Expanding indications for neuromodulation

Neuromodulation in one form or another has been studied for decades for various disease states. Although its mechanism of action remains un-explained, numerous clinical success stories suggest it is a therapy with efficacy and durability. Controlled studies have led to the approval of sacral neuromodulation for urinary urgency and frequency, urinary retention, and urinary urge incontinence. The future holds hopeful possibilities for the application of neuromodulation, namely in the areas of interstitial cystitis, in-tractable pain syndromes, fecal incontinence and constipation, spinal cord injury, and erectile dysfunction. Neuromodulators have also been used in nonurologic conditions, including chronic headaches and intractable chest pain. In adults and children, in the neurologically intact and neurologically impaired, neuromodulation has been shown to improve the quality of life of those suffering chronic disease states. Neuromodulation is changing the future of urology. Treatment of voiding dysfunction and likely other disorders, such as pelvic pain, sexual dysfunction, and bowel disorders, will no longer rely only on medications that are "OK" or destructive-reconstructive procedures that suffer from significant complications. Rather, by modulating the nerves, the urologists will treat these disorders in a minimally invasive fashion and neuromodulation will become the first-line therapy before any major surgery is undertaken.     

Current indications for thyroidectomy

Thyroid surgery, one of the most common interventions in endocrine surgery, is practiced by many specialists who perform this procedure exclusively. It accounts for the bulk of work even in reference centers that treat rare endocrine tumors (e.g. adrenal and gastrointestinal tract cancer). Better results are obtained by experienced and skilled operators. Surgeons who correctly perform thyroid surgery can achieve excellent outcomes even in other areas of endocrine surgery. So it is surprising that not more is being done to teach the procedure, which has always been considered something of an art, perhaps because surgical treatment of rare endocrine tumors is more stimulating to teach than routine surgical procedures. Nonetheless, teaching correct surgical technique is essential for reducing and avoiding postoperative complications caused by inadequate experience and knowledge. Numerous studies have reported that the incidence of complications is high and that the rate is growing: 5% involve permanent injury to the recurrent laryngeal nerve after intervention for a benign tumor, despite repeated reports that the incidence could be reduced to near zero or at least to 1%. Alarmingly high is the 20% incidence of persistent hypoparathyroidism after total thyroidectomy. Here, too, accurate technique could reduce this rate to 1%. An important point is that permanent laryngeal nerve injury and persistent hypoparathyroidism are both sources of considerable discomfort for patients. One of the chief objectives of modern endocrine surgery is, therefore, to reduce the complications rate to acceptable levels by establishing adequate, uniform teaching protocols and universal guidelines that would help improve the practice of surgery.     

Current and future techniques of neuromodulation for bladder dysfunction

Recent increase in the use of neuromodulation for the treatment of urinary urgency and frequency, urge incontinence, and nonobstructive urinary retention has coincided with improved knowledge of micturition physiology and concurrent technologic advances in nerve stimulation. Currently, the most common technology for bladder neuromodulation involves stimulation through the S3 foramen, or sacral neuromodulation, although other techniques of neuromodulation continue to be explored. Despite many advances in neuromodulation, the exact mechanism of action remains uncertain. Additionally, which patients will respond to neuromodulation remains unclear, and although there is a standard method for testing, this procedure is invasive and expensive. As we continue to improve patient selection criteria and better understand the mechanism of action, the efficacy and patient satisfaction should continue to increase. Currently, most patients considered for implantation with a neuromodulator are those unresponsive to other conservative treatments for bladder dysfunction.     

Current indications for magnetic resonance imaging

Magnetic resonance is a well-established imaging modality for CNS, but it's utility for visualizing the rest of the body has not been appreciated fully or exploited yet. The authors believe that MRI will become one of the primary imaging modalities for the body during the next several years. Current and future indications for magnetic resonance imaging of the body are discussed.     

