Cranial surgery among Medicare beneficiaries

BACKGROUND: This article examines the incidence of inpatient cranial surgery among Medicare beneficiaries. Many of these surgeries are trauma related or reflect chronic disabilities. The costs of care and the mortality rates are high for these patients. METHODS: A retrospective study examined the inpatient discharge data on Medicare fee-for-service beneficiaries during FY 1997 for diagnosis-related groups 1, 2, and 484. Incidence patterns, length of hospital stay, and mortality were examined by age, race, sex, source of admission, and discharge destination. RESULTS: Approximately 86% of the Medicare cranial surgery patients were 65 years of age or older, but only 10.2% were 85 years of age or older. The average patient age was 72 years. Nearly 51% of the patients were male, and 86.3% were white. Approximately 35% of the patients were admitted from the emergency room. The average length of stay was 9.6 days, and the average intensive care unit stay was 3.5 days. Whereas 42.3% of the patients were discharged to home, 44.6% were discharged to postacute care, and 10.9% died in the hospital. The average inpatient charge was $30,746. CONCLUSIONS: Cranial surgery in the Medicare population results in high inpatient mortality and high rates of postacute care use, especially as patient age increases.     

The ultrastructure of human male urethral stricture.

Biopsy material was examined from 20 urethral strictures at the time of urethroplasty, using ultramicroscopic methods not hitherto applied to the study of the pathogenesis of stricture. Abundant smooth muscle and elastic tissue was found in the post-inflammatory strictures. The scar tissue from post-traumatic strictures merely showed dense collagen. An anatomical basis for the well known difference between the fibrous and the resilent stricture is demonstrated, and the role of smooth muscle in the development and behaviour of strictures is discussed.     

Female urethral stricture disease

Female urethral stricture disease is a rare entity. The most common etiologies are traumatic injury, iatrogenic injury, and inflammatory disease resulting in periurethral fibrosis. Hallmark symptoms are frequency and urgency, and may also be dysuria, hesitancy, slow stream, incontinence, and recurrent urinary tract infections. Female bladder outlet obstruction is a difficult entity to define, and the subset representing stricture disease may also be elusive. The diagnosis of female urethral stricture disease is usually based on symptoms, meatal appearance, and difficult instrumentation of the patient. Other testing, such as urodynamics, voiding urography, or cystoscopy, may be helpful. Treatment options are conservative management with dilatation, endoscopic treatment, or open repair with various tissue flaps or grafts. Considerable controversy surrounds the efficacy of urethral dilatation in women with voiding dysfunction.     

Male urethral stricture disease

PURPOSE: The incidence of urethral stricture disease in the United States is unknown. We estimated the impact of urethral stricture disease by determining its prevalence, costs and other measures of burden, including side effects and the need for surgical intervention. MATERIALS AND METHODS: Analyses of services for urethral stricture disease were performed in 10 public and private data sets by epidemiological, biostatistical and clinical experts. RESULTS: Male urethral stricture disease occurred at a rate as high as 0.6% in some susceptible populations and resulted in more than 5,000 inpatient visits yearly. Yearly office visits for urethral stricture numbered almost 1.5 million between 1992 and 2000. The total cost of urethral stricture diseases in 2000 was almost $200 million, not including medication costs. A diagnosis of urethral stricture increased health care expenditures by more than $6,000 per individual yearly in insured populations after controlling for comorbidities. Urethral stricture disease appeared to be more common in the elderly population and in black patients, as measured by health care use. In most data sets services provided for urethral stricture disease decreased with time. Patients with urethral stricture disease appeared to have a high rate of urinary tract infection (41%) and incontinence (11%). CONCLUSIONS: Despite decreasing rates of urethral strictures with time the burden of urethral stricture disease is still significant, resulting in hundreds of millions of dollars spent and hundreds of thousands of caregiver visits yearly.     

Imaging of urethral stricture disease

Accurate imaging of urethral strictures is critical for preoperative staging and planning of reconstruction. The current gold standard, retrograde urethrography (RUG), allows for accurate diagnosis, staging, and delineation of urethral strictures, and remains a cornerstone in the management of urethral stricture disease. In complex situations, the RUG can be combined with voiding cystourethrogram (VCUG) in order to better visualize the posterior urethra or complex distraction defects. Direct visualization of the stricture by cystoscopy, either retrograde or antegrade, can provide additional information as to the location and appearance of stricture, as well as precise location on fluoroscopic imaging. Sonourethrography (SU) is a useful adjunct to allow for three-dimensional assessment of stricture length and location, and can be a useful intraoperative assessment tool, however, its use remains limited to a second-line setting. Cross-sectional imaging in the form of computed tomography (CT) or magnetic resonance urethrography can provide additional three-dimensional information of anatomic structures and their relations, and can serve as a useful adjunct in complex clinical scenarios.     

