Endoluminal isoproterenol reduces renal pelvic pressure during semirigid ureterorenoscopy: a porcine model

OBJECTIVE

To investigate the effects on the pressure‐flow relation of renal pelvic pressure during semirigid ureterorenoscopy and endoluminal perfusion of isoproterenol (ISO) 0.1 µg/mL, with emphasis on local effects and cardiovascular side‐effects, as topically administered ISO effectively and dose‐dependently causes relaxation of the upper urinary tract in pigs with no concomitant cardiovascular side‐effects.

MATERIALS AND METHODS

In anaesthetized female pigs (60 kg), 16 macroscopically normal upper urinary tract systems were subjected to ureterorenoscopy. Via a subcostal incision a 6‐F catheter was placed in the renal pelvis for pressure measurements, and a semirigid ureteroscope (7.8 F) was inserted retrogradely in the renal pelvis, through which the pelvis was perfused. The blood pressure and heart rate were recorded. The increase in renal pelvic pressure was examined with increasing flow rates (0, 4, 8, 12, 16, 25 and 33 mL/min) with saline alone or saline + ISO 0.1 µg/mL. Perfusion was initiated on the left side, with randomization for adding ISO or not. Thereafter perfusion was done on the right side as a control in each pig. The surgeons were unaware of whether ISO was added or not.

RESULTS

The mean (sd ) baseline pelvic pressures in the saline and ISO group were 28 (7.1) and 25 (9.8) mmHg, respectively, with no significant difference (P = 0.079). Endoluminal perfusion with ISO significantly inhibited the pelvic pressure increase to perfusion at all perfusion rates. The pressure‐flow relation was linear; the maximum relaxation (27%) was obtained at 4 mL/min, from 52 to 38 mmHg during saline alone and ISO 0.1 µg/mL perfusion, respectively. The mean blood pressure did not change significantly (P = 0.330). The mean (sd ) heart rate in the saline and ISO group were 109 (4.5) and 97 (2.1) beats/min, respectively (P < 0.001), i.e. a markedly greater rate in the saline than in the ISO group.

CONCLUSION

The pressure‐flow relation during semirigid ureterorenoscopy was linear. ISO 0.1 µg/mL in saline significantly reduced the pressure‐flow relation during semirigid ureterorenoscopy in this porcine model. ISO might be a potential additive to the irrigation fluid during upper urinary tract endoscopic procedures, minimizing pressure increases due to irrigation and manipulation.     

Irrigation with isoproterenol diminishes increases in pelvic pressure without side-effects during ureterorenoscopy: a randomized controlled study in a porcine model

OBJECTIVE: Recently, we showed that endoluminally administered isoproterenol (ISO) inhibits muscle function of the pyeloureter in swine. This may be of value in managing increases in pelvic pressure during upper urinary tract endoscopy. The purpose of this study was to examine the effect of endoluminally administered ISO on increases in pelvic pressure and cardiovascular function during flexible ureterorenoscopy. MATERIAL AND METHODS: The study was performed in anaesthetized female pigs. In terms of endoscopic procedures, the pigs were randomized as follows: Group 1, irrigation with 0.1 microg/ml ISO added to saline (n=12); and Group 2, irrigation with saline (n=10). A 5-Fr catheter was retrogradely placed in the renal pelvis and an 8-Fr catheter in the bladder for pressure measurements. Flexible ureterorenoscopy was performed with constant irrigation at a perfusion rate of 8 ml/min. Pelvic, bladder and blood pressure and heart rate were registered continuously. RESULTS: Mean baseline pelvic pressure was identical in both groups: 12+/-2.3 mmHg in Group 1 and 14+/-3.6 mmHg in Group 2 (p=0.26). During ureterorenoscopy, mean pelvic pressure increased to 26+/-2.3 mmHg in Group 1 and to 38+/-3.1 mmHg in Group 2. Hence ISO reduced the pressure increase due to ureterorenoscopy by 42% (p<0.001). Pelvic pressure seemed to be independent of bladder pressure, which showed no difference between the two groups (p=0.067). Blood pressure and heart rate showed no significant differences between the two groups: p=0.425 and p=0.166, respectively. CONCLUSIONS: ISO (0.1 microg/ml) added to irrigation fluid significantly reduces the increase in pelvic pressure during ureterorenoscopy in pigs, without concomitant side-effects.     

