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"Tyson, Mark"
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Single incision robotic cystectomy and urinary diversion
Purpose
In this review, we aim to provide readers with a balanced understanding of all aspects of single incision robotic cystectomy (SIRC) and urinary diversion using the single-port (SP) robot. The review will trace the historical progression from open surgery to the introduction of minimally invasive approaches and present an in-depth description of the SIRC technique, offering a step-by-step guide for reference. Emphasis will be placed on indications and patient selection criteria to equip surgeons with well-rounded insights for decision-making.
Methods
The review analyzes preliminary surgical outcomes by drawing from existing literature and clinical experiences, endeavoring to present a balanced view of the potential benefits and limitations. Addressing the learning curve and training prerequisites is paramount, and this review explores strategies and challenges in preparing surgeons for proficiency. Finally, the focus shifts to current challenges and future directions, identifying key issues and potential advancements in the field.
Conclusions
By presenting historical context, technical insights, clinical evidence, and strategic foresight, the review aims to provide a comprehensive resource that engages surgeons, researchers, and trainees from diverse perspectives.
Journal Article
Racial Disparities in Survival for Patients With Clinically Localized Prostate Cancer Adjusted for Treatment Effects
To examine whether racial disparities in survival exist among black, Hispanic, and Asian patients compared with white patients with clinically localized prostate cancer (CLPC) after adjustment for the effects of treatment.
We performed a retrospective cohort study of patients with CLPC diagnosed from January 1, 1995, through December 31, 2003, as documented in the Surveillance, Epidemiology, and End Results registry. Treatment-stratified, risk-adjusted Cox proportional hazards models were constructed.
During the study period, CLPC was diagnosed in 294,160 patients. Of these patients, 123,850 (42.1%) underwent surgery and 101,627 (34.5%) underwent radiotherapy, whereas 68,683 (23.3%) received no treatment. Overall 5-year and 10-year survival rates for Asians (85.6% and 67.6%, respectively), Hispanics (85.9% and 69.0%, respectively), and whites (83.9% and 65.7%, respectively) were higher than for blacks (81.5% and 61.7%, respectively) (P<.001). Prostate cancer–specific survival also varied significantly by race (P<.001). A risk-adjusted model stratified by primary treatment modality revealed that blacks had worse overall survival than whites (hazard ratio, 1.37; 95% CI, 1.33-1.41; P<.001), whereas Asians had better survival compared with whites (hazard ratio, 0.79; 95% CI, 0.76-0.83; P<.001). After the effects of treatment were accounted for, Hispanics had similar overall survival compared with whites (hazard ratio, 0.97; 95% CI, 0.94-1.01; P=.10).
Blacks with CLPC have poorer survival than whites, whereas Asians have better survival, even after risk adjustment and stratification by treatment. These data may be relevant to US regions with large underserved populations that have limited access to health care.
Journal Article
Partially redundant functions of two SET-domain polycomb-group proteins in controlling initiation of seed development in Arabidopsis
In Arabidopsis, a complex of Polycomb-group (PcG) proteins functions in the female gametophyte to control the initiation of seed development. Mutations in the PcG genes, including MEDEA (MEA) and FERTILIZATION-INDEPENDENT SEED 2 (FIS2), produce autonomous seeds where endosperm proliferation occurs in the absence of fertilization. By using a yeast two-hybrid screen, we identified MEA and a related protein, SWINGER (SWN), as SET-domain partners of FIS2. Localization data indicated that all three proteins are present in the female gametophyte. Although single-mutant swn plants did not show any defects, swn mutations enhanced the mea mutant phenotype in producing autonomous seeds. Thus, MEA and SWN perform partially redundant functions in controlling the initiation of endosperm development before fertilization in Arabidopsis.
Journal Article
Radical Prostatectomy Trends in the United States: 1998 to 2011
To determine the incidence and distribution of radical prostatectomy (RP) in the United States over time.
We conducted a serial cross-sectional analysis of time trends using the Nationwide Inpatient Sample of adult men older than 45 years who underwent RP between January 1, 1998, and December 31, 2011.
