经耻骨途径带蒂阴唇皮瓣治疗女性尿道狭窄合并尿道阴道瘘

目的 探讨经耻骨途径带蒂阴唇皮瓣治疗女性尿道狭窄合并尿道阴道瘘的疗效.方法 女性复杂性中段尿道狭窄合并尿道阴道瘘患者8例,年龄16～46岁,平均29岁,病程6～24个月.尿道狭窄部位:中段7例、中段至远端1例;狭窄段长度2.0～3.5 cm,平均2.7 cm;合并直肠阴道瘘1例.8例术前均行耻骨上膀胱造瘘,1例同时行乙状结肠腹壁造瘘.采用单侧带蒂阴唇皮瓣5例,双侧带蒂阴唇皮瓣3例.结果 8例手术顺利,无严重并发症.2例拔除尿道支架管后2周内有尿频,1例术后1个月内有压力性尿失禁,3例均未行特殊治疗而逐渐恢复.余5例患者拔管后排尿通畅.8例术后平均随访52(6～130)个月,尿瘘无复发,最大尿流率平均23.8(17.4～42.0)ml/s.结论 经耻骨途径带蒂阴唇皮瓣是治疗女性尿道狭窄合并尿道阴道瘘的一种有效方法.     

Urethroplasty in female-to-male transsexuals

OBJECTIVE: Female-to-male transformation includes total phallic reconstruction. Construction of a neourethra is necessary to achieve the goal of voiding while standing; however urethral fistula and stricture formation occur in a significant percentage of patients. METHODS: 25 patients with primary female transsexualism underwent phalloplasty with a free radial forearm flap, vaginectomy and urethroplasty in a one-stage procedure. In 16 of these patients the fixed part of the neourethra ("bulbar urethra") was constructed from a vaginal flap. In 9 patients flaps of the labia minora (5 patients) or the "urethral plate" (4 patients) were used. RESULTS: In 14 (58%) patients fistulas and/or strictures in the newly constructed urethra occurred. 11 (69%) of 16 patients in whom the "bulbar urethra" was constructed from a vaginal flap experienced fistulas and/or stricture formation. Fistulas and/or strictures occurred in 3 of 5 patients with labia minora flaps and none of 4 patients with the urethral plate procedure. Repair of fistula and strictures was performed by primary closure of fistulas, staged urethroplasty with local pedicle flaps or distant tissue grafts using buccal mucosa (2-6 procedures). CONCLUSION: One-stage total phalloplasty and urethroplasty is associated with a significant rate of fistulas and strictures. However, these complications can be corrected by the techniques used in modern urethral surgery.     

Cell-Seeded Tubularized Scaffolds for Reconstruction of Long Urethral Defects: A Preclinical Study

Background

The treatment options for patients requiring repair of a long segment of the urethra are limited by the availability of autologous tissues. We previously reported that acellular collagen-based tubularized constructs seeded with cells are able to repair small urethral defects in a rabbit model.

Objective

We explored the feasibility of engineering clinically relevant long urethras for surgical reconstruction in a canine preclinical model.

Design, setting, and participants

Autologous bladder epithelial and smooth muscle cells from 15 male dogs were grown and seeded onto preconfigured collagen-based tubular matrices (6 cm in length). The perineal urethral segment was removed in 21 male dogs. Urethroplasties were performed with tubularized collagen scaffolds seeded with cells in 15 animals. Tubularized constructs without cells were implanted in six animals. Serial urethrography and three-dimensional computed tomography (CT) scans were performed pre- and postoperatively at 1, 3, 6, and 12 mo. The animals were euthanized at their predetermined time points (three animals at 1 mo, and four at 3, 6, and 12 mo) for analyses.

Outcome measurements and statistical analysis

Statistical analysis of CT imaging and histology was not needed.

