Peritoneal dialysis catheter insertion

Peritoneal dialysis (PD) catheter insertion can be accomplished by any 1 of 3 techniques. These include dissective or surgical, the blind or modified Seldinger, and laparoscopic techniques. The dissective technique solely utilized by surgeons, places the catheter by mini-laparotomy under general anesthesia. In the blind or modified Seldinger technique a needle is inserted into the abdomen, a guide-wire placed, a tract dilated and the catheter is inserted through a split-sheath, all without visualization of the peritoneal cavity. Of the various laparoscopes, peritoneoscopic insertion uses a small optical peritoneoscope for direct inspection of the peritoneal cavity and identification of a suitable site for the intraperitoneal portion of the catheter. Hence, of the 3 techniques, only the latter allows for the direct visualization of the intraperitoneal structures. This technique can be easily used by nephrologists as well as surgeons. Peritoneoscopic placement varies from traditional laparoscopic techniques by using: a much smaller scope (2.2 mm diameter) and puncture size, only one peritoneal puncture site, a device to advance the cuff into the musculature, air in the peritoneum rather than CO2, and local anesthesia rather than general anesthesia. Prospective randomized and nonrandomized studies have shown that PD catheters peritoneoscopically placed by nephrologists have less incidence of complications (infection, exit site leak) and longer catheter survival rates than those inserted surgically. The current review focuses on the peritoneoscopic insertion of PD catheter and presents some of the complicating issues (bowel perforation, catheter migration, and prior abdominal surgery) related to this procedure.     

Percutaneous fluoroscopically guided placement of peritoneal dialysis catheters--a 10-year experience

Peritoneal dialysis (PD) catheters maybe inserted surgically or percutaneously. Since 1997, 209 patients in our unit have had a PD catheter inserted percutaneously with fluoroscopic guidance. Data on all these PD catheters were collected prospectively on a PROTON computer database. 5/209 (2.4%) insertion attempts were abandoned. 204 catheters were successfully placed giving an initial technical success of 97.6%. 200/204 catheters were used for dialysis. 13/200 (6.5%) catheters developed early exit site infections; 12/13 were successfully treated and dialysis proceeded uneventfully. 3/200 (1.5%) catheters developed early peritonitis; 1/3 was removed as antibiotic treatment was unsuccessful. 10/200 (5%) catheters developed an early leak; 2/10 did not resolve with conservative therapy and were removed. 14/200 (7%) catheters did not allow sufficient fluid entry for PD; all 14 had migrated out of the pelvis and were removed. In total, 18/200 (9%) catheters were removed in the first 2 months due to these early complications. The remaining 182/200 (91%) were fully functional for PD. Technical survival (excluding patient death with a functioning catheter and successful kidney transplantation) at 1, 2, and 5 years was 77%, 61%, and 31%, respectively. Our 10 year experience of PD catheters inserted percutaneously with fluoroscopic guidance demonstrates a high technical success and a low complication rate. The data presented may be used as the standard for this technique.     

Peritoneal dialysis access-related procedures by nephrologists

Traditionally the placement of a peritoneal dialysis (PD) catheter in a patient with end-stage renal disease (ESRD) has been accomplished by a surgeon and using general anesthesia. This approach often introduces delays in starting PD, incurs additional costs in utilizing an operating room as well as anesthesia services, and introduces the mortality risk associated with general anesthesia. Recent data have emphasized that interventional nephrologists can safely and successfully perform PD access procedures. In this context, operating room facilities and staff and anesthesia services are not required and catheter insertion can be performed in a procedure room using local anesthesia, thereby reducing costs and completely bypassing the mortality risk associated with general anesthesia. When performed by a nephrologist, the catheter insertion can be accomplished swiftly and dialysis therapy initiated in a timely manner. Once begun, the success of PD hinges on reliable and long-term access to the peritoneal cavity. Prospective randomized and nonrandomized studies have shown that PD catheters peritoneoscopically placed by nephrologists have fewer complications (infection, exit site leak) and longer catheter survival rates than those inserted surgically. Although PD offers a variety of advantages, it remains an underutilized form of renal replacement therapy. To counteract PD underutilization, at least two separate centers have demonstrated a positive impact on the growth of the PD population when catheter insertion is performed by nephrologists. This article presents PD access-related procedures currently performed by interventional nephrologists. Furthermore, some of the complicating issues (bowel perforation, catheter migration, prior abdominal surgery) related to PD catheter insertion and management are also discussed.     

