Study Type – Therapy (case series) Level of Evidence 4 OBJECTIVE To evaluate our experience with robotic partial nephrectomy in patients with previous abdominal surgery and evaluate the effect of previous abdominal surgery on perioperative outcomes. We also describe a technique for intraperitoneal access for patients with prior abdominal surgery utilizing the 8 mm robotic camera for direct‐vision trocar placement. PATIENTS AND METHODS From a prospective cohort of 197 consecutive patients who underwent robotic renal surgery at a single academic institution, a total of 95 patients underwent transperitoneal robotic partial nephrectomy (RPN). Patients with and without previous abdominal surgery were compared. Patients with prior abdominal surgery were subcategorized into two groups: upper midline or ipsilateral upper quadrant scar or lower abdominal, contralateral, or minimally‐invasive scar. Demographic and perioperative variables were compared between the surgery and no surgery groups. Access was obtained using a Veress needle or Hassan technique. We utilized a technique of direct vision placement of the initial trocar on our 10 most recent cases, using an 8 mm robotic camera placed through the obturator of 12 mm clear‐tipped trocar. Lysis of adhesions was performed as needed to allow for placement of additional robotic ports. RESULTS A total of 95 patients underwent transperitoneal RPN, of which 41 (43%) had a history of prior abdominal surgery and six had upper midline or ipsilateral upper quadrant scars. There were no statistically significant differences between patients with previous abdominal surgery and patients with no previous abdominal surgery in BMI (30.4 vs 29.4 kg/m2), median tumor size (2.5 cm vs 2.3), median total operative time (246 vs 250 min), median warm ischemia time (21 vs 16 min), median EBL (150 vs100 ml), clinical stage, transfusion rate, or complications. A total of six patients underwent 7 previous upper midline or ipsilateral upper quadrant surgeries, including open cholecystectomy‐2 patients (33%), open partial gastrectomy‐2 patients (33%) and exploratory laparotomy‐1 patient (17%). Complications in this group were an enterotomy during lysis of adhesions that was repaired robotically without sequelae and a mesenteric hematoma during Veress needle placement. A total of 35 patients underwent 16 other prior abdominal surgeries, including abdominal hysterectomy‐10 patients (29%), umbilical/inguinal hernia repair‐9 patients (26%) and appendectomy‐7 patients (20%). There were no access related injuries in the 10 cases in which the robotic 8 mm camera was used for initial trocar placement. CONCLUSIONS Transperitoneal robotic partial nephrectomy is feasible in the setting of prior abdominal surgery. The majority of these patients can have their procedure performed safely without an increase in complications. Direct‐vision intraperitoneal placement of initial trocar may be achieved by using an 8 mm robotic camera, without the need to switch between conventional and robotic cameras.
ObjectivesThis study aimed to determine the incidence of patient adherence with prescribed pelvic floor physical therapy (PFPT) in women presenting with fecal incontinence (FI) and to describe patient characteristics associated with nonadherence.MethodsThis is a retrospective cohort study of women presenting with FI who were prescribed PFPT between January 2010 and December 2019. Adherence with PFPT was defined as either completion of documented recommended physical therapy sessions or discharge from therapy by the therapist before completion of the prescribed sessions.ResultsComplete data were available for 248 patients. A total of 159 (64.1%) patients attended at least 1 session of PFPT. Patients who did not attend any sessions were more likely to have a concurrent diagnosis of pelvic organ prolapse (69.7% vs 55.3%, P = 0.03). When controlled for confounding variables, concurrent prolapse remained associated with nonattendance (adjusted odds ratio of 1.9 [95% confidence interval, 1.0–3.3]). Of the patients who attended PFPT, the adherence rate was 32.7% (n = 50), whereas the rate was 20% for the total cohort. Nonadherent patients were more likely to have a higher body mass index (28.9 vs 26.9, P = 0.02), but this was no longer statistically significant once other patient characteristics were controlled for. Of the entire cohort, 136 (54.8%) followed up with their physicians after the initial referral to PFPT. Of the 59 patients, 43.7% were offered second-line therapy.ConclusionOf the women prescribed PFPT for a diagnosis of FI, approximately two thirds attended at least a single session, but only one third of those patients were adherent with the recommended therapy.
Importance Discharge to home after surgery has been recognized as a determinant of long-term survival and is a common concern in the elderly population. Objective The aim of the study was to determine the incidence and risk factors for nonhome discharge in patients undergoing major surgery for pelvic organ prolapse. Study Design We performed a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program Database from 2010 to 2018. We included patients who underwent sacrocolpopexy, vaginal colpopexy, and colpocleisis. We compared perioperative characteristics in patients who were discharged home versus those who were discharged to a nonhome location. Stepwise backward multivariate logistic regression was then used to control for confounding variables and identify independent predictors of nonhome discharge. Results A total of 38,012 patients were included in this study, 209 of whom experienced nonhome discharge (0.5%). Independent predictors of nonhome discharge included preoperative weight loss (adjusted odds ratio [aOR], 5.9; 95% confidence interval [CI], 1.3–27.5), dependent health care status (aOR, 5.0; 95% CI, 2.6–9.5), abdominal hysterectomy (aOR, 2.3; 95% CI, 1.4–3.7), American Society of Anesthesiologists class 3 or greater (aOR, 2.0; 95% CI, 1.5–2.7), age (aOR, 1.1; 95% CI, 1.05–1.09), operative time (aOR, 1.005; 95% CI, 1.003–1.006), laparoscopic hysterectomy (aOR, 0.6; 95% CI, 0.4–1.0), and laparoscopic sacrocolpopexy (aOR, 0.5; 95% CI, 0.3–0.8). Conclusions In patients undergoing surgery for pelvic organ prolapse, nonhome discharge is associated with various indicators of frailty, including age, health care dependence, and certain comorbidities. An open surgical approach increases the risk of nonhome discharge, while a laparoscopic approach is associated with lower risk.
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