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Objective: This study was designed to examine the impact of patient socioeconomic, clinical, and hospital characteristics on the utilization of robotics in the surgical staging of endometrial cancer., Methods: Patients surgically treated for endometrial cancer at facilities that offered robotic and open approaches were identified from the National Inpatient Sample Database from 2008 to 2012. The groups were compared for socioeconomic, clinical, and hospital differences. Medical comorbidity scores were calculated using the Charlson comorbidity index. T tests and χ (2) were used to compare groups. Multivariable analyses were used to determine factors that were independently associated with a robotic approach., Results: A total of 18,284 patients were included (robotic, n = 7169; laparotomy, n = 11,115). Significant differences were noted in all patient clinical and socioeconomic characteristics and all hospital characteristics. Multivariable analyses identified factors that independently predicted patients undergoing robotic surgery. These patients were older [adjusted odds ratio (aOR) 1.008; 95 % confidence interval (CI) 1.004-1.011], white (aOR 1.38; 95 % CI 1.27-1.50), and privately insured (aOR 1.16; 95 % CI 1.07-1.26). Clinically, these women were more likely to be obese (aOR 1.20; 95 % CI 1.11-1.30) and to be undergoing an elective case (aOR 1.25; 95 % CI 1.11-1.40). Hospitals were more likely to be under private control (aOR 1.55, 95 % CI 1.39-1.71) but less likely to be located in the south (aOR 0.87; 0.81-0.93), quantified as large or medium (aOR 0.57; 95 %CI 0.50-0.67), or teaching hospitals (aOR 0.68; 95 % CI 0.63-0.74)., Conclusions: Socioeconomic status and hospital characteristics are factors that independently predict robotic utilization in the United States. These racial, socioeconomic, and geographic disparities warrant further study regarding the utilization of this important technology.

Background: Older patients are at increased risk of perioperative morbidity and mortality. There are limited data on the safety of a robotic approach in the staging for endometrial cancer., Objective: We compared outcomes in women undergoing laparotomy or robotic surgical staging for endometrial cancer., Study Design: Using the Healthcare Cost and Utilization Project National Inpatient Sample database from 2008 through 2010, we abstracted records for patients who had surgery for endometrial cancer with either a robotic approach or laparotomy. Patients were categorized by age (<65 vs ≥65 years and 5-year increments). Medical comorbidity scores were calculated using the Charlson Comorbidity Index. Outcomes included intraoperative/perioperative/medical complications, death, length of stay (LOS), and discharge disposition. Student t and χ(2) tests were used to compare groups and approach. Multiple analysis of variance models were used to compare differences between robotics and laparotomy and age groups., Results: We identified 16,980 patients who had surgery for endometrial cancer with either a robotic approach (age ≥65 years, n = 1228; age <65 years, n = 1574) or laparotomy (age ≥65 years, n = 5914; age <65 years, n = 8264). Older patients had a higher Charlson Comorbidity Index score at the time of surgery (2.6 vs 2.5, P < .001). In laparotomy cases, intraoperative complication rates were similar (4.1% vs 3.7%, P = .17). Older patients had higher rates of perioperative surgical (20.5% vs 15.4%, P < .001) and medical (23.3% vs 15.5%, P < .001) complications, longer LOS (5.1 vs 4.2 days, P < .001), and lower rates of discharge to home (71.2% vs 90.1%, P < .001). In robotic cases, rates of intraoperative complications were similar (5.9% vs 6.8%, P = .32). Older patients had higher rates of perioperative surgical (8.3% vs 5.2%, P = .001) and medical (12.3% vs 6.7%, P = .001) complications, longer LOS (2.00 vs 1.67 days, P < .001), and lower rates of discharge to home (88.8% vs 96.8%, P < .001). With both approaches, as age increased, perioperative surgical and medical complications also increased in a linear fashion. In a subanalysis of older patients (n = 7142), there were lower rates of perioperative surgical (8.3% vs 20.5%, P < .001) and medical (12.3% vs 23.3%, P < .001) complications, death (0.0% vs 0.8%, P < .001), shorter LOS (2.00 vs 5.13 days, P < .001) and higher rate of discharge to home (88.8% vs 71.2%, P < .001) in robotic compared to laparotomy cases., Conclusion: Although the risks of surgery increase with age, in patients age ≥65 years, a robotic approach for endometrial cancer appears to be safe given current selection criteria utilized in the United States., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: This study sought to determine the association between preoperative chemotherapy and postoperative morbidity and mortality in ovarian cancer patients., Methods: The American College of Surgeons National Surgical Quality Improvement Program was used to identify women who underwent surgery for ovarian cancer between 2005 and 2012. The women were divided into two groups based on whether they had received chemotherapy within 30 days before surgery or not. Preoperative variables, intraoperative measures, and postoperative morbidity and mortality were compared using χ(2) and Student's t test. Multivariable analyses using logistic regression modeling were used to correct for potential confounding variables., Results: Of 1807 patients, 1612 (89.2%) underwent primary surgery, and 195 (10.8%) received preoperative chemotherapy. The chemotherapy group had a lower preoperative platelet count (317,640 vs 249,740 plt/μL; P < 0.001), hematocrit (36.9 vs 33.1%; P < 0.001), and white blood cell (WBC) count (7970 vs 6060 WBC/μL; P < 0.001). Postoperatively, the chemotherapy group had a higher rate of organ/space infection (2.2 vs 4.6%; P = 0.04; odds ratio [OR], 2.12; 95% confidence interval [CI], 1.01-4.47) and a higher blood transfusion rate (17.1 vs 32.3%; P < 0.001; OR, 2.31; 95% CI, 1.67-3.20). A subanalysis of only those with disseminated cancer showed myelosuppression and an increased blood transfusion rate in the chemotherapy group. In multivariable analyses, preoperative chemotherapy, hematocrit, and ascites were independent predictors of postoperative blood transfusion in the entire cohort, whereas preoperative chemotherapy was the only independent predictor of postoperative blood transfusion in the disseminated cancer group., Conclusions: Preoperative chemotherapy for the treatment of ovarian cancer is associated with myelosuppression and an increased risk of postoperative blood transfusion.

