Management of adult anterior urethral stricture disease: nationwide survey among urologists in the Netherlands

Background

Adult anterior urethral stricture disease is most often treated with dilatation or direct vision internal urethrotomy (DVIU). Although evidence suggests that anastomotic urethroplasty for short bulbar strictures is more efficient and cost effective in the long term, no consensus exists. It is unclear by whom and how often urethroplasties are performed in The Netherlands and how results are being evaluated.

Objective

To determine national practice patterns on management of anterior urethral strictures among Dutch urologists. This information will help to define the nationwide need for training in urethral surgery.

Design, setting, and participants

We conducted a 16-question survey among all 323 Dutch urologists.

Results and limitations

The response rate was 74%. DVIU was practised by 97% of urologists. Urethroplasty was performed at least once yearly by 23%, with 6% performing more than five urethroplasties annually. In the group of urologists younger than 50 yr of age, 13% performed urethroplasty, with 3% of those performing more than five annually. In the case of a 3.5-cm-long bulbar stricture, DVIU was preferred by 49% of responders. Even after two recurrences, 20% continued to manage a 1-cm-long bulbar stricture endoscopically. Of responders, 79% believed that urethroplasty should be proposed only after a failed endoscopic attempt. Diagnostic workup and evaluation of success varied greatly.

Conclusions

Most Dutch urologists believe that urethroplasty is an option only after failed DVIU. Endoscopic procedures are widely used, even when the risk of recurrence is virtually 100%. The definition of success is hampered by nonstandardised methods of follow-up. Only a small group of mainly older urologists frequently performs urethroplasties. Training programmes seem necessary to guarantee a high standard of care for stricture disease in The Netherlands. A pan-European practice survey might be interesting to clarify the need for centralised fellowship programmes.     

Resultant hypospadias after epispadias repair in bladder exstrophy patients: a difficult surgical task with high complication rate

Background/Purpose

The aim of this study was to analyze the complication rate in male bladder exstrophy (BE) patients undergoing flap or graft urethroplasty for the repair of resultant hypospadias after epispadias repair.

Methods

We retrospectively reviewed the charts of 22 male BE patients who underwent 24 urethroplasties for resultant hypospadias between 2000 and 2009. Median patient age was 4.2 (range, 1.5-26.5) years, and median follow-up was 7.5 (range, 0.8-10.3) years. Meatal location after epispadias repair was midshaft in 6 cases and proximal shaft in 15. Complications were compared in relation to meatal position, type of urethroplasty (no graft vs graft), use of second-layer coverage of the urethroplasty, and use of suprapubic diversion.

Results

Overall, complications developed in 12 (50%) patients, including 10 urethrocutaneous fistulas and 2 urethroplasty dehiscence. Univariate analysis failed to show any differences between complicated and uncomplicated cases in all the variables. Only the 3 cases undergoing a 2-stage repair had fully successful outcomes.

Conclusions

Urethroplasty in patients with BE has a high complication rate. Quality of local tissue and presence of scarring are possibly the 2 major determinants of a poor outcome. A staged repair seems the safest, although this commits the patient to 2 procedures.     

Multiple failed urethroplasties: definitive repair with the Duckett island-flap technique

Background/Purpose:

The correction of postoperative complications after hypospadias repair presents frequently serious problems, and the results are not always satisfactory. The aim of this study is to present our experience with the tubularized island flap technique (Duckett procedure) in patients who had been submitted to repeated unsuccessful attempts for the repair of hypospadias and its complications.

Methods:

During an 8-year period (1994 through 2001), 21 patients, aged 4 to 18 years, presented with severe recurrent hypospadias (3 to 13 times). In all patients, the urethral orifice was quite proximal because of disruption of the neourethra and was associated with severe penile ventriflexion. In addition, there were diverticula with hair ingrowth in 5 boys and lack of the prepuce in 4. All patients underwent the Duckett island-flap technique. The inner layer of the prepuce was used in 17. The dorsal penile skin was used for the island flap formation in the remaining 4 patients in whom the prepuce had been resected during the previous operations.

Results:

After repair, the meatus was located at the top of the glans in all patients. There were 5 complications (24%): distal fistula near the glans (n = 1), meatal stenosis (n = 1), diverticula at the proximal anastomosis (n = 2), and anastomotic stenosis (n = 1). All of them were treated successfully by meatotomy, fistula closure, diverticula tapering, and dilatations, respectively.

