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Context Although miniaturized percutaneous nephrolithotomy (mPCNL) and retrograde intrarenal surgery (RIRS) are both options for treating >1 cm kidney stones, controversies exist on whether one is more effective and safer than the other. Objective To systematically appraise randomized trials comparing the effectiveness and safety of mPCNL and RIRS for treating >1 cm kidney stones. Evidence acquisition A systematic search on PubMed/Medline, Web of Science, Embase, and ClinicalTrials.gov was conducted in August 2020 following the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA). Randomized trials comparing mPCNL and RIRS for >1 cm kidney stones, and reporting stone-free rate (SFR), hemoglobin drop, transfusion rate, length of hospital stay (LOS), and/or complications, were included. Evidence synthesis Eight studies compared mPCNL and RIRS, but one was not included due to its high risk of bias. SFR was higher for mPCNL (RR: 1.06 [95% coefficient interval {CI}, 1.01–1.10], p = 0.008). Hemoglobin drop was higher for mPCNL (mean difference [MD]: 0.35 [95% CI, 0.05–0.65] g/dl, p = 0.02); however, transfusion rates were similar (p = 0.44). Complication rate was similar between mPCNL and RIRS (p = 0.39), and the LOS was higher for mPCNL (MD: 1.11 [95% CI, 0.06–2.16] d, p = 0.04). A subgroup analysis of lower pole stones showed that SFR was higher for mPCNL (RR: 1.09 [95% CI, 1.00–1.19], p = 0.05). Conclusions Both approaches are effective and safe. Among these approaches, mPCNL has a higher SFR than RIRS for overall >1 cm renal and lower pole stones, but longer LOS, and a higher hemoglobin drop that does not translate into higher transfusion rates. Complications are comparable. Patient summary Randomized trials have evaluated whether miniaturized percutaneous nephrolithotomy (mPCNL) or retrograde intrarenal surgery is more effective and safer for treating >1 cm stones. After comparing the stone-free rate, hemoglobin drop, transfusion rate, length of hospital stay, and complications between both the approaches, mPCNL was found to be slightly more effective, but both were equally safe.

Tranexamic acid (TXA) is a lysine analog that exhibits an anti-fibrinolytic effect by directly preventing the activation of plasminogen as well as inhibiting activated plasmin from degrading fibrin clots, thereby promoting hemostasis and reducing the duration and quantity of blood loss. The aims of this study were to summarize the indications, routes of administration, safety, and clinical outcomes of TXA use throughout the different subspecialities in orthopedic surgery. Given that orthopedic procedures such as TKA, THA, fracture fixation, and various spine surgeries involve significant intraoperative blood loss, TXA is indicated in providing effective perioperative hemostasis. Additionally, use of TXA in orthopedic trauma has been indicated as a measure to reduce blood loss especially in a group with potential for hemodynamic compromise. TXA has been implicated in reducing the risk of blood transfusions in orthopedic trauma, joint surgery, and spine surgery, although this effect is not seen as prominently in sports medicine procedures. There remains disagreement in literature as to whether TXA via any route of administration can improve other clinically significant outcomes such as hospital length of stay and total operative time. Procedures that rely extensively on clarity on visualization of the surgical field such as knee and shoulder arthroscopies can greatly benefit from the use of TXA, thereby leading to less intraoperative bleeding, with better visual clarity of the surgical field. While most studies agree thrombosis due to TXA is unlikely, new research in cells and animal models are evaluating whether TXA can negatively impact other aspects of musculoskeletal physiology, however with conflicting results thus far. As of now, TXA remains a safe and effective means of promoting hemostasis and reducing intraoperative blood loss in orthopedic surgery.

AIM The aim of the current study was to investigate whether the artery-first approach (AFA) improved surgical outcomes of pancreaticoduodenectomy (PD) at our non-high-volume center. PATIENTS AND METHODS We retrospectively reviewed data on 121 consecutive patients who underwent PD between January 2009 and December 2018. The perioperative data of 49 patients who underwent conventional PD (conventional group) and 72 patients who underwent PD via artery-first approach were analyzed and compared to assess the effectiveness of the AFA. RESULTS Although no significant difference was observed between the two groups overall, in those with pancreatic cancer, the duration of surgery, intraoperative blood loss and transfusion rate in the AFA group (n=33) were significantly lower than those for the conventional group (n=11) (p=0.011, p=0.021 and p=0.038 respectively). CONCLUSION AFA can be used to reduce the operative time, intraoperative blood loss, and transfusion rate in patients with pancreatic cancer.

Objective Rising maternal mortality and severe maternal morbidity (SMM) rates have drawn increasing public health attention. We evaluated patterns of SMM across the Washington State Perinatal Regional Network, in which neonatal intensive care unit (NICU) levels correlate with maternal level of care. Study Design Retrospective cohort study using de-identified patient and hospital-level rates of SMM diagnoses and procedures for all women who delivered at 58 hospitals from October 2015 to September 2016. Data were obtained from the Washington State Comprehensive Hospital Abstract Reporting System, which includes inpatient diagnosis with associated Present on Admission flags, procedure, and discharge information derived from hospital billing systems. Deliveries were stratified by having or not having SMM. For each SMM diagnosis, POA rates were tabulated. Hospital SMM rates (all SMM, transfusion only, and SMM excluding transfusion) were grouped according to their NICU level of care (critical access [CA] and 1–4). Odds ratios and 95% confidence intervals (CI) were calculated. Results Of 76,961 deliveries, 908 women (1.2%) had any SMM including 533 with transfusion only and 375 with all other SMM diagnoses/procedures. Rates of SMM were highest at level 1 and level 4 hospitals at 1.3 and 1.5%, respectively. Level 1 and CA hospitals had the highest transfusion rate (1.0%), while level 2, 3, and 4 hospitals had progressively lower rates (0.8, 0.7, and 0.5%, respectively; p Conclusion SMM diagnoses occur most frequently at the centers providing the highest level of care, likely attributable to the regional referral system. However, transfusion rates are increased in level 1/CA hospitals. Efforts to decrease SMM should focus on equipping level 1/CA hospitals with tools to decrease maternal morbidity and improve referral systems. Key Points

Clinical outcomes of transcatheter aortic valve implantation (TAVI) have significantly improved with the accumulation of operator and institution experience as well as the wide use of newer generation devices. There is limited data on TAVI outcomes compared with surgical aortic valve replacement (SAVR) in contemporary practice in the United States. We queried the 2018 Nationwide Readmission Database of the United States. International Classification Diagnosis code 10 was used to extract TAVI and SAVR admissions. A propensity-matched cohort was created to compare TAVI and SAVR outcomes. A weighted 48,349 TAVI and 24,896 SAVR for aortic stenosis were included and 4.9% of TAVI were performed with an embolic protection device. In propensity-matched cohort (12,708 TAVI and 12,708 SAVR), TAVI conferred lower in-hospital mortality (1.7% vs 3.8%), acute kidney injury (11.3% vs 22.9%), and transfusion rate (5.9% vs. 20.6%) whereas new pacemaker rate was higher in TAVI compared with SAVR (10.5% vs. 7.0%) (all p values0.001). Stroke rate was similar between TAVI and SAVR (1.5% vs. 1.5%) (p value = 0.79). The routine discharge was more frequent (66.9% vs 25.8%) and length of stay was shorter (4.8 vs. 9.8 days) in TAVI than SAVR. Hospitalization cost was higher in SAVR than TAVI (51,962 vs 57,754 U.S. dollars) (all p values0.001). In-hospital mortality was also lower in TAVI compared with isolated SAVR. TAVI was performed more frequently than SAVR in 2018 in the United States with lower in-hospital mortality of TAVI compared with both SAVR and isolated SAVR.

To evaluate the efficiency and efficacy of HoLEP, and methods of tissue retrieval, in patients with prostate volume (PV) ≥ 200 cc (Group 1) and to compare these to patients with PV 80–199 cc (Group 2). A database of all cases performed under the care of two surgeons at a tertiary HoLEP centre was reviewed. 157 patients with PV ≥ 200 cc were compared to 157 of the most recent consecutive cases with PV 80–199 cc. Median (IQR) enucleation efficiency was greater in Group 1 [2.8 g/min (2.2–3.5)] than Group 2 [2.1 g/min (1.6–2.5), p

Proctoring may facilitate a safe transition to robotic-assisted partial nephrectomy (RAPN) for centres performing open (OPN) and laparoscopic partial nephrectomies (LPN). This study compared the 5-year outcomes of RAPN, initiated with a team-based proctorship, with OPN and LPN. Following an observation course at the proctor's institution and a 3-surgeon performance of proctored RAPN in August 2014, a review of 90 RAPN, 29 LPN and 43 OPN consecutively performed by the same team from 2013 to 2019 at National University Hospital, Singapore was conducted. Peri-operative data, functional and oncological outcomes were compared amongst the three groups. Most cases were performed robotically after 2015 with comparable baseline characteristics in all groups. Median RENAL Nephrometry Score was not significantly different between RAPN (8 [IQR 6, 9]) and OPN (9 [IQR 7, 10]) (P = 0.12) but was significantly lower for LPN (7 [IQR 5, 8]) compared to RAPN (P = 0.002). RAPN achieved the lowest blood loss (226 ml vs.348 ml and 263 ml for OPN and LPN respectively, P = 0.02), transfusion rate (3% vs.21% and 17% respectively, P = 0.003) and median length of stay after surgery (4 vs.6 and 5 days respectively, P = 0.001). Complication rates, warm ischemic times were similar between the three approaches with no differences in 1-year and long-term renal function. The rate of positive surgical margin was 8%, 8% and 3% for RAPN, LPN and OPN, respectively (P = 0.76), with a single recurrence in each arm. Despite modest hospital volume, a team-based proctorship facilitated the transition to the Da Vinci robotic platform to perform partial nephrectomies of equivalent complexities as open surgery, achieving improved perioperative outcomes, while maintaining oncological and kidney functional results.

