Are Adult Ureteroscopes Safe in the Management of Urolithiasis in a Pediatric Population?

Introduction

Debate remains regarding the optimal caliber of ureteroscopes in the management of pediatric urolithiasis, ranging from pediatric scopes to standard scopes. The aim of this study was to assess the safety and efficacy of stone management in a pediatric population using standard adult ureteroscopes.

Methods

A retrospective review of all ureteroscopic procedures in patients under the age of 16 years was carried out. Standard adult 7.5 French semi-rigid and 6 French flexible ureteroscopes were used.

Results

During the study period, 8 patients underwent 21 ureteroscopic procedures. Two patients had rigid ureteroscopy, seven had flexible ureterorenoscopy and one had a subsequent open procedure. No patients required ureteric dilation. Double J ureteric stents were utilized in 7 patients. There were no complications. All patients required extra corporeal shock wave lithotripsy. Stone clearance was achieved in all patients.

Conclusion

Our series demonstrates that, in skilled hands, adult ureteroscopes can be use safely for the treatment of urolithiasis in pediatric patients.Key Words: Urolithiasis, Paediatric urolithiasis, Ureteroscopy     

Flexible and Rigid Cystoscopy in Women

Purpose:

Previous studies have evaluated the tolerability of rigid versus flexible cystoscopy in men. Similar studies, however, have not been performed in women. We sought to determine whether office-based flexible cystoscopy was better tolerated than rigid cystoscopy in women.

Materials and Methods:

Following full IRB approval, women were prospectively randomized in a single-blind manner. Patients were randomized to flexible or rigid cystoscopy and draped in the lithotomy position to maintain blinding of the study. Questionnaires evaluated discomfort before, during, and after cystoscopy.

Results:

Thirty-six women were randomized to flexible (18) or rigid (18) cystoscopy. Indications were surveillance (16), hematuria (15), recurrent UTIs (2), voiding dysfunction (1), and other (2). All questionnaires were returned by 31/36 women. Using a 10-point visual analog scale (VAS), median discomfort during the procedure for flexible and rigid cystoscopy were 1.4 and 1.8, respectively, in patients perceiving pain. Median recalled pain 1 week later was similar at 0.8 and 1.15, respectively. None of these differences were statistically significant.

Conclusions:

Flexible and rigid cystoscopy are well tolerated in women. Discomfort during and after the procedure is minimal in both groups. Urologists should perform either procedure in women based on their preference and skill level.     

Laparoscopic Appendectomy and Cholecystectomy During Pregnancy: Six Case Reports

Background:

Pregnancy was once considered a contraindication to laparoscopic cholecystectomy and appendectomy. The progression of laparoscopic techniques has resulted in a continued reassessment of laparoscopic procedures during pregnancy. There still exists some controversy as to the safety of laparoscopic procedures during pregnancy. This paper reviews our series of six pregnant patients treated laparoscopically for appendicitis and cholecystitis.

Methods:

Charts were reviewed of all pregnant patients who underwent laparoscopic cholecystectomy or appendectomy at St Clare''s Hospital Schenectady, New York between 1992 and 1996. Six patients were identified. Patients and obstetricians were contacted to investigate the results of the pregnancy.

Results:

All patients and fetuses survived the procedure. Two patients delivered prematurely but remote from the operative procedure. All infants were healthy postpartum. One patient underwent an elective abortion as she had planned. The abortion was remote from the surgical procedure.

Conclusion:

Our series adds to the growing evidence that laparoscopic cholecystectomy and laparoscopic appendectomy can be performed safely during pregnancy.     

Ureteric bupivicaine infusion for loin pain haematuria syndrome

INTRODUCTION

Loin pain haematuria syndrome is a common problem with complications including opiate dependence. Morbidity treatments include intra-ureteric capsaicin infusion, nephrectomy, autotransplantation and nephrolysis. We explored the use of flexible cystoscopic infusion of intra-ureteric bupivicaine.

PATIENTS AND METHODS

Patients presenting with chronic loin pain underwent urological and nephrological evaluation. Bupivicaine (0.5%, 20 ml) was infused via an intra-ureteric catheter under flexible cystoscopic guidance. Repeat infusions were offered if indicated.

