No surgical innovation without evaluation: the IDEAL recommendations

Ossiculoplasty in missing malleus and stapes patients: experimental and preliminary clinical results with a new malleus replacement prosthesis with the otology-neurotology database

OBJECTIVE

To present the preliminary results of new malleus replacement prosthesis combined with a total ossicular prosthesis in middle ear reconstruction in patients missing the malleus and stapes.

STUDY DESIGN

Prospective experimental and nonrandomized clinical study.

SETTING

Tertiary referral center.

METHODS

An original titanium malleus replacement prosthesis (MRP) was designed to be inserted into the external auditory canal and to replace a missing malleus for various middle ear pathologies. The MRP was tested experimentally and clinically. The vibratory properties of the new prosthesis were measured using laser Doppler vibrometry. Ninety patients with missing malleus and stapes, undergoing 92 ossicular reconstructions were enrolled in this study from September 1994 to March 2012. Comparative analyses were made between a group of 34 cases of ossicular reconstructions with total prosthesis (TORP) positioned from the tympanic membrane to the stapes footplate (TM-to-footplate assembly) and a group of 58 cases of ossicular reconstructions with TORP positioned from a newly designed malleus replacement prosthesis (MRP) to the stapes footplate (MRP-to-footplate assembly). Preoperative and postoperative audiometric evaluation using conventional audiometry, that is, air-bone gap (ABG), bone-conduction thresholds (BC), and air-conduction thresholds (AC) were assessed.

RESULTS

Experimentally, the vibratory properties of the MRP are promising and remain very good even when the MRP is cemented into the bony canal wall mimicking its complete osseous-integration, if this were to occur. This finding supports the short-term clinical results as in the TM-to-footplate group; the 3-month postoperative mean ABG was 23.3 dB compared with 12.5 dB in the MRP-to-footplate group (difference, 10.8; 95% confidence interval, 4.0-17.6); 37.0% of patients from the TM-to-footplate group had a postoperative ABG of 10 dB or less, and 48.1% of patients had a postoperative ABG of 20 dB or less, as compared with 58.1% and 79.1%, respectively, in the MRP-to-footplate group. The average gain in AC was 11.0 dB in the TM-to-footplate group as compared with 21.3 dB in the MRP-to-footplate group (difference, -10.3; 95% confidence interval, -18.2 to -2.4).

CONCLUSION

The results of this study indicate that superior postoperative hearing thresholds could be achieved using a MRP-to-footplate assembly, compared with a TM-to-footplate assembly in patients with an absent malleus undergoing ossiculoplasty. The postoperative AC thresholds, after 3 months and 1 year, are significantly lower in patients treated with the MRP-to-footplate assembly.

A review of national shoulder and elbow joint replacement registries

BACKGROUND

The aim was to review the funding, organization, data handling, outcome measurements, and findings from existing national shoulder and elbow joint replacement registries; to consider the possibility of pooling data between registries; and to consider wether a pan european registry might be feasible.

MATERIALS AND METHODS

Web sites, annual reports, and publications from ongoing national registries were searched using Google, PubMed, and links from other registries. Representatives from each registry were contacted.

RESULTS

Between 1994 and 2004, 6 shoulder registries and 5 elbow registries were established, and by the end of 2009, the shoulder registries included between 2498 and 7113 replacements and the elbow registries between 267 and 1457 replacements. The registries were initiated by orthopedic societies and funded by the government or by levies on implant manufacturers. In some countries, data reporting and patient consent are required. Completeness is assessed by comparing data with the national health authority. All registries use implant survival as the primary outcome. Some registries use patient-reported outcomes as a secondary outcome.

CONCLUSIONS

A registry offers many advantages; however, adequate long-term funding and completeness remain a challenge. It is unlikely that large-scale international registries can be implemented, but more countries should be encouraged to establish registries and, by adopting compatible processes, data could be pooled between national registries, adding considerably to their power and usefulness.

ASSIST applicability scoring of surgical trials. an investigator-reported assessment tool

Context

We aimed to develop a new tool for assessing and depicting the applicability of the results of surgical randomized controlled trials (RCTs) from the trial investigators' perspective.

Methods

We identified all items related to applicability by a systematic methodological review, and then a sample of surgeons used these items in a web-based survey to evaluate the applicability of their own trial results. For each applicability item, participants had to indicate on a numerical scale that was simplified as a three-item scale: 1) items essential to consider, 2) items requiring attention, and 3) items inconsequential to the applicability of the results of their own RCT to clinical practice. For the final tool, we selected only items that were rated as being essential or requiring attention for at least 25% of the trials evaluated. We propose a specific process to construct the tool and to depict applicability in a graph. We identified all investigators of published and registered ongoing RCTs assessing surgery and invited them to participate in the web-based survey.

Results

148 surgeons assessed applicability for their own trial and participated in the process of item selection. The final tool contains 22 items (4 dedicated to patients, 5 to centers, 5 to surgeons and 8 to the intervention). We proposed a straightforward process of constructing the graphical tool: 1) a multidisciplinary team of investigators or other care providers participating in the trial could independently assess each item, 2) a consensus method could be used, and 3) the investigators could depict their assessment of the applicability of the trial results in 4 graphs related to patients, centers, surgeons and the intervention.