Tamsulosin therapy improved the outcome of ureterorenoscopy for lower ureteral stones: A prospective,randomised, controlled,clinical trial

Introduction

Tamsulosin is an α-1A-specific blocker inducing selective relaxation of ureteral smooth muscle and inhibition of ureteral spasms leading to ureteral dilatation that can facilitates retrograde ureterorenoscopy (URS).

Intra-pelvic pressure changes after pelvic fracture: A cadaveric study quantifying the effect of a pelvic binder and limb bandaging over a bolster

IntroductionUnstable pelvic fractures can be life-threatening due to catastrophic haemorrhage. Non-invasive methods of reducing and stabilising these injuries include pelvic binder application and also lower limb bandaging over a knee-flexion bolster. Both of these methods help close the pelvic ring and should tamponade bleeding. This study aimed to quantify the intra-pelvic pressure changes that occurred with 3 different manoeuvres: lower limb bandaging over a bolster; a Trauma Pelvic Orthotic Device (T-POD) pelvic binder, and a combination of both.MethodsFollowing a pilot study with 2 soft embalmed cadavers, a formal study with 6 unembalmed cadavers was performed. For each specimen an unstable pelvic injury was created (OA/OTA 61-C1) by dividing the pelvic ring anteriorly and posteriorly. A 3–4 cm manometric water-filled balloon was placed in the retropubic space and connected to a 50 ml syringe and water manometer via a 3-way tap. A baseline pressure of 8cmH₂O (equating to the average central venous pressure) was used for each cadaver. Steady intra-pelvic pressures (more reliably reflecting the pressures achieved following an intervention) were used in the subsequent statistical analysis, using R statistical language and Rstudio. Paired t-test or Wilcoxon’s rank sum test were used (depending on the normality of the dataset) to determine the impact of each intervention on the intra-pelvic pressure.ResultsThe mean steady intra-pelvic pressures were significantly greater than the baseline pressure for each intervention. The binder and limb bandaging over a bolster alone increased the mean steady pelvic pressures significantly to 24 (SE = 5) (p < 0.036) and 15.5 (SE = 2) (p < 0.02)cmH₂O respectively. Combining these interventions further increased the mean steady pressure to 31 (SE = 7)cmH₂O. However, this was not significantly greater than pressures for each of the individual interventions.DiscussionBoth lower limb bandaging over a bolster and pelvic binder application significantly increased intra-pelvic pressure above the baseline pressure. This was further increased through combining these interventions, which could be useful clinically to augment haemorrhage control in these fractures.ConclusionLower-limb bandaging over a bolster, and pelvic binder application, both significantly increased intra-pelvic pressures, and were greatest in combination. These findings support the use of these techniques to facilitate non-surgical haemorrhage control.     

Covering of the toes during hindfoot and ankle surgery: a randomized, controlled, clinical study

BACKGROUND: Major advances in sterility over the last 140 years have dramatically reduced the rates of infection. The purpose of this study was to determine whether there was benefit to covering the toes during hindfoot or ankle surgery. METHODS: Forty consecutive hindfoot or ankle surgery patients were randomly assigned to one of two groups based on whether the toes were covered with a sterile glove or left uncovered. Three cultures were taken of the foot in the second web space. The first sample was taken before surgical preparation. The second sample was taken immediately after draping of the patient. The third sample was taken at the conclusion of the operation before dressing placement. The culture swab was moistened before sampling with sterile saline. The operative extremity was scrubbed with chlorhexidine gluconate and sterile water solution, followed by painting with 70% isopropyl alcohol. Before surgery, the patients were assigned to one of the two groups (covered or uncovered toes) on a random basis. A sterile size 6-1/2 glove was placed over the toes of the covered group and left in place until final wound closure. All patients received the same perioperative intravenous antibiotics. RESULTS: Thirty-five of 40 patients (87.5%) had positive cultures before the surgical preparation. One patient had a positive culture at the conclusion of the procedure but not immediately after the surgical preparation, and the toes were covered during the operation. Cultures before and after the procedure contained coagulase negative staphylococcus species. This patient did not develop any wound infection during the followup period. A second patient had positive cultures on all three samples. The species was coagulase positive staphylococcus. This patient did not have any wound infection problems postoperatively, although he was placed on prophylactic antibiotics 8 weeks after the initial surgery for a hardware removal procedure. The toes were not covered during the initial operation in this patient. In total, 10 patients were placed on antibiotics after the initial surgery. Three patients had erythema surrounding the incision, two patients had delayed wound healing, and one patient had erythema at the knee from a proximal tibial bone graft harvest site. The other four patients who received antibiotics had a hardware removal procedure within the 90-day followup period and received prophylactic antibiotics for that procedure. CONCLUSIONS: The results of this study indicate no benefits in covering the toes in hindfoot or ankle surgery after skin preparation with chlorhexidine gluconate and isopropyl alcohol. There were only two positive postoperative cultures and neither patient showed any signs of postoperative wound infection during the followup period.     