RESULTS

Sixteen of 17 patients with 1-year follow-up responded and were satisfied. Twelve of these required repeat infusions (mean, 2.9 infusions). The procedures were well tolerated by all patients without adverse effects.

CONCLUSIONS

Intra-ureteric bupivicaine infusion has a place in the management of patients with chronic renal pain. It offers a minimally invasive alternative to other treatments. This procedure warrants further investigation within a randomised, controlled trial setting.     

Computed tomography versus ureteroscopy in identification of renal tract stone with ureteral stent in situ

INTRODUCTION

The aim of this study was to validate the use of non-contrast computed tomography (CT) with a ureteral stent in situ instead of ureteroscopy for identification of renal tract stones.

METHODS

All patients who had stents inserted for renal tract stones and underwent non-contrast CT with the stent in situ followed by ureteroscopy between May 2008 and October 2009 at The Canberra Hospital, Australia, were analysed retrospectively. Statistical analysis was performed to compare any differences between CT and ureteroscopy in the identification of stones.

RESULTS

Overall, 57 patients were included in the study. The difference between CT and ureteroscopy findings was statistically significant. CT identification of stones with a stent in situ had a sensitivity of 86%, a specificity of 46%, a positive predictive value of 63%, a negative predictive value of 76% and an accuracy of 67%.

CONCLUSIONS

Our study suggests that non-contrast CT is inferior to the ‘gold standard’ of ureteroscopy. It lacks sensitivity, specificity, positive predictive value, negative predictive value and accuracy. Therefore, we cannot recommend using non-contrast CT to replace ureteroscopy.     

Audit of safety, efficacy, and cost-effectiveness of local anaesthetic cystodiathermy

INTRODUCTION

The aim of this study was to audit our experience of cystodiathermy under local anaesthetic (LA) at the time of flexible cystoscopy for recurrent superficial bladder transitional cell carcinoma (TCC).

PATIENTS AND METHODS

A total of 264 flexible cystoscopies were performed on patients with a past history of TCC. The number and site of recurrences were recorded and selected patients were offered cystodiathermy. Patient tolerability was noted. At follow-up, any recurrence was recorded.

RESULTS

Eighty patients (30%) had 91 procedures showing one or more recurrences. Fifty-one of the 80 patients (64%) were treated with cystodiathermy under LA. All completed treatment. Forty-five (88%) tolerated the procedure well. Forty-seven (92%) treatments were completed within 5 min. At a median follow-up of 15 weeks, 30 (59%) treated patients had no recurrence and three (6%) had recurrence at the site of treatment.

CONCLUSIONS

LA cystodiathermy is an effective and well-tolerated alternative to general anaesthetic cystodiathermy that enables treatment at the time of detection and may, thereby, reduce patient anxiety.     

Modified Lapidus Procedure with Joint Compression,Meticulous Surface Preparation,and Shear-Strain-Relieved Bone Graft Yields Low Nonunion Rate

Background

The modified Lapidus procedure is widely used to correct hallux valgus but has been reported with high nonunion rates. In this study, we retrospectively reviewed the nonunion rate of the modified Lapidus procedure performed with rigid cross screw fixation, meticulous joint preparation, and shear-strain-relieved calcaneal bone graft.

Questions/Purposes

Does the performance of the Lapidus procedure with rigid cross screw fixation, complete joint preparation, and shear-strain-relieved calcaneal bone graft achieve higher union rates than currently reported? If nonunion does occur, what is the clinical course?

Methods

We reviewed both radiographic and clinical results of the modified Lapidus procedure with the above technique in 171 patients (182 feet). Evaluation included age, gender, tobacco use, diabetic status, and radiographic analysis at least 3 months postoperatively.

Results

The modified Lapidus procedure described above resulted in a union rate of 97.3% (177 of 182 feet). Three of the five feet with radiographic nonunions were clinically symptomatic.

Conclusions

The union rate of the modified Lapidus procedure is higher than previously reported when performed with rigid cross screw fixation, meticulous joint preparation, and shear-strain-relieved bone graft. Nonunion of the first tarsometatarsal joint should be considered an infrequent occurrence.

Electronic supplementary material

The online version of this article (doi:10.1007/s11420-015-9462-8) contains supplementary material, which is available to authorized users.     

