Laser treatment of benign prostatic obstruction: basics and physical differences

Context

Laser treatment of benign prostatic obstruction (BPO) has become more prevalent in recent years. Although multiple surgical approaches exist, there is confusion about laser-tissue interaction, especially in terms of physical aspects and with respect to the optimal treatment modality.

Objective

To compare available laser systems with respect to physical fundamentals and to discuss the similarities and differences among introduced laser devices.

Evidence acquisition

The paper is based on the second expert meeting on the laser treatment of BPO organised by the European Association of Urology Section of Uro-Technology. A systematic literature search was also carried out to cover the topic of laser treatment of BPO extensively.

Evidence synthesis

The principles of generation of laser radiation, laser fibre construction, the types of energy emission, and laser-tissue interaction are discussed in detail for the laser systems used in the treatment of BPO. The most relevant laser systems are compared and their physical properties discussed in depth.

Conclusions

Laser treatment of BPO is gaining widespread acceptance. Detailed knowledge of the physical principles allows the surgeon to discriminate between available laser systems and their possible pitfalls to guarantee high safety levels for the patient.     

High pulmonary risk scoliosis surgery: role of noninvasive ventilation and related techniques

OBJECTIVE: There is little awareness among surgeons of the potential for noninvasive mechanical ventilation as an alternative to prolonged endotracheal intubation or tracheostomy for patients with neuromuscular scoliosis and ventilatory failure. These methods have not been reported for the perioperative management of scoliosis correction in patients with an inability to sustain their alveolar ventilation. METHODS: Five children with flaccid scoliosis secondary to muscular dystrophy or spinal muscular atrophy who had very high pulmonary risk were preoperatively trained in the use of noninvasive intermittent positive-pressure ventilation (IPPV) and mechanically assisted coughing prior to spinal fusion. RESULTS: All patients were extubated by the third postoperative day to noninvasive IPPV despite continuous ventilator dependence. No patient developed any postoperative pulmonary complications or required a tracheotomy. CONCLUSIONS: It is critical for the orthopedic surgeon to be aware of these noninvasive options to tracheotomy to decrease the tendency to avoid surgery for these otherwise high-risk surgical patients.     

Thulium:yttrium‐aluminium‐garnet laser prostatectomy in men with refractory urinary retention

OBJECTIVE

To evaluate the feasibility and efficacy of thulium:yttrium‐aluminium‐garnet (YAG) laser prostatectomy in patients with an indwelling transurethral catheter due to recurrent urinary retention secondary to benign prostatic obstruction.

PATIENTS AND METHODS

Preoperative data and postoperative outcome, as well as complications, were recorded in 65 patients with a history of recurrent urinary retention before surgery (group A), who were compared with a group of 143 men with no recurrent urinary retention (group B).

RESULTS

The mean (sd ) volume of the prostate was 45.6 (22.5) and 43.1 (24.5) mL in groups A and B, respectively. The respective preoperative prostate‐specific antigen levels were 3.6 (7.8) and 2.8 (6.4) ng/mL, the surgical duration 72.4 (28.9) and 65.6 (28.6) min, the mean laser time and energy 32.5 (11.8) min/140.7 (42.1) kJ and 29.4 (11.6) min/117.6 (11.6) kJ, the maximum urinary flow rate after surgery 19.6 (11.2) and 19.1 (9.6) mL/s, and the postvoid residual urine volume 26.7 (36.3) and 20.6 (27.3) mL. Recorded complications were: bleeding, at 3% in group A and 1.4% in group B; urinary tract infection 15.4% and 4.2%; and a second procedure, 3% and 2.3%. Overall, complications were more frequent in group A (P = 0.02).

CONCLUSION

Thulium:YAG prostatectomy is feasible and effective, even in patients with potentially impaired detrusor function. The long‐term durability of these promising results has yet to be confirmed.     

Intravenous Lidocaine Relieves Spinal Cord Injury Pain: A Randomized Controlled Trial

Background: Neuropathic pain in spinal cord injury is a common challenging therapeutic condition. The current study examines the analgesic effect of the sodium channel blocker lidocaine on neuropathic pain in patients with spinal cord injury and the predictive role of concomitant evoked pain on pain relief with lidocaine.

Methods: Twenty-four spinal cord injury patients with neuropathic pain at or below the level of injury were randomized and completed a double-blind crossover trial of 5 mg/kg lidocaine and placebo infused over 30 min. Twelve patients reported evoked pain, and 12 patients had no evoked pain. Spontaneous and evoked pains were assessed using a visual analog scale and quantitative sensory testing.

Results: Lidocaine significantly reduced spontaneous pain in all patients (P < 0.01) and in each of the two groups with (P < 0.01) and without (P = 0.048) evoked pain, with no difference in number of responders (pain reduction >= 33%) between the patients with (n = 6) and without (n = 5) evoked pain. Lidocaine significantly relieved both at-level and below-level neuropathic pain and decreased brush-evoked dysesthesia but not cold allodynia, pinprick hyperalgesia, or pain evoked by repetitive pinprick.     