Conclusions:

The island-flap technique gives satisfactory results in patients with multiple failed urethroplasties; it is applicable even in boys with resected prepuce and has an acceptable complication rate.     

Surgical complications of posterior urethral valve ablation: 20 years experience

Purpose

The aim of the study was to report the surgical complications that may occur during or after primary ablation of posterior urethral valve (PUV) in a large number of cases treated using different modalities.

Materials and Methods

We retrospectively reviewed a database of 291 patients with PUV treated by primary valve ablation from 2 separate centers between 1987 and 2006. Primary valve ablation was performed in all patients regardless of serum creatinine level or upper tract con?guration. A hot loop resectoscope was used in 122 patients, cold knife urethrotome in 108, a hook diathermy electrode in 18, a diathermy coagulation bugbee electrode in 20, whereas stripping using a Fogarty catheter was performed in 23.

Results

The follow-up duration ranged from 1.5 to 20 years (median, 6.5). Early postoperative complications occurred in 22 patients (7.5%). The most common complication was urinary retention in 16 patients (5.5%). Urinary extravasations occurred in 3 cases, significant hematuria from urethral bleeding occurred in 2, and obstructive anuria developed in 1 patient. Most of cases were treated conservatively. Urethral strictures developed in 6 patients (2%) mainly after endoscopic loop resection (4/6). All were treated by visual internal urethrotomy and urethral dilatation with successful results without the need of open urethroplasty.

Conclusions

Primary valve ablation seems to be safe and is associated with low rate of postoperative complications. All the complications could be treated conservatively. Urethral stricture may occur after valve ablation in a minority of cases and can be successfully treated endoscopically. Loop resection is associated with more strictures.     

Pain on injection of propofol: a comparison of methylene blue and lidocaine

Study Objective

To investigate whether methylene blue, given before injection of propofol, was effective in reducing the frequency and severity of pain associated with propofol injection.

Design

Prospective, randomized, double-blinded clinical study.

Setting

Operating room of a university hospital.

Patients

90 adult, ASA physical status 1 and 2 patients undergoing elective surgery.

Interventions

Patients were randomly allocated to one of three groups of 30 patients each. Group I received 50 mg of methylene blue, Group II received 40 mg of lidocaine, and Group III, the control group, was given normal saline. All drugs were given as a 2.0 mL bolus 45 seconds before propofol administration.

Measurements

Injection pain using vocal responses, facial grimacing, arm withdrawal, tears, and questioning of the patient were noted. A 4-point scale was used for documenting pain.

Main Results

Pain frequency was 90% in the saline group, whereas the frequencies were significantly lower in the lidocaine and methylene blue groups (26.7% and 40%, respectively).

Conclusions

Intravenous pretreatment with methylene blue appears to be effective in reducing the pain during propofol injection.     

Two-stage coloesophagoplasty in children with caustic burns of the esophagus: hemodynamic basis of delayed cervical anastomosis--theory and fact

Background/purpose

This study was carried out to survey the outcome in patients with corrosive burns of the esophagus who had undergone 2-stage coloesophagoplasty procedures.

Methods

Records of 81 patients with staged cervical coloesophagostomy procedures have been reviewed. In all cases, colon was pulled through the retrosternal route in an antiperistaltic fashion. The native esophagus was left in place. After the cologastric anastomosis at the antral level, cervical anastomosis was delayed for a second stage. Complications related to the procedure, corrective interventions, and long-term results were evaluated.

Results

In all patients, the retrosternal route was used for the replacement of the colon. The conduits were constructed from right colon in 20 (24.7%) and left colon in 61 (75.3%) patients. There were 3 leaks (3.7%) and 9 strictures (11%). Terminal necrosis of the cervical colonic piece occurred in 3 patients who had undergone resection of the sloughed terminal end, and all were further treated by right intrathoracic antehilar coloesophagostomies performed between the remaining parts of the transplanted colon and the upper thoracic esophagus. One of these patients had wound dehiscence with subsequent sepsis and died.