Current indications for intramedullary bundle nailing

Hackethal developed the nailing procedure named after him in 1959. The original method consisted in two steps: a non-sterile step in which mechanical reduction was performed with a traction device and a sterile step, i.e. nailing. The rationale of Hackethal nailing is an elastic jamming, which can only be achieved by obeying four rules: jamming of the nails in the cortical window, jamming then in the waist of the medullary cavity, spreading the bunch of nails in the metaphysis and filling up the conus of the medullary cavity with short nails. Hackethal believed it was possible to achieve an elastic jamming in all transverse and short oblique fractures of the shaft. He used his technique in fractures and non-unions of femur, tibia, humerus, radius and ulna. Extensive indications led to overuse of the method and resulted in a major rate of complications. Meanwhile, plating of shaft fractures has proved to involve an unexpectedly high rate of complications, and locking nails and new types of fixators have enlarged the surgeon's armamentarium for stabilization of fractures. Therefore, it seemed important to determine the present indications for Hackethal nailing. We confined Hackethal nailing to fractures of the middle third of the shaft in the upper extremity. All second- and third-degree open fractures were treated with fixators. In a 13-year period we performed Hackethal nailing of the humerus in 53 cases, of the radius in 20, of the ulna in 17, and in both of the forearm simultaneously in 12 cases. Plating and Hackethal nailing were combined for the treatment of forearm fractures in 10 cases.(ABSTRACT TRUNCATED AT 250 WORDS)     

Current indications for axillounifemoral and axillobifemoral bypass grafts

Revascularization of the lower extremities may require an axillofemoral bypass when an aortobifemoral bypass is contraindicated. Thirty-one patients underwent axillounifemoral and 59 had an axillobifemoral bypass, with a mortality rate of 9%. The indication for operation was limb salvage in 67%, intra-abdominal sepsis in 21%, and disabling claudication in 12%. Cumulative survival, patency, and limb salvage rates were determined by life-table analysis. The cumulative patency and limb salvage rates (with standard errors) at 3 years were 68% +/- 8% and 78% +/- 9%, respectively. When stratified for type of operation, axillobifemoral bypass had a superior patency rate compared with axillounifemoral bypass (log rank = 3.882, p less than 0.05). There was no significant difference when patients were stratified for diabetes (log rank = 2.213, p = no significance [NS]), operative indication (disabling claudication vs. limb salvage) (log rank = 0.0005, p = NS), or outflow (no profundaplasty vs. profundaplasty) (log rank = 2.011, p = NS). We conclude that axillofemoral bypass is a reasonable alternative for revascularization in high-risk patients or in those patients in whom a transabdominal approach is contraindicated. We recommend aggressive use of the profunda femoris artery when the superficial femoral artery is occluded to achieve optimal results.     

慢性踝关节外侧不稳手术适应证的现状

慢性踝关节外侧不稳在临床十分常见,以反复踝关节扭伤、局部疼痛为主要表现,但手术适应证争议较大。为此,本研究搜索了Pubmed、Web of Science、The Cochrane Library以及中国生物医学文献数据库、维普信息资源系统数据库。对文献进行全面分析,发现大多数手术医生容易接受的手术适应证为:(1)具有踝关节反复扭伤或者疼痛等不稳症状,保守治疗3~6个月后仍存在症状;(2)通过前抽屉试验或者距骨倾斜试验、或者应力位摄X线片、或者磁共振MRI检查,提示存在踝关节机械性不稳的表现。本文对此现状进行全面综述,为规范化临床治疗提供依据。     

Current opinion regarding indications for emergency department thoracotomy

BACKGROUND: Emergency department thoracotomy (EDT) is a dramatic but rarely lifesaving intervention. Clinical variability regarding indications for EDT has yet to be quantified. Members of the Eastern and American Associations for the Surgery of Trauma were questioned by mail to evaluate which clinical and demographic factors influence the decision to perform EDT and whether physicians perform EDT in accordance with current practice guidelines. METHODS: A single mailing of an anonymous survey was sent to 1,124 surgeons to collect institutional and physician demographics as well as indications for EDT on the basis of variable mechanisms of trauma, duration of arrest, and signs of life (SOL). Statistical analysis included the Pearson and linear-by-linear association chi(2) tests, independent samples t test, and univariate and multivariate analyses of variance; p values of < 0.05 were considered significant. RESULTS: Completed surveys were received from 358 respondents. After 54 surveys were excluded that were incomplete, late, or from noneligible respondents, 304 surveys were analyzed. There were no significant differences in EDT indications among institutions of differing caseload volume, exposure to penetrating trauma, trauma level designation, American College of Surgeons verification status, or residency program affiliation. In addition, neither the respondent's position nor whether attendings versus residents performed the majority of EDTs influenced clinical decision-making. Performance criteria for EDT were liberal in comparison with established guidelines, especially for blunt trauma. The presence or recent loss of SOL influenced responses, but respondents varied greatly in their definition of SOL. CONCLUSION: A lack of agreement exists regarding the indications for EDT in multiple clinical scenarios as well as in defining SOL. Indications for EDT were liberal, especially for blunt trauma-related indications, and were determined by clinical parameters, not by physician or institutional factors. Our results suggest that clinical practice is at variance with Advanced Trauma Life Support guidelines. We recommend that practice guidelines for EDT be established on the basis of a consensus definition of SOL to allow for a more uniform and selective approach to EDT.     