Results and limitations

CT urethrograms showed wide-caliber urethras without strictures in animals implanted with cell-seeded matrices. The urethral segments replaced with acellular scaffolds collapsed. Gross examination of the urethral implants seeded with cells showed normal-appearing tissue without evidence of fibrosis. Histologically, an epithelial cell layer surrounded by muscle fiber bundles was observed on the cell-seeded constructs, and cellular organization increased over time. The epithelial and smooth muscle phenotypes were confirmed using antibodies to pancytokeratins AE1/AE3 and smooth muscle–specific desmin. Formation of an epithelial cell layer occurred in the unseeded constructs, but few muscle fibers formed.

Conclusions

Cell-seeded tubularized collagen scaffolds can be used to repair long urethral defects, whereas scaffolds without cells lead to poor tissue development and strictures. This study demonstrates that long tissue-engineered tubularized urethral segments may be used for urethroplasty in patients.     

Tissue-Engineered Buccal Mucosa Urethroplasty—Clinical Outcomes

Introduction

Whilst buccal mucosa is the most versatile tissue for urethral replacement, the quest continues for an ideal tissue replacement for the urethra when substantial tissue transfer is needed. Previously we described the development of autologous tissue-engineered buccal mucosa (TEBM). Here we report clinical outcomes of the first human series of its use in substitution urethroplasty.

Methodology

Five patients with urethral stricture secondary to lichen sclerosus (LS) awaiting substantial substitution urethroplasty elected to undergo urethroplasty using TEBM, with full ethics committee support. Buccal mucosa biopsies (0.5 cm) were obtained from each patient. Keratinocytes and fibroblasts were isolated and cultured, seeded onto sterilised donor de-epidermised dermis, and maintained at air–liquid interface for 7–10 d to obtain full-thickness grafts. These grafts were used for urethroplasty in a one-stage (n = 2) or a two-stage procedure (n = 3). Follow-up was performed at 2 and 6 wk, at 3, 6, 9, and 12 mo, and every 6 mo thereafter.

Results

Follow-up ranged from 32 to 37 mo (mean, 33.6). The initial graft take was 100%, as assessed by visual inspection. Subsequently, one patient had complete excision of the grafted urethra and one required partial graft excision, for fibrosis and hyperproliferation of tissue, respectively. Three patients have a patent urethra with the TEBM graft in situ, although all three required some form of instrumentation.

Conclusions

Whilst TEBM may in the future offer a clinically useful autologous urethral replacement tissue, in this group of patients with LS urethral strictures, it was not without complications, namely fibrosis and contraction in two of five patients.     

One-stage repair of long bulbar urethral strictures using augmented Russell dorsal strip anastomosis: outcome of 234 cases

Objectives

Long bulbar urethral strictures (>2 cm) are not amenable to stricture excision and primary anastomosis procedure, which may result in a short urethra and chordee formation. For such strictures many procedures have been advocated including stricturotomy with subsequent graft or flap onlay, augmented anastomosis, and staged procedures, which is a combination of the Russell graft. We present our 10-yr experience with the augmented Russell procedure using a ventral onlay buccal mucosal patch graft for treatment of long bulbar urethral strictures not amenable to excision and primary anastomosis.

Methods

A total of 234 patients diagnosed by urethrograms as having long bulbar urethral strictures (mean, 4.2 cm) were managed by the augmented Russell urethroplasty. The procedure included excision of most of the diseased segment (mean, 2.8 cm) and anastomosis of a dorsal strip leaving an oval ventral defect. Augmentation was done in all patients using a buccal mucosa patch graft (mean, 4.7 cm).

Results

Mean follow-up was 36 mo. Urethrograms were done at 3 wk and 3 and 6 mo postoperatively and if the patients were symptomatic thereafter. Urethrocystoscopy was performed at 12 and 18 mo. A total of 223 patients completed the follow-up protocol; the overall success rate was 93.7% with 14 (6.3%) patients showing stricture recurrence at different intervals postoperatively. Ten patients in the failure group were successfully managed by single visualized internal urethrotomy (VIU), whereas the other four patients were treated by ventral penile pedicled flap. Postoperative dribbling of urine was noticed by 90 patients (40.4%) and temporary perioral numbness in most patients; no major donor site complications were noted in our series.

Conclusion

The augmented Russell technique is beneficial for long bulbar urethral strictures; 93.7% of the patients were stricture free. In the bulbar region, both ventral and dorsal onlays are applicable with nearly equal success rates. The buccal mucosa patch graft offers excellent material for augmentation.     