Peritoneoscopy: A valuable technic for surgeons

1. Modern peritoneoscopy which uses advanced optics and instrumentation now available is a valuable technic that can and should be learned by surgeons. 2. Peritoneoscopy is a safe procedure with a high diagnostic yield and minimal discomfort and inconvenience to the patient. 3. Earlier and more frequent use of peritoneoscopy will enable the surgeon to give appropriate surgical treatment more promptly and avoid unnecessary exploratory celiotomy. 4. The value of this technic in seventy-five consecutive cases is reported. There was no mortality and negligible morbidity. The over-all diagnostic accuracy was 91 per cent. An accurate peritoneoscopic diagnosis avoided surgical exploration in forty-five patients, and in fifteen patients the peritoneoscopic diagnosis provided indications for prompt abdominal surgery.     

Risk factors for early peritoneal dialysis catheter failure in children

Background

There is uncertainty regarding the optimal approach for surgical placement of peritoneal dialysis (PD) catheters in children. Operative technique, catheter selection, and patient variables (eg, age or prior surgical history) may influence catheter lifespan.

Methods

A retrospective review of all PD catheters placed at a tertiary children's medical center during a 6-year period was performed. Our primary outcome was catheter function 2 months after placement. Data were analyzed using Student 2-tailed t test or χ² analysis.

Results

There were 121 PD catheters placed in 81 patients. The median primary functional catheter lifetime was 109 days. Primary PD catheter failure (within 2 months) occurred in 36 catheters (30%). Patients with primary catheter failure (8 ± 7 years) were younger than patients with a functioning catheter at 2 months (12 ± 5 years; P = .002). Catheters placed without simultaneous omentectomy were more likely to fail (P = .042). Catheter failure rate was not significantly different based upon operative technique or catheter type.

Conclusion

Omentectomy at the time of catheter placement decreased the risk of early catheter failure. In contrast, type of catheter or laparoscopic placement did not influence the likelihood of early catheter failure.     

Clinical trials of the T-fluted (Ash Advantage) peritoneal dialysis catheter

The Ash Advantage is a T-shaped peritoneal catheter with a single transabdominal tube joining to a tube lying against the parietal peritoneum. Segments with long flutes (grooves) serve as fluid ports rather than 1-mm diameter holes. The folded catheter is placed through the expandable Y-TEC Quill positioned peritoneoscopically, similar to the procedure for a conventional Tenckhoff catheter. In a clinical study, we placed 18 Ash Advantage ("Advantage") catheters, 8 in patients with prior hydraulic or infectious complications of Tenckhoff catheters and 10 in patients initiating peritoneal dialysis. Mean follow-up has been 8.4 months. Outflow rate for the Advantage catheters is uniformly higher than for Tenckhoff catheters at 220 +/- 100 mL/min for the first 5 minutes and 145 +/- 72 mL/min for the next 5 minutes, with outflow completed in 6 to 15 minutes. Variation of outflow volumes for similar exchanges in the same patient is +/- 3% to 5%, much less than with Tenckhoff catheters. Four catheters failed after placement, each for a different reason including outflow failure because of preexisting intraperitoneal adhesions, preexisting peritonitis failing to clear, tubing kink during placement, and catheter break after a freak accident. Life-table analysis of the production version of the catheter in study patients and 12 additional unselected patients indicates a 90% survival at 12 months. In long-term use, the fixed position of the cuffs of this catheter may avoid catheter extrusion, pericatheter hernias, and pericatheter leaks. Multiple fluted ports appear to diminish omental attachment. The catheter may be a useful alternative to conventional Tenckhoff catheters in patients at high risk of catheter failure or in standard peritoneal dialysis patients.     