De novo pudendal neuropathy after TOT-O surgery for stress urinary incontinence

Background and Objectives:

Five cases of pelvic nerve complications after transobturator tape (TOT) inside-out surgical procedures for stress urinary incontinence are presented.

Methods:

We conducted a chart review of patients with complications referred to our practice.

Results:

Five patients with nerve complications after TOT inside-out procedures were investigated. Pudendal neuropathy and interstitial cystitis were seen in this series of patients with several patients having myofascial pain in the lower abdominal area.

Conclusions:

Although not commonly reported, complications from needle placement and from the area of needle exit in a TOT procedure can exist, and the surgeon must be careful when placing the needle through the area of the obturator fossa.     

Laparoendoscopic Single-Site Herniorrhaphy After Gynecologic Surgery

Background and Objectives:

Increased interest in laparoendoscopic single-site surgery has instigated research into trials of novel techniques. The procedure we propose may potentially improve patient satisfaction and cosmetic results while diminishing the incidence of trocar-site herniation. We report our initial experience with laparoendoscopic single-site totally extraperitoneal herniorrhaphy for postoperative incisional hernia to determine the procedure''s feasibility and safety.

Methods:

Three patients with incisional hernias after gynecologic surgery underwent laparoendoscopic single-site totally extraperitoneal procedures. We evaluated the patients'' preoperative and postoperative condition, as well as the details of their original surgery. We performed the procedure through a 2-cm umbilical incision followed by mesh insertion and transabdominal suture placement in all patients.

Results:

Laparoendoscopic single-site totally extraperitoneal herniorrhaphy was completed in 80 to 120 minutes. No intraoperative complications were encountered, and surgical blood loss was minimal. The duration of hospital stay ranged from 2 to 4 days. One patient had a postoperative wound infection. The patients have shown no sign of recurrence at 9 months'' follow-up.

Conclusion:

Laparoendoscopic single-site totally extraperitoneal herniorrhaphy appears to be feasible and safe. It may be performed with readily available instruments, although further experience and practice are warranted for a more efficient repair. The procedure has similar advantages to a multiport laparoscopic totally extraperitoneal procedure but yields better cosmetic results. More studies are needed to assess the long-term benefits and complications of this procedure.     

Surgical rates in subprovincial areas across Canada: rankings of 39 procedures in order of variation

Objective

To rank 39 surgical procedures in order of variation of inpatient surgical rates, according to a new index of variation and to test the hypothesis that there is greater variation for primarily discretionary operations than for primarily non-discretionary operations.

Design

A population-based retrospective cohort study.

Setting

Nine provinces (99.19% of Canada’s population).

Participants

All hospital inpatients who underwent any of 39 types of surgery and were separated from hospital between Apr. 1, 1988 and Mar. 31, 1990 (the most recent time period for which Canada-wide data were available at the subprovincial level analysed).

Main Outcome Measure

Rankings of the 39 procedures according to the index of variation, calculated from inpatient surgery rates in 255 census divisions across Canada.

Results

The 13 procedures with the greatest variation were all primarily discretionary. Thirteen of the 14 procedures with the lowest variation were primarily non-discretionary. All but one of the procedures whose degree of discretion was deemed intermediate were in the middle third of the rankings.

Conclusions

The greatest variation is found in primarily discretionary operations. Further investigation should be focused on identified geographical locations where rates for operations that are primarily discretionary are unusually high or low, and particularly on those operations for which there is disagreement regarding the indications for surgery.     

Incidence of Port-Site Incisional Hernia After Single-Incision Laparoscopic Surgery

Background and Objectives:

Single-incision laparoscopic surgery is gaining popularity among minimally invasive surgeons and is now being applied to a broad number of surgical procedures. Although this technique uses only 1 port, the diameter of the incision is larger than in standard laparoscopic surgery. The long-term incidence of port-site hernias after single-incision laparoscopic surgery has yet to be determined.

Methods:

All patients who underwent a single-incision laparoscopic surgical procedure from May 2008 through May 2009 were included in the study. Single-incision laparoscopic surgical operations were performed either by a multiport technique or with a 3-trocar single-incision laparoscopic surgery port. The patients were seen at 30 to 36 months'' follow-up, at which time they were examined for any evidence of port-site incisional hernia. Patients found to have hernias on clinical examination underwent repairs with mesh.