Surgical Treatment of 31 Complex Traumatic Posterior Urethral Strictures Associated with Urethrorectal Fistulas

Background

Urethrorectal fistulas (URF) in patients with complex posterior urethral strictures are rare and difficult to repair surgically. There is no widely accepted standard approach described in the published literature.

Objective

The aim of this study was to describe the outcomes of various operative approaches for the repair of URFs in patients with complex posterior urethral strictures.

Design, setting, and participants

From January 1985 to December 2007, 31 patients (age: 6–61 yr; mean: 28.4) with URFs secondary to posterior urethral strictures were treated using a perineal or combined abdominal transpubic–perineal approach.

Interventions

A simple perineal approach was used in 4 patients; a transperineal inferior pubectomy approach was used in 18 patients; and a combined transpubic–perineal approach was used in 9 patients. A bulbospongiosus muscle and subcutaneous dartos pedicle flaps were interposed between the repaired rectum and urethra in 22 patients. The combined transpubic–perineal approach used either a gracilis muscle flap (one patient) or a rectus muscle flap (eight patients).

Measurements

Suprapubic catheterisation was used for bladder drainage, and a urethral silicone stent was left indwelling for 4 wk.

Results and limitations

One-stage repair was successful in 4 patients (100%) using the perineal approach, in 16 of 18 patients (88.9%) using the transperineal–inferior pubectomy approach, and in 7 of 9 patients (77.8%) using the transpubic–perineal approach. Recurrent urethral strictures developed in two cases; one patient required regular dilation, and the other patient was treated successfully with tubed perineoscrotal flap urethroplasty. Recurrent URFs developed in two additional patients.

Conclusions

Surgical approaches for the treatment of URFs associated with complex urethral strictures should be based on a number of considerations including the location of the URF, its aetiology, the length of the urethral strictures, and a history of previous unsuccessful repairs. These results demonstrate that the transperineal–inferior pubic approach may be appropriate as a first-line procedure.     

Martius repair in urethrovaginal defects

Aim

To repair a urethrovaginal defect in childhood is a challenge for a pediatric surgeon. Martius fat-pad flap repair is being used in women successfully. Here, we report 2 girls who had Martius repair for their urethrovaginal defects.

Method

Topical estriol and asiaticoside perineally were administered for preoperative 3 weeks to reinforce the tissues. Martius repair was done using 1-sided labial fat-pad flap. Urethral and bladder catheters were inserted. Urethral catheter was removed on postoperative day 14 and bladder catheter on day 21 after controlling residual urine.

Patients

Patient 1, a 6-year-old girl, had lipomeningocele repair at the age of 18 months and had an iatrogenic urethrovaginal fistula that is caused by catheter insertion. She developed urinary incontinence, and 3 primary repair attempts were unsuccessful.Patient 2 is a 5-year-old girl who had pouch colon with persistent cloacal malformation and had posterior anorectovaginourethroplasty. The urethrovaginal septum did not heal, and she was incontinent. One attempt of primary repair was unsuccessful. The urethrovaginal wall was completely open at the time of Martius repair in both patients.

Results

Urethral wall was completely healed after Martius repair in both patients.

Conclusion

Martius fat-pad flap repair can be used to repair urethrovaginal fistulas in girls. It has both functionally and cosmetically good results, and neourethra is easily catheterizable.     

Temporal national trends of minimally invasive and retropubic radical prostatectomy outcomes from 2003 to 2007: results from the 100% Medicare sample

Background

Although the use of minimally invasive radical prostatectomy (MIRP) has increased, there are few comprehensive population-based studies assessing temporal trends and outcomes relative to retropubic radical prostatectomy (RRP).

Objective

Assess temporal trends in the utilization and outcomes of MIRP and RRP among US Medicare beneficiaries from 2003 to 2007.

Design, setting, and participants

A population-based retrospective study of 19 594 MIRP and 58 638 RRP procedures was performed from 2003 to 2007 from the 100% Medicare sample, composed of almost all US men ≥65 yr of age.