Objectives: Endometrial cancer is a hormonally responsive malignancy. Response to progestins is associated with estrogen receptor (ER) and progesterone receptor (PR) status. CD133 is a marker of endometrial cancer stem cells. We postulated that CD133+ cells express ER and PR and that progestin therapy differentially regulates CD133+ cells., Methods: The Ishikawa (ER/PR positive) and KLE (ER/PR negative) cell lines were examined for the presence of CD133 populations. Cell lines were treated with 30.4μM medroxyprogesterone 17-acetate (MPA) for 6days. After treatment, cell counts, apoptosis assays and CD133+ populations were examined. In a clinical project, we identified 12 endometrial cancer patients who were treated with progestin drugs at our institution. Using immunohistochemistry, CD133, ER, PR, and androgen receptor (AR) expression was scored and evaluated for change over time on serial biopsies., Results: CD133+ populations were identified in Ishikawa and KLE cell lines. MPA treatment resulted in a significant reduction in the percentage of live cells (Ishikawa, P=0.036; KLE, P=0.0002), significant increase in apoptosis (Ishikawa, P=0.01; KLE, P=0.0006) and significant decrease in CD133+ populations (Ishikawa, P<0.0001; KLE, P=0.0001). ER, PR, AR and CD133 were present in 96.4%, 96.4%, 89.3% and 100% of patient samples respectively. Paralleling the in vitro results, CD133 expression decreased in patients who had histologic response to progestin treatment., Conclusion: CD133+ populations decreased after treatment with MPA in an in vitro model and in patients responding to treatment with progestins. Progestin treatment differentially decreases CD133+ cells., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective. Gelatin-thrombin matrix (GTM) tissue sealant use was previously identified as an independent predictor of pelvic infection following hysterectomies. We aim to elucidate contributing factors by assessing influence of GTM on bacterial colony formation and characterizing bacteria present at the vaginal cuff. Methods. Escherichia coli was incubated in phosphate-buffered saline (PBS) and pelvic washings with and without GTM to assess influence on colony formation. Pelvic washings of the vaginal cuff were collected from hysterectomies occurring from June through October 2015. In vitro techniques, 16S rRNA gene qPCR, and 16S amplicon sequencing were performed with washings to characterize bacteria at the vaginal cuff. Results. Mean bacterial colony formation in PBS was greater for E. coli incubated in the presence of GTM (1.48 × 10(7) CFU/mL) versus without (9.95 × 10(5) CFU/mL) following 20-hour incubation (p = 0.001). Out of 61 pelvic washings samples, 3 were culture positive (≥5000 CFU/mL) with Enterococcus faecalis. Conclusion. In vitro experiments support a facilitating role of GTM on colony formation of E. coli in PBS. However, given the negative results of surgical site washings following adequate disinfection, the role of GTM in promoting posthysterectomy pelvic infections may be limited. Analysis of pelvic washings revealed presence of E. faecalis, but results were inconclusive. Further studies are recommended.