Laparoscopic-assisted peritoneal dialysis catheter placement, an improvement on the single trocar technique

In 2002, Ochsner laparoscopic surgeons and nephrologists began placing peritoneal dialysis (PD) catheters via a laparoscopic-assisted method. We compared laparoscopically placed PD catheters (LAPD) with catheters most recently placed without laparoscopic aid (STPD). The method for this study is a retrospective chart review. Demographics of both groups were similar. Nine of 20 (45%) in the STPD group and 16 of 23 (70%) in the LAPD group had had previous abdominal surgery. Three of 20 (15%) of STPD had complications, including one small bowel injury. Four of 23 (17.4%) of the LAPD had complications. One of 20 (5%) in the STPD group and 3 of 23 (13%) in the LAPD group had dialysate leaks. In the STPD group, 8 of 20 (40%) had catheter problems that led to removal in 7 (35%). In the LAPD group, 6 of 23 (26%) had catheter malfunction: 3 were salvaged with a laparoscopic procedure; 3 (13%) were removed for malfunction. 1) LAPD allows proper PD placement after complex abdominal surgery; 2) Although dialysate leak complications are increased, bowel perforation risk is less; 3) Because of proper placement, PD catheter malfunction rate is less with LAPD; 4) Although no results obtained statistical significance, we found LAPD superior to STPD and have converted to this technique.     

Percutaneous technique of presternal peritoneal dialysis catheter placement

Presternally exiting peritoneal dialysis (PD) catheters have been described as advantageous compared to abdominally exiting catheters with regard to infection, wound healing, and other complications. Placement of such catheters has only been described with open surgical techniques and not by percutaneous means. In this article we describe 15 patients who received percutaneously placed PD catheters with a presternal exit site. These patients received their procedures in an outpatient procedure room performed by an interventional nephrologist. In all but one case, immediate technical success was achieved. In only one case was peritonitis documented. All catheters are still functional, including some with follow-up as long as 15 months. Percutaneous placement of presternally exiting PD catheters is technically straightforward and can avoid an open surgical procedure.     

Videolaparoscopy as rescue therapy and placement of peritoneal dialysis catheters: a thirty-two case single centre experience.

BACKGROUND: Malfunction of the peritoneal catheter is a frequent complication in peritoneal dialysis (PD). Videolaparoscopy is a minimal invasive technique that allows rescue therapy of malfunctioning catheters and consecutive immediate resumption of PD. Furthermore, Tenckhoff catheters can be safely positioned in patients with previous abdominal surgery. We analysed the clinical diagnosis, videolaparoscopic treatment and the outcome of PD patients on whom videolaparoscopic interventions had been performed at our centre. METHODS: Thirty-two cases of videolaparoscopic interventions were performed for salvage of malfunctioning peritoneal catheters, implantation and abdominal surgical interventions in 25 PD patients. The videolaparoscope was inserted through a mini-laparotomy site of 15 mm diameter which was closed with purse-string sutures at the end of the intervention. RESULTS: Videolaparoscopy was used in 21 cases of catheter malfunction mostly due to omental wrapping (12 cases) and dislocation (five cases). In eight patients with previous surgical abdominal interventions, laparoscopic placement of the PD catheter was performed. In two cases the gall bladder was removed. One case of intestinal occlusion was evaluated laparoscopically in an attempt to minimize invasive surgery. Leakage of the peritoneal fluid presented the only complication caused by insufficient closure of one mini-laparotomy site. Minimal follow-up time of rescued catheters was 5 months. Videolaparoscopy prolonged PD catheter function by a median of 163 days (range 5-1469 days). CONCLUSIONS: Videolaparoscopy prolongs peritoneal catheter survival by treating directly the causes of malfunction. In patients with preceding abdominal interventions, the PD catheter can be placed safely even in cases necessitating surgical preparation like adhesiolysis.     