Fractures of the proximal femur in the elderly population are rising. Teaching the appropriate surgical treatment of these fractures is of paramount importance. The aim of the study was to evaluate differences in outcome of surgical procedures between supervised trainees and senior surgeons.Are there more surgical complications, poorer quality or an increased operating time if the procedure (in this case: fixation of proximal femur fractures) is performed by trainees under supervision in comparison to experienced surgeons.All patients treated with the proximal femur nail antirotation (PFNA) between 2015 and 2016 at a level one trauma centre were included in this study. The retrospective review of the 299 patients compared supervised surgical trainees and senior surgeons. Parameters included operating time, tip apex distance, position of the blade, Hb-difference, transfusion rate, surgical complications as well as mortality, and were compared between the groups.153 of 299 procedures were performed by supervised surgical trainees. In comparison to senior surgeons, there was no significant difference in operating time (WA 54.48 min; OA 60.47 min; p 0,05), Hb-difference (WA 2.8 g/dl; OA 2.6 g/dl; p 0.05), tip-apex distance (WA 21.2 mm; OA 20.5 mm, p = 0.37) or rate of surgical complications. There was no difference in the rate of optimal blade positions between the groups (WA 87.5%; OA 89.0%; p = 0.366). Furthermore, mortality showed no difference between the groups, but was greater in older patients or high ASA grade.Supervised surgical training during treatment of proximal femur fractures shows no increase in operating time, complications or mortality and no difference in quality. With the fast growth of the elderly population, surgical training of fragility fractures should receive more attention in the future.Die Anzahl der proximalen Femurfrakturen wird aufgrund der demografischen Entwicklung in der Zukunft weiter zunehmen. Um eine adäquate Versorgung der Patienten auch weiterhin sicherzustellen, muss eine stringente Ausbildung der angehenden Fachärzte der Orthopädie und Unfallchirurgie (OU) erfolgen. Ziel der Studie war der Vergleich der Versorgung von hüftgelenksnahen Femurfrakturen durch einen angeleiteten Weiterbildungsassistenten (WA) oder durch einen Fach-/Oberarzt (OA) für Orthopädie und Unfallchirurgie.Führt die operative Ausbildung von WA zu vermehrten Komplikationen, einer erhöhten OP-Zeit oder niedrigeren Qualität?Retrospektiv untersucht wurden alle Patienten, die mittels PFNA (proximaler Femurnagel Antirotation) von 2015 bis 2016 in einem überregionalen Traumazentrum versorgt wurden. Die zu vergleichenden Parameter umfassten OP-Zeit, Tipp-Apex-Abstand, Klingenposition, chirurgische Komplikationen, Mortalität, Hämoglobindifferenz prä- zu postoperativ und die Transfusionsrate.Von den 299 operierten Patienten wurden 146 Eingriffe durch die Gruppe der OA und 153 durch angeleitete WA durchgeführt. Zwischen den Gruppen konnten keine signifikanten Unterschiede bez. der OP-Zeit (WA 54,48 min, OA 60,47 min; p 0,05), der Hämoglobindifferenz (WA 2,8 g/dl, OA 2,6 g/dl; p 0,05), dem Tipp-Apex-Abstand (WA 21,2 mm, OA 20,5 mm; p = 0,37) oder dem Auftreten von chirurgischen Komplikationen gefunden werden. In der Subgruppenanalyse der homogenen Gruppe der A1-Frakturen zeigte sich eine OP-Zeit-Verlängerung von 9 min. Signifikante Differenzen für OP-Zeit und Hb-Differenz waren jedoch auch in der Subgruppenanalyse nach AO-Klassifikation nicht nachweisbar. Eine optimale Klingenposition konnte in vergleichbar vielen Fällen erreicht werden (WA 87,5%, OA 89,0%; p = 0,366). Die Mortalität zeigte ausschließlich einen signifikanten Zusammenhang mit dem Alter des Patienten und der ASA-Klassifikation.Eine stringente Ausbildung von WA in der OU geht nicht mit signifikant erhöhten OP-Zeiten und damit Kosten einher. Bei fachärztlicher Anleitung zeigen sich keine Abstriche in der Qualität oder vermehrte Komplikationen. Aufgrund der demografischen Entwicklung sollte die Ausbildung der operativen Versorgung von proximalen Femurfrakturen zunehmend im Fokus jeder weiterbildenden Abteilung stehen.

To evaluate the outcomes of complete supine percutaneous nephrolithotomy (csPCNL) for staghorn stones and multiple large non-staghorn stones.The records of 886 patients who underwent csPCNL from September 2009 to October 2019 were considered. Out of them, 201 cases met the eligibility criteria and they were divided into three groups: 63 cases of staghorn, 68 cases of multiple medium (20 mm diameter ≤ 30 mm) non-staghorn and 70 cases of multiple large non-staghorn ( 30 mm) stones. Almost all outcomes and stone-related factors were analyzed.There was not any significant difference regarding age, body mass index, history of urinary tract infection, transfusion rate, complication rate, pre and post-surgery serum creatinine, hemoglobin drop and total hospital stay between the three groups. Stone free rate was 98.5% in multiple medium group, 97.1% in multiple large group and 84.1% in staghorn group (P = 0.001). The operation duration was significantly shorter for the multiple medium group (P 0.001) but it was not significantly different between the multiple large non-staghorn and staghorn group.The results demonstrated that almost all outcomes were not significantly different between the three groups (especially between staghorn and larger non-staghorn ones). These findings reveal that surgeons could choose csPCNL for treatment of staghorn stones and multiple large non-staghorn stones and consider staghorn stones as challenging as multiple large (especially diameter 30 mm) non-staghorn stones.

Despite several blood management strategies available, blood transfusion rates following total hip arthroplasty remain high. Therefore, this study evaluated transfusion rates following bilateral hip arthroplasty via direct anterior approach using a multimodal blood loss management approach for 213 consecutive patients. All patients received standard surgical and post-operative procedures, with allogenic transfusion performed if hemoglobin was less than 8.0 g/dL with persistent clinical symptoms. Thirty-two patients (15%) required transfusion, with those patients significantly older and had lower pre-operative hemoglobin compared to non-transfusion patients. This transfusion rate was much lower than previous literature and could be an appropriate, multimodal blood loss management strategy.

Background Laparoscopic nephrectomy is the standard of care for nephrectomy in most developed countries. Its adoption in our setting has been limited due to lack of equipment and expertise. This paper sets out to show that laparoscopic nephrectomy is technically feasible in the state sector in South Africa. Methods A retrospective chart review was performed of all patients having undergone nephrectomy over a five-year period at two state hospitals in KwaZulu-Natal Province, South Africa. Demographic information, pre-operative imaging findings, operative information and post-operative outcomes were analysed. Results Nephrectomy was performed in 196 patients. Open nephrectomy (ON) was the intended surgical approach in 73% (n = 143) and laparoscopic nephrectomy (LN) in 27% (n = 53). The conversion rate from LN to ON was 11% (n = 6). For malignancies, there was no difference in surgical resection margin status across the ON, LN and conversion groups; however, tumour size was larger in the conversion group compared to the LN group. Estimated blood loss and transfusion rates were lower in the LN group. The average length of hospital stay was shorter in the LN group (5 vs 10 days). High dependency unit (HDU) admission rate was lower in the LN group (12.1%) compared to the ON group (50%) and the conversion group (40%). No difference in high-grade complications was noted between the ON and LN groups, and more patients in the LN group (82.5%) had no complications compared to the open group (9.9%). Conclusion LN is non-inferior to ON in terms of operative time, oncology outcomes and high-grade complications. LN is superior in terms of blood loss, transfusion rate, length of hospital stay and overall complication rate. LN appears to show technical feasibility in the state sector and highlights the need for laparoscopic training.