Intervention

MIRP and RRP.

Measurements

We measured 30-d outcomes (cardiac, respiratory, vascular, genitourinary, miscellaneous medical, miscellaneous surgical, wound complications, blood transfusions, and death), cystography utilization within 6 wk of surgery, and late complications (anastomotic stricture, ureteral complications, rectourethral fistulae, lymphocele, and corrective incontinence surgery).

Results and limitations

From 2003 to 2007, MIRP increased from 4.9% to 44.5% of radical prostatectomies while RRP decreased from 89.4% to 52.9%. MIRP versus RRP subjects were younger (p < 0.001) and had fewer comorbidities (p < 0.001). Decreased MIRP genitourinary complications (6.2–4.1%; p = 0.002), miscellaneous surgical complications (4.7–3.7%; p = 0.030), transfusions (3.5–2.2%; p = 0.005), and postoperative cystography utilization (40.3–34.1%; p < 0.001) were observed over time. Conversely, overall RRP perioperative complications increased (27.4–32.0%; p < 0.001), including an increase in perioperative mortality (0.5–0.8%, p = 0.009). Late RRP complications increased, with the exception of fewer anastomotic strictures (10.2–8.8%; p = 0.002). In adjusted analyses, RRP versus MIRP was associated with increased 30-d mortality (odds ratio [OR]: 2.67; 95% confidence interval [CI], 1.55–4.59; p < 0.001) and more perioperative (OR: 1.60; 95% CI, 1.45–1.76; p < 0.001) and late complications (OR: 2.52; 95% CI, 2.20–2.89; p < 0.001). Limitations include the inability to distinguish MIRP with versus without robotic assistance and also the lack of pathologic information.

Conclusions

From 2003 to 2007, there were fewer MIRP transfusions, genitourinary complications, and miscellaneous surgical complications, whereas most RRP perioperative and late complications increased. RRP versus MIRP was associated with more postoperative mortality and complications.     

Botulinum toxin a versus placebo for refractory detrusor overactivity in women: a randomised blinded placebo-controlled trial of 240 women (the RELAX study)

Background

Emerging data suggest botulinum toxin is an effective treatment for detrusor overactivity (DO), but large studies confirming efficacy and safety are lacking.

Objective

Study the efficacy and safety of onabotulinumtoxinA (onaBoNTA) for the treatment of DO.

Design, setting, and participants

A double-blind placebo-controlled randomised trial in eight UK urogynaecology centres was conducted between 2006 and 2009. A total of 240 women with refractory DO were randomised to active or placebo treatment and followed up for 6 mo.

Intervention

Treatment consisted of 200 IU onaBoNTA or placebo injected into the bladder wall (20 sites; 10 IU per site in 1 ml saline).

Measurements

Primary outcome was voiding frequency per 24 h at 6 mo. Secondary outcomes included urgency and incontinence episodes and quality-of-life data. Intention-to-treat analysis was used with imputation of missing data.

Results and limitations

A total of 122 women received onaBoNTA and 118 received the placebo. Median (interquartile range) voiding frequency was lower after onaBoNTA compared with placebo (8.3 [6.83–10.0] vs 9.67 [8.37–11.67]; difference: 1.34; 95% confidence interval [CI], 1.00–2.33; p = 0.0001). Similar differences were seen in urgency episodes (3.83 [1.17–6.67] vs 6.33 [4.0–8.67]; difference: 2.50; 95% CI, 1.33–3.33; p < 0.0001) and leakage episodes (1.67 [0–5.33] vs 6.0 [1.33–8.33]; difference: 4.33; 95% CI, 3.33–5.67; p < 0.0001). Continence was more common after botulinum toxin type A (BoNTA; 31% vs 12%; odds ratio [OR]: 3.12; 95% CI, 1.49–6.52; p = 0.002). Urinary tract infection (UTI; 31% vs 11%; OR: 3.68; 95% CI, 1.72–8.25; p = 0.0003) and voiding difficulty requiring self-catheterisation (16% vs 4%; OR: 4.87; 95% CI, 1.52–20.33; p = 0.003) were more common after onaBoNTA.