Conclusions

This investigator-reported assessment tool could help readers define under what conditions they could reasonably apply the results of a surgical RCT to their clinical practice.

Laparoendoscopic single-site partial nephrectomy without ischemia for very small, exophytic renal masses: surgical details and functional outcomes

BACKGROUND

Laparoendoscopic single-site surgery (LESS) has emerged as a natural progression from standard laparoscopy aiming to further minimize the morbidity of urologic procedures.

OBJECTIVE

To describe our technique and report the surgical and functional outcomes of unclamped LESS partial nephrectomy (PN) in the treatment of small renal masses (SRMs).

DESIGN, SETTING, AND PARTICIPANTS

Prospective evaluation of pre- and postoperative variables of patients undergoing the LESS-PN without ischemia between 2009 and 2012. The indications were single exophytic SRMs.

SURGICAL PROCEDURE

Unclamped LESS-PN was performed through a transperitoneal approach. A pararectal Hasson access technique was preferred. Single-port access was achieved via different single-port devices. A combination of straight and articulating laparoscopic instruments was used. The tumor was excised using bipolar scissors during normal renal perfusion. Hemostasis was achieved by bipolar electrocautery, parenchymal stitches, and hemostatic agents.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Demographic, operative, postoperative, and pathologic outcomes data were recorded and analyzed.

RESULTS AND LIMITATIONS

A total of 21 LESS-PN were performed (operative time: 111 ± 41 min; blood loss: 196 ± 195 ml: tumor size: 2.0 ± 0.3 cm). Neither conversion to open surgery nor transfusions occurred. Three patients required conversion to standard laparoscopy. Postoperatively, three complications (Clavien grades 2, 3a, and 4) were recorded. Pathologic examination revealed 14 clear cell carcinomas, four renal cysts, two oncocytomas, and one angiomyolipoma. Hospital stay was 4.4 ± 1.9 d. At the last follow-up (mean: 17±11.5 mo), no port-site, local, or distant recurrences were detected. No significant variation in serum creatinine and estimated glomerular filtration rate was observed. Subjective scar evaluation indicated 66% of patients were very satisfied/enthusiastic. Study limitations include the small sample size, the lack of a control group, the short follow-up period, and the arbitrary measure of patient's scar perception.

CONCLUSIONS

Unclamped LESS-PN for selected SRMs is a safe and feasible procedure providing favorable postoperative outcomes and ensuring high levels of subjective, cosmetic satisfaction.

Medium-term effects of a monofilament polypropylene mesh for pelvic organ prolapse and sexual function symptoms

This report is aimed at describing the effects and complications of a polypropylene mesh in standard gynaecological practice. This is single centre prospective cohort observational study performed at a University affiliated hospital in the UK. It involved the prospective symptom assessment of 41 consecutive patients in 2007 who underwent anterior and/or posterior Avaulta Plus™ or Avaulta™ Biosynthetic Support System (BARD). The validated International Consultation on Incontinence Modular Questionnaire - Vaginal Symptoms (ICIQ-VS) was completed in the clinic preoperatively. Postal questionnaires were sent to the patients up to 3 years postoperatively. Preoperatively the mean overall Quality of life (QoL) was 19.78 (SD 9.052) and at follow-up was 1.67 (SD 1.0) with p< 0.008. Mean VAS preoperatively was 15.00 (SD 7.566) and at follow-up was 0.44 (SD 0.882) with p< 0.008. A decrease in this score over time, indicates improved symptoms. In select patients, repair with mesh augmentation using Avaulta™ or Avaulta Plus™ is a safe and effective procedure up to 3 years with a median follow-up of 27 months (range 20-36 months).

[Clinical trials investigating the therapeutic benefit of medical devices in orthopaedics and trauma surgery: practice examples plus commentary]

Patients recognise relevant symptoms of the two leading diseases in orthopaedics and trauma surgery: osteoarthritis and fractures. Treatment effects can be demonstrated by patient reported outcomes. Total hip arthroplasty as an example for standard treatment regimen achieves large treatment effects. It is hard to demonstrate an additional benefit against standard treatment while observing ceiling effects. Alternative instruments are needed. Navigated total knee arthroplasty is done for better control of the postoperative axis as well as to reduce the revision burden. The time interval needed to demonstrate the decrease in revision has not yet passed. Additional benefits of total knee navigation have been observed for certain patient populations and for the training of physicians. These benefits have not been investigated so far. Using registries, expert opinions and case series the desired benefit from the use of medical devices can be shown. Safety is one major aspect of innovative medical devices as an additional benefit. The safety paradigm needs intense investigation in the future. The IDEAL Statement provides the clinical researcher with the methodological framework. The METEOR Statement focused on the medical problem and the possible benefit with using innovative medical devices. Within these recommendations a broad number of study types can be employed to demonstrate the benefits for patients.