Introduction: The effect of pelvic fixation on postoperative medical complications, blood transfusion, length of hospital stay, and discharge disposition is poorly understood. Determining factors that predispose patients to increased complications after spinopelvic fusion will help surgeons to plan these complex procedures and optimize patients preoperatively. Methods: We conducted a retrospective cohort study using data from the ACS-NSQIP database between 2006 and 2016 of patients who underwent lumbar fusion with and without spinopelvic fixation. Data regarding demographics, complications, hospital stay, and discharge disposition were collected. Results: A total of 57,417 (98.5%) cases of lumbar fusion without spinopelvic fixation (LF) and 887 (1.5%) cases of lumbar fusion with spinopelvic fixation (SPF) were analyzed. The transfusion rate in the SPF group was 59.3% vs 13% in the LF group (p < 0.001). The mean length of stay (LOS) and discharge to skilled nursing facility (SNF) were significantly different (LOS: SPF 6.5 days vs LF 3.5 days p < 0.001; SNF: SPF 21.3% vs LF 10.4% p < 0.001). After controlling for demographic differences, the overall complication rates were not significantly different between the groups (p = 0.531). The odds ratio for transfusion in the SPF group was 2.9 (p < 0.001). The odds ratio for increased LOS and increased care discharge disposition were elevated in the SPF group (LOS OR: 1.3, p < 0.012, Discharge disposition OR: 1.8, p < 0.001). Conclusions: Patients who underwent SPF had increased complications, transfusion rate, LOS, and discharge to SNF or subacute rehab facilities as compared with patients who underwent LF. SPF remains an effective technique for achieving lumbosacral arthrodesis. Surgeons should consider the implications of the associated complication profile for SPF and the value of preoperative optimization in a select cohort of patients.

The impact of liver cirrhosis on the difficulty of minimal invasive liver resection (MILR) remains controversial and current difficulty scoring systems do not take in to account the presence of cirrhosis as a significant factor in determining the difficulty of MILR. We hypothesized that the difficulty of MILR is affected by the presence of cirrhosis. Hence, we performed a 1:1 matched-controlled study comparing the outcomes between patients undergoing MILR with and without cirrhosis including the Iwate system and Institut Mutualiste Montsouris (IMM) system in the matching process. Between 2006 and 2019, 598 consecutive patients underwent MILR of which 536 met the study inclusion criteria. There were 148 patients with cirrhosis and 388 non-cirrhotics. One-to-one coarsened exact matching identified approximately exact matches between 100 cirrhotic patients and 100 non-cirrhotic patients. Comparison between MILR patients with cirrhosis and non-cirrhosis in the entire cohort demonstrated that patients with cirrhosis were associated with a significantly increased open conversion rate, transfusion rate, need for Pringles maneuver, postoperative, stay, postoperative morbidity and postoperative 90-day mortality. After 1:1 coarsened exact matching, MILR with cirrhosis were significantly associated with an increased open conversion rate (15% vs 6%, p = 0.03), operation time (261 vs 238 min, p

Background In an enhanced recovery after surgery program, a growing number of orthopedists are reconsidering the necessity of tourniquet use in total knee arthroplasty (TKA). However, the impact of tourniquet use on transfusion rate and postoperative length of stay (PLOS) in TKA remains controversial. Therefore, we carried out a study to investigate the effect of tourniquet application in routine primary TKA on transfusion rate and PLOS. Methods We analyzed data from 6325 patients who underwent primary unilateral TKA and divided them into two groups according to whether a tourniquet was applied during the procedure, and a tourniquet was used in 4902 and not used in 1423. The information for transfusion and PLOS was extracted from patients’ electronic health records, and the data were analyzed with logistic and linear regression analyses. Results Following TKA, the transfusion rate and PLOS were 14.52% and 7.72 ± 3.54 days, respectively, in the tourniquet group, and 6.47% and 6.44 ± 3.48 days, respectively, in the no-tourniquet group. After adjusting for the different related variables, tourniquet use was significantly correlated with a higher transfusion rate (risk ratio = 1.888, 95% confidence interval (CI) 1.449–2.461, P B) = 0.923, 95%CI 0.690–1.156, P Conclusions Our findings suggested that tourniquet use in routine primary TKA was related to a higher transfusion rate and a longer PLOS. The impact of tourniquet use on transfusion rate and PLOS should be taken into account in clinical practice.

Background: In this study, we present our single-center experience in robotically-assisted endoscopic surgery versus conventional median sternotomy approach in patients undergoing cardiac myxoma excision. Methods: Between January 2011 and September 2019, a total of 46 patients (24 males, 22 females; mean age 54.1±12.5 years; range, 25 to 79 years) who had a confirmed diagnosis of isolated cardiac myxoma were included in the study. The patients were divided into two groups as those undergoing robotic-assisted surgery (n=16) and those undergoing conventional median sternotomy (n=30). Clinical characteristics, operative, and postoperative outcomes were compared. Robotic approach to right or left-sided tumors and postoperative pain scores were also analyzed. Results: There was no mortality or major complication. No conversion to sternotomy was needed in robotic procedures. The mean cardiopulmonary bypass and aortic cross-clamp times were significantly shorter in the median sternotomy group (p=0.001 for both). The mean ventilation time and the length of hospital stay were significantly shorter in robotic surgery than sternotomy group (p=0.043 and p=0.048, respectively). The mean amount of postoperative blood loss and transfusion rate were significantly lower in robotic surgery patients (p=0.001 and p=0.022, respectively). The mean postoperative pain scores were significantly lower in patients undergoing robotic surgery (p=0.022). Conclusion: Robotic-assisted endoscopic surgery can be performed safely and effectively for cardiac myxoma excision with shorter hospital stay, less pain, and less amount of blood product use, as well as more favorable cosmetic results compared to conventional median sternotomy.

Introduction Every year more than 300,000 proximal femur fractures are diagnosed. Their number will double within 30 years. In femoral neck fractures treated with hip hemiarthroplasty 90-days mortality is 29.5-51.6%. Haemorrhage is one amongst other complications that is associated with increasing postoperative mortality. Transfusion rate in these patients ranges from 25.7% to 39%. Blood transfusions expose to complications. Fibrin sealants are useful in reducing perioperative need for transfusions, total blood loss, blood loss from drainage. The aim of this study is to assess whether the use of a fibrin sealant during hip hemiarthroplasty implant reduces the need for transfusion. Patient and methods All patients admitted with a proximal femur fracture from September 2018 to May 2019 were reviewed. Inclusion criteria were: femoral neck fracture AO 31B2-3, hip hemiarthroplasty. Exclusion criteria were: previous surgery on the affected hip, coagulation disorders, hematopoietic disorders. Patients were divided in fibrin sealant group and control group. All patients underwent partial hip replacement through a posterolateral approach. 4 ml of fibrin sealant (EVICEL, Omrix Biopharmaceuticals, Diegem, Belgium) were sprayed on the soft tissues of patients included in the fibrin sealant group. Primary outcome of our study was need for perioperative transfusion. Secondary outcomes were: mean red blood cell transfused volume, variations in haematocrit and haemoglobin and total blood volume loss. Results Eighty-one consecutive patients were enrolled. EVICEL was used on 19 patients, standard haemostatic care on 62 patients. Two patients were transfused in the fibrin sealant group, 22 in the control group (p 0,0371). Mean transfused volume was 21,05 ml in the fibrin sealant group and 116,16 ml in the control group (p 0,0017). No significant difference could be found in haematocrit and haemoglobin variation and total blood loss. Discussion A reduction in transfusional need with the use of fibrin sealants was reported in studies on total hip arthroplasty and was confirmed by our study. Conclusion EVICEL reduces need for transfusion in patients undergoing hip hemiarthroplasty for a femoral neck fracture. It must be held among the options when a stricter control on transfusional requirement is needed.

Introduction Incidence of hip fractures is increasing with upward estimates representing one of the most current health problems. According to some authors this condition is associated with an early mortality rate ranging between 20% and 35% and low outcomes. One of the predictive factors of poor outcome after hip fracture is anaemia. In fragile patients, hormonal changes due to fracture and surgical trauma, may occur in the hypophyseal hypothalamus axis which may lead to the Euthyroid Sick Syndrome (ESS). This pathological condition is characterized by a reduction in the concentration of triiodothyronine (T3) with normal or slightly reduced thyrotropin (TSH) values and with or without a reduction (cancellata) ​​of thyroxine (T4). ESS has been associated to an increased mortality in elderly patients. Materials and methods Inclusion criteria were: age > 65y, X-ray diagnosis of proximal femoral fracture classified as AO 31A or 31B requiring surgical treatment, admittance to the emergency room within 72 hours from trauma. Exclusion criteria were: any thyroid-related pathology, concomitant acute coronary syndrome, active pneumonia, concomitant neoplastic disease, assumption of medications able to affect thyroid function, refusal to undergo surgical treatment. All patients underwent routine blood testing and a complete thyroid-hormone profile dosage before surgical operation. The same blood tests performed before surgical operation were repeated on the first and third post-operative days. Results Thirtytwo patients met the inclusion criteria and were enrolled after they accepted to participate to the study. Sixteen patients presented with ESS on admission and 16 patients did not. The mean age was 82,5 yo. There was no statistically significant difference in bleeding risk factors among the two groups. In the ESS group there was a number of blood transfusions of 1.06 units higher than the control group (p=0.01). Conclusions We have demonstrated that patients with ESS have a higher need of red blood cells transfusion compared to patients without ESS and, thus they have a higher risk to develop anemia in the peri-operative period. We believe it would be useful to diagnose ESS in fragile patients at their arrival to the emergency room and apply a peri-operative therapeutic protocol to prevent anemia.