Conclusions

This randomised controlled trial of BoNTA for refractory DO, the largest to date, confirms efficacy and safety of the compound. UTI (31%) and self-catheterisation (16%) are common. A third of women achieved continence.

Trial registration

The study received ethical committee approval from the Scottish Multicentre Research Ethics Committee (reference: 04/MRE10/67). The trial has a EudraCT number (2004-002981-39), a clinical trial authorisation from the UK Medicines and Healthcare Regulatory Agency, and it was registered on Current Controlled Trials (ISRCTN26091555) on May 26, 2005.     

Two modes of acupuncture as a treatment for hot flushes in men with prostate cancer--a prospective multicenter study with long-term follow-up

Background

Hot flushes are common and distressing among men with castrational treatment for prostate cancer. Of the few treatments, most have side effects.

Objective

Assess changes in hot flushes of electrostimulated (EA) and traditional acupuncture (TA).

Design, Setting, and Participants

Thirty-one men with hot flushes due to prostate cancer treatment were recruited from three urological departments in Sweden, from 2001 to 2004.

Intervention

Thirty-one men were randomized to EA (12 needle points, with 4 electrostimulated) or TA (12 needle points) weekly for 12 wk.

Measurements

Primary outcome: number of and distress from hot flushes in 24 h and change in “hot flush score.” Secondary outcome: change in 24-h urine excretion of CGRP (calcitonin gene–related peptide).

Results and Limitations

Twenty-nine men completed the treatment. Hot flushes per 24 h decreased significantly, from a median of 7.6 (interquartile range [IQR], 6.0–12.3) at baseline in the EA group to 4.1 (IQR, 2.0–6.5) (p = 0.012) after 12 wk, and from 5.7 (IQR, 5.1–9.5) in the TA group to 3.4 (IQR1.8–6.3) (p = 0.001). Distress by flushes decreased from 8.2 (IQR, 6.5–10.7) in the EA group to 3.3 (IQR, 0.3–8.1) (p = 0.003), and from 7.6 (IQR, 4.7–8.3) to 3.4 (IQR, 2.0–5.6) (p = 0.001) in the TA group after 12 wk, (78% and 73% reduction in “hot flush score,” respectively). The effect lasted up to 9 mo after treatment ended. CGRP did not change significantly. Few, minor side effects were reported.Limitations: small number of patients; no placebo control, instead a small group controlled for 6 wk pretreatment.

Conclusions

EA and TA lowered number of and distress from hot flushes. The hot flush score decreased 78% and 73%, respectively, in line with or better than medical regimens for these symptoms. Acupuncture should be considered an alternative treatment for these symptoms, but further evaluation is needed, preferably with a non- or placebo-treated control group.     

Upgrading and downgrading of prostate cancer from biopsy to radical prostatectomy: incidence and predictive factors using the modified Gleason grading system and factoring in tertiary grades

Background

Prior studies assessing the correlation of Gleason score (GS) at needle biopsy and corresponding radical prostatectomy (RP) predated the use of the modified Gleason scoring system and did not factor in tertiary grade patterns.

Objective

To assess the relation of biopsy and RP grade in the largest study to date.

Design, setting, and participants

A total of 7643 totally embedded RP and corresponding needle biopsies (2004–2010) were analyzed according to the updated Gleason system.

Interventions

All patients underwent prostate biopsy prior to RP.

Measurements

The relation of upgrading or downgrading to patient and cancer characteristics was compared using the chi-square test, Student t test, and multivariable logistic regression.

Results and limitations

A total of 36.3% of cases were upgraded from a needle biopsy GS 5–6 to a higher grade at RP (11.2% with GS 6 plus tertiary). Half of the cases had matching GS 3 + 4 = 7 at biopsy and RP with an approximately equal number of cases downgraded and upgraded at RP. With biopsy GS 4 + 3 = 7, RP GS was almost equally 3 + 4 = 7 and 4 + 3 = 7. Biopsy GS 8 led to an almost equal distribution between RP GS 4 + 3 = 7, 8, and 9–10. A total of 58% of the cases had matching GS 9–10 at biopsy and RP. In multivariable analysis, increasing age (p < 0.0001), increasing serum prostate-specific antigen level (p < 0.0001), decreasing RP weight (p < 0.0001), and increasing maximum percentage cancer/core (p < 0.0001) predicted the upgrade from biopsy GS 5–6 to higher at RP. Despite factoring in multiple variables including the number of positive cores and the maximum percentage of cancer per core, the concordance indexes were not sufficiently high to justify the use of nomograms for predicting upgrading and downgrading for the individual patient.

