难治性膀胱疼痛综合征/间质性膀胱炎患者的骶神经根神经调节治疗:单中心的14年经验

<正>为对照研究慢性骶神经调节(SNM)治疗膀胱疼痛综合征/间质性膀胱炎(PBS/IC)患者症状的效果,从而评价SNM的长期成功率和耐受性。作者回顾性分析研究1994~2008期间该院泌尿外科所有经周围神经评估(PNE)和慢性骶神经调节治疗控制PBS/IC症状的患者,同时应用整体反应量表作为有效性工具来测量慢性     

Troubleshooting Sacral Neuromodulation Issues

In the past decade, the use of sacral neuromodulation has increased exponentially. The introduction of the tined lead, the posterior location, and the smaller IPG has changed the frequency and types of complications. These facts explain the reduction of the revision and explantation rates in the most contemporary series, as compared with the earlier data. Infection, pain at the IPG site, and reduced clinical response with or without impedance abnormalities are now the most frequently reported complications. Although infection should be managed with explantation of the entire system, device interrogation should be part of the physician's algorithm for managing patients with decreased sensation or new onset of pain, in order to check the integrity of the system. Patients who are not improved with new programs will most likely need surgical revision. The implanting physician should be aware of the ways to evaluate and manage complications and suboptimal responses, to appropriately troubleshoot patients, and to reduce the need for surgical revision.     

Specific Tips for General Controversies in Sacral Neuromodulation

The field of Sacral Neuromodulation is continually evolving and still in its infancy. Common dilemmas experienced with this therapy will be discussed in this article, including ways to avoid and manage them. The focus will be on test evaluations performed with either peripheral nerve evaluation (PNE) or staged procedure, the clinical effectiveness and safety of unilateral versus bilateral test stimulation for both the PNE and staged procedures, and best methods to determine the success of the trial phase. We will also discuss how to deal with the problem of declining efficacy of the device over time. The article presents a discussion on future technological innovations to enhance techniques and mode of positioning and use of leads, which along with a refined understanding of how neuromodulation is effective for different problems, will lead to better outcomes.     

Contrasting the Percutaneous Nerve Evaluation Versus Staged Implantation in Sacral Neuromodulation

Sacral neuromodulation is increasingly used for the treatment of voiding dysfunction, pelvic pain syndromes, and gastrointestinal disorders. While increased use of this technology has led to a greater understanding of its potential as well as its limitations, difficulty persists in identifying the patients that will benefit most. Either of two trial stimulation techniques is performed before placement of a permanent neuromodulator: the monopolar percutaneous nerve evaluation and the tined quadripolar staged trial. The preponderance of recent literature asserts the superior sensitivity of the staged trial over percutaneous nerve evaluation. However, the techniques offer disparate advantages, and other issues, such as cost-effectiveness, remain largely unexplored. The role of sacral neuromodulation will continue to expand as physicians and patients become increasingly aware of its therapeutic potential. Widespread adoption of this clinically superior technique will most rapidly help the greatest number of patients.     

Psychological Aspects of Living Kidney Donation in Poland: Experience of One Center

Background

Living kidney transplantation is the optimal treatment of end-stage renal disease. The benefits for recipients are obvious. The psychological consequences for living kidney donors in Poland are not known.

Renal Transplantation With Expanded Criteria Donors: The Experience of One Portuguese Center

Background

The shortage of kidneys available for transplantation has led to enlarged criteria donors (ECD): namely, donors older than 60 years or aged between 50 and 59 years with 2 of the following characteristics-hypertension, predonation serum creatinine level higher than 1.5 mg/dL or cerebrovascular disease as the cause of death. The aim of this study was to analyze renal transplants using ECD compared with standard criteria donors (SCD) concerning the incidences of delayed graft function (DGF), acute rejection episodes (ARE), and patient and graft survivals.

Materials and Methods

This retrospective study of 409 cadaveric renal transplants over the last 4 years identified ECD in contrast with SCD.

Results

Of the transplants, 24.4% used ECD. The baseline characteristics of recipients of ECD versus SCD kidneys were similar, except for age and cold ischemia time. Comparing ECD and SCD, we observed an higher incidence of DGF (35% vs 18%), occurrence of ARE (34.4% vs 16.6%), average serum creatinine levels at 6 (1.87 vs 1.4 mg/dL), and 12 months (1.88 vs 1.43 mg/dL) as well as lower graft survival at 1 (82% vs 91%) and 3 years (75% vs 84%) after transplantation. Recipient survival at 1 year was not different. Multivariate analysis identified recipient age, cold ischemia time, ARE, and DGF as risk factors for graft failure.

Conclusions

Renal transplantation with grafts from ECD shows significantly worse outcomes with higher rates of DGF and ARE, worse graft function, and lower graft survival.     

Pregnancy Outcomes After Kidney Transplantation and Long-Term Evolution of Children: A Single Center Experience

BackgroundPregnancies in women who underwent kidney transplants are at high risk compared with the general population.MethodsIn this study, we aimed to retrospectively assess the obstetrical complications, delivery outcomes, and impact of pregnancy on kidney allograft function in a single-center cohort of kidney transplant recipients (KTRs). We provide data regarding the long-term evolution of children.ResultsThirty-two KTRs underwent a total of 57 pregnancies between 1994 and 2010. Fourteen pregnancies (24 %) did not survive caused by miscarriages (n = 9), stillborn (n = 1), ectopic pregnancies (n = 2), and medical abortion (n = 2). Live birth occurred in 76% of pregnancies. Delivery was by cesarean in 66%. The mean gestational age was 30.45 ± 11.3 weeks and 65% of newborns were premature. A low birth weight <2500g was noted in 46%. Obstetric complications were de novo hypertension in 4%, pre-eclampsia in 9%, and gestational diabetes in 2%. The 5- and 10-year post-delivery death-censored graft loss rates were 3.1% and 12.5%, respectively. Data on 21 children were collected via a self-questionnaire. After a median follow-up time of 17 years, they appeared in good medical and psychological health. None of them suffered from chronic disease (especially uronephrological condition) or was taking chronic medication.ConclusionsLong-term evolution of children born to women who underwent kidney transplants seems favorable. Pregnancies in KTRs are successful in two-thirds of cases but are at increased risk of prematurity, delivery by cesarean, and low birth weight.