Results:

A total of 211 patients met the criteria for inclusion in the study. The types of operations included were cholecystectomy, appendectomy, sleeve gastrectomy, gastric banding, Nissen fundoplication, colectomy, and gastrojejunostomy. We found a port-site hernia rate of 2.9% at 30 to 36 months'' follow-up.

Conclusion:

Port-site incisional hernia after single-incision laparoscopic surgical procedures remains a major setback for patients. The true incidence remains largely unknown because most patients are asymptomatic and therefore do not seek surgical aid.     

Video-Assisted Thoracoscopy for the Diagnosis of Mediastinal Masses in Children

Background and Objectives:

Video-assisted thoracoscopy has been successfully used for several different thoracic procedures in adults. However, its use in children has been limited. The present study evaluated our experience with video-assisted thoracoscopy in the diagnosis of mediastinal masses in children.

Methods:

Nine children (age range, 3 to 18 years) with undiagnosed mediastinal masses underwent video-assisted thoracoscopy. The operation was performed using general anesthesia, with the patient intubated with a single lumen endotracheal tube.

Results:

In all cases adequate tissue for diagnosis was obtained. Three patients had tuberculosis, two had Hodgkin''s disease, two had granuloma, one had metastatic Wilms1 tumor, and one had thymic hyperplasia. There were no complications related to the operative procedure.

Conclusions:

Video-assisted thoracoscopy for the diagnosis of mediastinal masses in children is a safe procedure. It provides good visualization, access to the mediastinum and adequate tissue for diagnosis. Further, postoperative discomfort is tolerable and cosmetic results are excellent.     

Non-traumatic acute abdomen: videolaparoscopic approach.

Background and Objectives:

Although videolaparoscopy has been considerated a safe method for many elective procedures, its use in traumatic and non-traumatic acute abdomen needs to be evaluated. The aim of this article is to evaluate the role of videolaparoscopy in non-traumatic acute abdomen as a method of diagnosis and treatment.

Methods:

Between January 1992 and December 1996, 462 patients'' charts were reviewed, retrospectively. Patients were admitted to the emergency room of Sao Rafael Hospital with symptoms of non-traumatic acute abdomen. Routine investigation of abdominal pain was performed in all patients, followed by videolaparoscopy. The laparoscopic procedures were done with four main purposes: diagnosis (ie, enteritis); diagnosis and treatment (ie, appendicitis); treatment only, when the diagnosis was known (ie, acute cholecystitis); and in cases where the conversion to conventional laparotomy was necessary, indicating the best incision.

Results:

The vast majority of patients had inflammatory causes of acute abdomen (82.03%); others causes were hemoperitoneum (11.03%), bowel obstruction (3.25%), perforation of a hollow viscera (1.74%), vascular occlusion (1.3%), and negative laparoscopy (0.65%).

Conclusion:

This study shows that laparotomy was necessary in only 7.14% of the patients. The videolaparoscopic approach was used for diagnosis (99.35%) and treatment (92.86%) of patients with acute abdomen.     

Conversion to Stoppa Procedure in Laparoscopic Totally Extraperitoneal Inguinal Hernia Repair

Background and Objectives:

Conversion to open surgery is an important problem, especially during the learning curve of laparoscopic totally extraperitoneal (TEP) inguinal hernia repair.

Methods:

Here, we discuss conversion to the Stoppa procedure during laparoscopic TEP inguinal hernia repair. Outcomes of patients who underwent conversion to an open approach during laparoscopic TEP inguinal hernia repair between September 2004 and May 2010 were evaluated.

Results:

In total, 259 consecutive patients with 281 inguinal hernias underwent laparoscopic TEP inguinal hernia repair. Thirty-one hernia repairs (11%) were converted to open conventional surgical procedures. Twenty-eight of 31 laparoscopic TEP hernia repairs were converted to modified Stoppa procedures, because of technical difficulties. Three of these patients underwent Lichtenstein hernia repairs, because they had undergone previous surgeries.

Conclusion:

Stoppa is an easy and successful procedure used to solve problems during TEP hernia repair. The Lichtenstein procedure may be a suitable option in patients who have undergone previous operations, such as a radical prostatectomy.     

Cost Minimisation Using Clinic-Based Treatment for Common Hand Conditions – A Prospective Economic Analysis

INTRODUCTION

The purpose of this study was to compare the cost of treatment of Dupuytren''s disease, ganglia and trigger digits in the out-patient department with the operating theatre.