Conclusions

Almost 20% of RP cases have tertiary patterns. A needle biopsy can sample a tertiary higher Gleason pattern in the RP, which is then not recorded in the standard GS reporting, resulting in an apparent overgrading on the needle biopsy.     

Thirty-Day Mortality After Nephrectomy: Clinical Implications for Informed Consent

Background

The existing literature suggests that the surgical mortality (SM) observed with nephrectomy for localised disease varies from 0.6% to 3.6%.

Objective

To examine age- and stage-specific 30-d mortality (TDM) rates after partial or radical nephrectomy.

Design, setting, and participants

We relied on 24 535 assessable patients from the National Cancer Institute (NCI) Surveillance, Epidemiology, and End Results (SEER) database.

Measurements

In 12 283 patients, logistic regression models were used to develop a tool for pretreatment prediction of the probability of TDM according to individual patient and tumour characteristics. External validation was performed on 12 252 patients.

Results and limitations

In the entire cohort of 24 535 patients, 219 deaths occurred during the initial 30 d after nephrectomy (0.9% TDM rate). TDM increased with age (≤49 yr: 0.5% vs 50–59 yr: 0.7% vs 60–69 yr: 0.9% vs 70–79 yr: 1.2% vs ≥80 yr: 2.0%; χ² trend p < 0.001) and stage (0.3% for T1–2N0M0 vs 1.3% for T3–4N0–2M0 vs 4.2% for T1–4N0–2M1; χ² trend p = <0.001). TDM decreased in more recent years (1988–1993: 1.3% vs 1994–1998: 0.9% vs 1999–2002: 0.7% vs 2003–2004: 0.6%; χ² trend p < 0.001) and was lower after partial versus radical nephrectomy (RN) (0.4% vs 0.9%; p = 0.008). Only age (p < 0.001) and stage (p < 0.001) achieved independent predictor status. The look-up table that relied on the regression coefficients of age and stage reached 79.4% accuracy in the external validation cohort.

Conclusions

Age and stage are the foremost determinants of TDM after nephrectomy. Our model provides individual probabilities of TDM after nephrectomy, and its use should be highly encouraged during informed consent prior to planned nephrectomy.     

Influence of the analgesic strategy on the respiratory function after thoracic surgery for lobectomy

Objective

To compare the influence of thoracic epidural analgesia (TEA) with intravenous patient-controlled analgesia with morphine (PCA) on the early postoperative respiratory function after lobectomy.

Study design

Prospective and comparative observational study.

Patients and methods

Fourty-four patients scheduled for lobectomy (n = 22 per group) were studied on the evolution of the postoperative respiratory function assessed by the forced vital capacity (FVC) and the forced expired volume (FEV₁) during the first two postoperative days and the analysis of noctural arterial desaturation during the three first postoperative nights.

Results

The use of TEA resulted in fewer decrease both in FEV₁ (1.01 ± 0.34 versus 1.31 ± 0.51 l/s for Day 1, P = 0.03; 1.13 ± 0.37 versus 1.53 ± 0.59 l/s for Day 2, P = 0.01) and in FVC (1.23 [1.05-1.51] versus 1.57 [1.38–2.53] l for day 1, P = 0.008; 1.33 ± 0.43 versus 2.24 ± 0.87 l for day 2, P < 0.001). Moreover, the duration of arterial desaturation < 90% were longer in the PCA group during the first (8.6 [0.8–28.2] versus 1.3 [0–2.6] min, P = 0.02) and the second postoperative night (13.5 [3.5–54] versus 0.4 [0–2.6] min, P = 0.025).