Background Major postoperative morbidity after laparoscopic sleeve gastrectomy (LSG) is often related to staple line leaks (SLL). Of note, a recent study suggested a central role of the absolute numbers of stapler firings as a predictive factor for postoperative morbidity due to SLL. In addition, a larger gastric remnant volume could be responsible for lower weight loss after LSG, and nevertheless, the gastric resection volume (GRV) is strictly related to the residual volume. Methods Prospectively, collected data of 384 consecutive patients with complete follow-up at 12 months after LSG at our institution were retrospectively analyzed. Patients were stratified according to three different variables (i.e., number of stapler firings, GRV, and GRV/stapler firings-ratio), and respective impact on postoperative complications and weight loss was analyzed. Results High absolute number of stapler firings was linked to increased intraoperative and postoperative bleeding and prolonged hospitalization, but was not associated with SLL, transfusion rate or revisional procedures. Absolute GRV showed no impact on both complications and outcome after LSG. Interestingly, higher ratio of GRV/stapler firings was not only linked to decreased intraoperative bleeding and shorter hospital stay but also to higher Excess Body Mass Index Loss (EBMIL) at 12 months after LSG. Conclusions Here, we introduce GRV/stapler firings-ratio as a simple predictive factor for identifying patients at risk for postoperative complications and impaired weight loss that is superior compared with absolute number of stapler firings or GRV alone.

Introduction The most common indication for retroperitoneoscopy in children is poorly functioning kidney, related to reflux or obstruction. Few pediatric urologists attempt to conduct a mass resection operation under retroperitoneoscopy, especially in infants with oncological diseases. Aim In this study, we describe our experience in a series of resection operations under retroperitoneoscopy to demonstrate its safety and efficacy in children, especially in the treatment of pediatric urology tumor. Material and methods A retrospective review of 18 consecutive retroperitoneoscopic resection operations from December 2017 to July 2019 was made. Then a comparison study between retroperitoneoscopy and transperitoneal laparoscopy for exclusively oncological patients was conducted. Results Retroperitoneoscopic surgery was successfully performed on 18 patients, 11 having solid tumors, 2 with cysts, and 5 with nonfunctioning or poorly functioning kidneys. The mean age was 69.5 ±46.9 months. The mean operative time was 138.6 ±57.7 min, while the mean size of the mass was 6.4 ±3.8 cm in the largest diameter. Two patients were converted to open surgery because of large diameter of the mass. The 11 solid tumors which were operated on by retroperitoneoscopic surgery were then compared with 13 consecutive oncological patients undergoing transperitoneal laparoscopy. Retroperitoneoscopy has a lower transfusion rate (p < 0.05) and faster recovery (p < 0.01) compared to transperitoneal laparoscopy. Conclusions This study demonstrates that the resection operation of a renal or adrenal specimen under retroperitoneoscopy is feasible and safe in children. It is useful not only to treat patients with benign diseases but also in oncological patients. Retroperitoneoscopy is a recommended surgical approach for children.

Background: Monopolar transurethral resection of the prostate (M-TURP) has been the gold standard of surgical intervention in patients with benign prostatic hyperplasia with the indication for surgery. This can be achieved using varieties of irrigation fluids. Objectives: To document our experience with M-TURP using water as irrigation fluid in 123 consecutive patients. Materials and Methods: A retrospective study of all patients who had M-TURP with water as irrigation fluid was performed between January 2017 and July 2019. Information retrieved from theatre records and case notes includes patient's socio-demographic data, indications for surgery, intra-operative findings, the volume of resected chips and irrigation fluid used, post-operative complications and patient's satisfaction with the outcome of the procedure. These data were analysed using SPSS version 23. Results: Data from 123 patients were analysed and presented. The age range was 44–96 years with a mean of 69 years. Prostate volume ranges from 13.9 to 276.00 mls with a mean of 95.69 mls while resected prostate volume ranges from 2.0 to 158.0 mls with a mean of 56.68 mls. Volume of the sterile water used as irrigation fluid ranged from 5.0 L to 174.0 L with a mean of 68.7 L. Mean reduction in International Prostate Symptoms Score, improvement in Q-max and reduction in post-void residual urine were 22.1, 16.9 and 141.6 mls, respectively. Transfusion rate was 6.5% while the duration of admission ranges from 1 to 6 days, with a mean of 2.5 days. The overall complication rate was 26.0%. Ninety-six percent were satisfied with the outcome. Conclusion: M-TURP using water as irrigation fluid is safe and is as good as using the more rather expensive glycine or normal saline in bipolar TURP.

Background: Femoral and pelvic osteotomies are potential hemorrhagic interventions where transfusion requirements can be necessary.Objective: We undertook a secondary analysis of patients who underwent femoral and pelvic osteotomy in the initial cohort. The objective of this secondary analysis was to describe intraoperative and postoperative outcomes and to describe intraoperative management in these patients in terms of blood product management, fluid and hemodynamic therapy with the aim of implementing optimization management protocols for postoperative outcome improvement.Methods: A secondary analysis of patients who underwent femoral and pelvic osteotomy surgery was included in the initial retrospective study.Results: There were eighteen patients with a mean age of 104± 47.1 months. Four (22.2%) patients had intraoperative and/or postoperative complications. One patient (5.6%) had intraoperative hemorrhagic shock, two patients (11.1%) had postoperative neurologic failure, and one patient (5.6%) had postoperative wound sepsis. Transfusion rate was 50% in nine patients.Conclusion: Femoral and pelvic osteotomies are interventions where blood, transfusion and fluid requirements can be increased; thus, this implies the necessity of a global patient blood management protocol with point-of-care tests and fluid- and hemodynamic-guided protocols with validated tools in children for intraoperative and postoperative outcome optimization.

Purpose The purpose of this study is to determine whether tranexamic acid (TXA) use was associated with lower rates of blood transfusion in patients undergoing pelvic and/or acetabular fracture surgery. Methods Four studies were included, 3 of which were included in the pooled data analysis for a total of 308 patients. Results The transfusion rate was significantly lower in the TXA group (44%) compared with the non-TXA group (57%) (P = 0.02). Conclusion TXA use was associated with a significantly lower transfusion rate in patients who underwent pelvic and/or acetabular fracture surgery. Level of evidence Level 3. Systematic review of retrospective cohort studies and prospective randomized controlled trials.

OBJECTIVE The aim of this study was to analyze outcomes of open lobectomy (OL), video-assisted thoracoscopic lobectomy (VATS) and robotic-assisted lobectomy (RL). SUMMARY BACKGROUND DATA Robotic-assisted lobectomy has seen increasing adoption for treatment of early-stage lung cancer. Comparative data regarding these approaches is largely from single-institution case series or administrative datasets. METHODS Retrospective data was collected from 21 institutions from 2013-2019. All consecutive cases performed for clinical stage IA-IIIA lung cancer were included. Neoadjuvant cases were excluded. Propensity-score matching (1:1) was based on age, gender, race, smoking-status, FEV1%, Zubrod score, ASA score, tumor size and clinical T and N stage. RESULTS A total of 2,391 RL, 2,174 VATS, and 1,156 OL cases were included. After propensity-score matching there were 885 pairs of RL vs. OL, 1,711 pairs of RL vs. VATS, and 952 pairs of VATS vs. OL. Operative time for RL was shorter than VATS (p < 0.0001) and OL (p = 0.0004). Compared to OL, RL and VATS had less overall postoperative complications, shorter hospital stay (LOS), and lower transfusion rates (all p < 0.02). Compared to VATS, RL had lower conversion rate (p < 0.0001), shorter hospital stay (p < 0.0001) and a lower postoperative transfusion rate (p = 0.01). RL and VATS cohorts had comparable postoperative complication rates. In-hospital mortality was comparable between all groups. CONCLUSIONS RL and VATS approaches were associated with favorable perioperative outcomes compared to OL. Robotic-assisted lobectomy was also associated with a reduced length of stay and decreased conversion rate when compared to VATS.

