Faculty Bibliography

BACKGROUND:Ileostomies are a routine part of the care of patients with rectal cancer, but are associated with significant risk for dehydration, readmission, and acute kidney injury. Telemedicine has proven beneficial in decreasing readmission in chronic medical illnesses, but its utility in patients with an ileostomy is not well studied. OBJECTIVE:The purpose of this study was to evaluate the feasibility of televideoconferencing in the assessment of ileostomy output. DESIGN/METHODS:An institutional review board-approved, prospective clinical trial was conducted at a single institution from November 2014 through December 2015. SETTINGS/METHODS:The study was conducted in a single, large academic medical center. PATIENTS/METHODS:Patients >18 years of age undergoing surgery with plans for ileostomy were eligible. INTERVENTIONS/METHODS:Televideoconference assessments of ileostomy output and the need for medical intervention were conducted during the postoperative stay and compared with in-person assessment. MAIN OUTCOME MEASURES/METHODS:The primary end point of the trial was the feasibility of using teleconferencing to assess the need for medical intervention, defined as 90% agreement between telemedicine and in-person assessments. Secondary end points included patient/provider satisfaction, and correlative studies examined dehydration events and readmission. RESULTS:Twenty-seven patients underwent 44 teleconferencing assessments of ileostomy output. Compared with in-person treatment decisions, there was a 95% match (95% CI, 85%-99%). The readmission rate for the study participants was 31%, and 18% experienced dehydration events. Both patients and faculty responded favorably to surveys regarding the use of telemedicine in the perioperative period. LIMITATIONS/CONCLUSIONS:The study is limited by its in-hospital use of technology and small sample size. CONCLUSIONS:Televideoconference evaluation is a feasible, reliable means of assessing ileostomy output with high patient and physician acceptance. Our pilot study provides rationale for further study in the postdischarge setting for patients with ileostomies. The incorporation of televideoconference assessment within a teledischarge program may enable early intervention to improve patient outcomes. See Video Abstract at http://links.lww.com/DCR/A455.

OBJECTIVE: To evaluate the association of body mass index (BMI) and spermatic vein diameters (SVDs) in men treated for varicocele. SUBJECTS AND METHODS: One hundred fourteen men who underwent scrotal color duplex ultrasounds prior to microsurgical varicocelectomy were classified as normal (BMI = 18.5-24.9), overweight (25-29.9), or obese (>/=30). SVDs were measured with and without Valsalva, standing and supine. SVD, pre- and postoperative semen analyses (SA) were compared. RESULTS: Forty-six (40.4%) men had normal BMI, 54 (47.3%) were overweight, and 14 (12.3%) were obese. Higher BMI was associated with smaller left testis volume and larger left SVD when supine (with and without Valsalva). The association was absent when standing. Men with higher BMI had smaller differences between their left SVD Valsalva diameters when standing vs supine. There were no differences among BMI classes for right SVD measurements, preoperative SA, and postoperative SA improvement. CONCLUSION: Increased BMI is associated with larger left SVD while supine, suggesting that increased abdominal pressure while recumbent may contribute to varicocele pathology in this population. Interestingly, as in the general population, a majority of the men were overweight.

Multiphoton microscopy (MPM) enables real-time imaging of various cellular processes at submicron resolution. MPM is currently being used in neuroscience, oncology, and immunology. MPM has demonstrated promising results in urology. MPM has been used in the identification of spermatogenesis, evaluation of bladder cancer, and tissue identification in prostate cancer surgery. MPM has allowed the visualization of seminiferous tubules within the testis in a rat model and identified areas of spermatogenesis. MPM could potentially improve the efficacy of testicular sperm extraction. In bladder cancer evaluation, MPM has proven to be an effective imaging tool in identifying areas suspicious for malignancy. The imaging technology could be utilized in the future to provide urologists with an immediate impression of extracted bladder tissue, or as part of a cystoscopic device to evaluate the bladder in real time. Similarly, MPM has proven to be a useful imaging technique to evaluate prostate cancer. MPM could be utilized during a prostatectomy to help differentiate prostate from cavernous nerves that are closely adherent to the prostate. MPM uses a laser and safety studies will need to be performed prior to its utilization in the clinical setting.

Varicocele is the most common correctible cause of male infertility and is present in 15% to 20% of the male population. Despite its prevalence, the pathophysiology of varicocele remains under investigation. One of the largest obstacles in studying varicocele is that it is almost exclusively found in humans. This has necessitated the creation of an animal model of varicocele. The most commonly used animal model involves the creation of a varicocele in a rodent by partially occluding the left renal vein. This model has provided a significant amount of data on varicocele, and a modification of this model utilizing microsurgery appears even more promising. Animal models have proven critical to investigating the pathophysiology of varicocele.

PURPOSE: A rat varicocele model using partial occlusion of the left renal vein was described previously. Reproducibility in creating this model has met with varied success. Alternate routes of testicular venous drainage may negate the effect of partial renal vein occlusion on varicocele creation. We hypothesized that varicocele induction would be more effective if microsurgical ligation of the gonadal venous drainage to the common iliac vein was combined with partial occlusion of the left renal vein. MATERIALS AND METHODS: We randomly assigned a total of 36 rats to 3 groups, including sham surgery, partial renal vein occlusion alone (the classic technique) and microsurgical ligation. Half of the rats in each group were evaluated at 5 and 12 weeks, respectively. We evaluated internal gonadal vein and spermatic cord diameter, testicular weight, cauda epididymal sperm concentration and motility and testicular histology using the Johnsen score as well as serum and intratesticular testosterone and dihydrotestosterone. RESULTS: Five weeks after varicocele creation the microsurgical ligation group had a larger spermatic cord diameter and lower Johnsen scores than rats in the classic technique and sham surgery groups. At 12 weeks the microsurgical ligation group had a larger spermatic cord diameter, lower cauda epididymal sperm concentration, lower sperm motility and worse histology than the classic technique and sham surgery groups. There was no difference in serum androgen outcomes but the microsurgical ligation group had lower intratesticular androgens. CONCLUSIONS: Adding microsurgical ligation of testicular vein collaterals in the pelvis to partial renal vein occlusion appears to improve the effectiveness of creating a rat varicocele model.