The changing landscape of product development and randomized trials

Controversy exists about whether or not similar standards apply to the clinical evaluation of orthopaedic implants and pharmaceuticals. The long-lasting dispute is likely to be abandoned shortly, given that certain regulatory bodies in Europe now mandate proof of effectiveness by randomized controlled trials (RCTs) prior to market approval of innovative devices. This is a timely signal--it will help to strengthen both the credibility of orthopaedic researchers among all health-care disciplines and the role of manufacturers as creative minds and scientific partners. Yet, it must be accompanied by substantial changes in the current trial landscape. Given the level of perfection of available orthopaedic technology, superiority of a new product over an established standard will become a rare finding. Noninferiority or equivalence must be accepted as important trial results by investigators, sponsors, clinicians, and health authorities to enhance the spectrum of therapeutic options and help to individualize patient care. Specific problems are slow recruitment rates and long intervals from the protocol stage to publication of results. This may counteract the innovative potential of a novel product. Pragmatic trial designs, lean but complete documentation, limited but precise end points, the avoidance of competing trials, and the fostering of international collaboration are possible ways to streamline clinical trials of orthopaedic devices. Finally, RCTs should be conducted, conditional to the presumed level of innovation of a new implant, and supplemented by data from registries to fully determine the utility, value, and safety of the intervention.

Hyperthermic isolated limb perfusion for extremity soft tissue sarcomas: systematic review of clinical efficacy and quality assessment of reported trials

BACKGROUND AND OBJECTIVES

Extremity soft tissue sarcomas (STS) are managed with radiotherapy and limb-sparing surgery however aggressive or recurrent cases require amputation. Hyperthermic isolated limb perfusion (HILP) has been proposed as an alternative. Our aim was to systematically review phase II HILP trials, assess tumor response, limb salvage (LS), and quality of scientific publications on this technique.

METHODS

We conducted a literature search of electronic databases (MEDLINE, EMBASE, Scopus, Cochrane Library) and clinical trial registries for phase II HILP trials on non-resectable extremity STS. Outcomes of interest were complete response (CR), partial response (PR), and LS rates. Quality of published trials was assessed using a quality checklist.

RESULTS

Of 518 patients across 12 studies, 408 had some response (CR or PR), and 428 had the limb spared. Median CR, PR, and LS rates were 31%, 53.5%, and 82.5%, respectively. Median Wieberdink loco-regional toxicity rates were 3.8%, 45.5%, 17%, 1%, and 0% for levels 1-5, respectively. No trial fulfilled either all ideal or essential quality criteria. Seven trials did not include statistical methodology.

CONCLUSION

HILP seems effective in treating advanced extremity STS. However, poor publication quality hinders results validity. Technical and methodological standardization, well-designed, multi-institutional trials are warranted.

Reconstructive surgery after female genital mutilation: a prospective cohort study

BACKGROUND

Women who have undergone female genital mutilation rarely have access to the reconstructive surgery that is now available. Our objective was to assess the immediate and long-term outcomes of this surgery.

METHODS

Between 1998 and 2009, we included consecutive patients with female genital mutilation aged 18 years or older who had consulted a urologist at Poissy-St Germain Hospital, France. We used the WHO classification to prospectively include patients with type II or type III mutilation. The skin covering the stump was resected to reveal the clitoris. The suspensory ligament was then sectioned to mobilise the stump, the scar tissue was removed from the exposed portion and the glans was brought into a normal position. All patients answered a questionnaire at entry about their characteristics, expectations, and preoperative clitoris pleasure and pain, measured on a 5-point scale. Those patients who returned at 1 year for follow-up were questioned about clitoris pain and functionality. We compared data from the 1-year group with the total group of patients who had surgery.

FINDINGS

We operated on 2938 women with a mean age of 29·2 (SD 7·77 years; age at excision 6·1, SD 3·5 years). Mali, Senegal, and Ivory Coast were the main countries of origin, but 564 patients had undergone female genital mutilation in France. The 1-year follow-up visit was attended by 866 patients (29%). Expectations before surgery were identity recovery for 2933 patients (99%), improved sex life for 2378 patients (81%), and pain reduction for 847 patients (29%). At 1-year follow-up, 363 women (42%) had a hoodless glans, 239 (28%) had a normal clitoris, 210 (24%) had a visible projection, 51 (6%) had a palpable projection, and three (0·4%) had no change. Most patients reported an improvement, or at least no worsening, in pain (821 of 840 patients) and clitoral pleasure (815 of 834 patients). At 1 year, 430 (51%) of 841 women experienced orgasms. Immediate complications after surgery (haematoma, suture failure, moderate fever) were noted in 155 (5%) of the 2938 patients, and 108 (4%) were briefly re-admitted to hospital.

INTERPRETATION

Reconstructive surgery after female genital mutilation seems to be associated with reduced pain and restored pleasure. It needs to be made more readily available in developed countries by training surgeons.

FUNDING

French Urological Association.

Monitoring the use and outcomes of new devices and procedures: how does coding affect what Hospital Episode Statistics contribute? Lessons from 12 emerging procedures 2006-10

BACKGROUND

New devices and procedures are often introduced into health services when the evidence base for their efficacy and safety is limited. The authors sought to assess the availability and accuracy of routinely collected Hospital Episodes Statistics (HES) data in the UK and their potential contribution to the monitoring of new procedures.