Mini-Percutaneous Nephrolithotomy (M-PCNL) and Retrograde Intrarenal Surgery (RIRS) are commonly used methods in treatment of kidney stones. The aim of our study is to compare the efficacy and safety of M-PCNL and RIRS in kidney stone treatment over 50 years old patients. A total of 125 patients, 65 of whom had RIRS, and 60 of whom had M-PCNL, were included in the study. Age, gender, BMI (Body-Mass Index), ASA (American Society of Anesthesiology) scores of the patients; stone size, stone location, operation side, ESWL history, HU (Hounsfield Unit) values, hospital stay durations, SFR, complication rates according to Clavien modification system, postoperative hemoglobin loss, postoperative transfusion rates, and patients who needed a secondary operation were recorded. SFR values were calculated in the postoperative third and sixth months. The data between the two groups had similar characteristics in terms of age, gender, BMI, HU, stone size, operation side, stone location, ESWL history, operation time, postoperative transfusion rate, postoperative Clavien complications ( p > 0.05). When the ASA categories were evaluated, the mean ASA scores, ASA I, and ASA II data had similar characteristics in both groups ( p > 0.05). When the ASA 3 scores were evaluated, the number of ASA III patients in the RIRS group was statistically significantly higher ( p

Objectives To evaluate whether continuing the antiplatelet drug acetylsalicylic acid≤100mg (ASA) during Robotic-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) increases the risk of peri-and postoperative hemorrhagic complications and overall morbidity. Indeed, guidelines recommend interrupting antiplatelet therapy before radical cystectomy; however, RARC with ICUD is associated to reduced estimated blood loss and blood transfusions compared to its open counterpart. Methods Data from a multicentric European database were analyzed. All participating centers maintained a prospective database of patients undergoing RARC with ICUD. We identified patients receiving antiplatelet therapy by acetylsalicylic acid ≤100mg. Patients were divided into three groups: those not taking acetylsalicylic acid (no-ASA), those where ASA was continued perioperatively (c-ASA) and those where ASA was interrupted perioperatively (i-ASA). Estimated blood loss and peri-and post-operative transfusions were recorded. Hemorrhagic complications, ischemic, thrombotic and cardiac morbidity was recorded and classified using the Clavien-Dindo score by a senior urologist. Results 640 patients were analyzed. Patients on acetylsalicylic acid were significantly older and had more comorbidities. No significant difference was found for estimated blood loss between no-ASA, c-ASA and i-ASA (280 vs. 300 vs. 200ml respectively; P = 0.09). Similarly, no significant difference was found for intraoperative (5% vs. 9% vs. 11%; P = 0.07) and postoperative transfusion rate (11% vs. 13% vs. 18%; P = 0.17). Higher ischemic complications were noted in the i-ASA group compared to no-ASA and c-ASA (4% vs. 0.6% vs. 1.4%; P = 0.03). On uni and multivariate logistic regression, continuing acetylsalicylic acid was not significantly associated to either major complications or post-operative transfusions. Conclusions Peri-operative acetylsalicylic acid continuation in RARC with ICUD does not increase hemorrhagic complications. Interrupting acetylsalicylic acid peri-operatively may expose patients to a higher risk of ischemic events.

Aims Total hip arthroplasty (THA) using the direct anterior approach (DAA) is undertaken with the patient in the supine position, creating an opportunity to replace both hips under one anaesthetic. Few studies have reported simultaneous bilateral DAA-THA. The aim of this study was to characterize a cohort of patients selected for this technique by a single, high-volume arthroplasty surgeon and to investigate their early postoperative clinical outcomes. Methods Using an institutional database, we reviewed 643 patients who underwent bilateral DAA-THA by a single surgeon between 1 January 2010 and 31 December 2018. The demographic characteristics of the 256 patients (39.8%) who underwent simultaneous bilateral DAA-THA were compared with the 387 patients (60.2%) who underwent staged THA during the same period of time. We then reviewed the length of stay, rate of discharge home, 90-day complications, and readmissions for the simultaneous bilateral group. Results Patients undergoing simultaneous bilateral DAA-THA had a 3.5% transfusion rate, a 1.8 day mean length of stay, a 98.1% rate of discharge home, and low rates of 90-day infection (0.39%), dislocation (0.39%), periprosthetic fracture (0.77%), venous thromboembolism (0%), haematoma (0.39%), further surgery (0.77%), and readmission (0.77%). These patients were significantly younger (mean 58.2 years vs 62.5 years; p < 0.001), more likely to be male (60.3% vs 46.5%; p < 0.001), and with a trend towards having a lower mean BMI (27.8 kg/m2 vs 28.4 kg/m2; p = 0.071) than patients who underwent staged bilateral DAA-THA. Conclusion Patients selected for simultaneous bilateral DAA-THA in a single surgeon’s practice had a 3% rate of postoperative transfusion and a low rate of complications, readmissions, and discharge to a rehabilitation facility. Simultaneous bilateral DAA-THA appears to be a reasonable and safe form of treatment for patients with bilateral symptomatic osteoarthritis of the hip when undertaken by an experienced arthroplasty surgeon with appropriate selection criteria. Cite this article: Bone Joint J 2021;103-B(7 Supple B):116–121.

BACKGROUND The standardized management of anticoagulation during the cardiopulmonary bypass seems inaccurate because of patients and surgeries variability. This study evaluates if an individualized management of heparin and protamine guided by the HMS Plus system during cardiopulmonary bypass could reduce postoperative blood loss. METHODS We conducted a prospective, controlled, unblinded, single-center study. One-hundred and eighthy-eight patients operated for cardiac surgery were included. Patients were divided in ACT Plus group (standardized approach) and HMS Plus group (individualized approach). The primary outcome was blood-loss volume during the first 24 postoperative hours. The main secondary outcomes were the need for allogeneic blood transfusions and the final protamine/heparin ratio. RESULTS There was no difference between the two groups for baseline characteristics. Medium blood-loss volume in the ACT Plus group was 522±260 mL vs. 527±255 mL in the HMS Plus group (P=0.58). The final protamine/heparin ratio in the ACT Plus group was 0.94±0.1 vs. 0.58±0.1 in the HMS Plus group (P

Introduction The use of closed-suction drainage systems after total knee arthroplasty (TKA) is common practice in India, but with no consensus on its use. In this retrospective study, we compared whether clamped or unclamped drainage has any advantages over the other in unilateral TKA. Methods Group-A (n = 351) had an unclamped drain removed at 24 h postoperative, with measurement of total drainage at 24 h between January 2011 and February 2013. Group B (n = 349) had drains kept for a total of 8 h-clamped for the first 4 h and unclamped for a further 4, between March 2013 to September 2016. Drainage volume, as well as the hemodynamic markers-hemoglobin (Hb) drop, transfusion rate were evaluated. Results Mean drain output in Group- A was significantly higher than Group- B (215.64 ml versus 28.34 ml). The postoperative Hb was significantly higher in Group-B (11.46 g/dl versus 10.57 g/dl). Mean Hb drop was significantly higher in Group A (2.16 g/dl versus 1.18 g/dl). The transfusion rates were lower in Group-B, though not statistically significant. Conclusions The 4- hour clamping method effectively reduces drain output and fall in hemoglobin. For those who continue using closed suction drains, clamping could prove to be an effective way of reducing post-operative blood loss and the need for transfusions.

Background Left hepatic trisectionectomy (LHT) is a complex hepatic resection; its’ role and outcomes in hepatobiliary malignancies remains unclear. Materials and methods All patients undergoing LHT at the tertiary HPB referral unit at RSCH, Guildford, UK from September 1996 to October 2015 were included. Data were collected from a prospectively maintained database. Results Twenty-eight patients underwent LHT. The M:F ratio was 1.8:1. Median age was 60 years (range 43–76 years). Diagnoses included colorectal liver metastases (CRLM; n = 20); cholangiocarcinoma (CCA; n = 4); and other (neuroendocrine tumour metastases (NET; n = 3) and breast metastases (n = 1)). Median duration of surgery was 270 min (range 210–585 min). Median blood loss was 750 ml (300–2400 ml) with a perioperative transfusion rate of 21% (n = 6/28). The rate of all post-operative complications was 21% for all patients, and given the extensive resection performed four patients (14%) developed varying degrees of hepatic insufficiency. One patient with cholangiocarcinoma developed severe hepatic insufficiency, which was fatal within 90 days of surgery. 1 and 3-year survivals were 92% and 68% respectively. Conclusion This study supports LHT in patients with significant tumour burden. Despite extensive resection, our favourable morbidity and mortality rates show this is a safe and beneficial procedure for patients with all hepatobiliary malignancies. Given the nature of resection the incidence of post-operative hepatic insufficiency is higher than less extensive hepatic resections., Highlights • LHT is an extended resection reported to have higher incidences of morbidity and mortality compared with less extensive hepatic resections. • This procedure is useful for the surgical management of patients with hepatic lesions that were previously considered unresectable. • We report favourable outcomes following LHT at our institution compared with less extensive hepatic resections. • An initial post-operative lactate of >1.5 mmol/L was associated with an increased risk of developing post-operative complications (p = 0.035).

