratio [OR] 1.2, 95% confidence interval [CI] 0.94-1.53, p = 0.147; 3-4: OR 2.2, 95% CI 1.54-3.15, p < 0.001). CONCLUSIONS MetS patients have an increased risk of MI following PCNL given their pre-existing comorbidities. Routine preoperative cardiac testing may benefit this population before PCNL.

Posterior urethral valves (PUV) in pediatric practice - Promoting methods to understand how to diagnose and incise (PUV).

Pediatric cystourethroscopy is a time honored procedure important to assess the urethra and bladder. Yet, there is only limited research on specific agreements for how to make assessments. For example, objective endoscopic assessment of ureter orifice hydrodistention in cases of vesicoureteral reflux is helpful to perform endoscopic injection therapy [1,2]. In addition, the authors have performed survey research showing e-learning improves accuracy for endoscopic diagnosis of posterior urethral valves [3]. Herein, the authors present follow up as creation of a new, independent e-learning interactive. This interactive is designed to promote training the skill of understanding “how to diagnose and incise posterior urethral valves (PUV)”. We have done this because it is important for residency training programs to be able to determine if resident trainees have mastered milestone skills [4]. Knowledge of diagnosis and incision of PUV is now especially pertinent because of the advent of increased patient volume presenting for newborn assessment after fetal diagnosis and improved recognition of dysfunctional elimination syndrome. We expect pediatric urological management of these diagnoses will benefit from agreements on methods for endoscopic diagnosis of PUV. Specifically, making PUV diagnosis applies both to infants who are being assessed for follow-up of fetal hydronephrosis and to toddlers and youths who are being assessed for the possibility that PUV is an underlying cause of failure to resolve dysfunctional elimination syndrome. In order to promote better understanding of how to perform endoscopic diagnosis of PUV, we have re-formatted the surgery plan utilizing a CEVL (Computer Enhanced Visual Learning) context (MM) [5,6]. CEVL provides