METHODS

Four years of HES data (April 2006-March 2010) were analysed to identify episodes of hospital care involving a sample of 12 new interventional procedures. HES data were cross checked against other relevant sources including national or local registers and manufacturers' information.

RESULTS

HES records were available for all 12 procedures during the entire study period. Comparative data sources were available from national (5), local (2) and manufacturer (2) registers. Factors found to affect comparisons were miscoding, alternative coding and inconsistent use of subsidiary codes. The analysis of provider coverage showed that HES is sensitive at detecting centres which carry out procedures, but specificity is poor in some cases.

CONCLUSIONS

Routinely collected HES data have the potential to support quality improvements and evidence-based commissioning of devices and procedures in health services but achievement of this potential depends upon the accurate coding of procedures.

Meta-analytic comparison of randomized and nonrandomized studies of breast cancer surgery

BACKGROUND

Randomized controlled trials (RCTs) are thought to provide the most accurate estimation of "true" treatment effect. The relative quality of effect estimates derived from nonrandomized studies (nRCTs) remains unclear, particularly in surgery, where the obstacles to performing high-quality RCTs are compounded. We performed a meta-analysis of effect estimates of RCTs comparing surgical procedures for breast cancer relative to those of corresponding nRCTs.

METHODS

English-language RCTs of breast cancer treatment in human patients published from 2003 to 2008 were identified in MEDLINE, EMBASE and Cochrane databases. We identified nRCTs using the National Library of Medicine's "related articles" function and reference lists. Two reviewers conducted all steps of study selection. We included studies comparing 2 surgical arms for the treatment of breast cancer. Information on treatment efficacy estimates, expressed as relative risk (RR) for outcomes of interest in both the RCTs and nRCTs was extracted.

RESULTS

We identified 12 RCTs representing 10 topic/outcome combinations with comparable nRCTs. On visual inspection, 4 of 10 outcomes showed substantial differences in summary RR. The pooled RR estimates for RCTs versus nRCTs differed more than 2-fold in 2 of 10 outcomes and failed to demonstrate consistency of statistical differences in 3 of 10 cases. A statistically significant difference, as assessed by the z score, was not detected for any of the outcomes.

CONCLUSION

Randomized controlled trials comparing surgical procedures for breast cancer may demonstrate clinically relevant differences in effect estimates in 20%-40% of cases relative to those generated by nRCTs, depending on which metric is used.

Use and benefits of laparoscopic hysterectomy for stage I endometrial cancer among medicare beneficiaries

PURPOSE

Laparoscopic hysterectomy is associated with shorter hospital stays, less postoperative pain, and earlier resumption of activity. We analyzed predictors of access to laparoscopy and compared the outcomes of laparoscopic and open hysterectomy for stage I endometrial cancer.

METHODS

Using the SEER-Medicare database we examined women 65 years of age with stage I endometrial cancer who underwent hysterectomy between 1997 and 2005. The associations of patient, tumor, and physician-related factors with use of laparoscopic hysterectomy were analyzed. Surgical quality, morbidity, and survival were compared.

RESULTS

We identified 8,545 patients, including 8,018 (93.8%) who underwent abdominal hysterectomy and 527 (6.2%) who had a laparoscopic hysterectomy. Performance of laparoscopic hysterectomy increased from 3.9% in 1997 to 8.5% in 2005. More recent year of diagnosis, younger age, white race, fewer comorbidities, higher socioeconomic status, lower tumor grade and stage, and residence in a metropolitan area were associated with use of laparoscopy (P < .05 for each). Physician characteristics associated with performance of laparoscopy included training in the United States, specialization in gynecologic oncology, academic practice, and later year of graduation (P < .05 for all). Surgical site complications (odds ratio [OR] = 0.46; 95% CI, 0.30 to 0.71) and medical complications (OR = 0.67; 95% CI, 0.47 to 0.95) were less common in patients who underwent laparoscopy. The route of hysterectomy had no effect on cancer-specific survival (OR = 0.74; 95% CI, 0.38 to 1.44).

CONCLUSION

Despite the fact that laparoscopic hysterectomy for endometrial cancer results in fewer complications, uptake has been slow.

[Barriers to clinical studies involving medical devices]

Clinical trials with medical devices need to be considered in terms of the complexity of surgical procedures. Creating the proper environment for the conduct of trials includes improved academic career opportunities in the field of clinical research, methodological competence, and established structures. The challenges and pitfalls in the design of clinical trials involving medical devices are based on aspects such as blinding, placebo, learning curves and surgeons' expertise. Surgical procedures should be standardised, and a study hypothesis needs to be established which is answerable by a relevant and feasible sample size. Besides the above-mentioned challenges, efficient interactions between authorities, universities, hospitals, and medical device manufacturers are mandatory to allow for quality and relevance of clinical studies in this field.