The current status of robot-assisted radical cystectomy was reviewed 16 years after the initial robot-assisted radical cystectomy for the treatment of invasive bladder cancer. Articles associated with robot-assisted radical cystectomy and written in English were selected from the PubMed database from January 2003 to February 2019. The present review article focused on the distribution of robot-assisted radical cystectomy, patient selection, preoperative management, surgical technique, lymph node dissection, urinary diversion, recurrence pattern, oncological outcomes, cost, learning curve, complications and educational programs. A total of 400 articles were divided according to the country of the first author's affiliation. The USA was the most dominant at 198 (50%), whereas the number of articles from the countries belonging to the Urological Association of Asia was 15 (3.8%) for China, 17 (4.3%) for South Korea, 10 (2.5%) for Japan, eight (2%) for Taiwan, eight (2%) for Turkey and one (0.2%) for Iran. The percentage of robot-assisted radical cystectomy carried out is increasing, and intracorporeal urinary diversion and ileal neobladder are also frequently carried out. With a refined technique being performed in high-volume centers, robot-assisted radical cystectomy has contributed to the reduction in transfusion rate, length of stay and severe complications; however, it has not yet shown any cancer-specific survival benefits. Robot-assisted radical cystectomy is not fully spread throughout the Urological Association of Asia. Further investigation with respect to worldwide results is needed to prove the real benefit of robot-assisted radical cystectomy regarding low morbidity, reduced total medical cost, and survival benefit. In the era of precision medicine, appropriate drug and surgery will be given based on each genetic profile.

Objective: To compare bleeding and transfusion rate between patients who undergo standard transurethral resection of the prostate (TURP) and patients who undergo DRY CUT® TURP.Materials and methods...

Introduction: Endoscopic strip craniectomy with helmeting (ESCH) has been shown to be a safe and efficacious alternative to fronto-orbital remodeling (FOR) for selected children with craniosynostosis. In addition to clinical factors, there may be economic benefits from the use of ESCH instead of FOR. Methods: A retrospective review of 23 patients with nonsyndromic unicoronal craniosynostosis (UCS) treated with FOR was carried out at Great Ormond Street Hospital (GOSH) for Children in London, UK. Secondary data were used for the ESCH cohort from a paper published by Jimenez and Barone (2013). Data were collected on surgical time, transfusion rates, length of hospital stay, adverse event rates, reintervention rates, and overall costs. Costs were categorized and then assigned to the appropriate data sets. Results: The mean age of patients undergoing FOR (vs. ESCH) was 17.4 mo (vs. 3.1 mo) with a mean surgical time of 234 min (vs. 55 min), mean transfusion volume of 221.6 mL (vs. 80.0 mL), mean transfusion rate of 14/23 (vs. 2/115), and a total immediate overnight stay of 3.13 days (vs. 97% next-day discharge). The FOR group had a higher adverse event rate (5/23 vs. 4/115, p=

Background We evaluate tranexamic acid use in high-risk shoulder arthroplasty patients, hypothesizing that tranexamic acid will decrease transfusion rates in patients with low preoperative haematocrit. Methods A retrospective review of shoulder arthroplasty patients with preoperative anaemia compared those treated with and without perioperative tranexamic acid. Inclusion criterion was any shoulder arthroplasty with a preoperative haematocrit (Hct) Results Of the 435 arthroplasties performed, 109 patients had preoperative Hct Discussion Perioperative tranexamic acid in high-risk shoulder arthroplasty patients with preoperative Hct

OBJECTIVES The current trends in RBC use and pre- and post-transfusion Hb levels were analysed to improve practice and to provide international comparison. BACKGROUND Indications for RBC transfusion have changed with growing scientific evidence. The lowest acceptable haemoglobin (Hb) level has decreased, and transfusing single units instead of pairs has become the new standard. Evidence-based guidelines and patient blood management (PBM) programmes increase clinician awareness of rational RBC use. In Finland, however, no formal PBM programme has been established to date. METHODS The study was registry-based, retrospective and observational. All RBC transfusions for adult patients from 2011 to 2016 in the southern region of Finland were analysed. RESULTS RBC usage decreased from 34·9 to 27·5 units per 1000 population (P

Background: Transfusion is a known risk of total hip arthroplasty (THA). It has been associated with a multitude of medical complications and increased cost. Prior studies report transfusion rates associated with THA, with wide variation, but most cannot differentiate the surgical approach utilized. The anterior approach (AA) for THA has been associated with increased operative time, complications, and blood loss, but little data exists regarding the actual transfusion rate associated with the approach. Methods: We performed a retrospective review of 390 consecutive, elective, primary unilateral AA THA procedures. Patient demographic, clinical and perioperative data was analyzed. A modern perioperative pathway, including a simple protocol to limit blood loss, is defined. Results: The group consisted of a typical inpatient arthroplasty population, with wide ranges of age, body mass index (BMI), and health status. The average age was 64.05 years (+ 10.67, range 27-94). BMI averaged 29.76 kg/m2 (+ 5.98, range 16-47). The majority of patients were American Society of Anesthesiologists (ASA) class 2 (45.6%) or 3 (50.3%), with 10 patients ASA 4 (2.6%). Average preoperative hemoglobin was 13.48 g/dL (+ 1.47, range 9.1-18.2). Operative time averaged 91.22 minutes (+ 14.2). 83.3% of patients received a spinal anesthetic. Most patients were discharged on postoperative day one (93.1%) to home (99%). Estimated blood loss averaged 264mL (+ 95.19, range 100-1000). No patient required perioperative transfusion or readmission for symptomatic anemia within 30 days postoperative. Conclusion: A modern protocol we utilize and define is capable of limiting blood loss and transfusion risk in anterior approach total hip arthroplasty.

BACKGROUND Aim of our study was to evaluate learning curve of the Millin simple prostatectomy analysing three expert laparoscopic surgeons. METHODS Learning curve of 3 expert laparoscopic surgeons with excellent radical prostatectomy training was evaluated. Surgeon 1 had more than 20 years of experience, while other surgeons had 10 years of experience. The first 45 procedures of the surgeons were considered for analysis. The cumulative sum (CUSUM) technique, one of the methods developed to monitor the performance and quality of the industrial sector, was adopted to analyse learning curves. The variables included to evaluate learning curve of the surgeons were: operative time (OT), hospitalisation (HO) and complication rate. RESULTS Overall 135 patients were included in the analysis. Median age was 68 (64/74), median prostate volume was 83 (75/97), median Qmax 9 ml/s (6/11) and median IPSS 20 (18/22). Complications included: 9/135 (7%) transfusion, 4/135 (3%) Urinary retention, 3/135 (2%) fever, 1/35 (

Study Objective To determine the impact of uterine tourniquet on blood loss and transfusion rates during myomectomy. Design This study is a systematic review and meta-analysis. Electronic databases were searched from inception until October 3, 2020, for relevant articles. Setting Two reviewers independently screened all studies and extracted the data for the meta-analysis. Patients or Participants Studies involving pre-menopausal patients with benign, symptomatic uterine fibroids undergoing open, laparoscopic, or robotic myomectomy were included. Studies with pregnant or postmenopausal patients were excluded. Interventions Use of a tourniquet around the uterine isthmus and/or the infundibulopelvic ligament compared to control group which received no blood conservation intervention. Measurements and Main Results Five studies published between 2005 to 2020 were included, involving a total of 369 patients. 198 patients had a tourniquet used intra-operatively. All patients underwent open myomectomy. Three studies were randomized control trials and two were retrospective cohort studies. Estimated blood loss was significantly lower in the tourniquet group, with an effect size of 330 mL, z = 4.35, p Conclusion The use of uterine tourniquet at the time of abdominal myomectomy decreases blood loss and may decrease post operative transfusion. The intervention is inexpensive, simple and does not increase operative time or complications. Further high-quality research is needed.

Background: The aim of this study was to compare the outcomes of unstable intertrochanteric femur fractures treated with cementless calcar-replacement bipolar hemiarthroplasty (CRH) and proximal femoral nail (PFN) in elderly patients. Methods: All consecutive unstable intertrochanteric fractures treated with cementless CRH or PFN at our institution between January 2015 and January 2019 were reviewed retrospectively. The primary outcome measures were postoperative complications, reoperation rate, and hip function. The secondary outcome measures were intraoperative blood loss, transfusion rate, surgical time, hospital stay, and two- year mortality. Results: Ninety-four patients in the hemiarthroplasty group and 77 patients in the PFN group were included for analysis. There were no significant differences between the two groups regarding the complications, ASA score, and reoperation rate. Significant differences were found between hemiarthroplasty and PFN group in comparison of the average length of hospital stay (P < 0.05), time from hospitalization to operation (P < 0.05), intraoperative blood loss (P < 0.001), transfusion rate (P < 0.001), operation time (P < 0.001), Harris Hip Score (HHS; P < 0.001), and two-year mortality (P < 0.05). Conclusion: Both hemiarthroplasty and PFN produce satisfactory results in surgically treated unstable intertrochanteric femur fractures in the elderly. Both groups are associated with their own complications, but in the PFN group, better functional results, less surgery-related trauma, and lower mortality rates are the main advantages.