Ultrasound/fluoroscopy-assisted placement of peritoneal dialysis catheters

Peritoneal dialysis (PD) catheters may be inserted blindly, surgically, and either by laparoscopic, peritoneoscopic, or fluoroscopic approach. A modified fluoroscopic technique by adding ultrasound-assistance was performed in the present study to ensure entry into the abdominal cavity under direct ultrasound visualization. From March 2005 to May 2007, ultrasound-fluoroscopic guided placement of PD catheters was attempted in 32 end-stage renal disease (ESRD) patients. Preoperative evaluation was performed on all patients prior to the procedure. After initial dissection of the subcutaneous tissue anterior to the anterior rectus sheath, the needle was inserted into the abdominal cavity under the guidance of ultrasound. The position of the epigastric artery was also examined using ultrasonography to avoid the risk of arterial injury. PD catheters were successfully placed in 31 of the 32 ESRD patients using this technique. In all of these patients, the needle could be seen entering the abdominal cavity using an ultrasound. In one patient the procedure was abandoned because of bowel puncture by the micro-puncture needle that was inadvertently advanced into a loop of bowel. This patient did not develop acute abdomen nor needed any intervention. One patient died 4 days after placement of the catheter of unrelated causes. One patient was started on acute peritoneal dialysis the same day of catheter placement without any complications. The rest of the patients started peritoneal dialysis within 2-6 weeks of catheter placement. None of the patients had bleeding related to arterial injury as ultrasound was able to visualize the epigastric artery. Our experience shows that ultrasound-fluoroscopic technique is minimally invasive and allows for accurate assessment of the entry into the abdominal cavity. This technique can avoid the risk of vascular injury altogether.     

Carcinoma of the lung in patients under 40 years of age

Bronchogenic carcinoma in the young population (40 years of age or less) is reported to present in an advanced stage and to have a virulent course. Between 1969 and 1979, 101 patients (65 men and 36 women) presented with cancer of the lung. Their mean age was 36.2 +/- 3.9 years (range 18 to 40 years). Eighty-seven percent had a history of cigarette smoking. Fifty percent of the patients had a strong familial history of malignancy of several organs. The interval between onset of symptoms and diagnosis was 4.01 +/- 3.48 months (3.56 +/- 3.34 for the surgically treated group and 4.16 +/- 3.53 for the nonoperated or unresectable group). Diagnosis was made at bronchoscopy in 32 patients, during thoracotomy in 30 patients, during nodal biopsy in 28 patients, and on cytologic examination of the sputum in 9 patients. The most common cell types were adenocarcinoma in 39 patients, squamous carcinoma in 29 patients, and oat cell carcinoma in 18 patients. Eighty-six patients (the majority) presented in stage III, whereas 9 were in stage I and 6 were in stage II. Twenty-seven patients (26.7 percent) underwent resection for cure, whereas 18 patients were inoperable at surgery. Eighteen of the surgical patients had adjuvant radiotherapy, and chemotherapy, immunotherapy, or both. The average length of survival for the nonresected patients was 7.12 +/- 5.9 months (range 1 to 36 months) and the actuarial survival was 1.5 percent at 36 months. The survival for the surgically managed patients was 56.1 +/- 52.6 months (range 3 to 168 months) or 48 percent at 36 months. At 46 to 168 months after treatment, the only survivors were 13 patients who were surgically managed. Stage III patients had longer survival after surgery (24.1 +/- 24.6 months to 7.09 +/- 5.90 months; range 3 to 74 months and 1 to 36 months, respectively). The survival at 5 years for patients with stage I disease was 78.8 percent, stage II disease 66.6 percent, and stage III disease, 3.6 percent. Early diagnosis and aggressive surgical management are necessary to improve the survival of patients with bronchogenic carcinoma under 40 years of age.     

Malpositioned peritoneal dialysis catheters: a critical reappraisal of correction by stiff-wire manipulation

Tenckhoff peritoneal dialysis (PD) catheter malposition is one of the leading causes of catheter malfunction. Fluoroscopically directed stiff-wire manipulation of malpositioned PD catheters has been advocated as a method of catheter salvage. Two hundred eighty-nine single-cuff PD catheters were placed surgically into 203 patients during this 4-year study. Thirty-three patients developed catheter malfunction attributed to malposition. Forty-eight stiff-wire manipulations were performed on these patients. Thirty-eight (78%) of the manipulations were described as successful at the time of transfer from radiology. However, only 25 (51%) and 12 (25%) resulted in functioning catheters at 1 week and 1 month, respectively. Only 11 of 33 patients who underwent manipulation had functional prolongation of catheter life beyond 1 month. The PD catheter was replaced by a column-disk PD catheter without additional catheter dysfunction in six patients. A second single-cuff Tenckhoff PD catheter was inserted in another six patients. Three of these six catheters again malpositioned. We conclude that stiff-wire manipulation is a useful and safe technique worth using on a limited basis for the initial episode of catheter malposition. Catheters that repetitively malposition should be replaced with a catheter that is resistant to malpositioning.     