Health Technology Assessment in Surgery

This review focuses on how surgical methods should be assessed from a health technology perspective. The use of randomized controlled trials, population based registries, systematic literature research and the recently published IDEAL method are briefly discussed.

Advanced technologies in trauma critical care management

Care of critically injured patients has evolved over the 50 years since Shoemaker established one of the first trauma units at Cook County Hospital in 1962. Modern trauma intensive care units offer a high nurse-to-patient ratio, physicians and midlevel providers who manage the patients, and technologically advanced monitors and therapeutic devices designed to optimize the care of patients. This article describes advances that have transformed trauma critical care, including bedside ultrasonography, novel patient monitoring techniques, extracorporeal support, and negative pressure dressings. It also discusses how to evaluate the safety and efficacy of future advances in trauma critical care.

Why I use mesh: a personal perspective

The issue of using vaginally inserted polypropylene mesh is currently much debated. This personal view, stimulated by a live debate on the topic, sets out to look at some of the issues surrounding mesh, and aims to encourage discussion of this matter.

Uterus transplantation: animal research and human possibilities

Uterus transplantation research has been conducted toward its introduction in the human as a treatment of absolute uterine-factor infertility, which is considered to be the last frontier to conquer for infertility research. In this review we describe the patient populations that may benefit from uterus transplantation. The animal research on uterus transplantation conducted during the past two decades is summarized, and we describe our views regarding a future research-based human attempt.

The role of transoral robotic surgery in the management of oropharyngeal cancer: a review of the literature

Background. Transoral robotic surgery (TORS) is an emerging treatment option for the treatment of head and neck malignancies, particularly for oropharyngeal squamous cell carcinoma (OPSCC). Preliminary studies have demonstrated excellent oncologic and functional outcomes that have led to a resurgence of interest in the primary surgical management of OPSCC. The aim of the present study was to review the evidence base supporting the use of TORS in OPSCC. Methods. Studies evaluating the application of TORS in the treatment of head and neck squamous cell carcinoma (HNSCC), and more specifically OPSCC, were identified for review. Further searches were made of reference lists for complete evaluation of minimally invasive surgery (MIS) in treating OPSCC. Results. Seventeen results relating to the application of TORS in treatment of OPSCC were identified. Further results relating to the role of transoral laser microsurgery (TLM) in OPSCC were included for review. Feasibility, oncologic, and functional data is summarized and discussed. Discussion. Management strategies for patients with OPSCC continue to evolve. Minimally invasive surgical techniques including TORS and TLM offer impressive functional and oncologic outcomes particularly for patients with early T-classification and low-volume regional metastatic disease. Potential exists for treatment deintensification, particularly in patients who are HPV positive.

Focal therapy for localised unifocal and multifocal prostate cancer: a prospective development study

Background

Radical whole-gland therapy can lead to significant genitourinary and rectal side-effects for men with localised prostate cancer. We report on whether selective focal ablation of unifocal and multifocal cancer lesions can reduce this treatment burden.

Methods

Men aged 45–80 years were eligible for this prospective development study if they had low-risk to high-risk localised prostate cancer (prostate specific antigen [PSA] ≤15 ng/mL, Gleason score ≤4 + 3, stage ≤T2), with no previous androgen deprivation or treatment for prostate cancer, and who could safely undergo multiparametric MRI and have a general anaesthetic. Patients received focal therapy using high-intensity focused ultrasound, delivered to all known cancer lesions, with a margin of normal tissue, identified on multiparametric MRI, template prostate-mapping biopsies, or both. Primary endpoints were adverse events (serious and otherwise) and urinary symptoms and erectile function assessed using patient questionnaires. Analyses were done on a per-protocol basis. This study is registered with ClinicalTrials.gov, number NCT00561314.

Findings

42 men were recruited between June 27, 2007, and June 30, 2010; one man died from an unrelated cause (pneumonia) 3 months after treatment and was excluded from analyses. After treatment, one man was admitted to hospital for acute urinary retention, and another had stricture interventions requiring hospital admission. Nine men (22%, 95% CI 11–38) had self-resolving, mild to moderate, intermittent dysuria (median duration 5·0 days [IQR 2·5–18·5]). Urinary debris occurred in 14 men (34%, 95% CI 20–51), with a median duration of 14·5 days (IQR 6·0–16·5). Urinary tract infection was noted in seven men (17%, 95% CI 7–32). Median overall International Index of Erectile Function-15 (IIEF-15) scores were similar at baseline and at 12 months (p=0·060), as were median IIEF-15 scores for intercourse satisfaction (p=0·454), sexual desire (p=0·644), and overall satisfaction (p=0·257). Significant deteriorations between baseline and 12 months were noted for IIEF-15 erectile (p=0·042) and orgasmic function (p=0·003). Of 35 men with good baseline function, 31 (89%, 95% CI 73–97) had erections sufficient for penetration 12 months after focal therapy. Median UCLA Expanded Prostate Cancer Index Composite (EPIC) urinary incontinence scores were similar at baseline as and 12 months (p=0·045). There was an improvement in lower urinary tract symptoms, assessed by International Prostate Symptom Score (IPSS), between baseline and 12 months (p=0·026), but the IPSS-quality of life score showed no difference between baseline and 12 months (p=0·655). All 38 men with no baseline urinary incontinence were leak-free and pad-free by 9 months. All 40 men pad-free at baseline were pad-free by 3 months and maintained pad-free continence at 12 months. No significant difference was reported in median Trial Outcomes Index scores between baseline and 12 months (p=0·113) but significant improvement was shown in median Functional Assessment of Cancer Therapy (FACT)-Prostate (p=0·045) and median FACT-General scores (p=0·041). No histological evidence of cancer was identified in 30 of 39 men biopsied at 6 months (77%, 95% CI 61–89); 36 (92%, 79–98) were free of clinically significant cancer. After retreatment in four men, 39 of 41 (95%, 95% CI 83–99) had no evidence of disease on multiparametric MRI at 12 months.