Conclusion

The results of this study suggest that the use of TEA is associated with a better preservation of respiratory function assessed by spirometric data and noctural arterial desaturation recording after thoracic surgery for lobectomy.     

Technique of Laparoscopic-Endoscopic Single-Site Surgery Radical Nephrectomy

Background

Laparoscopic-endoscopic single-site surgery (LESS) represents the closest surgical technique to scar-free surgery.

Objective

To assess the feasibility of LESS radical nephrectomy (LESS-RN).

Design, setting, and participants

Ten patients with body mass index (BMI) ≤30 underwent LESS-RN for renal tumour by two experienced laparoscopists.

Surgical procedure

TriPort (Olympus Winter &; Ibe, Hamburg, Germany) was inserted through a transumbilical incision. A combination of standard laparoscopic instruments and flexible grasper and scissors was used. A 5-mm 30° camera was also used. The standard laparoscopic transperitoneal nephrectomy technique was performed.

Measurements

Patient demographics, operative details, and final pathology were prospectively recorded. Postoperative evaluation of pain and use of analgesic medication were recorded.

Results and limitations

Ten cases were successfully accomplished (two right-sided tumours and eight left-sided tumours; tumour diameter ranges: 4–8 cm). The mean patient age was 63.5 yr (22–77 yr), and median BMI was 23.56 (18.2–26.6). The mean operative time was 146.4 min (120–180 min), and the mean blood loss was 202 ml (50–900 ml). Pathological examination observed organ-confined T1 renal cell carcinoma in nine cases and pT3b tumour in one case. One bleeding complication occurred. Limitations regarding the intraoperative instrument ergonomics and the requirement for ambidexterity of the surgeon were noted.

Conclusions

LESS-RN proved to be safe and feasible. Further clinical investigation in comparison to the established techniques should take place to evaluate the outcome of LESS-RN.     

The factor age and the recovery of severely burned children

Purpose

It is not known if the recovery of pediatric burn patients is age-dependent. The aim of this study was to investigate the effect of age on the recovery of body composition of severely burned children.

Procedures

Pediatric patients with massive burns, ≥40% of total body surface area, were followed over 2 years. Patients were divided into two age groups: 0–3.9 years old and 4–17.9 years old at the time of burn.Body composition was determined at hospital discharge, 6, 9, 12, 18, and 24 months after burn using dual-X-ray absorptiometry. Data analysis was performed using a two way ANOVA followed by Tukey's correction when appropriate. Significance was accepted at p < 0.05.

Findings

Twenty-four patients were enrolled (age 0–3.9: n = 9; age 4–17.9: n = 15). Percent changes in height and bone mineral content were significantly increased in the younger age group, p < 0.05. In contrast, percent changes in lean body mass were significantly lower in younger patients, p < 0.05. Percent changes in total body fat mass were not affected.

Conclusion

Patterns of recovery in pediatric burn patients are determined by age. This observation should be considered in the development of therapeutic approaches.     

Tension-Free Vaginal Tape in the Management of Recurrent Urodynamic Stress Incontinence after Previous Failed Midurethral Tape

Background

Data about the use of tension-free vaginal tape (TVT) in the management of recurrent urodynamic stress incontinence (RUSI) after previous failed midurethral sling procedure (MUSP) are limited.

Objective

Assessment of the efficacy and the indications of the TVT procedure in the management of patients with RUSI after failed previous MUSP.

Design, setting, and participants

Thirty-one patients with RUSI after previous failed MUSP were prospectively enrolled at a single tertiary academic center.

Measurements

Preoperatively and postoperatively, patients were assessed with physical examination, urinalysis, urine culture, bladder diary for 2–3 d, Q-tip test, uroflow, filling and voiding cystometry, urethral profilometry, and 1-h pad test. Mean follow-up was at 18.6 mo (range: 12–28 mo).

Results and limitations

Overall, the objective cure rate based on the pad test findings was 74%, the improvement rate was 6.5%, and the failure rate was 19.5%. The objective cure rate based on cough stress test during filling cystometry was 77.4%, and the subjective cure rate based on patients’ answers was 71%. The study could have some limitations. The relatively small number of patients enrolled could affect the findings of study to some degree. Additionally, because urethral pressure profiles show a significant degree of directional dependence when side-hole microtip transducers are used, as in the present study, the orientation of the transducer could affect the values measured.

