Long-term comparative outcomes between 2 common ureteroneocystostomy techniques for renal transplantation

PURPOSE: We compared the incidence of ureteral complications between the classic (Lich-Gregoir) technique and the recently popularized single stitch (Shanfield) technique in renal transplantation. MATERIALS AND METHODS: The charts of 721 consecutive transplant recipients from May 1999 to July 2002 were retrospectively reviewed. Ureteral and nonureteral complications were reviewed at 3 to 5-year followup. RESULTS: Of the 721 recipients evaluated 713 were included in the study. There were 360 recipients in the Lich-Gregoir group and 353 in the Shanfield group. A significantly higher rate of ureteral complications occurred in the Shanfield group compared to the Lich-Gregoir group (15.6% vs 3.9%, p <0.0001). The Shanfield group consisted of 20 patients with ureteral leakage, 21 with hematuria, 11 with strictures and 3 who had ureteral stones. The Lich-Gregoir group had 8 patients with ureteral leakage, 5 with hematuria and 1 with a stricture. In comparison, urinary tract infections, delayed graft function and rejection rates were not significantly different between the 2 groups (p = 0.76, 0.12 and 0.19, respectively). CONCLUSIONS: In contrast to other reports, the Shanfield group had significantly more ureteral complications. In particular the Shanfield technique may predispose patients to higher rates of hematuria and stone formation. Based on this large series and published meta-analyses we believe that the stented Lich-Gregoir anastomosis is the superior ureteroneocystostomy technique in renal transplantation.     

Comparison of the responsiveness of the SF-36 and WOMAC in patients undergoing total hip arthroplasty

This study examines the responsiveness of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Short Form-36 (SF-36) in patients undergoing total hip arthroplasty. Eighty-nine patients completed the WOMAC and SF-36 preoperatively and postoperatively. Standardized response means (SRMs) and effect sizes (ES) were used to measure responsiveness. Mean follow-up was 17 months. The SRMs for the WOMAC ranged from -0.93 to -1.49, and the ES ranged from -1.02 to -1.53. The SRMs for the SF-36 ranged from 0.22 to 1.64, and the ES ranged from 0.20 to 1.97. The highest values occurred with the physical functioning, bodily pain, and Physical Component Summary Scales. This study demonstrates a similar level of responsiveness of the WOMAC and several components of the SF-36. This suggests that the isolated use of the SF-36 may be adequate to monitor outcomes after total hip arthroplasty. There may still be a role for the WOMAC when comparing outcomes of specific designs or techniques of total hip arthroplasty.     

Bladder neck contracture

Bladder neck contracture (BNC) is a well-described complication of the surgical treatment of benign and malignant prostate conditions. Nevertheless, etiologies of BNC development are highly dependent on the primary treatment modality undertaken with BNC also occurring after pelvic radiation. The treatment options for BNC can range from simple, office-based dilation procedures to more invasive, complex abdomino-perineal reconstructive surgery. Although numerous strategies have been described, a patient-specific approach is usually necessary in the management of these complex patients. In this review, we highlight various therapeutic maneuvers described for the management of BNC and further delineate a tailored approach utilized at our institution in these complicated patients.     

Identification of 22 novel loci associated with urinary biomarkers of albumin,sodium, and potassium excretion

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Intratumoral Heterogeneity of Bladder Cancer by Molecular Subtypes and Histologic Variants

Molecular subtyping may inform on prognosis and treatment response in bladder cancer. However, intratumoral molecular heterogeneity is not well studied in this disease and could complicate efforts to use molecular subtyping to guide patient management. To investigate intratumoral heterogeneity in bladder cancer, we examined molecular subtypes in a consecutive, retrospective cystectomy series of histologic variant bladder cancers and conventional urothelial carcinomas co-occurring with them. Molecular subtypes were assigned as per the approach reported by Lund University, an approach that incorporates cell cycle alterations and markers of differentiation, to give the urothelial-like, genomically unstable, basal-squamous, mesenchymal-like, and neuroendocrine-like subtypes. The majority (93%) of tumors were classified as urothelial like, genomically unstable, or basal squamous. Among patients with more than one tumor histology, 39% demonstrated molecular heterogeneity among the different tumor histologies. This was greatest for the basal-squamous subtype, 78% of which co-occurred with either urothelial-like or genomically unstable carcinoma (among cases with multiple histologies). In contrast, there was no co-occurrence of urothelial-like and genomically unstable carcinoma in the same patient. The findings indicate that bladder cancer is often molecularly heterogeneous, particularly in the basal-squamous subtype. This raises the concern for sampling error in laboratory tests that guide therapy based on molecular subtyping.Patient summary: In this report, we investigated molecular diversity among different areas from the same tumor in patients with bladder cancer. We found that different areas from the same tumor are often molecularly different. We conclude that this biological diversity must be taken into account when interpreting clinical molecular tests performed on bladder cancer samples.     

Octylcyanoacrylate skin closure in laparoscopy.