Interpretation

Focal therapy of individual prostate cancer lesions, whether multifocal or unifocal, leads to a low rate of genitourinary side-effects and an encouraging rate of early absence of clinically significant prostate cancer.

Funding

Medical Research Council (UK), Pelican Cancer Foundation, and St Peters Trust.

RSA prediction of high failure rate for the uncoated Interax TKA confirmed by meta-analysis

BACKGROUND AND PURPOSE

In a previous radiostereometric (RSA) trial the uncoated, uncemented, Interax tibial components showed excessive migration within 2 years compared to HA-coated and cemented tibial components. It was predicted that this type of fixation would have a high failure rate. The purpose of this systematic review and meta-analysis was to investigate whether this RSA prediction was correct.

MATERIALS AND METHODS

We performed a systematic review and meta-analysis to determine the revision rate for aseptic loosening of the uncoated and cemented Interax tibial components.

RESULTS

3 studies were included, involving 349 Interax total knee arthroplasties (TKAs) for the comparison of uncoated and cemented fixation. There were 30 revisions: 27 uncoated and 3 cemented components. There was a 3-times higher revision rate for the uncoated Interax components than that for cemented Interax components (OR = 3; 95% CI: 1.4-7.2).

INTERPRETATION

This meta-analysis confirms the prediction of a previous RSA trial. The uncoated Interax components showed the highest migration and turned out to have the highest revision rate for aseptic loosening. RSA appears to enable efficient detection of an inferior design as early as 2 years postoperatively in a small group of patients.

Comparative effectiveness of robotic versus laparoscopic hysterectomy for endometrial cancer

PURPOSE

Use of robotics in oncologic surgery is increasing; however, reports of safety and efficacy are from highly experienced surgeons and centers. We performed a population-based analysis to compare laparoscopic hysterectomy and robotic hysterectomy for endometrial cancer.

PATIENTS AND METHODS

The Perspective database was used to identify women who underwent a minimally invasive hysterectomy for endometrial cancer from 2008 to 2010. Morbidity, mortality, and cost were evaluated using multivariable logistic and linear regression models.

RESULTS

We identified 2,464 women, including 1,027 (41.7%) who underwent laparoscopic hysterectomy and 1,437 (58.3%) who underwent robotic hysterectomy. Women treated at larger hospitals, nonteaching hospitals, and centers outside of the northeast were more likely to undergo a robotic hysterectomy procedure, whereas black women, those without insurance, and women in rural areas were less likely to undergo a robotic hysterectomy procedure (P < .05 for all). The overall complication rate was 9.8% for laparoscopic hysterectomy versus 8.1% for robotic hysterectomy (P = .13). The adjusted odds ratio (OR) for any morbidity for robotic hysterectomy was 0.76 (95% CI, 0.56 to 1.03). After adjusting for patient, surgeon, and hospital characteristics, there were no significant differences in the rates of intraoperative complications (OR, 0.68; 95% CI, 0.42 to 1.08), surgical site complications (OR, 1.49; 95% CI, 0.81 to 2.73), medical complications (OR, 0.64; 95% CI, 0.40 to 1.01), or prolonged hospitalization (OR, 0.85; 95% CI, 0.64 to 1.14) between the procedures. The mean cost for robotic hysterectomy was $10,618 versus $8,996 for laparoscopic hysterectomy (P < .001). In a multivariable model, robotic hysterectomy was significantly more costly ($1,291; 95% CI, $985 to $1,597).

CONCLUSION

Despite claims of decreased complications with robotic hysterectomy, we found similar morbidity but increased cost compared with laparoscopic hysterectomy. Comparative long-term efficacy data are needed to justify its widespread use.

The impact of complications on costs of major surgical procedures: a cost analysis of 1200 patients

OBJECTIVE

To assess the impact of postoperative complications on full in-hospital costs per case.

BACKGROUND

Rising expenses for complex medical procedures combined with constrained resources represent a major challenge. The severity of postoperative complications reflects surgical outcomes. The magnitude of the cost created by negative outcomes is unclear.

PATIENTS AND METHODS

Morbidity of 1200 consecutive patients undergoing major surgery from 2005 to 2008 in a tertiary, high-volume center was assessed by a validated, complication score system. Full in-hospital costs were collected for each patient. Statistical analysis was performed using a multivariate linear regression model adjusted for potential confounders.