Conclusions

The TVT procedure as a second operation could provide an overall cure rate of 74% with a low complication rate in female patients with RUSI after previous failed midurethral tape procedures.     

Increased fluid resuscitation can lead to adverse outcomes in major-burn injured patients, but low mortality is achievable

Background

Excessive fluid resuscitation of large burn injuries has been associated with adverse outcomes. We reviewed our experience in patients with major-burn injury to assess the relationship between fluid, clinical outcome and cause of variance from expected resuscitation volumes as defined by the Parkland formula.

Methods

Eighty patients with new burns ≥15% total body surface area (TBSA) admitted to the intensive care unit within 48 h of injury were included.

Results

Mean fluid volume was 6.0 ± 2.3 mL/kg/% TBSA at 24 h. Bolus fluids for hypotension and oliguria explained 39% of excess variance from Parkland estimates and inaccurate burn size and weight assessment explained 9% of variance. Higher fluid volume was associated with pneumonia (adjusted odds ratio [AOR] = 2.0; 95% confidence interval [CI] 1.2–3.4) and extremity compartment syndrome (AOR = 7.9; 95% CI 2.4–26). Colloid use during the first 24 h reduced the risk of extremity compartment syndrome (AOR = 0.06; 95% CI 0.007–0.49) and renal failure (AOR = 0.11; 95% CI 0.014–0.82). In-hospital mortality was low (10%) and not associated with >125% Parkland resuscitation (P = 0.39).

Conclusions

Although fluid resuscitation in excess of the Parkland formula was associated with several adverse events, mortality was low. A multi-centre trial is needed to more specifically define the indications and volumes needed for burns fluid resuscitation and revise traditional formulae emphasising patient outcome. Improved training in burn size assessment is needed.     

Out-of-hospital assessment of elderly patients' preference for ICU care

Objective

To estimate the adequacy between elderly patients’ preference for ICU care when treated for a life-threatening pathology, and the strategy proposed by the medical team on scene.

Study design

Prospective, observational study.

Patients and methods

All patients older than 80 treated out-of-hospital for a life threatening pathology were included, except in case of language barrier, or when patients were unable to answer and absence of next-of-kin. The results of the questionnaire on quality of life and patients’ preference concerning ICU care were compared to the responses provided blindly by the medical team.

Results

Fifty-five patients were included. Quality of life as expressed by the patients was 7 (5–10) and by the physician 7 (6–8) (P = 0.69). Thirty-six patients (65%) expressed the wish to be resuscitated, while ICU admission would have been proposed for 44 patients (80%) by the doctors (P = 0.01). Among the 14 patients reluctant to ICU admission, 11 would have been proposed for ICU admission. In multivariate analysis, age (OR: 1.55 [1.04–2.32], P = 0.03) and history of neurological pathology (OR: 11,91 [5.68– > 100], P = 0.04) were associated with such an inadequacy.

Conclusion

The inadequacy between elderly patients’ preferences and doctors’ opinion concerning ICU cares is frequent. The present results support a more systematic collection of patients’ preferences when treated on scene for a life-threatening pathology.     

Comparison of the rates of elongation provided by multiple smaller rhomboid flaps and larger single rhomboid flap--an experimental study

Background

The rhomboid flap is one of the geometric relaxation techniques used for releasing burn scar contractures.

Purpose

In the present study, we evaluated the question; ‘which is better: one larger rhomboid flap or a series of multiple smaller rhomboid flaps?’

Methods

Ten male Wistar rats each weighing 250–300 g were used. In the groups, 2.5 cm of the inguinal region was used. Two 1 cm long rhomboid flaps with spaced by 0.5 cm were used in the right side and a single 2.5 cm long rhomboid flap was used in the left side.

Conclusion

An elongation by using single larger rhomboid flap (66%) is significantly bigger than an elongation by using multiple smaller rhomboid flaps (26%) (p < 0.01).