The role of peritoneoscopy (laparoscopy) in the evaluation of the acute abdomen in critically ill patients

Emergency peritoneoscopy (laparoscopy) to evaluate a suspected intraabdominal catastrophe was performed in ten critically ill patients over a 3-year period. The examination was negative in six cases, thereby avoiding celiotomy in this high-risk group. The examination was positive in four cases and, on this basis, celiotomy was recommended. Verification of the peritoneoscopic findings by clinical follow-up, operative findings, or autopsy was obtained in eight out of the ten cases. Based on our experience, we feel that peritoneoscopy is of value in defining the indications for celiotomy in this high-risk group of patients.     

Laparoscopic omental fixation technique versus open surgical placement of peritoneal dialysis catheters

Background: Continuous ambulatory peritoneal dialysis (CAPD) is an effective form of treatment for patients with end-stage renal disease. Open insertion of peritoneal dialysis (PD) catheters is the standard surgical technique, but it is associated with a relatively high incidence of catheter outflow obstruction and dialysis leak. Omental wrapping is the most common cause of mechanical problems. The purpose of this study was to determine the efficacy of the laparoscopic omental fixation technique to prevent the obstruction caused by omental wrapping and also to compare this laparoscopic technique with open peritoneal dialysis catheter insertion with respect to postoperative discomfort, complication rates, and catheter survival. Methods: Between March 1998 and October 2001, 42 double-cuff, curled-end CAPD catheters were placed in 42 patients. The outcomes of the 21 patients in whom the PD catheters were placed laparoscopically with omental fixation technique were compared with those of the 21 patients in whom the catheters were placed with open surgical technique. Recorded data included patient demographics, catheter implantation method, early and late complications, catheter survival, and catheter outcome. Results: Early peritonitis episodes occurred in 8 of 21 patients (38.0%) in the open surgical group (OSG) versus 2 of 21 patients (9.5%) in the laparoscopic omental fixation group (LOFG) (p < 0.05); late peritonitis episodes occurred in 3 of 21 patients (14.2%) in the OSG versus 1 of 21 patients (4.7%) in the LOFG (p < 0.05). Early exit site infection occurred in 8 of 21 patients (38.0%) in the OSG versus 4 of 21 patients (19.0%) in the LOFG (p < 0.05), with many catheter-related problems in the conventional surgical group. There was no outflow obstruction in the LOFG. The conventional procedure was faster than the laparoscopic omental fixation technique. Analgesic requirements and hospital stay were less in the laparoscopic group. Laparoscopic surgery also enabled diagnosis of intraabdominal pathologies and treatment of the accompanying surgical problems during the same operation. Occult inguinal hernia was diagnosed in 2 patients, inguinal hernioplasty was performed in 4 patients, adhesiolysis was performed in 8 patients who had previous abdominal surgery, and liver biopsy was taken in 2 patients. Ovarian cystectomy was performed in another patient during laparoscopic CAPD catheter placement. Conclusion: The laparoscopic omental fixation technique (described by Öünç and published in 1999) is a highly effective and successful method for preventing obstruction due to omental wrapping with a better catheter survival. Laparoscopic surgery also allows the diagnosis and treatment of the accompanying surgical pathologies during the same operation.     

The Ash Split CathTM as long-term IJ access: Hydraulic performance and longevity

A prospective observational study was performed to determine the duration of use of the Ash Split Cath placed as primary or bridge access in ESRD patients; 164 ESRD patients received a Split Cath in the IJ location, with transcutaneous placement guided by ultrasound. Mean follow-up time was 19.3 months (maximum up to 48 months). During the follow-up, there were 36 catheter failures resulting in removal, 53% due to infection and the others due to outflow failure or break (leak) of the catheter. By Kaplan-Maier analysis 82% of placed catheters were functional at 12 months and half-life of catheter duration was 26 months. Blood flow rates during dialysis were not distinguishable between IJ catheter patients and those with functioning grafts or fistulas. Function, safety and duration of use of the Split Cath in the IJ location all compare favorably to AV grafts.     