Artifactual urethral stricture in male child.

Artifactual urethral obstruction at the suspensory ligament of the penis may be produced if the penis is left in its normally dependent position during a urethrogram. We present 2 such cases to re-emphasize this phenomenon so that caution is taken in interpreting distal bulbous urethral strictures.     

Surgical management of urethral stricture in the male

Urethral dilatation has long been the standard treatment for patients with urethral stricture. However, in many patients such dilatations may be difficult, painful, or have to be done at frequent intervals. The alternative techniques of direct vision urethrotomy or urethroplasty have been considered in 101 patients over a twelve-year period. Skin inlay urethroplasty in this series showed a significant level of complications and an absolute failure rate of 15 per cent. A prospective study of 39 patients undergoing urethrotomy using the Sachse optical urethrotome has shown that 82 per cent of patients are symptom-free and 13 per cent symptomatically improved at a follow-up ranging from sixteen months to three and one-half years (mean twenty-five months). We believe that urethrotomy using the Sachse optical urethrotome should now be the initial treatment of choice in the management of urethral stricture. Urethral dilatations or urethroplasty should be reserved for those patients who have persisting stricture despite such urethrotomy.     

Epidemiology of carotid endarterectomies among Medicare beneficiaries.

Extensive debates exist in the literature on the indications, effectiveness, and risks of carotid endarterectomy. However, no investigations analyze the procedure's epidemiology. Medicare paid for essentially all carotid endarterectomies on patients over 65 years old, more than two thirds of all such surgery. Accordingly, we identified all 1985 to 1989 Medicare bills for ICD-9-CM code 38.12. This report found an average annual decrease of 6.4% in the frequency of carotid endarterectomies. Higher proportions and incidence rates occurred among 65- to 79-year-old people, men, and whites. Larger, urban, and nonprofit hospitals performed the procedure more often. The number of hospitals performing this procedure has increased over time. Mortality rates within 30 days decreased from 3.0% of procedures in 1985 to 2.5% in 1989. Higher than average death rates occurred among older, male, and black patients, and in low volume hospitals. Clinical trials undertaken in large, urban, teaching, high-volume institutions reported only 1% deaths. The institutions actually performing carotid endarterectomies differ from the clinical trials in their demography and perioperative mortality rates. This difference in community practice may limit the applicability of the clinical trials.     

前尿道替代膜部尿道治疗男性后尿道狭窄52例报告

目的：探讨长段后尿道狭窄手术治疗方法。方法：同顾性总结前尿道替代膜部尿道端端吻合治疗狭窄段〉2cm的后尿道狭窄患者52例。结果：一次手术成功49例,成功率94．2％,3例术后尿线细,排尿不畅经内窥镜切除0．3～0．5cm瘢痕后排尿通畅。随访5～20年,全部排尿通畅,最大尿流率20～25ml／s,平均22ml／s。结论：切除狭窄段瘢痕前尿道替代膜部尿道端一端吻合治疗后尿道狭窄成功率高,远期效果好。术中彻底切除瘢痕,满意的无张力外翻端一端吻合及术后预防感染是手术成功的关键。     

Canadian Urological Association guideline on male urethral stricture

Urethral stricture is fundamentally a fibrosis of the urethral epithelial and associated corpus spongiosum, which in turn, causes obstruction of the urethral lumen. Patients with urethral stricture most commonly present with lower urinary tract symptoms, urinary retention or urinary tract infection but may also experience a broad spectrum of other signs and symptoms, including genitourinary pain, hematuria, abscess, ejaculatory dysfunction, or renal failure. When urethral stricture is initially suspected based on clinical assessment, cystoscopy is suggested as the modality that most accurately establishes the diagnosis. This recommendation is based on several factors, including the accuracy of cystoscopy, as well as its wide availability, lesser overall cost, and comfort of urologists with this technique. When recurrent urethral stricture is suspected, we suggest performing retrograde urethrography to further stage the length and location of the stricture or referring the patient to a physician with expertise in reconstructive urology. Ultimately, the treatment decision depends on several factors, including the type and acuity of patient symptoms, the presence of complications, prior interventions, and the overall impact of the urethral stricture on the patient’s quality of life. Endoscopic treatment, either as dilation or internal urethrotomy, is suggested rather than urethroplasty for the initial treatment of urethral stricture. This recommendation applies to men with undifferentiated urethral stricture and does not apply to trauma-related urethral injuries, penile urethral strictures (hypospadias, lichen sclerosus), or suspected urethral malignancy. In the setting of recurrent urethral stricture, urethroplasty is suggested rather than repeat endoscopic management but this may vary depending on patient preference and impact of the symptoms on the patient.The purpose of this guideline is to provide a practical summary outlining the diagnosis and treatment of urethral stricture in the Canadian setting.     