Conclusions

Terminal necrosis of the graft is not related to staging of the technique, but the decreased rate of cervical anastomotic strictures seem to be directly correlated with staging of cervical anastomosis. Possibly, an ischemic anastomosis at the terminal end of the graft after extensive mobilization and retrosternal placement is avoided with a delayed anastomosis performed after full restoration of the microcirculation.     

Esophageal strictures in children with recessive dystrophic epidermolysis bullosa: an 11-year experience with fluoroscopically guided balloon dilatation

Background

Recessive dystrophic epidermolysis bullosa (RDEB) is an inherited blistering skin disorder that is associated with significant esophageal strictures, resulting in dysphagia and nutritional failure. Although endoscopically guided balloon dilatation is a widely used treatment, the use of an endoscope carries the risk of oropharyngeal trauma. To minimize this risk, we have eliminated its use.

Method

We reviewed the charts of all RDEB patients who underwent balloon dilatation for esophageal strictures between August 1993 and March 2005. Balloon dilatation procedures were performed under anesthesia and with fluoroscopic control.

Results

We performed 92 dilatations on 25 RDEB patients. Most patients reported immediate relief of symptoms, rapid recovery, and resumption of adequate food intake within 1 day. The mean interval between dilatations was 1 year. Six patients (24%) have required only 1 dilatation, and 1 of these 6 has had a dilatation-free interval of 25 months. One patient with a history of multiple dilatations has remained dilatation-free for 5 years. No procedure-related complications have occurred.

Conclusions

Fluoroscopically guided balloon dilatation is a gentle, safe, effective, and repeatable technique that should be considered as a first line of treatment.     

Endoscopic Management of Urologic Complications Following Renal Transplantation: Impact of Ureteral Anastomosis

Objective

To evaluate the success of ureteral stent placement to treat or prepare for surgical treatment of urologic complications after renal transplantation, according to a type of ureteral anastomosis.

Patient and methods

From May 1989 to December 2006, we performed 703 kidney transplantations including 412 extravesical ureteroneocystostomy (according to Lich-Gregoire technique) and 265 transvesical ureteroneocystostomy (according to Politano-Leadbetter technique). We retrospectively analyzed our endoscopic management of urinary leaks and ureteral strictures. The criteria of success were the feasibility to place a ureteral stent, permitting good drainage of the upper renal graft tract before further endoscopic or surgical treatment.

Results

Forty-three urinary leaks or ureteral strictures occurred after extravesical ureteroneocystostomy (n = 21) or after Politano-Leadbetter anastomosis (n = 22). The success rate of endoscopic management was 75% (n = 16) for Politano-Leadbetter anastomosis versus 53% (n = 11) for the Lich-Gregoire anastomosis. There was no statistical difference (P = .1).

Conclusion

Ureteroneocystostomy according to Lich-Gregoire procedure were twice less complicated than those according to the Politano-Leadbetter technique, but were associated with a rate of failure of ureteral stent placement in urgency higher to 25%.     

Health and cost consequences of surgical versus conservative treatment for a comminuted proximal humeral fracture in elderly patients

Objective

This study aims to evaluate the costs and health outcome for surgical and conservative treatment of displaced proximal humeral fractures.

Design

This study is a randomised controlled trial.

Participants

This study included 50 patients aged 60 or older admitted to hospital with a severely displaced three- or four-part fracture.

Interventions

The patients were treated surgically with an angular stable interlocking implant (25 patients) or conservative treatment (25 patients).

Main outcome measure

The outcomes measured included quality-adjusted life years (QALYs) and societal costs.

Results

At 12 months’ follow-up, the mean difference in the number of QALYs was 0.027 (95% confidence interval (CI) = −0.025, 0.078) while the mean difference in total health-care costs was €597 in favour of surgery (95% CI = −5291, 3777).

Conclusion

There was no significant difference in QALYs or costs between surgical and conservative treatment of severe displaced proximal humeral fractures.     

Anastomotic stricture after surgical repair of esophageal atresia: frequency, risk factors, and efficacy of esophageal bougie dilatations

Aims

The aim of this study was to evaluate the frequency and risk factors of postoperative anastomotic stricture, and the efficacy and complications of esophageal bougie dilatations for symptomatic anastomotic stricture in a population of children with esophageal atresia.

Patients and Methods

The medical records of 62 children operated on for esophageal atresia type III (Ladd and Gross) over a 5-year period were retrospectively reviewed.