Long-Term Complication Rates and Survival of Peritoneal Dialysis Catheters: The Role of Percutaneous Versus Surgical Placement

Considerable controversy currently exists in the literature concerning the mode of catheter placement and its impact on the technical success of peritoneal dialysis (PD). We decided to compare the impact of the surgical versus the percutaneous insertion technique on peritoneal dialysis catheter (PDCs) complications and survival. Our study population comprised 152 patients in whom 170 PDCs were inserted between January 1990 and December 2007 at the main PD unit on the island of Crete. Eighty four catheters were surgically placed (S group) and 86 were placed percutaneously by nephrologists (N group). The total experience accumulated was 4997 patient-months. The overall complications did not differ between the two groups. Only early leakage was more frequent in N group than S group (10.3 versus 1.9 episodes per 1000 patient-months; p  < 0.001). However, it was easily treated and did not constitute a cause of early catheter removal. Catheter survival was 91.1%, 80.7%, and 73.2%, in the S group versus 89.5%, 83.7%, and 83.7% for the N group at 1, 2, and 3 years, respectively ( p  = 0.2). Catheter survival has significantly increased over the last decade. Factors positively affecting PDC survival appeared to be the use of mupirocin for exit site care and the utilization of the coiled type of catheter, practices implemented mainly after 1999. Peritonitis-free survival and patient survival were not associated with the mode of placement, while in Cox regression analysis, were longer in patients treated with automated PD. The placement mode did not affect PD outcomes. Percutaneous implantation proved a safe, simple, low cost, immediately available method for PDC placement and helped to expand our PD program.     

Laparoscopic placement of peritoneal dialysis catheters: 7 years experience

Background: Since 1994 we have placed all peritoneal dialysis (Tenckhoff) catheters at our hospital laparoscopically using a technique that incorporates suture fixation into the pelvis. The purpose of this study was to determine the long‐term outcome of this approach. Method: Perioperative and follow‐up data for all patients undergoing placement of a peritoneal dialysis catheter at the Royal Adelaide Hospital were collected prospectively and managed on unit specific and hospital wide computerized databases. A total of 148 procedures were carried out in 123 patients from March 1994 to November 2001. Follow‐up ranged from 3 to 68 months (median, 42 months). All procedures were undertaken or supervised by one surgeon, and catheters were routinely sutured into the pelvis at laparoscopy. Results: There was no perioperative mortality in this series, and only one catheter could not be placed laparoscopically. This was in a patient with extensive intra‐abdominal adhesions. Mean operative time was 27 min (range, 10?100 min), and mean postoperative stay was 2.8 days (range, 1?12 days). Seven (5%) patients experienced peri/postoperative haemorrhage, and four of these underwent surgical re‐exploration. Twenty‐five (17%) catheters are still used for dialysis. Thirty‐four (23%) catheters were removed when the recipient received a subsequent renal transplant, and 42 (28%) patients died during follow‐up. Forty‐six (31%) patients required catheter revision or removal because of technical problems; 26 (18%) recurrent peritonitis or exit site infection; and 20 (14%) catheter blockage. Twenty‐eight reinsertion procedures were carried out in 25 patients. Ten (7%) patients developed port site hernias at late follow‐up, and required hernioplasty. Catheter migration leading to malfunction (poor drainage) occurred in eight (5%) patients only. Conclusions: Laparoscopic placement of peritoneal dialysis catheters is a safe and effective procedure. The majority of patients will dialyse successfully using this technique. Suturing the catheter tip into the pelvis is associated with a low rate of catheter migration.     