Current indications for chemotherapy in prostate cancer patients

Recently, data from two randomized studies, TAX327 and SWOG 9916, which compared docetaxel-based chemotherapy to mitoxantrone-based therapy, have demonstrated that treatment with docetaxel can prolong life in a statistically significant way in patients with hormone refractory prostate cancer (HRPC). In the TAX237 trial the median overall survival rates for patients treated with docetaxel every 3 wk was 18.9 mo, compared with 16.4 mo for the patients in the control arm (p=0.009). Patients treated with the combination of docetaxel and estramustine in the SWOG trial had a significant improvement in median survival (18 mo vs 16 mo, p=0.01), longer progression-free survival (6 mo compared with 3 mo, p<0.0001), and a 20% reduction in the risk of death. The optimal timing of docetaxel-based chemotherapy is still unknown because there are no prospective clinical trials indicating whether earlier treatment is more effective than delayed treatment. There are now increasing options also for second-line therapies in the palliative treatment of HRPC, and ongoing studies on new drugs such as satraplatin and ixabepilone will define the role of these agents in this setting. Preliminary neoadjuvant and adjuvant chemotherapy studies in high-risk prostate cancer patients have demonstrated that these approaches are feasible and do not add morbidity to surgery or radiotherapy, but their impact on survival still needs to be proven in randomized studies.     

Current opinion: complications and troubleshooting of sacral neuromodulation

The complications of sacral neuromodulation have been minimized as technology has improved. The main surgical complication remains to be surgical site infection. We review evidence-based suggestions and procedure-specific techniques that reduce the infection rate to less than 2%. In the past, surgical revision was reported as high as 40%. The current revision rate at Mayo Clinic Florida is 10%. The most common reason for surgical revision is either battery end-of-life or loss of effectiveness. We review the best practices of the procedure and a systematic approach to troubleshoot loss of effectiveness.     

Current indications for laparoscopy and retroperitoneoscopy in pediatric urology

Laparoscopy has raised great interest in the past few years in the field of pediatric urology. It has evolved from a simple diagnostic maneuver to complex operative procedures. The aim of this study was to review urologic laparoscopy literature and provide a critical review of this field to establish current indications for videosurgery in pediatric urology. In general, from an anatomic point of view, retroperitoneoscopy seems to be more suitable than the transperitoneal laparoscopic approach for reaching the upper urinary tract. It also is less invasive and complies with the criteria for open renal surgery. With respect to current indications for videosurgery in pediatric urology, the authors have identified several well-established clinical procedures, although no large series have been published for any of the procedures, except for the treatment of varicocele, nonpalpable testis, and nephrectomy. In conclusion, the data reviewed suggest that videosurgery is a safe and feasible technique in pediatric urology if performed by expert surgeons, and that it certainly will develop further in the next few years. Online publication: 13 October 2004     

Current indications for surgical treatment of asymptomatic primary hyperparathyroidism

The clinical picture of hyperparathyroidism has gone toward deep modifications in the last few decades, and currently this disease is more frequently asymptomatic. So, the question is raising concerning which patients have to be operated, due to the substantial benignity of the disease and the lack of well defined symptoms. Classical indications for surgery have been formulated more than a decade ago and are as follows: calcemia higher than 3 mmol/L, previous episode of life threatening hypercalcaemia, reduced creatinine clearance, nephrolithiasis, hypercalciuria, osteoporosis. In the last years other indications have been added, on the basis of clinical and epidemiological studies that have contributed to broaden our knowledgement on the evolution and compliances of the disease. Among these, the following data have to been kept in mind: history of previous atraumatic fractures, vertebral osteopenia (Z-score < -2), vitamin D deficiency, perimenopausal status, neuromuscular or psychical disturbances.