Results

Anastomotic stricture developed in 23 (37%) of patients. Anastomotic tension during primary repair of esophageal atresia was associated with subsequent stricture formation (P < .05). Patients required esophageal dilation at a mean age of 149 days (range, 30-600 days). Stricture resolution occurred after a mean of 3.2 dilatations per patient (range, 1-7). Dilation was successful in 87% of patients. Three patients continued to present mild (n = 1) to severe (n = 2) dysphagia, mainly related to esophageal dysmotility. No complications were observed during or after the dilatation sessions.

Conclusions

Anastomotic stricture, secondary to the surgical treatment of esophageal atresia, remains a frequent complication in patients with esophageal atresia. Esophageal dilation with Savary-Gilliard bougies is a safe and effective procedure in the management of strictures.     

MANAGEMENT OF URETHRAL STRICTURES AFTER HYPOSPADIAS REPAIR

Purpose

We conducted a retrospective study of patients with strictures after hypospadias repair to identify factors contributing to the development of strictures and to attempt to define an optimal strategy for management.

Materials and Methods

patients with the diagnosis of hypospadias who had undergone direct vision internal urethrotomy, urethral dilation or urethroplasty were identified. The original location of the meatus, type of initial repair, subsequent procedures and outcome of the interventions were recorded.

Results

A total of 38 patients were identified. Of the 29 patients who were initially treated with direct vision internal urethrotomy or urethral dilation 23 (79%) ultimately required open urethroplasty and did well. Of the 8 patients treated with initial urethroplasty 7 had successful outcomes. Overall success, defined as asymptomatic voiding without fistula or residual stricture, was 78% at a mean followup of 6.3 years.

Conclusions

Stricture disease continues to be a significant complication of hypospadias reconstruction. Initial therapy should be urethral dilation but it should be recognized that the majority of these patients will ultimately require open urethroplasty.     

Prophylactic glycopyrrolate prevents bradycardia after spinal anesthesia for Cesarean section: a randomized, double-blinded, placebo-controlled prospective trial with heart rate variability correlation

Study Objective

To determine if prophylactic glycopyrrolate prevents bradycardia after spinal anesthesia.

Design

Prospective, randomized, double-blinded, placebo-controlled study.

Setting

Large university-affiliated community hospital.

Patients

81 consecutive term parturients (not in active labor) who were scheduled for elective Cesarean section.

Interventions

Parturients received 1.0 to 1.5 L of intravenous Ringer's lactate and either glycopyrrolate 0.4 mg or an equal volume of saline, with caregivers blinded to the immediate sequelae of study drug. Each patient received intrathecal bupivacaine (12 to 14 mg) with morphine sulfate (0.1 to 0.2 mg).

Measurements

Continuous heart rate (HR) and blood pressure monitoring occurred for 20 minutes, with the minimum HR recorded for each 5-minute epoch. Heart rates < 60 beats per minute defined bradycardia. Heart rate variability (HRV) analysis occurred offline.

Main Results

None of 34 patients administered glycopyrrolate and 6 of 35 (17%) patients receiving saline experienced bradycardia (P = 0.02476). Time domain, frequency domain, and nonlinear and embedded spectrum entropy analyses all reflected the decrease in HRV accompanying administration of glycopyrrolate.

Conclusion

Bradycardia after spinal anesthesia occurs commonly. Prophylactic glycopyrrolate may prevent the bradycardia, but not necessarily the hypotension.     

Intravenous landiolol, a novel β(1)-adrenergic blocker, reduces the minimum alveolar concentration of sevoflurane in women

Study Objective

To investigate the effect of intravenous (IV) landiolol, a novel β₁-adrenergic blocker, on the minimum alveolar concentration (MAC) of sevoflurane in adult women.

Design

Prospective, randomized study.

Setting

University hospital.

Patients

42 ASA physical status 1 and 2 women, aged 24-57 years, who were scheduled to undergo elective abdominal surgery.

Interventions

Anesthesia was induced in all patients by vital capacity rapid inhalation induction of sevoflurane. In the landiolol group, administration of landiolol began when patients took a vital-capacity breath: 0.125 mg/kg/min for one minute and then 0.04 mg/kg/min. Normal saline was administered in the control group.

Measurements

MAC was determined by a technique adapted from the conventional up-down method.