The long-term results of pubovaginal sling surgery using acellular cross-linked porcine dermis in the treatment of urodynamic stress incontinence

PURPOSE: Acellular cross-linked porcine dermis is a potential substitute for rectus fascia as a sling material with the advantage of decreased morbidity. However, the long-term efficacy is unknown. We compared the 3-year efficacy of PD vs autologous rectus fascia as a sling material for pubovaginal sling surgery in the treatment of urodynamic stress incontinence. MATERIALS AND METHODS: Between July 2000 and December 2001 a total of 101 consecutive, nonrandomized patients with USI underwent a PD (51) or RF (50) sling procedure. Patients were assessed at 6 weeks, and at 3, 6 and 12 months postoperatively. Urodynamic study was repeated in cases of treatment failure. A detailed survey questionnaire was mailed to all patients at least 36 months after surgery and all responders were then retested by telephone interview by a blinded assessor. The primary outcome measure was patient perceived success rate (cured or improved) at least 36 months after PVS. Secondary outcome measures were patient satisfaction 36 months after surgery, durability of success with time and reoperation rate. RESULTS: Complete data were available on 94 patients (48 treated with PD and 46 treated with RF sling). The groups were well matched for age, leak point pressure, prior incontinence surgery and urge symptoms. Pubovaginal sling was successful (cured or improved) in 37 (80.4%) patients treated with RF but in only 26 (54%) patients treated with PD 36 months after surgery (Fisher's exact test p = 0.009; 95% CI 8.03, 44.4). Treatment failure occurred by 9 months after RF and by 24 months after PD sling procedure. Repeat urodynamic study showed USI to be the cause of treatment failure in 18 (37.5%) of 20 patients treated with PD but in only 3 (6.5%) of 8 patients treated with RF. CONCLUSIONS: We have shown that use of the PD sling, although reducing early morbidity, results in a significantly inferior long-term cure rate in comparison to the RF sling. Therefore, acellular cross-linked porcine dermis should not be used as a substitute for rectus fascia.     

Percutaneous Peritoneal Dialysis Catheter Placement in Patients with Complex Abdomen

Peritoneal dialysis (PD) is an effective treatment for end‐stage renal disease. There are several techniques of percutaneous PD catheter placement including trocar or Seldinger techniques. Placement can be performed with fluoroscopy and/or sonography or as a blind percutaneous procedure. Historically, percutaneous PD catheters have been placed in patients even if they had prior abdominal surgeries. The outcomes of percutaneous PD catheter placement in patients with complex abdomen (patients with two or more abdominal surgeries or known adhesions) are unknown. This study was carried out to determine the outcomes of percutaneous PD catheter placements using Seldinger technique with sonography and fluoroscopy in patients with complex abdomen. Preprocedure sonography was also used to identify site of adhesions and blood vessels. The goal was to see if ultrasound and fluoroscopy would support placement of PD catheters in patients with complex abdomens. There were total of 10 catheter placements in 10 patients with complex abdomen. The initial success rate was 100%. The patients had an average of 2.8 abdominal surgeries. The mean BMI was 28.4. There were no incidences of perforation or failed placements. One catheter was replaced due to outflow failure and one patient discontinued PD due to peri‐catheter leak. One year catheter survival was 80% . Our study demonstrates benefits of using ultrasonography and fluoroscopy during percutaneous PD catheter placement by the Seldinger technique in patients with complex abdomen.     

Recurrent spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension: a prospective study

OBJECT: Intracranial hypotension due to a spontaneous spinal cerebrospinal fluid (CSF) leak is an increasingly recognized cause of postural headaches, but reliable follow-up data are lacking. The authors undertook a study to determine the risk of a recurrent spontaneous spinal CSF leak. METHODS: The patient population consisted of a consecutive group of 18 patients who had been evaluated for consideration of surgical repair of a spontaneous spinal CSF leak. The mean age of the 15 women and three men was 38 years (range 22-55 years). The mean duration of follow up was 36 months (range 6-132 months). The total follow-up time was 654 months. A recurrent spinal CSF leak was defined on the basis of computerized tomography myelography evidence of a CSF leak in a previously visualized but unaffected spinal location. Five patients (28%) developed a recurrent spinal CSF leak; the mean age of these four women and one man was 36 years. A recurrent CSF leak developed in five (38%) of 13 patients who had undergone surgical CSF leak repair, compared with none (0%) of five patients who had been treated non-surgically (p = 0.249). The recurrent leak occurred between 10 and 77 months after the initial CSF leak, but within 2 or 3 months of successful surgical repair of the leak in all patients. CONCLUSIONS: Recurrent spontaneous spinal CSF leaks are not rare, and the recent successful repair of such a leak at another site may be an important risk factor.