Impact of Tamsulosin,Tolterodine and drug-combination on the outcomes of lower urinary tract symptoms secondary to post-ureteroscopy ureteral stent: A prospective randomized controlled clinical study

Objectives

To compare the role of alpha-blocker (Tamsulosin) monotherapy, anticholinergic (Tolterodine) monotherapy or combination of both drugs versus analgesics in improving post-ureteroscopy (URS) lower urinary tract symptoms related to double-J ureteral stent.

Durability of flexible ureteroscopes: a randomized, prospective study

PURPOSE: We performed a randomized, prospective, multi-institutional study evaluating the durability of commercially available flexible ureteroscopes. MATERIALS AND METHODS: A total of 192 patients were randomized to the use of 7 less than 9Fr flexible ureteroscopes, including the Storz 11274AA and Flex-X, the ACMI DUR-8 and DUR-8 Elite, Wolf models 7330.170 and 7325.172, and the Olympus URF-P3. Information about total and lower pole use time, the number and method of ureteroscope insertion, and they type and duration of accessory instrumentation was recorded. Surgeons were asked to rate the visibility and maneuverability of the instrument on a scale of 0-poor to 10-excellent. RESULTS: The indication for ureteroscopy was upper tract calculi in 87% of cases. Of ureteroscope insertions 97% were performed through an access sheath. The average of number of cases before repair ranged from 3.25 for the Wolf 7325 to 14.4 for the ACMI DUR-8 Elite. Average ureteroscope operative time was statistically longer for the DUR-8 Elite (494 minutes) than for the Flex-X (p = 0.047), and the Wolf 7325 and 7330 (p = 0.001 and 0.001, respectively). Duration of use before repair for the URF-P3 (373 minutes) was statistically longer than for the Wolf 7325 and 7330 (p = 0.016 and 0.017, respectively). Minutes of use with an instrument in the working channel were significantly more with the DUR-8 Elite and the URF-P3 than the Wolf 7330 (p = 0.017 and 0.008) and 7325 (p = 0.012 and 0.005, respectively). The ureteroscope that experienced the greatest average duration of lower pole use was the URF-P3, while the shortest was the Wolf 7325 (103 vs 20 minutes, p = 0.005). Average minutes of laser use before breakage was significantly longer for the DUR-8 Elite than for the Wolf 7325 (110 vs 21 minutes, p = 0.021) and 7330 (24 minutes, p = 0.025). CONCLUSIONS: Currently available less than 9Fr flexible ureteroscopes remain fragile instruments. The DUR-8 Elite and Olympus URF-P3 proved to be the most durable devices.     

Effect of the degree of reverse Trendelenburg position on intraocular pressure during prone spine surgery: a randomized controlled trial