Main Results

The MAC of sevoflurane was 2.2% ± 0.2% in the control group and 1.7% ± 0.2% in the landiolol group, a statistically significant difference (P = 0.0005).

Conclusions

IV landiolol reduces the MAC of sevoflurane in women by approximately 20%.     

Caecal volvulus

Background

Caecal volvulus accounts for 30% of all cases of volvulus of the colon.

Methods

We recorded clinical data and accurate images of volvulus of the cecum.

Results

A detorsion with resection and primary anastomosis was performed. We reviewed the management and surgical strategies for cecal volvulus.

Conclusions

Caecal volvulus is an uncommon entity with potentially severe outcomes and requires surgical management.     

Colonic Perforation After Renal Transplantation: Risk Factor Analysis

Introduction

The incidence of gastrointestinal (GI) complication in renal transplantation is relatively high. These complications may be severe, leading to graft loss and patient death.

Materials and Methods

We reviewed 1651 patients who underwent renal transplantation between 1976 and 2007, analyzing the incidence of colonic perforations and the clinical prognostic factors.

Results

Twenty-one patients (1.3%) developed colonic perforations with 7 subsequent deaths. Diverticulitis and ischemia were the most common causes of perforation. Eleven patients (52.3%) were diagnosed and treated within the first 24 hours; their mortality was 18.1%. The 10 patients (47.7%) who were diagnosed and treated 24 hours after the clinical event displayed an high mortality rate (50%). Diverting stoma procedures were performed in all cases.

Conclusions

The follow-up of the kidney transplant patients should include a careful evaluation for possible GI complications and colonic perforations. Early diagnosis and timely treatment were associated with improved outcomes, regardless of the surgical procedures, the cause of perforation or the clinical and laboratory parameters.     

Evolving strategies to prevent biliary strictures after living donor liver transplantation

Introduction

The optimal surgical technique has not been elucidated that reduces the occurrence of biliary strictures after living donor liver transplantation (LDLT).

Method

We performed retrospective analysis of 193 consecutive LDLTs, including 78 right and 115 left lobe grafts. An external biliary stent was used for all of the cases.

Results

The overall 1-, 3-, and 5-year biliary stricture-free survival rates were 87.5%, 85.3%, and 85.3%, respectively. The 1- and 3-year biliary stricture-free survival rates for duct-to-duct reconstruction were 86.9% and 84.9%, and those for hepaticojejunostomy were 90.1% and 80.8%, respectively. A multivariate analysis revealed that the original number of graft bile ducts greater than the number of external stents, right lobe grafts, bile leaks, and recipient age older than 60 years represented the significant risk factors (P < .05) to develop a biliary stricture after LDLT. All cases with biliary strictures (n = 61) were initially managed nonsurgically, but 4 patients ultimately required interventions.

Conclusions

Biliary reconstruction in LDLT using an appropriate number of external stents resulted in fairly acceptable outcomes. However, not only the proper use of stents or graft selection, but also nonsurgical factors, are important factors that determine the incidence of biliary strictures after LDLT.     

Establishment of an Ex Vivo Lung Perfusion Model Using Non-Heart-Beating Large Pigs

Background

Functional evaluation of potentially damaged lungs donated after cardiac death is crucial for widespread clinical transplantation. To date, the mean weight of animals used in studies of ex vivo lung perfusion (EVLP) has been 60 kg; however, in the clinical setting, donor weight may be greater.

Objective

To investigate EVLP using lungs from large pigs (mean weight, 115 kg) to simulate human adult lungs donated after cardiac death.

Materials and Methods

Five heart-lung blocks were obtained at 20 minutes after death at the slaughterhouse. The lungs were flushed and preserved on ice for 6 hours before being connected to an ex vivo lung circuit, and were perfused for at least 2 hours.

Results

In all cases, perfusion was sustained for at least 2 hours. Mean (SEM) final flow rate was 4.9 (0.1) L/min, pulmonary artery pressure was 14.8 (1.7) mm Hg, and oxygen tension/fraction of inspired oxygen was 518.0 (18.0) mm Hg. The shunt fraction was 20.5% (4.0%). Histologic analysis demonstrated no significant pulmonary edema at the end of perfusion.

Conclusion

We successfully completed EVLP using lungs from large pigs.     