RESULTS

This study population included 393 complex liver/bile duct surgeries, 110 major pancreas operations, 389 colon resections, and 308 Roux-en-Y gastric bypasses. The overall 30-day mortality rate was 1.8%, whereas morbidity was 53.8%. Patients with an uneventful course had mean costs per case of US$ 27,946 (SD US$ 15,106). Costs increased dramatically with the severity of postoperative complications and reached the mean costs of US$ 159,345 (SD US$ 151,191) for grade IV complications. This increase in costs, up to 5 times the cost of a similar operation without complications, was observed for all types of investigated procedures, although the magnitude of the increase varied, with the highest costs in patients undergoing pancreas surgery.

CONCLUSION

This study demonstrates the dramatic impact of postoperative complications on full in-hospital costs per case and that complications are the strongest indicator of costs. Furthermore, the study highlights a relevant savings capacity for major surgical procedures, and supports all efforts to lower negative events in the postoperative course.

Indications for fenestrated endovascular aneurysm repair

Background

Endovascular technology has advanced rapidly in the development of fenestrated endovascular aneurysm repair (FEVAR). Current evidence for endovascular aneurysm repair is limited to infra-renal aortic aneurysms. With increased costs and complexity of FEVAR, its current role is unclear. A national multicentre, cross-disciplinary consensus model was developed to propose indications for FEVAR.

Methods

All UK FEVAR centres and a wide selection of high-volume aneurysm treatment centres were invited to participate. The RAND appropriateness methodology was used. Five key steps were undertaken: meta-analysis of current literature; survey of current UK practice; nominal group establishment and definition of key clinical attributes; round 1—online survey of case vignettes; and round 2—nominal group consensus meeting.

Results

More than 90 per cent of UK FEVAR centres participated. Literature review showed heterogeneous case series with no clear indications for use of FEVAR. Survey of current practice showed wide variations in aneurysm management. Consensus agreement on the role of FEVAR was achieved in 68·8 per cent of cases. Consensus for FEVAR was agreed in areas of moderate risk from open repair and need for suprarenal clamping, but it was less likely to be indicated in patients aged 85 years or more with 5·5–6-cm aneurysms, or short-necked infrarenal aortic aneurysms.

Conclusion

These data record areas of agreement and define the grey area of equipoise. Consequently, guidelines and recommendations can be developed on the indications for FEVAR to inform clinicians, commissioners and health economists.

A method for early evaluation of a recently introduced technology by deriving a comparative group from existing clinical data: a case study in external support of the Marfan aortic root

OBJECTIVE

During the early phase of evaluation of a new intervention, data exist for present practice. The authors propose a method of constructing a fair comparator group using these data. In this case study, the authors use the example of external aortic root support, a novel alternative to aortic root replacement.

DESIGN

A matched comparison group, of similar age, aortic size and aortic valve function to those having the novel intervention, was constructed, by minimization, from among patients having conventional aortic root replacement in other hospitals during the same time frame.

SETTING

Three cardiac surgical units in England.

PATIENTS

The first 20 patients, aged 16-58 years with aortic root diameters of 40-54 mm, having external support surgery were compared with 20 patients, aged 18-63 years and aortic root diameters of 38-58 mm, who had conventional aortic root replacement, between May 2004 and December 2009.

INTERVENTIONS

A pliant external mesh sleeve, customised by computer-aided design, encloses the whole of the ascending aorta. The comparator group had conventional aortic root replacement, 16 valve-sparing and four with composite valved grafts.

MAIN OUTCOME MEASURES

Duration of cardiopulmonary bypass (CPB), myocardial ischaemic time, blood loss and transfusion of blood, platelets and clotting factors.

RESULTS

Comparing total root replacement and customised aortic root support surgery: CPB (median (range)) was 134 (52-316) versus 0 (0-20) min; myocardial ischaemia 114 (41-250) versus 0 (0-0) min; 4 h blood loss was 218 (85-735) versus 50 (25-400) ml; and 9/18 had blood transfusion, 9/18 platelets and 12/18 fresh frozen plasma after root replacement versus 1/20, 0/20 and 0/20, respectively, for the novel surgery.

CONCLUSIONS

Avoidance or large reductions in CPB, myocardial ischaemia and blood product usage were achieved with the novel surgery. These data are of use in decision analysis and health economic evaluation and are available early in evaluation before randomised trial data are available.