OBJECTIVES: Octylcyanoacrylate (Dermabond) is a dermal bond useful in closing surgical skin incisions. We compared skin octylcyanoacrylate with subcuticular skin sutures to close laparoscopic trocar sites. METHODS: A randomized, double-armed, prospective study was performed with 59 patients, in whom 228 trocar sites were closed. Twenty-nine patients underwent subcuticular closure of laparoscopic incisions, and 30 patients received closure with octylcyanoacrylate. Sutured trocar sites were closed with subcuticular 4-0 absorable suture. Octylcyanoacrylate wounds received closure in accordance with the recommendations of the manufacturer (Ethicon, Somerville, NJ). The number of sutures or vials of octylcyanoacrylate used, closure times, and postoperative wound problems were recorded. Wounds were assessed 2 weeks postoperatively for healing complications. Closure costs were estimated using published operating room time per hour plus the cost of octylcyanoacrylate or suture. The Student paired t test was used for statistical analysis. RESULTS: The overall mean time for skin closure using octylcyanoacrylate and suture was 3.7 minutes and 14 minutes, respectively (P<0.00001). An average of 2.2 packets of suture were used to close all port sites, while those closed with octylcyanoacrylate required an average of 3.4 vials per patient. Wound complications consisted of subcuticular seroma with skin separation. No difference was noted in complication rates between the 2 groups. Overall average cost per closure using octylcyanoacrylate was 198 dollars while cost for closure using suture was 497 dollars (P<0.00001). CONCLUSIONS: Laparoscopic port-site skin closure with octylcyanoacrylate is rapid and effective. Closure with octylcyanoacrylate yields cost savings and a decrease in operative time of more than 9 minutes per case.     

A prospective randomized comparison of patellar tendon versus semitendinosus and gracilis tendon autografts for anterior cruciate ligament reconstruction

Seventy patients with patellar tendon or hamstring tendon autografts for single-incision anterior cruciate ligament reconstruction were evaluated at least 2 years after surgery. All reconstructions were performed by the same surgeon, and metal interference screws were used for fixation of all grafts. No significant differences were noted between groups for Lysholm score, reduction in activity, KT-1000 arthrometer findings, quadriceps muscle size, return to sports, or ability to jump and do hard cuts and pivots. Significantly more patients in the patellar tendon group had patellofemoral pain at 6 months after surgery than did the hamstring tendon patients (48% versus 20%), and at last follow-up the incidence of patellofemoral pain was 42% and 20%, respectively. Fourteen patients in the patellar tendon group and seven in the hamstring tendon group had loss of motion (approximately 5 degrees ). Four patients (two in each group) had treatment failures and their results were not included in the clinical examination data. At 2 years' follow-up, 97% of patients with patellar tendon grafts and 100% of patients with hamstring tendon grafts rated their results as good or excellent. We found that hamstring tendon grafts performed similarly to patellar tendon grafts, although fewer patients in the hamstring tendon group had patellofemoral pain and loss of motion.     

Reduction of flow-related signal loss in flow-compensated 3D TOF MR angiography, using variable echo time (3D TOF-VTE).

High-resolution MRA with phase/frequency flow compensation may require very long echo times (TEs). Variable TE (VTE) was implemented into flow-compensated 3D TOF to minimize the effective TE and reduce the flow-related signal void. The k-space of the 3D TOF was divided into segment groups ranging from two to 32 segments with different TEs. The TEs were minimized and the flow-compensation gradient lobes were calculated to null the total first moment at the peak of the echo for each segment. Possible artifacts and off-resonance effects were evaluated, with respect to the number of TE segments, using the point spread function (PSF) and corresponding experiments. The optimal number of TE segments for the least artifact was determined to be one-half of the number of slices. Two types of artifacts caused by VTE were predicted and subsequently observed. The developed pulse sequence 3D TOF-VTE was tested on clinical MRI systems, by performing scans of the cervical carotid artery and intracranial carotid artery at the carotid siphon. The signal distribution near the bifurcation and the siphon was much more uniform with VTE, and the flow-related signal loss was greatly reduced. The resultant MR angiograms provided improved vessel detail. The results show that VTE improved the quality of flow-compensated 3D TOF MRA.     

No association between high-altitude tolerance and the ACE I/D gene polymorphism

PURPOSE: The absence (deletion allele [D]) of a 287 base-pair fragment in the ACE gene is associated with higher ACE tissue activity than its presence (insertion allele [I]) and, as such, may enhance vasoconstriction and fluid retention through increased levels of angiotensin II and aldosterone. Because fluid retention is found in acute mountain sickness (AMS) and exaggerated pulmonary hypertension is essential in the pathophysiology of high-altitude pulmonary edema (HAPE), we hypothesized that the DD genotype is associated with increased susceptibility to these illnesses. METHODS: ACE genotype was thus determined in 83 mountaineers staying over night at 4559 m and related to AMS symptoms. Genotype was similarly determined in 76 mountaineers who had participated in previous studies at 4559 m; 38 of the latter group had a history of HAPE, and 25 had developed HAPE again during these studies. RESULTS: The allele frequency was in Hardy-Weinberg equilibrium in both investigations. Neither the history nor the observed episodes of HAPE nor the prevalence of AMS defined as an AMS-C score >/= 0.70 (environmental symptom questionnaire) in the first study or in both studies taken together were significantly different between the genotypes DD, ID, and II. CONCLUSION: We conclude that I/D-ACE gene polymorphism has no important effect on susceptibility to AMS or HAPE.