Background contextPostoperative vision loss complicates an estimated 1 in 1,100 prone spine surgical cases. This complication has been attributed to ischemic optic neuropathy, with one proposed reason being perioperative elevations in intraocular pressure (IOP). Previous research has studied the effects of table inclination on IOP in awake volunteers; however, the effects in spine surgery patients have not been investigated for reverse Trendelenburg positioning using a prospective, randomized controlled study design.PurposeTo assess the effect of table inclination on IOP in patients undergoing prone spine surgery.Study designSingle-center, prospective randomized controlled study.Patient sampleNineteen patients with no history of eye pathology, undergoing prone spine surgery at Dwight D. Eisenhower Army Medical Center, were randomly assigned to a table position: neutral, 5°, or 10° of reverse Trendelenburg.Outcome measuresIntraocular pressure, mean arterial pressure (MAP), estimated blood loss, fluid resuscitation, and ophthalmologic complication were assessed before and after induction and at incremental times during surgery, beginning at 30 minutes, 60 minutes, and 60-minute increments thereafter.MethodsMultivariate analyses evaluated surgical time, IOP, MAP, estimated blood loss, and fluid resuscitation as a function of table inclination to determine the effect of patient positioning on identified risk factors for postoperative vision loss.ResultsSurgical times ranged from 33 to 325 minutes. A rapid increase in IOP was noted after prone positioning, with continued increases as time elapsed. The neutral group exhibited statistically higher IOP compared with the 5° reverse Trendelenburg group after 60 minutes and the 10° group through 60 minutes of surgery. The trend continued through 120 minutes; however, because of a lack of power, we were unable to determine the statistical significance. There were no statistically significant differences between the 5° and 10° reverse Trendelenburg groups.ConclusionsReverse Trendelenburg positioning elicits decreased IOP compared with prone positioning for surgery times less than 120 minutes. Ten degrees of reverse Trendelenburg attenuate the rise in IOP during prone spine surgery superiorly in comparison with 5°. No significant complications were associated with reverse Trendelenburg positioning.     

Utilization of surgical procedures for pelvic organ prolapse: a population-based study in Olmsted County, Minnesota, 1965–2002

To describe trends in the utilization of surgical procedures for pelvic organ prolapse among women in Olmsted County, MN, we retrospectively identified all county residents undergoing pelvic organ prolapse repair from January 1, 1965 through December 31, 2002. From 1965 to 2002, 3,813 women had pelvic organ prolapse surgeries: 3,126 had hysterectomy combined with pelvic floor repair (PFR) procedures and 687 had PFR alone. The age-adjusted utilization of hysterectomy plus PFR and of PFR alone decreased by 62% (P < 0.001) and 32% (P = 0.02), respectively. In both groups, utilization decreased in all age groups over time except in women aged 80 years and older undergoing hysterectomy plus PFR and women aged 70 years and older undergoing PFR only. The most common indication for PFR was uterovaginal prolapse. Among women in the community, the rate of utilization and age distribution of pelvic organ prolapse surgery changed substantially between 1965 and 2002.     

The development of pelvic organ prolapse after colposuspension: a prospective, long-term follow-up study on the prevalence and predisposing factors

The objectives of this prospective study were to determine the prevalence of pelvic organ prolapse (POP) after colposuspension and to investigate possible preoperative and operative risk factors. Seventy-seven women who underwent colposuspension between 1996 and 1997 were investigated. POP was assessed before colposuspension using the pelvic organ prolapse quantification system (POPQ). Women were reassessed at one and seven to eight years (or when referred with symptomatic POP). By seven to eight years, of the 77 women, 29 (38%) had developed symptomatic prolapse, 29 (38%) had asymptomatic prolapse, 7 (9%) had no symptoms and no prolapse, and 12 (15%) could not be assessed. POP at one year was significantly associated with the presence of posterior vaginal descent before colposuspension (odds ratio 3.07, 95% CI 1.10–8.60, p=0.03). No variable reached statistical significance by eight years postcolposuspension. In conclusion, this is the first study to assess POP prospectively using a validated method before and after colposuspension. The results add support to the view that there is an association between colposuspension and the development of symptomatic POP (requiring surgery).     

Pentosan polysulfate sodium therapy for men with chronic pelvic pain syndrome: a multicenter, randomized, placebo controlled study

Purpose:We evaluated the efficacy and tolerability of pentosan polysulfate sodium (PPS) for the treatment of men with chronic pelvic pain syndrome (CPPS), National Institutes of Health (NIH) category III.Materials and Methods:In a 16-week double-blind study 100 men with a clinical diagnosis of CPPS were randomized to receive 300 mg PPS or placebo 3 times daily. Clinical Global Improvement (CGI) was the primary outcome measure. Additional outcome measures were the NIH-Chronic Prostatitis Symptom Index (CPSI), Subjective Global Assessment and Symptom Severity Index assessment tools.Results:Significantly more patients receiving PPS experienced moderate to marked improvement based on CGI assessment (18 or 37% vs 8 or 18%, p = 0.04). However, mean CGI scores were not significantly different between the PPS group (1.0) and placebo groups (1.0 vs 0.6, p = 0.107). All NIH-CPSI domains suggested a positive effect for PPS and for total NIH-CPSI the difference approached statistical significance (−5.9 or 22% vs −3.2 or 12%, p = 0.068). The PPS group showed significantly greater improvement in NIH-CPSI quality of life domain scores than the placebo group (−2.0 or 22% vs −1.0 or 12%, p = 0.031). Of patients receiving PPS 67% and 80% of those receiving placebo completed the 16-week study. Diarrhea, nausea and headache were the most common adverse events.Conclusions:Pentosan polysulfate (900 mg daily) was more likely than placebo to provide relief for CPPS symptoms.     