Weighted estimates revealed that 962,917 men underwent RP during the study period. The annual rate of RP remained relatively stable, from 1425 RPs per million in the period 1998 to 1999 to 1330 RPs per million in the period 2010 to 2011 (7% decrease; P=.90). The annual rate of open RP decreased from 1424 per million to 435 per million (P<.001), whereas the annual rate of minimally invasive RP increased from less than 1 per million to 895 per million (P<.001). Since 2006, hospitals providing open RP decreased by 18% (from 2288 to 1870; P<.001), whereas hospitals providing minimally invasive RP increased by 191% (from 341 to 993; P<.001). The median open RP caseload per hospital decreased by 7% (from 68 to 63; P<.001), whereas the median caseload for hospitals providing minimally invasive RP declined by 17% (from 122 to 101; P<.001). The hospitals providing fewer than 50 minimally invasive RPs per year increased from 12% to 26% (from 144 of 1240 to 3020 of 11,644; P<.001).
Per capita utilization of RP in the United States has remained stable from 1998 to 2011. Rapid expansion of the use of minimally invasive RP has reduced open RP utilization rates and median annual hospital caseload.
Journal Article
Wide Variation in Opioid Prescribing After Urological Surgery in Tertiary Care Centers
To describe postoperative opioid prescribing practices in a large cohort of patients undergoing urological surgery.
We identified 11,829 patients who underwent 21 urological surgical procedures at 3 associated facilities from January 1, 2015, through December 31, 2016. After converting opioids to oral morphine equivalents (OMEs), prescribing patterns were compared within and across procedures. Subgroup analysis for opioid-naive patients (those without a history of long-term opioid use) was performed. Statistical analysis was utilized to evaluate variations based on demographic and perioperative/postoperative variables.
Of the 11,829 patients, 9229 (78.0%) were prescribed an opioid at discharge, and the median (interquartile range [IQR]) OME prescribed was 188 (150-225). The remaining 9253 patients (78.2%) were considered opioid naive. Striking variation in prescribing patterns was observed within and across surgical procedures. For instance, IQR ranges of 150 or greater were observed for open cystectomy (median, 300; IQR, 210-375], open radical nephrectomy (median, 300; IQR, 225-375), retroperitoneal node dissection (median, 300; IQR, 225-375), hand-assisted laparoscopic nephrectomy (median, 225; IQR, 150-300), and penile prosthesis (median, 225; IQR, 150-315). On multivariate analysis, younger age, cancer diagnosis, and inpatient hospitalization were associated with higher likelihood of receiving a highest-quartile OME prescription for opioid naive patients. Thirty-day refill rates varied from 1.6% to 25.9%. Interestingly, refill rates were higher in patients receiving more opioids at discharge.
The United States is facing an opioid epidemic, and physicians must take action. In this study, we found considerable variation in opioid prescribing patterns within and across surgical procedures. These data provide support for the development of standardized opioid prescribing guidelines for postoperative analgesia.
Journal Article
Variation in Lymph Node Yield After Radical Cystectomy: The Role of the Pathology Assistant
Objectives: To test the hypothesis that lymph node yield will vary by pathology assistant (PA) in patients undergoing radical cystectomy (RC) with pelvic lymph node dissection (PLND). Methods: This is a single-institution retrospective review that included patients who underwent an RC with PLND for bladder cancer from January 1, 2007, to January 1, 2018. Predicted mean lymph node counts were generated using multivariable regression analysis. Results: In a total of 430patients who underwent RC with PLND, the median lymph node count (interquartile range) was 15.0 (11.0-21.0). The frequency of the limits of lymphadenectomy was as follows: external iliac, internal iliac, and obturator (true pelvis) (33.3%); true pelvis plus common iliac to the level of the aortic bifurcation (47.9%); and inferior mesenteric artery (18.8%). On descriptive analysis, there were differences in lymph node yield when evaluating the following variables: level of dissection, clinical stage, neoadjuvant chemotherapy, surgical approach, surgeon, pathologist, and PA (P <.05). On multivariable analysis, adjusted lymph node counts varied between surgeons, pathologists, clinical stage, and level of dissection but not by PA (P =.18). Conclusions: Lymph node yield after RC varies on several known levels, including surgeon, extent of lymphadenectomy, clinical stage, and pathologist. This study found no significant variation in lymph node yield according to PA. Key Words: Lymphadenectomy; Bladder cancer; Cystectomy; Processing
Journal Article
Variation in Lymph Node Yield After Radical Cystectomy
Abstract
Objectives
To test the hypothesis that lymph node yield will vary by pathology assistant (PA) in patients undergoing radical cystectomy (RC) with pelvic lymph node dissection (PLND).