A new method for measuring AFO deformation,tibial and footwear movement in three dimensional gait analysis

Solid ankle-foot orthoses (AFOs) are designed to immobilise the ankle but numerous studies have measured a considerable ankle range of motion (ROM) in AFO users. Measurement of ankle kinematics may be affected by soft-tissue artefact (STA) of the knee marker, deformation of the AFO or tibial movement within the AFO. A new model based on the Conventional Gait Model (CGM) was developed to calculate these effects. Although movement of the AFO within the shoe should not affect the measured ankle joint angle the model also allows an estimation of this movement.Seven children (13 limbs) with spastic diplegic cerebral palsy were assessed to present the benefits of the new model compared to the CGM. STA of the knee marker was estimated to result in a 1.5° overestimation of total ankle ROM (from 8.2° to 9.7°). STA error was strongly related to angle of knee flexion (r = 0.82) with an average maximum error of 3.8°. AFO deformation contributed approximately two thirds of the ankle ROM (6.0 ± 4.3°) with the remaining third from tibial movement relative to the AFO (2.8 ± 0.9°). Movement of the AFO within the footwear was very small (1.8 ± 0.8°). A strong positive relationship (r = 0.9) was found between body mass (kg) and AFO deformation which was statistically significant (p < 0.001). This is the first model to attempt to quantify different contributions to ankle dorsiflexion measured during gait analysis of people wearing AFOs.     

Improved visualization of carcinoid liver metastases by indium-111 pentetreotide scintigraphy following treatment with cold somatostatin analogue

Five patients with hepatic metastases of midgut carcinoid underwent somatostatin receptor scintigraphy with indium-111 pentetreotide before and during treatment with octreotide. Octreotide treatment changed the biodistribution of ¹¹¹In-pentetreotide significantly. Whereas the radioactivity in liver, spleen and kidney decreased, hepatic metastases showed increased contrast. In one patient, liver metastases could only be detected during octreotide treatment. These data suggest that the diagnostic reliability of somatostatin receptor scintigraphy in carcinoid liver metastases is not necessarily compromised by octreotide therapy. Because of different biodistributions, the detection of liver metastases may even be improved during octreotide therapy. Correspondence to: U. Dörr     

Radiocarpal fusion

Limited wrist fusion is a common and often effective method of treatment for many painful wrist conditions. When post-traumatic, inflammatory and noninflammatory arthritis affects only the articular surfaces of the proximal carpal joint, a limited radiocarpal fusion can be considered. Specific indications are painful arthritis following distal radial fractures, rheumatoid arthritis with ulnar shift of the carpus, scapholunate instability with radioscaphoid arthritis, and stage IV Kienbock's disease. It is necessary for the midcarpal joint surfaces to be essentially normal. Either a radioscapholunate or radiolunate fusion can be performed, depending on the underlying condition. Up to 70 degrees of wrist flexion-extension can be obtained after a radioscapholunate fusion. Keys to a successful postoperative result are proper alignment of the scaphoid and lunate, use of bone graft or bone graft substitute and careful positioning of internal fixation devices. Evidence of radiographic union is usually seen by eight weeks. Nonunion rates are quoted to be from 10 to 20%.     

Radiographic versus ultrasound evaluation of the Risser Grade in adolescent idiopathic scoliosis: a prospective study of 46 patients

The determination of skeletal age is essential in the management of patients with scoliosis. One of the most frequently used techniques to determine skeletal maturity is the method described by Risser. However, repeated X-ray exposure in the follow-up examinations of scoliosis patients may increase the risk of cancer. We compared conventional radiological evaluation of the Risser grade with ultrasound evaluation. For scoliosis patients routine application of ultrasound in the follow-up examinations may significantly reduce radiation exposure. 46 adolescent idiopathic scoliosis patients (median age, 14.5 years) were investigated. Sonographic and radiographic assessment of Risser sign was carried out by two independent senior staff skeletal radiologists. Agreement of Risser Grade between the two diagnostic methods was determined by Kappa statistics. Coefficients <0.21, 0.21–0.40, 0.41–0.60, 0.61–0.80, and >0.80 were rated as poor, fair, moderate, good, and very good agreement. For Risser Grades I–III 100% agreement was found between the two methods. Disagreement between radiographic and sonographic evaluation was found in Risser Grades IV and V. In five patients, X-ray evaluation yielded Risser Grade V while ultrasound showed Risser Grade IV. In one patient, radiographic examination resulted in Risser Grade IV while Grade V was detected in ultrasound. Overall, the Kappa value showed very good agreement between the two diagnostic methods. Our findings suggest that ultrasound can be applied as an alternative method to X-ray evaluation in Risser Grade determination. It should be routinely used in clinical practice to reduce the patients exposure to radiation.