DIAGNOSTIC UROLOGY, URINARY DIVERSION AND PERIOPERATIVE CARE
to schedule postoperative appointments. For the remaining 29% of patients in this group 94% of visits were deemed medically unnecessary and were usually precipitated by anxiety or some unrelated issue. Patients and families are increasingly reluctant to spend time driving in traffic, parking and waiting to be seen for simple face-to-face reassurance. At the same time providers are reluctant to allocate clinic time and resources for unnecessary and uncompensated visits. Evidence is mounting (mostly from international centers) that patients prefer the convenience of telephonic or electronic followup strategies. The success of these limited protocols depends on clear, detailed instructions and patient responsibility. The other side of the coin argues that defensive medicine is needed to protect against lawsuits if complications should ensue. As urological manpower in this country becomes increasingly scarce, allocation of health care resources must be purposeful and impactful. This is especially true at regional referral centers, where travel costs may be considerable. I congratulate the authors of this thoughtful study, and I agree that this type of thinking is safe and intelligent. Allen F. Morey, MD
Diagnostic Urology, Urinary Diversion and Perioperative Care Re: Increased Intra-Abdominal Fat Predicts Perioperative Complications Following Minimally Invasive Partial Nephrectomy M. A. Gorin, J. K. Mullins, P. M. Pierorazio, G. Jayram and M. E. Allaf James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, Maryland Urology 2013; 81: 1225e1230.
Abstract available at http://jurology.com/ Editorial Comment: The authors retrospectively reviewed the preoperative imaging studies of 195 patients who had undergone laparoscopic or robotic partial nephrectomy to determine if there was an association between perioperative complications and body mass index or outer or intraabdominal fat. Intra-abdominal fat was an independent factor in complications. However, outer or intra-abdominal fat and body mass index were not associated with increased operative time or length of hospitalization. Richard K. Babayan, MD
Laparoscopy/New Technology Re: Blunt versus Bladed Trocars in Laparoscopic Surgery: A Systematic Review and Meta-Analysis of Randomized Trials S. A. Antoniou, G. A. Antoniou, O. O. Koch, R. Pointner and F. A. Granderath € nchengladbach, Germany Center for Minimally Invasive Surgery, Hospital Neuwerk, Mo Surg Endosc 2013; 27: 2312e2320.
Abstract available at http://jurology.com/
385
GERIATRICS
386
Editorial Comment: The authors analyzed 8 randomized studies that enrolled 720 patients, and compared trocar associated complications with the use of blunt and bladed trocars. The primary outcome measure was risk of abdominal wall trocar site bleeding, and secondary outcomes were risk of vascular or visceral injuries and overall trocar related morbidity. As expected, the risk of abdominal wall bleeding was threefold greater with bladed trocars (9% vs 3%) and the risk of complications excluding abdominal wall bleeding was also greater (0.7% vs 0.2%), although complications were rare. Use of blunt or dilating trocars for robotic and laparoscopic surgery should be standard. Jeffrey A. Cadeddu, MD
Geriatrics Re: Haematuria and Acute Kidney Injury in Elderly Patients Admitted to Hospital with Supratherapeutic Warfarin Anticoagulation A. K. Lim and D. A. Campbell Department of General Medicine, Monash Medical Centre, Clayton, Victoria, Australia Int Urol Nephrol 2013; 45: 561e570.
Abstract available at http://jurology.com/ Editorial Comment: Older adults frequently have medical conditions that necessitate use of anticoagulation therapy. Chronic anticoagulation can be associated with a number of potential risks and side effects, including hematuria and acute kidney injury. Monitoring anticoagulation status is important to avoid either subtherapeutic or supratherapeutic levels of medication. This study demonstrated that the prevalence of supratherapeutic anticoagulation levels was quite high (54%) among older adults. Rates of acute kidney injury and hematuria were also high at 18.7% and 13.3%, respectively. Hematuria evaluation with contrast based imaging and cystoscopy should be routinely considered because underlying pathological conditions can be found in a substantial proportion of patients. Anticoagulation can unmask these otherwise silent conditions and could subsequently prompt other needed urological treatments. Tomas L. Griebling, MD, MPH
Suggested Reading Davis R, Jones JS, Barocas DA et al: Diagnosis, evaluation and follow-up of asymptomatic microhematuria (AMH) in adults: AUA guideline. J Urol, suppl., 2012; 188: 2473.
Re: Comprehensive Geriatric Assessment Can Predict Postoperative Morbidity and Mortality in Elderly Patients Undergoing Elective Surgery K. I. Kim, K. H. Park, K. H. Koo, H. S. Han and C. H. Kim Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea Arch Gerontol Geriatr 2013; 56: 507e512.