Biliary strictures after orthotopic liver transplantation: long-term results of percutaneous treatment in patients with nonfeasible endoscopic therapy

Purpose

The aim of this study was to evaluate our experience with percutaneous treatment of biliary strictures after orthotopic liver transplantation in adult patients without the endoscopic access possibility and to evaluate the technical outcomes and long-term clinical results of this treatment.

Materials and methods

Thirty percutaneous procedures were performed in adult liver transplant recipients (13 men, 17 women, mean age 46.4 years) in our institution between 1996 and 2010. Patients were treated with balloon dilatation and biliary duct drainage due to anastomotic stenosis (n = 20), nonanastomotic stenosis (n = 7), or due to stenosis caused by lymphoproliferation (n = 3). The percutaneous procedure was the first line of treatment due to hepaticojejunoanastomosis (n = 18) or after unsuccessful endoscopic therapy (n = 12).

Results

Technical success was achieved in 27 patients (90%). The remaining three patients only achieved external drainage with subsequent surgery. There were two complications (6.3%). Long-term clinical success, defined as the absence of clinical, laboratory, or sonographic signs of stricture recurrence was achieved in 22 patients (73.3%) for a mean follow-up of 5.8 years.

Conclusion

Percutaneous treatment—balloon dilatation and biliary duct drainage—is a first-line option to manage biliary duct strictures in liver recipient, when endoscopic treatment is not possible or unsuccessful. It has a high technical success rate and low complication rate with favorable long-term results.     

Control of presacral venous bleeding during rectal surgery

Background

Presacral venous hemorrhage is an uncommon but potentially life-threatening complication of rectal surgery. It is difficult to control presacral venous hemorrhage with conventional hemostatic measures and several alternative methods for hemostasis have been proposed. We described our experience of using the combination of a hemostatic matrix and an absorbable hemostat as an alternative method of hemostasis.

Methods

From September 2007 to March 2009, 83 patients underwent rectal surgery for cancer, ulcerative colitis, or familial adenomatous polyposis. Three patients (3.6%) had severe presacral hemorrhage, which was controlled by the combined use of a hemostatic matrix (FloSeal; Baxter, USA) and an absorbable hemostat (Surgicel Fibrillar; Ethicon, USA).

Results

Intraoperative blood transfusion was required in 1 patient. Postoperative blood loss was minimal and drain was removed on day 4 in all 3 patients.

Conclusions

The use of synthetic hemostatic agents is an effective and simple way to arrest presacral bleeding where conventional methods fail.     

The effect of donor-recipient relationship on long-term outcomes of living related donor renal transplantation

Background

Presensitization to human leukocyte antigen (HLA) tends to decrease renal graft survival. During the pregnancy, fetal blood is frequently exposed to the maternal circulation possibly inducing maternal immunization to paternal HLA inherited by the fetus. In this way, pregnancy may occasionally present a hazard to renal graft survival. In this study, we compared retrospectively graft survivals according to living related donor-recipient pairs.

Materials and methods

From July 1979 to January 2011, 374 patients underwent living related renal transplantation sharing at least one HLA haplotype with their donor. We compared acute rejection and complication rates as well as long-term graft survival according to the donor-recipient paring: child-to-mother, child-to-father, mother-to-child, father-to-child, and one haplotype-matched siblings. All patients received immunosuppressive therapy, consisting of a calcineurin inhibitor, mycophenolate mofetil, or azathioprine and prednisolone.

Results

Twenty-one cases (5.6%) were child-to-father paring; 28 (7.5%), child-to-mother; 179 (47.9%), one-haplotype-matched siblings; 46 (12.3%), father-to-child; and 100 (26.7%), mother-to-child paring. Child-to-father pairing displayed the best graft survival; child-to-mother (hazard ratio [HR] = 1.709, P = .662) and one-haplotype-matched siblings (HR = 6.589, P = .062) showed no significant difference. Father-to-child pares experienced poorer outcomes than child-to-father pairs (HR = 11.579, P = .017) and mother-to-child, the poorest graft survival (HR 17.188, P = .005).

Conclusion

Pregnancy continues to be a significant source of presensitization in the course of gestation and after parturition. Graft failure can result from an anamnestic reaction subsequent to intrauterine exposure of the mother to HLA of a fetus due to sensitization.