To examine admission and transfer patterns of isolated low-grade renal trauma given lack of evidenced based guidelines.We employed a retrospective cohort design to analyze patients with low grade renal trauma from 2005 to 2018. We used an Abbreviated Injury Score (AIS)3 for non-abdominal categories to ensure that intensive care unit admission/hospital transfer was due to renal trauma (n = 87). Treatment and discharge survival were compared.Mean age for floor (n = 31) and intensive care unit (ICU) (n = 46) patients were 33 (IQR = 20) and 42 (IQR = 46) years old, respectively. Mean injury severity score (ISS) was 7.7 (IQR 4) for floor and 8 (IQR=3.75) for ICU admissions (P = .61) Mean ISS was 7.53 (IQR = 4) for transfers and 8.27 (IQR = 3.25) for non-transfers (P = .26). Blood products were administered only to 3 (6.5%) ICU patients all over 60 years old. Fourteen (45.1%) and 26 (56.5%) of floor and ICU admissions were transferred from a lower-level trauma center. ICU mean length of stay (LOS) was 37 hours (IQR = 23 h.). Mean hospital LOS was 43.4 hours and 71.9 hours for the floor and ICU patients (P = .08), and 69.02 hours and 52.58 hours for transfer vs non-transferred (P = .31). All patients were discharged alive and the majority (94%) was discharged home.Given expedient ICU discharge, low transfusion rate, and low complication rate, inter-hospital transfer and ICU admission are unnecessary for patients under 65 years. Transfer and admission protocols for isolated renal trauma are needed to avoid resource overutilization.

Introduction and objectives Preoperative renal artery embolization (PRAE) for large renal masses may be performed prior to nephrectomy in order to simplify the procedure and reduce intraoperative bleeding. The objective of this work is to determine the role of PRAE on intraoperative bleeding and postoperative complications in left renal tumors with tumor thrombus limited to the left renal vein (level 0). Material and methods Retrospective analysis to evaluate 46 patients who underwent left radical nephrectomy and thrombectomy for the treatment of renal cell carcinoma with level 0 tumor thrombus during the period 1990–2020. PRAE was limited to those cases in which surgical access to the main renal artery was presumed a priori difficult in the preoperative imaging study (n = 9; 19.6%). Intraoperative bleeding was estimated based on the perioperative transfusion rate, and postoperative complications were categorized according to the Clavien–Dindo classification. The Chi-squared test was used for comparisons. A multivariate analysis was performed to identify predictors of transfusion and complications. Results There were no significant differences in the overall complication rate (11.1% vs. 32.4%, p = 0.19), major complication rate (0% vs. 8.1%, p = 0.51), or transfusion rate (11.1% vs. 19%, p = 0.49) between both groups (PRAE vs. non-PRAE). In the multivariate analysis, PRAE did not behave as a predictor of complications (OR: 0.11, 95%CI 0.01–2.86; p = 0.18) nor transfusion (OR: 0.46, 95%CI 0.02–7.38; p = 0.58). Conclusions In our study on left RCC with level 0 tumor thrombus and difficult access to the main renal artery, PRAE was not associated with increased bleeding or postoperative complications, and it did not behave as an independent predictor of these variables. Therefore, it could be used as a preoperative maneuver to facilitate vascular management in selected cases.

Background: Cardiovascular surgeries increase the risk of receiving blood transfusions. Erythropoietin stimulating agents (ESAs) have been used to decrease the transfusion rate. The objective of this study was to evaluate the administration of blood products post-cardiothoracic surgery after receiving ESAs. Methods: This is a single-center, retrospective cohort study. Results: Between May 2017 to May 2018, 52 adult patients underwent cardiac surgery and received ESAs pre-operatively and/or post-operatively. A total of 35 patients were included in the study and 21 (60%) patients did not require a blood transfusion while 14 (40%) patients required a blood transfusion ( p = 0.597). The change in hemoglobin (Hgb = 0.773 g/dL, 1.7 g/dL; p = 0.002) and hematocrit (Hct = 2.31%, 4.3%; p = 0.04) was significantly different in patients who received ESAs alone versus ESAs with blood transfusion. Adverse drug reactions showed no significant difference between groups. Conclusions: In patients undergoing cardiac surgery, ESAs did not significantly reduce the need for blood transfusion. Future and larger studies are necessary to evaluate the effect of ESAs on blood transfusion.

Background There are concerns that trainee performed knee arthroplasty (KA) may adversely affect patient outcomes. Demand for KA is projected to increase, and trainees must therefore be competent to perform it. Methods A systematic literature search was performed identifying articles comparing outcomes following trainee versus consultant surgeon performed primary KA. Outcomes included rate of revision surgery, rate of infection, operation time, length of stay and functional outcomes. A meta-analysis was conducted using Odds ratios (ORs) and weighted mean differences (WMD). A quality assessment of studies and qualitative analysis was performed. Results The analysis included 9 studies of 92,309 arthroplasties, 80,655 were performed by consultants, 11,654 by trainees. The mean age was 69.2. There was no significant difference between the two groups’ rate of revision (OR 0.79; 95% CI 0.61–1.02; p = 0.07. Trainees were associated with a lower rate of infection (5 studies; OR 0.75; 95% CI 0.58–0.97; p = 0.03). There was no difference in the rate of neurological deficit, transfusion rate or thrombosis. There was no difference in operation time (5 studies; WMD 3.50; 95% CI −3.9–10.89; p = 0.35). The trainee group had less favourable functional outcome scores (7 studies; WMD −1.26; 95% CI −1.44–−1.07; p Conclusions The study suggests that supervised trainees can achieve similar outcomes to consultant surgeons and in selected cases, trainee performed supervised KA is therefore safe and effective.

Background: As percutaneous renal biopsies (PRBs) are increasingly performed by radiologists, an increase in the use of 18-gauge automated needle stands to compromise adequacy. We compare the adequacy and safety of PRB with 14-, 16-, and 18-gauge automated needles. Methods: PRB of native (N-592) and transplant (T-1,023) kidneys was performed from January 2002 to December 2019 using real-time ultrasound. Baseline clinical and laboratory data, biopsy data (number of cores, total glomeruli, and total glomeruli per core), and outcome (hematoma on renal US at 1-h, complications, and transfusion) were collected prospectively. PRB with N14g (337) versus N16g (255) and T16g (892) versus T18g (131) needles were compared. A p value of Results: PRB with an 18-g needle yielded the lowest number of total glomeruli per biopsy (N14g vs. N16g: 33 ± 13 vs. 29 ± 12, p < 0.01 and T16g vs. T18g: 34 ± 16 vs. 21 ± 11, p < 0.0001), significantly fewer total glomeruli per core (T16g vs. T18g: 12.7 ± 6.4 vs. 9.6 ± 5.0, p < 0.001 and N16g vs. T18g: 14.2 ± 6.3 vs. 9.6 ± 5.0, p < 0.001). A hematoma by renal US 1-h post-PRB was similar for native (14g–35% vs. 16g–29%, p = 0.2), and transplant biopsies (16g–10% vs. 18g–9%, p = 0.9) and the complication rate for native (14g–8.9% vs. 16g–7.1%, p = 0.5), transplant biopsies (16g–4.6% vs. 18g–1.5%, p = 0.2) and transfusion rate for native (14g–7.7% vs. 16g–5.8%, p = 0.4), and transplant biopsies (16g–3.8% vs. 18g–0.8%, p = 0.1) were similar irrespective of needle size. Conclusions: PRB of native and transplant kidneys with the use of a 16-gauge needle provides an optimal sample. However, our experience in transplant biopsies suggests the use of an 18-gauge needle stands to jeopardize the diagnostic accuracy of the PRB while not improving safety.

Objectives:. The purpose of this study was to evaluate potential differences in time to surgery, bleeding risk, wound complications, length of stay, transfusion rate, and 30-day mortality between patients anticoagulated with direct oral anticoagulants (DOACs) and those not anticoagulated at the time of evaluation for an acute hip fracture. Design:. Retrospective chart review Level III Study. Setting:. One university-based hospital in Rochester, NY. Patients/Intervention. : Patients 65 years and older undergoing operative treatment of a hip fracture over a 5-year period. Chart review identified patients on DOAC therapy at the time of injury as well as an age and sex-matched control group not on anticoagulation. Main outcome measurements. : Demographics, procedure type, admission/postoperative laboratory work, perioperative metrics, transfusion metrics, discharge course, reoperation, readmission, wound complications, and 30-day mortality were obtained for comparison. Results:. Thirty-six hip fractures anticoagulated on DOACs were compared to 108 controls. The DOAC group had delays to operative treatment (27.6 h, SD 16.3 h, 95% CL [22.0–33.1]) vs the control group (19.8 h, SD 10.5 h, 95% CL [17.7–21.8], P = .01). No differences were found in estimated blood loss, procedure time, or change in hemoglobin. Transfusion rates were not significantly different between groups (58.3% DOAC vs 47.2% control, P = .25). No difference in reoperation, readmission, wound complication, deep venous thrombosis rates, or 30-day mortality rates were found. Conclusion:. Patients presenting on DOAC therapy at the time of hip fracture have a delay to surgery compared with age and sex-matched controls, but no increase in short term complications or mortality rates. Expedited surgery (within 48 h) appeared to be safe and effective treatment for hip fracture patients on DOAC therapies.