Abstract available at http://jurology.com/
to schedule postoperative appointments. For the remaining 29% of patients in this group 94% of visits were deemed medically unnecessary and were usually precipitated by anxiety or some unrelated issue. Patients and families are increasingly reluctant to spend time driving in traffic, parking and waiting to be seen for simple face-to-face reassurance. At the same time providers are reluctant to allocate clinic time and resources for unnecessary and uncompensated visits. Evidence is mounting (mostly from international centers) that patients prefer the convenience of telephonic or electronic followup strategies. The success of these limited protocols depends on clear, detailed instructions and patient responsibility. The other side of the coin argues that defensive medicine is needed to protect against lawsuits if complications should ensue. As urological manpower in this country becomes increasingly scarce, allocation of health care resources must be purposeful and impactful. This is especially true at regional referral centers, where travel costs may be considerable. I congratulate the authors of this thoughtful study, and I agree that this type of thinking is safe and intelligent. Allen F. Morey, MD
Diagnostic Urology, Urinary Diversion and Perioperative Care Re: Increased Intra-Abdominal Fat Predicts Perioperative Complications Following Minimally Invasive Partial Nephrectomy M. A. Gorin, J. K. Mullins, P. M. Pierorazio, G. Jayram and M. E. Allaf James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, Maryland Urology 2013; 81: 1225e1230.
Abstract available at http://jurology.com/ Editorial Comment: The authors retrospectively reviewed the preoperative imaging studies of 195 patients who had undergone laparoscopic or robotic partial nephrectomy to determine if there was an association between perioperative complications and body mass index or outer or intraabdominal fat. Intra-abdominal fat was an independent factor in complications. However, outer or intra-abdominal fat and body mass index were not associated with increased operative time or length of hospitalization. Richard K. Babayan, MD
Laparoscopy/New Technology Re: Blunt versus Bladed Trocars in Laparoscopic Surgery: A Systematic Review and Meta-Analysis of Randomized Trials S. A. Antoniou, G. A. Antoniou, O. O. Koch, R. Pointner and F. A. Granderath € nchengladbach, Germany Center for Minimally Invasive Surgery, Hospital Neuwerk, Mo Surg Endosc 2013; 27: 2312e2320.
Abstract available at http://jurology.com/
385
GERIATRICS
386
Editorial Comment: The authors analyzed 8 randomized studies that enrolled 720 patients, and compared trocar associated complications with the use of blunt and bladed trocars. The primary outcome measure was risk of abdominal wall trocar site bleeding, and secondary outcomes were risk of vascular or visceral injuries and overall trocar related morbidity. As expected, the risk of abdominal wall bleeding was threefold greater with bladed trocars (9% vs 3%) and the risk of complications excluding abdominal wall bleeding was also greater (0.7% vs 0.2%), although complications were rare. Use of blunt or dilating trocars for robotic and laparoscopic surgery should be standard. Jeffrey A. Cadeddu, MD
Geriatrics Re: Haematuria and Acute Kidney Injury in Elderly Patients Admitted to Hospital with Supratherapeutic Warfarin Anticoagulation A. K. Lim and D. A. Campbell Department of General Medicine, Monash Medical Centre, Clayton, Victoria, Australia Int Urol Nephrol 2013; 45: 561e570.
Abstract available at http://jurology.com/ Editorial Comment: Older adults frequently have medical conditions that necessitate use of anticoagulation therapy. Chronic anticoagulation can be associated with a number of potential risks and side effects, including hematuria and acute kidney injury. Monitoring anticoagulation status is important to avoid either subtherapeutic or supratherapeutic levels of medication. This study demonstrated that the prevalence of supratherapeutic anticoagulation levels was quite high (54%) among older adults. Rates of acute kidney injury and hematuria were also high at 18.7% and 13.3%, respectively. Hematuria evaluation with contrast based imaging and cystoscopy should be routinely considered because underlying pathological conditions can be found in a substantial proportion of patients. Anticoagulation can unmask these otherwise silent conditions and could subsequently prompt other needed urological treatments. Tomas L. Griebling, MD, MPH
Suggested Reading Davis R, Jones JS, Barocas DA et al: Diagnosis, evaluation and follow-up of asymptomatic microhematuria (AMH) in adults: AUA guideline. J Urol, suppl., 2012; 188: 2473.
Re: Comprehensive Geriatric Assessment Can Predict Postoperative Morbidity and Mortality in Elderly Patients Undergoing Elective Surgery K. I. Kim, K. H. Park, K. H. Koo, H. S. Han and C. H. Kim Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea Arch Gerontol Geriatr 2013; 56: 507e512.
Abstract available at http://jurology.com/
