ESPU Meeting on Saturday 11, June 2022, 11:35 - 12:40
11:35 - 11:38
S23-1 (OP)
Nicolas FERNANDEZ 1, Daniel LOW 2, Mark CAIN 1, Paul MERGUERIAN 1 and Martin LYNN 2
1) Seattle Childrens Hospital - University of Washington, Urology, Seattle, USA - 2) Seattle Childrens Hospital - University of Washington, Anesthesia, Seattle, USA
PURPOSE
The aim of this project was to increase capacity in the operating room by reducing the time in “anesthesia ready to cut time” (surgical prepping time). Success would mean the team was able to care for more patients without extending their working day.
MATERIAL AND METHODS
Adaptive Clinical Management approach using AdaptX was used to identify variation in practice amongst surgeons. Outliers with the best prepping times were identified. A common prepping time protocol was developed based on their input. Whole group implemented the new protocol. Prepping times were evaluated before and after interventions. Balancing measures included time for last case end and prevalence of surgical siste infections.
RESULTS
A total of 2506 patients were included for analysis with 1333 prior to intervention and 1173 after.
Baseline prepping time was 13.7 minutes. Providers with best prepping times were 11.21 minutes. Team leader implementated new prepping protocol with consistent special cause variation and average prepping time of 14.63 minutes prior and 11.6 minutes after implementation. All surgeons adopted the new protocol and average prepping time improved from 13.77 to 11.97 minutes. An overall increase from 70 to 90 cases per month was identified after protocol implementation. ‘Last Case End Time’ before was 15.7 min over the end of block time and - 20.8 minutes (earlier expected block end) after. No increase in surgical site infections was noticed during the study period.
CONCLUSIONS
Adaptive clinical management allows to identify and implement changes supported by real-time data. Standardized prepping protocols in high-volume outpatient centers demonstrated a feasible and sustainable model to improve capacity. This improvement may reflect as an additional $2.5 million dollare additional revenue for the institution.
11:38 - 11:41
S23-2 (OP)
Caroline JAMAER, Camille BERQUIN, Piet HOEBEKE, Erik VAN LAECKE and Anne-Françoise SPINOIT
Ghent University Hospital, Urology, Ghent, BELGIUM
PURPOSE
To make teaching as efficient as possible, increasing attention has been given to surgical learning curve and curriculum measuring proficiency. Limited data is however available on the perception of teaching moments and the different experiences by a resident, fellow and supervisor. We report variations in stress levels (SL) in controlled identical teaching settings.
MATERIAL AND METHODS
A prospective observational study was conducted between November 2021 and January 2022 in a tertiary referral centre, FEAPU accredited teaching site. A last year resident, a FEBU certified fellow and a FEBU FEAPU certified urologist wore the Garmin ConnectTM activity-tracker when operating to record their SL, based on heart rate variability. The activity-tracker scales SL between 0 and 100 into: Resting state (RS:0-25), Low stress (LS:26-50), Medium stress (MS:51-75), High stress (HS:76-100). Procedures included orchidopexies, RA pyeloplasties and ureteral reimplantations.
RESULTS
The resident's stress level remained stable during all procedures (MS) regardless operating or assisting. Teacher's SL was impacted by the type and difficulty of surgery: higher stress levels were observed during procedures with higher complication risks (HS during RA pyeloplasty compared to RS during orchidopexy) and in RA procedures, despite use of dual console. Lower SL were correlated to higher teacher's proficiency in the procedure (RS for orchidopexy, MS for ureterreimplantation, HS for RApyeloplasty).
CONCLUSIONS
This study focuses on SL while teaching surgical procedures in the mentor versus the mentee. Knowledge of variations in SL while teaching might help improve proficiency curriculum, hopefully leading to better patient care. Larger studies are needed to confirm these initial series.
11:41 - 11:44
S23-3 (OP)
Roger ANTHONY IDI 1, Ganesh VYTHILINGAM 1, Abraham CHERIAN 1, Imran MUSHTAQ 1, David DE BEER 2 and Navroop JOHAL 1
1) Great Ormond Street Hospital for Children, Urology, London, UNITED KINGDOM - 2) Great Ormond Street Hospital for Children, Anaesthesia, London, UNITED KINGDOM
PURPOSE
There are no paediatric urological studies evaluating the economic benefits of ERAS. This study aims to provide evidence that implementation of ERAS pathway leads to a reduction in the average treatment costs.