Objective To assess the use of an evidence-based oxytocin protocol for management of the third stage of labor to decrease non-beneficial clinical variation and improve clinical outcomes. Design This is a cohort study of pregnant patients delivering before implementation of an evidence-based oxytocin protocol compared to patients delivering after implementation of an evidence-based oxytocin protocol. Setting A level III maternal care referral hospital with an average delivery volume of approximately 3000 deliveries. Participants Pregnant patients delivering over a 60-month period from January 2013 to December 2017. Intervention An evidence-based oxytocin protocol: 3 units of oxytocin administered over 3 minutes, with a second 3-unit bolus if inadequate tone, then oxytocin infusion at 18 units/hour × 1 hour and then 3.6 units/hour for 3 hours. Main outcome measures Postpartum hemorrhage (PPH) rate (EBL ≥500 ml for vaginal and ≥1000 ml for cesarean). Results Data from 14 603 deliveries were analyzed, 8408 pre-protocol and 6195 post-protocol. We demonstrated a significant decrease in PPH from 5.2% to 2.9% (P Conclusion A standardized oxytocin infusion protocol in the third stage of labor resulted in a significant decrease in PPH for both vaginal and cesarean deliveries.

Introduction: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) led to an extensive reorganization of the healthcare system in Italy, with significant deferment of the treatment of urology patients. We aimed to assess the impact of deferred treatment during the SARS-CoV-2 pandemic on the need for blood transfusions in 3 Italian urology departments. Methods: We reviewed hospital chart data on blood transfusions at the urology units of 3 academic centers in the north of Italy from March to April 2020. Data were compared with values from the same time frame in 2019 (March to April 2019). Results: We observed significant reductions of the number of patients admitted to the urology units from March to April 2020 (373 vs. 119) and the number of performed surgeries (242 vs. 938) compared to 2019. Though, the number of transfused blood units was comparable between the 2 years (182 vs. 252), we found a greater mean number of blood units transfused per admission in 2020 (0.49 vs. 0.22; p < 0.0001). As a whole, the transfusion rate for hematuria was higher in 2020 than in 2019 (36 vs. 7.9%; p < 0.0001). Discussion/Conclusion: The observed increased number of blood transfusions needed throughout the SARS-CoV-2 era could have had a negative impact on both patients and the healthcare system. It is possible to speculate that this is the consequence of a delayed diagnosis and deferred treatment of acute conditions.

The application of patient blood management (PBM) combined with tranexamic acid administration (TXA) results in decreased total blood loss volume (TVB) and transfusions in total hip replacements (THRs). Dosages, timing, and routes of administration of TXA are still under debate as all these aspects, as well as interpatient variations, may affect the efficacy of the protocol. This study aims to examine the effectiveness of timing and route of administration of TXA in combination with PBM by reducing the TBV following THR surgery. Consecutive primary uncemented THRs operated by a single surgical and anaesthetic team had the data prospectively collected and then retrospectively studied. Five treatment groups were formed, reflecting the progressive evolution of our protocol. Group 1 included patients managed with PBM alone (preoperative erythrocyte mass optimisation to at least 14 g/dL haemoglobin (Hb), hypotensive spinal anaesthesia and restrictive red blood cell transfusion criteria). Group 2 included patients with PBM and topical 3 g TXA diluted in normal saline to a total volume of 50 mL. Group 3 were patients with PBM and an IV dose of 20 mg/kg TXA at induction, followed by 20 mg/kg TXA as a continuous infusion for the duration of the operation. Group 4 consisted of patients managed as per Group 3 plus another 20 mg/kg TXA at three-hour post-procedure. Group 5 (combined): PBM and IV TXA as per Group 4 and topical TXA as per Group 2. A generalised linear model with the treatment group as an independent variable was modelled, using TBV as the dependent variable. The transfusion rate for all groups was 0%. TBV at 24 h, oscillated from 613.5 &plusmn, 337.63 mL in Group 1 to 376.29 &plusmn, 135.0 mL in Group 5. TBV at 48 h oscillated from 738.3 &plusmn, 367.3 mL (PBM group) to 434 &plusmn, 155.2 mL (PBM + combined group). The multivariate regression model confirmed a significant decrease of TBV in all groups with TXA compared with the PBM-only group. Overweight and preoperative Hb were confirmed to significantly influence TBV. The optimal regime to achieve the least TBV and a transfusion rate of 0% requires PBM and one loading 20 mg/kg dose of TXA, followed by continuous infusion of 20 mg/kg for the duration of the operation in uncemented THRs. Additional doses of TXA did not add a clear benefit.

Background Despite decreasing transfusion rates, routine type and screens are frequently used before primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). The aims of this study were to characterize transfusion rates and identify any factors that affect the likelihood of transfusion to determine if it is safe to discontinue routine preoperative type and screens at an academic hospital. Methods A retrospective chart review was performed for all patients who underwent primary THA or TKA in 2019 at an academic institution by a fellowship-trained arthroplasty surgeon. Data on preoperative type and screens, transfusion rates, bleeding disorders, and anticoagulation status were obtained. Patients were considered to have a preoperative type and screen if it was performed within 30 days before surgery. Results Overall, 379 patients were included in the study. Of these, 210 underwent primary THA and 169 underwent primary TKA. Four patients received transfusions during their hospitalization for a cumulative transfusion rate of 1.06%. No patients received an intraoperative transfusion. One (0.59%) patient received a postoperative transfusion after TKA, and 3 (1.43%) patients received a postoperative transfusion after THA. The mean preoperative hemoglobin of the 4 transfused patients was 10.8 g/dL. Conclusions In summary, performing a preoperative routine type and screen is likely unnecessary at academic medical centers. Consideration for obtaining a type and screen may include complex primary surgeries or when patients have preoperative hemoglobin of less than 11 g/dL. Ultimately, preoperative type and screen should be considered on a case-by-case basis using clinical judgment.

Background Blood product utilization in injured children is poorly characterized; the decision to prepare products or transfuse patients can be difficult due to a lack of reliable evidence of transfusion needs across pediatric age-groups and injury types. We conducted an audit of transfusion practices in pediatric trauma based on age, injuries, and mechanism of injury. Methods We reviewed and cross-referenced blood product transfusion practice data from the trauma registry and the anesthesia transfusion record database at a level 1 pediatric trauma center over a 10-year period. Demographic data, injury severity scores, and survival statistics were obtained from the trauma registry. Transfusion rates are reported separately for hospital admission and for intraoperative transfusions for procedures performed during the first two hospital days. Descriptive statistical analysis was used to compare specific groups based on age, injury type, and mechanism of injury. Results We report 14 569 trauma admissions of 14 606 patients. The transfusion rate during the admission was 1.56% (227/14 569). 4591 (30.9%) admissions had surgical interventions in first two days of hospitalization with an intraoperative transfusion rate of 2.98%. Patients younger than one year had the highest transfusion rate during admission (2.8%), and the highest transfusion rate during surgical procedures performed in the first two days of the admission (18.87%). Admissions due to vascular injuries had the highest transfusion rates in infancy followed by hollow visceral injuries in adolescents (71.4% and 25%, respectively). Vascular injuries in most age-groups also had high transfusion rates ranging from 11% in 5- to 9-year age-group to 71% in infants. Mechanisms with the highest transfusion rates were firearm wounds in patients older than one year and vehicular accidents for patients younger than one year. Conclusions The overall blood product needs in the pediatric trauma population are low (1.56%). Selected populations requiring higher rates of need include infants younger than one year, and children with thoracic and vascular injuries. Understanding transfusion patterns is important to optimize resource allocation.

BACKGROUND Transfusion patterns in Sweden have not been characterized on a nationwide level. STUDY DESIGN AND METHODS We conducted a nationwide descriptive cohort study in Sweden from 2008 to 2017. Data on blood donors, donations, component manufacture, transfusions, and transfused patients were extracted from Swedish portion of the Scandinavian Donations and Transfusions (SCANDAT3-S) database. RESULTS A total of 708 436 patients received 5 587 684 red cell, plasma, or platelet transfusions during the study period. The age-standardized transfusion rate decreased markedly during the study period for red cell units (from 53 to 39 units/1000 persons) and plasma units (from 11 to 4.9 units/1000 persons), but remained relatively constant for platelet concentrates. The transfusion rate was 30%-40% higher in males than in females in the first year of life, and higher in males over 45 years than in females. Between age 20 and 45, the majority of red cells were transfused to female patients with obstetric indications, whereas trauma was the predominant indication for male contemporaries. In females over 80 years, the largest proportion of red cells were administered due to trauma. Overall, hematological patients received 36% of all platelet units. There were large regional differences in transfusion rates for red cell units, ranging from less than 30 to greater than 60/1000 persons. CONCLUSION Transfusion rates in Sweden remain high but have decreased strikingly during the study period - with the exception of platelet transfusions. Based on the available data, it is difficult to draw firm conclusions about whether transfusion rates can be further reduced.