Methods
This is a single-institution retrospective review that included patients who underwent an RC with PLND for bladder cancer from January 1, 2007, to January 1, 2018. Predicted mean lymph node counts were generated using multivariable regression analysis.
Results
In a total of 430 patients who underwent RC with PLND, the median lymph node count (interquartile range) was 15.0 (11.0-21.0). The frequency of the limits of lymphadenectomy was as follows: external iliac, internal iliac, and obturator (true pelvis) (33.3%); true pelvis plus common iliac to the level of the aortic bifurcation (47.9%); and inferior mesenteric artery (18.8%). On descriptive analysis, there were differences in lymph node yield when evaluating the following variables: level of dissection, clinical stage, neoadjuvant chemotherapy, surgical approach, surgeon, pathologist, and PA (P < .05). On multivariable analysis, adjusted lymph node counts varied between surgeons, pathologists, clinical stage, and level of dissection but not by PA (P = .18).
Conclusions
Lymph node yield after RC varies on several known levels, including surgeon, extent of lymphadenectomy, clinical stage, and pathologist. This study found no significant variation in lymph node yield according to PA.
Journal Article
Robot-assisted partial nephrectomy for complex renal masses
To determine whether the approach for partial nephrectomy is influenced by tumor complexity and if the introduction of robotic techniques has allowed us to treat more complex tumors minimally invasively. Data from 292 patients who underwent partial nephrectomy for renal masses from November 1999 to July 2013 at a tertiary referral center were retrospectively reviewed. Nephrometry scores and perioperative outcomes were stratified based on when robotic techniques were introduced. Mean follow-up time was 2.6 years. Preoperative RENAL nephrometry scores and perioperative outcomes were analyzed. Of the 292 patients, 31.5 % underwent robot-assisted partial nephrectomy, 46.2 % laparoscopic partial nephrectomy and 22.9 % open partial nephrectomy. Robot-assisted partial nephrectomy mean nephrometry score was significantly higher than laparoscopic and equivalent to open. Significant perioperative differences were estimated blood loss (
p
= 0.0001), length of stay (
p
= 0.0001) and Clavien score (
p
= 0.0069), all favoring robot-assisted partial nephrectomy. Limitations include retrospective design and single center data. Robot-assisted partial nephrectomy is a safe and effective surgical modality that allows for complex renal tumors that were previously reserved for open partial nephrectomy in the pure laparoscopic era to be managed with a minimally invasive approach.
Journal Article
Intraoperative magnesium sulfate is not associated with improved pain control after urologic procedures
Objective
To evaluate effects of intraoperative magnesium sulfate infusion on pain control and analgesic use in the postanesthesia care unit (PACU).
Methods
This is a retrospective review of patients undergoing robot-assisted radical prostatectomy (RARP) and endoscopic procedures of the bladder, prostate, and urethra from 2/2021 to 12/2021. Patients receiving Mg infusion (Mg group) received an intravenous 2-g bolus of Mg at anesthesia induction, followed by infusion of 1 g/h until procedure end. Outcomes were compared with patients who underwent similar procedures during this timeframe without Mg (Control). Endpoints were use of anticholinergic (AC) and belladonna and opium suppositories (BO), maximum pain score, and morphine milligram equivalents (MME) in PACU.
Results
There were 182 patients, with 89 (48.9%) patients in the Mg group and 93 (51.1%) in the Control. Significantly, fewer patients in the Mg group were given AC/BO in PACU (9.0% vs. 21.7%,
p
= 0.02), with odds of using AC/BO which was 0.36 (95%
CI
0.14, 0.83). No differences were found in pain score (
p
= 0.62) or MME administration (
p
= 0.94). In subgroup univariate analysis, only those who underwent bladder procedures had a significant difference in use of AC/BO (9.5% vs. 30.2%;
p
= 0.02). Across all surgeries, Mg infusion was associated with decreased use of AC/BO in the PACU (
OR
0.34,
p
= 0.02); however, stratifying by procedure type did not find a difference in AC/BO use postoperatively.
Conclusion
Intravenous infusion of magnesium was found to decrease use of AC/BO in the PACU; however, this significance was lost after multivariable analysis stratifying by procedure type.
Journal Article