MATERIAL AND METHODS
In this prospective study, a cost-analysis of 13 patients who underwent urological reconstruction in a single institution between 2019-2021 was performed and compared to a non-ERAS cohort of matched patients (18 patients).
Primary outcomes were the average unit cost per patient and mean length of stay (LOS) while the secondary outcomes were number of 30-day of unplanned readmissions. Complications were defined by Clavien-Dindo (CD)
Cost calculations were generated from the electronic medical record system and assigned into 7 domains to identify area of savings.
RESULTS
The average unit cost per patient under ERAS amounted to £20 078 compared to £26 147 for non-ERAS patients. This amounted to a savings of £6 069 (Table1). There was a 5-day reduction in mean LOS.
Table 1: Cost savings as defined by different categories
|
COST CATEGORY |
ERAS/NON-ERAS |
DIFFERENCES/SAVINGS% |
|
WARD COSTS/STAFFING |
£8080/£11244 |
-£3164/52.1% |
|
|
|
|
|
THEATRE |
£10908/£12358 |
-£1450/23.9% |
|
|
|
|
|
PHARMACY/DRUGS |
£540/£493 |
£47 |
|
|
|
|
|
BLOODS/PATHOLOGY |
£236/£664 |
-£428/7.1% |
|
|
|
|
|
DIAGNOSTICS |
£135/£364 |
-£229/3.8% |
|
|
|
|
|
ALLIED-RESOURCES |
£159/£556 |
-£397/6.5% |
|
|
|
|
|
MISCELLANOUS |
£20/£468 |
-£448/6.6% |
2 from the ERAS cohort required readmissions. (CD 1 and CD3b) While, there was 1 readmission within the non-ERAS group (CD3b)
CONCLUSIONS
Implementation of the ERAS protocol led to a reduced mean LOS which translated to a reduction in the average unit cost per patient
11:47 - 11:50
S23-5 (OP)
Timothy LITTLE and Stephen ADAMS
Waikato Hospital, Paediatric Surgery, Hamilton, NEW ZEALAND
PURPOSE
The recent COP26 meeting has seen countries commit to more concrete proposals than ever before in the fight against climate change. Much has been written on sustainability in the last 2 years, with WHO guidance published in 2020. NZ has announced that the public sector should be carbon neutral by 2025.
MATERIAL AND METHODS
The seven most frequently performed elective paediatric urological procedures were identified, as well as their minimally invasive equivalents (no robotic surgery is performed at our centre). All equipment required was identified and kilograms of carbon dioxide equivalents (kgCO2e) calculated by established conversion factors. Energy use was estimated from data on consumption for the theatre block. Staff travel was estimated using the distances travelled and average emissions per km.
RESULTS
The kgCO2e per procedure ranged from approximately 8 for a circumcision to 30 for a laparoscopic pyeloplasty. Across the board, laparoscopic procedures were more energy intensive than open procedures. By far the biggest contributor to emissions was staff transport.
CONCLUSIONS
Whilst clinical decision-making should be primarily based on clinical need, where there is equivalence, there is an opportunity to reduce the carbon footprint of a procedure. Given travel is a major contributor to the carbon footprint of procedures, hospitals should be active in encouraging less carbon intensive modes of transport. Surgery in regional centres should be undertaken where possible, enabling reduction in the travel of patients and caregivers.
12:10 - 12:13
S23-6 (OP)
Aznive AGHABABIAN, Sahar EFTEKHARZADEH, Sameer MITTAL, Katherine FISCHER, John WEAVER, Karl GODLEWSKI, Connie TAN, Natalie PLACHTER, Dana WEISS, Christopher LONG, Mark ZAONTZ, Thomas KOLON, Stephen ZDERIC, Douglas CANNING and Jason VAN BATAVIA
Children's Hospital of Philadelphia, Department of Surgery, Division of Urology, Philadelphia, USA
PURPOSE
Opioid stewardship is an important clinical priority and our group previously reported marked reductions in narcotic administration after implementation of an opioid reduction protocol for pediatric ambulatory urologic surgery. We hypothesized that a similar decrease in post-operative and discharge opioid administration has occurred after inpatient reconstructive surgery without an accompanying increase in short-term adverse events.