Background: This study aimed to assess the safety of robotic surgery for older women undergoing surgery for endometrial cancer., Methods: A retrospective chart review of women undergoing surgery for endometrial cancer between October 2010 and December 2012 was conducted at the authors' institution. This cohort was divided by age (≥65 vs <65 years) and surgical approach (laparotomy vs robotic surgery). Postoperative morbidity and mortality were compared using standard statistical analysis., Results: Of 228 patients identified, 73 (32 %) were 65 years old or older, and 98 (43 %) had undergone robotic surgery. Among the robotic surgery patients, women 65 years old or older had a higher Charlson comorbidity score (7.6 vs 4.9; p < 0.01) and were more likely to undergo pelvic lymphadenectomy (73 vs 39 %; p < 0.01). The complication rates did not differ between the groups except for increased urinary retention in the older group (15 % vs 3 %; p = 0.04). Older patients had a longer hospital stay (2.2 vs 1.3 days; p < 0.01) and a similar rate of discharge home (100 vs 96 %; p = 0.09). For the patients 65 years old or older, robotic surgery was associated with less blood loss (131 vs 235 ml; p = 0.03), a lower rate of ileus (0 vs 15 %; p = 0.04), a lower perioperative surgical complication rate (4 vs 30 %; p = 0.01), a shorter hospital stay (2.2 vs 4.4 days; p < 0.01), and a similar rate of discharge home (96 vs 91 %; p = 0.45) compared with laparotomy., Conclusion: Robotic surgery appears to be associated with less postoperative morbidity than laparotomy for endometrial cancer staging in women 65 years old or older. The complication rates after robotic surgery were similar between the two age groups.

Renal cyst infection-pyocystis-is a potentially life-threatening complication of autosomal-dominant polycystic kidney disease. Differentiation of pyocystis from pyelonephritis is important for antibiotic management. A 56-year-old woman with autosomal-dominant polycystic kidney disease and recurrent urinary tract infections was admitted to the hospital with suspicion of pyelonephritis. CT and static planar In-labeled WBC examinations failed to show a specific focus of infection. Abdominal imaging with In-labeled WBC SPECT/CT revealed abnormal leukocyte accumulation within a solitary right renal cyst. Precise SPECT/CT localization of the infected renal cyst is illustrated along with comparative CT images.

A 29-year-old female patient exhibited a solitary neck mass, severe hypercalcemia, and multiple skeletal lytic lesions consistent with metastatic neoplastic disease. Fine-needle aspiration (FNA) cytology of the neck lesion indicated a follicular thyroid neoplasm. CT-guided bone biopsy was non-diagnostic. Subsequent 18F-FDG PET/CT examination demonstrated avid glucose uptake within the neck mass and diffuse bony lesions of variable metabolic activity. Repeat biopsy utilizing PET/CT guidance produced core tissue with classic histologic features of a brown tumor. Postoperative histology revealed an exclusively oncocytic parathyroid adenoma. Atypical radiotracer uptake of this rare functioning adenoma subtype is illustrated with discussion of improved procedural diagnostic yield utilizing PET/CT.

Objective: This study aims to examine the prognostic importance of preoperative cervical cytologic diagnosis with atypical glandular cells (AGC) or malignant cells (MC) as a predictor of poor outcomes in endometrial cancer., Materials and Methods: A total of 563 patients were surgically staged for endometrial adenocarcinoma from 2002 to 2012 at our institution. Of these patients, 106 were included to perform a case-control study (39 patients with AGC or MC and 67 controls). Included patients were not significantly different from excluded patients and were matched for age, race, and body mass index. Outcome variables included presence of extrauterine disease (International Federation of Gynecology and Obstetrics stage ≥II) and high intermediate risk (HIR) disease. Further analysis sought to improve the prediction combining AGC or MC with other factors, such as grade and CA-125 levels. Standard statistical analyses were used., Results: Among the patients with AGC or MC, 53.8% had HIR disease compared with 30.3% with normal cervical cytologic diagnosis (odds ratio [OR], 2.68; 95% confidence interval [CI], 1.18-6.09; P = 0.02). Extrauterine disease was found in 43.6% of patients with AGC or MC compared with that of 15.2% in patients with normal cervical cytologic diagnosis (OR, 4.33; 95% CI, 1.72-10.90; P < 0.01). Multivariate analysis confirmed that AGC or MC was an independent predictor of HIR disease (OR, 8.41; 95% CI, 1.34-52.78; P = 0.02) and extrauterine disease (OR, 4.78; 95% CI, 1.26-18.1; P = 0.02). The combination of elevated CA-125 levels with AGC or MC cervical cytologic diagnosis increased the statistical prediction of extrauterine disease (OR, 13.3; 95% CI, 3.1-56.8; P < 0.01) and HIR disease (OR, 5.83; 95% CI, 1.44-23.71; P = 0.02)., Conclusions: Patients with AGC or MC on preoperative cervical cytology are at risk for extrauterine and HIR disease. These preoperative findings should warn surgeons of the potential of extrauterine or occult metastatic disease.