PATIENTS AND METHODS

All patients seen in a new patient hand clinic with a diagnosis of Dupuytren''s disease, trigger digit or ganglion of the wrist or hand requiring treatment were prospectively identified over a 6-month period. The numbers undergoing a procedure in the out-patient clinic or theatre were recorded. Costings of theatre time and out-patient time, as well as national tariff income, were obtained from the hospital management.

RESULTS

Over the 6-month period, 80, 26, and 52 patients were treated with regard to Dupuytren''s disease, ganglia and trigger digits, respectively. Of these, 37, 23, and 44 were treated by an out-patient procedure, and 43, 3 and 8 underwent a formal operation. The total cost of the out-patient procedures was calculated at £1560 over 6 months. To perform these as formal operations would have cost £64,896. The cost savings were, therefore, £63,336, or £126,672 per annum.

CONCLUSIONS

Out-patient interventions for Dupuytren''s disease, ganglia and trigger digits result in significant cost savings over formal surgical treatment.     

Outcomes after severe trauma at a northern Canadian regional trauma centre

Objective

To evaluate outcomes of trauma patients at a northern community trauma referral centre that does not meet several of the guidelines for a trauma centre.

Design

A retrospective study.

Setting

Sudbury General Hospital in northern Ontario.

Participants

All trauma patients admitted between 1991 and 1994 who had an Injury Severity Score (ISS) greater than 12.

Outcome measures

Actual survival to discharge was compared to survival predicted by TRISS analysis. Z, W and M scores were calculated by standard TRISS techniques.

Results

Of 526 patients with an ISS greater than 12, 416 (79%) were suitable for TRISS analysis. Of these 416 patients, 310 (74%) were men. The mean age was 39 years. Two hundred and sixty-one (63%) patients were admitted directly to the Sudbury General Hospital, whereas 155 (37%) were transferred from other hospitals. The leading causes of injury were motor vehicle–traffic accidents in 48%, motor vehicle–nontraffic in 21% and falls in 8%. Overall, there were more unexpected survivors than patients who died. The Z score for survivors was 4.95, and the W score was 5.66.

Conclusions

In the setting of a geographically isolated, medium-volume trauma centre where blunt injuries predominate, excellent trauma survival can be achieved without meeting all trauma centre guidelines for staffing and facilities. Relaxing stringent requirements for the availability of physicians may facilitate surgical recruitment and retention.     

SINGLE-PORT FOR LAPAROSCOPIC GASTRIC RESECTION WITH A NOVEL PLATFORM

Introduction

Laparoscopic gastrointestinal resections using single-port are possible, but triangulation problems and the need of articulated instruments difficult the procedures.

Aim

To present a surgical alternative using single-port laparoscopic device on gastric resection.

Technique

The patient is placed in a supine and reverse Trendelenburg position with surgeon between patient''s legs. First assistant was on the right side of the patient with the monitor placed on the patient''s cranial side. With the patient under general anesthesia, a transumbilical 3 cm skin incision is performed. A single-incision advanced access platform with gelatin cap, self-retaining sleeve and wound protector is introduced through this incision. Three 5-12 mm operating ports were introduced through the single-port device. Due to the gel cap and sleeves, no articulated instruments are necessary. CO₂ pneumoperitoneum is established at 12 mmHg. A rigid 30 degree 10 mm laparoscope is introduced. Operation begins with access to the lesser sac by opening the omentum along the greater curvature of the stomach using harmonic scalpel. Once the stomach is fully exposed and a stay suture is place around the tumor. Gastric wall is divided with cautery 1 cm away from the tumor. Tumor is excised. Gastric wall is sutured with two-layer running suture. No drain was used. Umbilical incision was closed.

Results

This procedure was used in one patient with gastric duplication. Operative time was 200 minutes. Blood loss was minimal. Recovery was uneventful and patient discharged on postoperative day 2. Final aspect of the umbilical incision was good.

Conclusions

Gastric resection with single-port laparoscopic platform is feasible and may be safely performed in selected patients.     

Cryosurgery for malignant tumours of the liver

Objective

To evaluate the safety and efficacy of ultrasound-guided cryosurgery to treat malignant tumours of the liver.