MATERIAL AND METHODS
All pediatric patients undergoing open or robotic-assisted laparoscopic pyeloplasty or ureteral reimplantation between 2015 and 2019 were included. Patient demographics, opioid and NSAID quantity (inpatient and at discharge), urology related ED visits, readmissions, and reoperations within 30 days of surgery were aggregated.
RESULTS
438 patients, median age of 3.5 years (IQR 1.5-8.3) at surgery, met inclusion criteria. Annual rates of inpatient opioid administration and prescriptions decreased significantly over the study period while annual rates of intra-operative, inpatient, and prescribed NSAIDs significantly increased. When comparing patients that were not prescribed opioids at discharge to those that were, we did not find an impact on urology related ED visits, readmissions, or reoperations within 30 days of surgery. Multivariate regression showed that when controlling for age and procedure, patients who did not receive opioids at discharge were not at a higher risk of complications and were at a lower risk for having unplanned encounters including ED visit, readmission, or reoperation (OR:0.5, 95%CI: 0.2-0.9, p=0.04).
CONCLUSIONS
Opioid administration after open and robotic-assisted laparoscopic pediatric urinary tract reconstruction can be drastically reduced without impacting unplanned encounters, readmissions or complications.
12:13 - 12:16
S23-7 (OP)
Sander GROEN IN T WOUD 1, Wout FEITZ 2, Nel ROELEVELD 1, Michiel SCHREUDER 3 and Loes VAN DER ZANDEN 1
1) Radboud University Medical Center, Department for Health Evidence, Radboud Institute for Health Sciences, Nijmegen, NETHERLANDS - 2) Radboud University Medical Center, Radboudumc Amalia Children's Hospital, Department of Urology, Radboud Institute for Molecular Life Sciences, Nijmegen, NETHERLANDS - 3) Radboud University Medical Center, Radboudumc Amalia Children's Hospital, Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Nijmegen, NETHERLANDS
PURPOSE
A solitary functioning kidney (SFK) in children is a condition leading to increased risks of kidney injury, although it is unclear to which magnitude. Our objective was to investigate the risk and risk factors for kidney injury in children with SFK.
MATERIAL AND METHODS
Children with congenital or acquired SFK were recruited in 36 hospitals throughout The Netherlands. Information on risk factors for and signs of kidney injury were collected from electronic patient files. Kaplan-Meier models were used to estimate survival without signs of kidney injury and Cox regression was used to evaluate risk factors.
RESULTS
Detailed clinical information was available from 944 patients with SFK. After a median follow-up of 9.9 years, proteinuria was present in 68 patients (7%), a GFR <90 ml/min/1.73m2 in 290 (31%), and high blood pressure in 323 (34%), while antihypertensive medication was used by 84 patients (9%). In total, 553 patients (59%) exhibited at least one sign of kidney injury and cumulative proportions of children with kidney injury were 23% at 5 years, 43% at 10 years, 63% at 15 years, and 76% at 18 years of age. Being overweight at last follow-up showed the strongest association with kidney injury (hazard ratio 1.9, 95% confidence interval 1.2-3.1).
CONCLUSIONS
Data from this largest SFK cohort so far indicate that 76% of patients with SFK will have signs of kidney injury at 18 years of age, which stresses the need for specific long term follow-up protocols. Being overweight was associated with kidney injury, indicating the importance of lifestyle management.
12:16 - 12:19
S23-8 (OP)
Romy GANDER 1, Marino ASENSIO 1, Gloria Fatou ROYO 1, Montserrat AGUILERA 1, Gabriela GUILLÉN 1, José Andrés MOLINO 1, Mercedes PÉREZ 2, Alejandra CASTRILLO 1 and Manuel LÓPEZ 1
1) University Hospital Vall d'Hebron, Pediatric Surgery, Barcelona, SPAIN - 2) University Hospital Vall d'Hebron, Interventional Radiology, Barcelona, SPAIN
PURPOSE
Nonoperative management (NOM) of blunt renal trauma (BRT) in children is currently standard of care and seems to be reliable and safe even in high-grade renal injuries (HGRI) (grade IV-V). The aim of this study was to evaluate the outcomes and complications of NOM of HGRI.