Radiofrequency-assisted intact specimen biopsy of breast tumors: critical evaluation according to the IDEAL recommendations

Radiofrequency-assisted intact specimen biopsy (RFIB) has been introduced for percutaneous biopsy or removal of breast tumors. Using radiofrequency cutting, the system enables the radiologist to obtain an intact sample of the target lesion. According to the IDEAL recommendations, we performed a critical evaluation of our initial experience with RFIB. Between June and November 2010, radiography-guided RFIB was performed in 19 female patients. All patients presented with suspicious microcalcifications (BI-RADS III-V) on mammography. Biopsy specimen integrity, thermal damage and histologic diagnosis were assessed by an expert breast pathologist. Data on technical success, diagnostic and therapeutic accuracy and periprocedural complications were collected and analyzed. The median age of the patients was 59 years. Median lesion diameter on mammography was 8 mm (range 2–76 mm). The procedure was successful in 16/19 (84%) patients and unsuccessful in 3/19 (16%) patients (2 non-representative samples, 1 sample with extensive thermal damage). Histologic analysis of the RFIB specimen revealed 12/19 (63%) benign lesions and 7/19 (37%) malignancies (4 ductal carcinoma in situ (DCIS) lesions and 3 invasive ductal carcinomas). In 1 patient, a DCIS lesion was completely removed with RFIB. Overall, 3 periprocedural complications occurred (1 wound leakage, 1 arterial hemorrhage and 1 infection requiring oral antibiotics). Tissue sampling of suspicious breast lesions can be performed successfully with RFIB. In 1 patient DCIS was radically excised with RFIB, which illustrates its potential as a minimally invasive therapeutic procedure for removal of small breast tumors. This is an interesting focus for further research when larger probe sizes become available.

Perception of surgical complications among patients, nurses and physicians: a prospective cross-sectional survey

Background

Several scores grade the severity of post-operative complications but it is unclear whether such scores truly reflect the perception of patients and practicing nurses and physicians.

Study Design

227 patients, 143 nurses and 245 physicians independently rated the severity of 30 common post-operative complications on a numerical analogue scale from 0 (not severe at all) to 100 (extremely severe) while being blinded towards the Clavien-Dindo classification. We considered a difference in ratings of >10 to be clinically important in distinguishing between grades of severity and groups. We evaluated the level of reproducibility of responses by calculating intraclass correlation coefficients (ICC) and compared scores across severity grades and between groups using the generalized estimating equations.

Results

Reproducibility of the ratings was good for all three groups (ICCpatients 0.71 (95%-CI 0.64-0.76), ICCnurses 0.83 (0.78-0.87) and ICCphysicians 0.87 (0.83-0.90)). The participants' perceptions of the severity of complications reflected the Clavien-Dindo classification (median of grade I: 20 (IQR 10-30), grade II: 40 (31.3-52.5), grade IIIa: 50 (40-60), grade IIIb: 70 (60-75), grade IVa: 85 (80-90) and grade IVB: 95 (90-100)). Although patients' perception differed significantly from those of physicians (average difference -8.7 (95%-CI -10.4 to -6.9, p < 0.001) and nurses (difference -2.8 (-4.8 to -0.8, p = 0.007) they did not reach our thresholds for clinical importance.

Conclusions

The severity of post-operative complications is perceived similarly by patients, nurses and physicians and reflects the Clavien-Dindo classification well. Our results support the use of Clavien-Dindo classification system as part of the shared or informed decision making process.

[Size and quality of clinical research on non-medical interventions: a systematic analysis of IQWiG reports]

BACKGROUND

A sufficient number of randomised controlled clinical trials (RCTs) with high methodological reliability are required to allow a critical assessment of therapeutic interventions. The aim of this study was to evaluate the final reports of the Institute for Quality and Efficiency in Health Care (IQWiG) addressing non-medical interventions. These reports were analysed in order to determine how many endpoint-related comparisons were evaluated by clinical studies, how many by RCTs and how many by methodologically reliable RCTs.

METHODS

Seventeen out of eighteen final reports of the IQWiG department of non-medical interventions were critically analysed. The final reports had been generated from 2006 till 2009. Comparison of therapeutic procedures and patient relevant endpoints were taken from the final reports. Additional patient relevant endpoints were considered whenever these had been included in the result section. RCTs considered essential for the assessment were identified. RCTs obtaining the biometric rating no shortcomings, moderate shortcomings or low bias were considered to be of methodological reliability.

RESULTS

A total of 537 comparisons addressing single endpoints were identified. Clinical studies were available for 50% of these comparisons (n=272). For 38% of the comparisons (n=205) RCTs could be included, but in only 18% these RCTs had reliable methods. The number of reports containing zero, one, and more than one RCT was 6, 4, and 7, respectively. Methodologically reliable RCTs were included in only 8 out of 17 final reports.

DISCUSSION

The analysis of evidence showed that both the number and the quality of studies were insufficient. This is why better standards for the evaluation of non-medical interventions need to be established. This may be achieved by raising the regulatory requirements and by intensifying research from independent institutions.

Health technology assessment: an evidence-based medicine perspective

A challenge of health technology assessment is integrating the information from different disciplines. This talk focuses on the evidence-based medicine perspective and challenges 3 assumptions of health technology assessment: assumptions about effectiveness, assumptions about coverage by health technology assessment, and assumptions about costs being immutable. Challenging these assumptions has several implications. First is the need for better evidence on effects: both low-volume, high-cost technologies and low-cost, high-volume technologies that are ineffective drains on health care systems' resources. Second, cheap but effective technologies should be better promoted, as they can displace high-cost technologies. Finally, for effective but expensive technologies, we should work to lower the price and/or costs.