Design

A prospective nonrandomized trial. The follow-up was complete and ranged from 8 to 35 months.

Setting

A university-affiliated hospital.

Patients

Ten patients with secondary malignant tumours of the liver; 1 with primary hepatoma.

Interventions

Computed portography for preoperative staging; laparotomy and ultrasonographic examination of the liver; cryosurgical ablation of liver tumours with or without a concomitant resection. Thirteen procedures were performed on 11 patients.

Main Outcome Measures

Preoperative morbidity, disease-free and overall survival.

Results

Of 24 lesions frozen, the procedure on 4 lesions was considered a technical failure because of persistent disease. There were no perioperative deaths. One patient had a liver abscess that resolved with percutaneous drainage. One patient had a biliary fistula that resolved spontaneously, and one had a transient rise in the serum creatinine level. Of 11 patients treated, 7 had a recurrence in the liver (persistent disease in 2 and new liver metastases in 5); 2 of these patients died. One patient died of distant disease with no local recurrence. At the time of writing, one patient was alive with extrahepatic disease and no local recurrence and two were free of disease.

Conclusions

Cryosurgery of the liver is a relatively safe procedure that allows treatment of otherwise un-resectable malignant disease. Proof of long-term benefit requires further experience and follow-up.     

The role of diagnostic block in the management of Morton’s neuroma

Objective

To determine the outcome of surgical excision of Morton’s neuroma after a local anesthetic diagnostic block into the neuroma has relieved symptoms.

Design

A cohort study.

Setting

A university affiliated hospital.

Patients

A sequential series of 37 patients who underwent 41 excisions with at least 2 years’ follow-up. Seven patients had undergone repeat excision of a neuroma, and 34 primary excisions were performed. Surgery was performed by a specialist in orthopedic surgery of the foot and ankle.

Intervention

Excision of the Morton’s neuroma after a positive diagnostic block.

Main outcome measures

Grade of symptoms at follow-up done by independent review on a 4-point scale.

Results

Of 41 procedures, 11 had an unfavourable outcome: 4 procedures were graded 3, and 7 procedures were graded 4. Eight (24%) of the 34 primary procedures were reported as failures, and 3 (43%) of the 7 revision procedures were reported as failures. Most patients reported poor results owing to persistent pain.

Conclusions

Diagnostic blocks do not improve the results of surgery for excision of Morton’s neuroma and are not recommended. Because failure rates are greater than 20%, surgery for Morton’s neuroma should only be offered after a full course of nonoperative management.     

Thorascopic sympathectomy performed using laser

INTRODUCTION

Thorascopic sympathectomy is accepted as an effective treatment for palmar hyperhidrosis, facial blushing and to a lesser extent for digital ischaemia and axillary hyperhidrosis.

PATIENTS AND METHODS

Data were collected retrospectively on patients undergoing thorascopic sympathectomy at St Peter''s Hospital between 1987 and 2006. Patients were followed up by telephone interview.

RESULTS

A total of 233 thorascopic sympathectomy procedures were performed by a single operator in 123 patients. Ages ranged from 9–71 years and 75 were women. In patients, 105 had a bilateral and 13 a unilateral procedure, 5 patients had a bilateral procedure performed in two stages. In 6 upper limbs, the procedure could not be done. Overall, 110 patients (90%) had the procedure performed for palmar hyperhidrosis, 8 (6%) for facial blushing and in 5 (4%) patients the operation was performed for digital ischaemia with tissue loss. There were no deaths and all patients were discharged on day 1 following the procedure. Complications included bleeding (2), pulmonary oedema (1) and failed procedure (2); however, no incidences of Horner''s syndrome occurred. Only 40 of 123 (32.5%) patients gave follow-up information. Of this small group, 33 of 40 (83%) were cured, 4 of 40 (10%) were better, 2 of 40 (5%) were unchanged and 1 patient was worse. Only 22 out of 40 (55%) of these patients were troubled by compensatory sweating, with only 4 of 40 (10%) reporting this as a major problem.

CONCLUSIONS

Thorascopic sympathectomy is safe and can be carried out as a single bilateral procedure in the majority of cases. The laser allows the use of a single port, requires less dissection than surgical or clipping techniques, is more precise than diathermy and may be less likely to cause a Horner''s syndrome.