MATERIAL AND METHODS
Retrospective study of pediatric patients sustaining HGRI and treated at our institution between January 2002-December 2021. Injury grade was assigned according to the AAST injury severity scale. All patients were initially managed nonoperatively, regardless of injury grade. Failure of NOM was considered as the need for operative intervention within the first 72 hours. Percutaneous Angioembolization (PA) was considered as NOM.
RESULTS
Out of 72 patients with renal injuries treated at our center, 22 were HGRI (20 grade IV and 2 grade V). Mean age at the time of injury was 12 years (SD: 3.7).Hematuria was present in all patients. Four (18.2%) presented hemodynamic instability at time of admission but had a favorable response to initial resuscitation.
All patients were managed initially non-operatively. Seven (31.8%) underwent angiography due to signs of active bleeding at CT:4 were subjected to angioembolization and 1 stent insertion owing to renal artery thrombosis. Eight (36,4%) had urinary extravasation at inicial CT.
NOM was successful in 20/22 (90.9%) patients: 1 emergent nephrectomy after angiography due to vascular amputation and 1 urgent nephrectomy at 24 hours due to persistent bleeding.
Complications of NOM appeared in 10 (45.5%): pseudoaneurysm (1), arteriovenous fistula (1), pleural effusion (1), persistent urinary leak (5) and hematuria with clots (2). Four out of 10 required further angioembolization. Only 2/5 patients with persistent urinary leakage required urological intervention. Mean follow-up was 119 months (SD: 68).
CONCLUSIONS
NOM of HGRI is effective. Complications of NOM, even if not uncommon, can be treated conservatively as well. In our series, urological intervention for persistent urinary leakage was rarely needed.
12:19 - 12:22
S23-9 (OP)
Roberto LOPES 1, Fernanda BACHEGA 2, Caio SUARTZ 1, Francisco DÉNES 1, Berenice MENDONCA 2 and Maria Candida FRAGOSO 2
1) Pediatric Urology Unit, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, Urology, São Paulo, BRAZIL - 2) Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, Endocrinology, São Paulo, BRAZIL
PURPOSE
Pediatric adrenocortical tumor (TACP) is a rare neoplasm (0.3/million). The aim of this study is to analyze the criteria associated with the presence of metastasis (M) from TACP in a cohort of patients from a tertiary center.
MATERIAL AND METHODS
Retrospective analysis of epidemiological, hormonal, histopathological, genetic and radiological data from 102 patients with TACP. Histology review (Weiss score, modi]ed Weiss, Weineke), TNM and McFarlane staging, genetic analysis (KI67), overall and disease-free survival were performed.
RESULTS
The analyses have shown that 90% of patients were from the South/Southeast region, the F/M gender ratio was 2.4/1, with no difference between groups (p>0.05). The OS of groups non metastatic (NM) and M was 20.7 and 12 years, respectively (p=0.02); 17% of patients died and 2 relapsed. Age at diagnosis was higher in group M than in NM (7.9±6.9 vs 4.9±5.6 years, p=0.002), as was size (9.6±4.8 vs 4.7 ±2.1cm, p<0.01), weight (340±419 vs 55.3±74cm, p<0.01); WEISS (6.6±1.8 vs 4±2 p<0.01), Modified WEISS (5.1±1.3 vs 3.6±2, p<0.01), KI67 (27% vs 12 %, p<0.05) and mitotic index (0.4±0.3 vs 0.17±0.2, p=0.04). McFarlane IV was more associated with group M than NM; 77% of patients had the TP53 variant (no difference between groups, p>0.05) and 15% of these had the pathogenic variant of MSH6 or MLH1. Patients in the NM group and with a family history do not tend to develop metastasis (p<0.01). Tumor hormone secretion did not correlate with biological behavior (p>0.05 between groups): virilization 53.2%, virilization with Cushing's syndrome (CS) 34%, CS 7.4%, feminization 4.3% and 1 non-functioning tumor. The surgical technique did not affect the patient's outcome, as there was no tumor rupture.
CONCLUSIONS
Parameters such as weight, size, age at diagnosis,Weiss, modi]ed Weiss,KI67 and mitotic index may be predictors of malignancy in patients with TACP guiding therapeutic decisions.