Background and Objectives: The degradation in robotic skills that occurs during periods of robotic surgical inactivity in newly trained surgeons was measured. The role of animate training in robotic skill was also assessed., Methods: Robotically naive resident and attending surgeons underwent training with the da Vinci robot on needle passage (DN), rocking ring transfer peg board (RPB), and running suture pod tasks (SP). Errors were established to convert actual time to adjusted time. Participants were deemed "proficient" once their adjusted times were within 80% of those set by experienced surgeons through repeated trials. Participants did not use the robot except for repeating the tasks once at 4, 8, and 12 weeks (tests). Participants then underwent animate training and completed a final test within 7 days., Results: Twenty-five attending and 29 resident surgeons enrolled; 3 withdrew. There were significant increases in time to complete each of the tasks, and in errors, by 4 weeks (Adjusted times: DN: 122.9 +/- 2.2 to 204.2 +/- 11.7, t = 6.9, P < .001; RPB: 262.4 +/- 2.5 to 364.7 +/- 8.0, t = 12.4, P < .001; SP: 91.4 +/- 1.4 to 169.9 +/- 6.8, t = 11.3, P < .001). Times decreased following animate training, but not to levels observed after proficiency training for the RPB and SP modules., Conclusions: Robotic surgical skills degrade significantly within 4 weeks of inactivity in newly trained surgeons. Animate training may provide different skills than those acquired in the dry lab.

Objective: The purpose of this study was to use MRI of the shoulder to analyze the axillary arch muscle and its anatomic relations to lymph nodes and the brachial plexus., Materials and Methods: In this retrospective study at a single clinic, five observers blinded to the patient's condition assessed images from 1,109 consecutive initial shoulder MRI examinations for the presence and anatomic relations of the axillary arch. MRI interpretation reports were reviewed for documentation of previous injuries and upper extremity radicular pain or numbness for possible correlations between presence of the arch and symptoms of nerve entrapment. Results were reported as prevalence percentage or mean ± SD with 95% CI. Groups were compared by use of Student's t test or chi-square test as indicated (p < 0.05)., Results: An arch muscle was found in 71 of 1,109 (6%) examinations, and variability was found in arch insertion and visualization. A statistically significant 65 of 71 (92%) arches had a course superficial to the lymph nodes. The insertion of 50 of 71 (70%) arches was within 5 mm of the brachial neurovascular bundle. Excluding documented injuries, significantly more patients with an arch had upper extremity neurologic abnormalities than did patients without an arch (p = 0.02)., Conclusion: The axillary arch muscle is situated in such a way that it can conceal lymph nodes and impinge on the brachial plexus, causing symptoms of upper extremity nerve entrapment. Radiologists' familiarity with the arch can improve their recognition of this muscular variant so that they can communicate appropriate clinical correlations to referring physicians.

The new means and modalities of communication and information technologies have significantly revolutionized access to surgical education. The introduction of the Internet information highway into mainstream clinical practice as an information sharing medium offers a wide range of opportunities to healthcare professionals. High-speed Internet broadcasting allows the display of high-quality full-screen videos. Access to surgical procedures through the Internet already plays a major role in continuing medical education nowadays and will undoubtedly be gaining grounds in the future. WebSurg.com, the World Virtual University, a web-based surgical university, is dedicated to minimally invasive laparoscopic surgery. Using brand-new multimedia data, the electronic university provides thorough descriptions of over 150 procedures in minimal access surgery and 265 videos of surgical interventions. Such a teaching tool recreates all the prerequisites and requirements of a traditional School of Medicine, incorporating the manifold standpoints of world-renowned experts about specific topics and hands-on hints in various surgical specialities. Following the evolution of technologies, recent advances have made it possible to display items of Websurg.com on handheld devices (personal data/digital assistance also known as PDAs, Pocket PCs, and smart phones). Integrating all these elements into a unique World Virtual University, Websurg.com epitomizes the concept of a unified academic center providing teaching and tutorials administered by international experts. The Internet assuredly contributes to the worldwide diffusion of scientific information in an easy and user-friendly way.

A malignant mesenchymoma arising in the spermatic cord of a 79-year-old patient is described. The radiologic appearance was that of a predominantly calcified mass. Histologically the tumor was composed primarily of malignant cartilage. In other areas there were spindle-shaped cells and large eosinophilic and multinucleated giant cells. Staining for intermediate filaments revealed vimentin throughout the neoplasm with some areas showing positive staining for desmin, the latter confirming the muscular origin of some of the neoplastic elements. No cytokeratins were identified, effectively ruling out the possibility of a malignant teratoma.