后腹腔镜下根治性肾切除术完整标本取出切口的随机对照研究

目的 探讨后腹腔镜下根治性肾切除术完整取出标本的适宜切口.方法 因肾癌需实施后腹腔镜下根治性肾切除术的连续性住院病例119例,按随机数字表随机分为2组,腹部切口组60例,腰部切口组59例.手术均由同一组医生实施,完整标本取出均由同一位医生完成.统计分析2组手术时间、标本取出时间、切口长度、标本质量、术后下床活动时间、术后胃肠功能恢复时间、术后住院日、术后止痛剂用量、并发症发生率等方面的差异.结果 2组患者性别、年龄、体质指数、肾脏最大横径、肿瘤分期等比较差异均无统计学意义(P＞0.05).2组手术时间分别为(99±14)、(115±12)min(P=0.000),切口长度分别为(4.9±0.3)、(5.3±0.4)cm(P=0.000),标本取出时间分别为(14±2)、(24±6)min(P=0.000),术后止痛剂用量分别为(35±27)、(52±29)mg(P=0.002),下床活动时间分别为(20±2)、(21±4)h(P=0.016),组间比较差异均有统计学意义;2组胃肠功能恢复时间分别为(21±3)、(20±4)h(P=0.457),术后住院日分别为(6±1)、(6±1)d(P=0.476),标本质量分别为(469±181)、(459±169)g(P=0.776),组间比较差异均无统计学意义.119例切口均甲级愈合,无切口液化、感染病例.89例获随访,随访时间6～18个月,中位时间12个月,未见切口疝、肿瘤切口种植病例.结论后腹腔镜下根治性肾切除术完整取出标本时,腹部切口具有切口小、损伤少、手术时间短、术后恢复快、疼痛轻等优点,是完整取出标本较为合适的路径.

Abstract：

Objective To investigate the appropriate incision for intact specimen extraction during retroperitoneoscopic radical nephrectomy. Methods One hundred and nineteen patients in need of retroperitoneoscopic radical nephrectomy were randomized into two groups. One group of 60 patients received intact specimen extraction through a muscle-splitting abdominal incision. The second group of 59 patients received intact specimen extraction through a muscle-cutting lumbar incision. All procedures were performed by the same team of surgeons, and the intact specimens were extracted by the same surgeon. Standard operative features were measured and recorded (operative time, the time of specimen extraction, incision length, specimen weight, the time to get out of bed, the recovery time of gastrointestinal function, postoperative hospital stay, analgesia requirement, and complication rate). Results The two groups were matched in regard to patient age, body mass index, the maximum diameter of the kidney, and the stage of TNM (each P>0.05). There were significant differences between the abdominal incision group and lumbar incision group in terms of operative time (99±14 min vs 115±12 min; P=0.000), incision length (4.9±0.3 cm vs 5.3±0.4 cm; P=0.000), the time of specimen extraction (14±2 min vs 24±6 min; P=0.000), analgesia requirement (35±27 mg vs 52±29 mg; P=0.002), the time to get out of bed (20±2 h vs 21±4 h; P=0.016). The differences were not significant between the 2 groups in terms of the recovery time of gastrointestinal function (21±3 h vs 20±4 h; P=0.457), hospital stay (6±1 d vs 6±1 d; P=0.476), and specimen weight (469±181 g vs 459±169 g; P=0.776). There was no complication of incision in the 2 groups at 12 months′ follow-up (rang, 6 to 18 months). Conclusion A muscle-splitting abdominal incision for intact specimen extraction is more appropriate than a lumbar incision during retroperitoneoscopic radical nephrectomy, with small incision, little injury, short operative time, quick recovery, and less pain.