The diagnosis and management of acquired urethral stricture disease

Urethral stricture disease is a commonly presenting problem to the urologist. Any condition that damages the urethral epithelium or underlying spongy tissue has the potential to cause a stricture. Patients with a urethral stricture can present either acutely or chronically with a range of urinary symptoms. An understanding of urethral stricture disease and a systematic approach to the history and investigations will enable clinicians to manage patients appropriately. This article aims to give an overview, appropriate for surgeons in their early years of training, on the aetiology, presentation and investigation of urethral stricture disease, as well as a basic understanding of the principles of management.     

The diagnosis and management of acquired urethral stricture disease

Urethral stricture disease is a commonly presenting problem to the urologist. Any condition that damages the urethral epithelium or underlying spongy tissue has the potential to cause a stricture. Patients with a urethral stricture can present either acutely or chronically with a range of urinary symptoms. An understanding of urethral stricture disease and a systematic approach to the history and investigations will enable clinicians to manage patients appropriately. This article aims to give an overview, appropriate for surgeons in there early years of training, on the aetiology, presentation and investigation of urethral stricture disease, as well as a basic understanding of the principles of management.     

Two-stage urethroplasty for urethral stricture disease

Of 97 patients who underwent first-stage urethroplasty 23 per cent required at least 1 revision. Sixty-seven patients underwent second-stage reconstruction with a 90 per cent success rate. The various factors influencing the outcome of 2-stage urethroplasty procedures are analyzed critically.     

The diagnosis and management of acquired urethral stricture disease

Urethral stricture disease is a commonly presenting problem to the urologist. Any condition that damages the urethral epithelium or underlying spongy tissue has the potential to cause a stricture. Patients with a urethral stricture can present either acutely or chronically with a range of urinary symptoms. An understanding of urethral stricture disease and a systematic approach to the history and investigations will enable clinicians to manage patients appropriately. This article aims to give an overview, appropriate for surgeons in there early years of training, on the aetiology, presentation and investigation of urethral stricture disease, as well as a basic understanding of the principles of management.     

Long-term results of the treatment of male urethral stricture

The authors present 56 patients treated for urethral stricture between 1976 and 1983. Patients without recurrence of the stricture were followed for more than 5 years, the mean follow-up was 8 years +/- 2.1 (standard-deviation) (5 to 12 years). Thirty-eight patients (67.9%) had a recurrent stricture. Patient age ranged from 29 to 86 years (mean age 61 +/- 12.8 years). The best results were obtained with a one-stage anastomotic procedure and urethroplasty with foreskin graft. Patient age and topography of the stricture are not prognostic factors. Traumatic and infectious strictures have a better prognosis than other forms (the difference is statistically significant: chi-square = 3.9; P inferior to 0.05).     

Increasing costs of urinary incontinence among female Medicare beneficiaries

PURPOSE: We measured the financial burden of urinary incontinence in the United States from 1992 to 1998 among women 65 years old or older. MATERIALS AND METHODS: We analyzed Medicare claims for 1992, 1995 and 1998 and estimated spending on the treatment of urinary incontinence. Total costs were stratified by type of service (inpatient, outpatient and emergency department). RESULTS: Costs of urinary incontinence among older women nearly doubled between 1992 and 1998 in nominal dollars, from $128 million to $234 million, primarily due to increases in physician office visits and ambulatory surgery. The cost of inpatient services increased only slightly during the period. The increase in total spending was due almost exclusively to the increase in the number of women treated for incontinence. After adjusting for inflation, per capita treatment costs decreased about 15% during the study. CONCLUSIONS: This shift from inpatient to outpatient care likely reflects the general shift of surgical procedures to the outpatient setting, as well as the advent of new minimally invasive incontinence procedures. In addition, increased awareness of incontinence and the marketing of new drugs for its treatment, specifically anticholinergic medication for overactive bladder symptoms, may have increased the number of office visits. While claims based Medicare expenditures are substantial, they do not include the costs of pads or medications and, therefore, underestimate the true financial burden of incontinence on the aging community.