改良骶管阻滞麻醉在泌尿系结石手术中的应用

目的：探讨治疗输尿管中下段结石、膀胱结石和尿道结石的简单可行麻醉方法。方法：50例泌尿系结石患者,应用2％利多卡因单次骶管阻滞麻醉,施行输尿管镜或肾镜下气压弹道／超声碎石治疗,采用疼痛分级问卷调查表及根据术中情况判断麻醉效果。结果：除1例患者术中改为硬膜外麻醉外,49例患者在骶管麻醉下成功施行手术,麻醉止痛作用起效时间：5min 4例;10min 36例;15min 10例,疼痛抑制效果满意,麻醉满意评分为：0度38例;Ⅰ度8例;Ⅱ度4例;其中1例出现轻微的头晕、心慌、心悸症状,其余未见明显麻醉并发症。结论：单次骶管阻滞麻醉是施行的一种简单、安全和有效的麻醉方法,费用低,尤适用于输尿管下段结石,甚至女性的输尿管中段结石,结石最大径不超过1cm,膀胱结石、尿道结石。     

Robotic urological surgery in patients with prior abdominal operations is not associated with increased complications

BACKGROUND: The da Vinci Surgical Robotic System is being increasingly used to perform complex urological operations by minimally invasive techniques. Prior abdominal surgery associated with intra-abdominal adhesions may complicate robotic surgery. METHODS: We used a cohort of consecutive 49 patients undergoing a variety of robotic urological procedures at our institution to study the impact of prior abdominal operations on early perioperative complications. RESULTS: A total of 21/49 (43%) patients (Group A) had no history of prior abdominal surgery and the rest 28/49 (57%; Group B) had undergone prior abdominal surgery. The incidence of peritoneal adhesions was significantly higher in patients with prior abdominal surgery compared to the rest of the cohort, 54% versus 10% (P=0.002). The median operative time, estimated blood loss, postoperative drop in hemoglobin, time to hospital discharge, postoperative narcotic analgesic use and postoperative complication rate between group A and group B were not statistically different. The overall perioperative complication rate for the entire cohort was 14.3%, with 6-8% of complications occurring in each of the two groups (P=1.0). Comparative subset analysis of 28 patients in Group B, 15 (54%) and 13 (46%) with or without intra-abdominal adhesions did not reveal a significant difference in perioperative complication rates either. However, operative time was longer in patients with intra-abdominal adhesions compared to patients without, median of 590 (281-922) and 434 (153-723) min respectively, although not statistically significant (P=0.059). CONCLUSION: Our study demonstrates that robotic urological surgery can be performed in patients with prior abdominal surgery without increased perioperative complications.     

腹腔镜手术在泌尿外科的应用(附81例报告)

目的探讨腹腔镜手术在泌尿外科的应用。方法2004年3月-2006年1月采用腹腔镜手术治疗泌尿系统疾病81例。其中肾上腺肿瘤手术19例，肾盂输尿管上段切开取石术16例，肾囊肿去项术11例，肾盂输尿管离断成形术8例，单纯肾切除术7例，肾癌根治性切除7例，肾输尿管全切5例，乳糜尿肾蒂淋巴管结扎术2例。肾部分切除术2例，精索静脉高位结扎术1例，腹腔型隐睾切除术1例，全膀胱切除术1例，前列腺癌根治性切除术1例。结果76例手术顺利完成，中转开放手术5例，无严重并发症发生，疗效满意，术后住院时间3～21d。平均8d。结论腹腔镜手术与开放手术相比具有创伤小、出血少、康复快、安全性高、并发症少等优占脓虔蒋特可壹且右京辑拍应用前导．     

A minimally invasive temporary cavernoso-saphenous shunt in the management of priapism after failed conservative treatment

Abstract

Priapism is an urological emergency with detrimental consequences, if not managed expeditiously. Though a rare condition with an incidence between 0.3 and 1.5 per 100,000 population, its management options are limited and decision making could be challenging. We present a case of late presenting priapism for which the initial routine clinical care (aspiration, intracavernosal injection, and distal shunt) failed to relieve erection. Subsequently, the patient was successfully treated by a temporary cavernoso-saphenous shunt using carotid shunt and repeated heparin flushes. This novel surgical treatment offers an alternate method of relieving priapism, avoiding the long-term undesired effects associated with permanent proximal shunts such as cavernoso-venous grafts. Moreover, interval flushes (and/or repeated aspirations) with heparin ensures patency of this new shunt during the perioperative period. The patient recovered without any complications and the shunt was removed after one week. He has regained partial erection, however refused to have further treatment. Temporary cavernoso-saphenous shunt using carotid shunt offers an alternate option of management of priapism in patients with failed initial conservative treatment and distal shunts.     

Protective effect of mitochondria-targeted antioxidants in an acute bacterial infection

Acute pyelonephritis is a potentially life-threatening infection of the upper urinary tract. Inflammatory response and the accompanying oxidative stress can contribute to kidney tissue damage, resulting in infection-induced intoxication that can become fatal in the absence of antibiotic therapy. Here, we show that pyelonephritis was associated with oxidative stress and renal cell death. Oxidative stress observed in pyelonephritic kidney was accompanied by a reduced level of mitochondrial B-cell lymphoma 2 (Bcl-2). Importantly, renal cell death and animal mortality were both alleviated by mitochondria-targeted antioxidant 10(6′-plastoquinonyl) decylrhodamine 19 (SkQR1). These findings suggest that pyelonephritis can be treated by reducing mitochondrial reactive oxygen species and thus by protecting mitochondrial integrity and lowering kidney damage.Normally, the kidney and urinary tract are germ-free. However, during their lifetimes, about 40% of women and 12% of men experience urinary tract infections (UTIs) (1). Acute pyelonephritis (APN) is a potentially life-threatening complication of UTI that occurs when infection progresses to the upper urinary tract. The uropathogen most frequently associated with this disease is the pyelonephritogenic subset of Escherichia coli, which is responsible for up to 85% of both complicated and uncomplicated UTIs (2). This disease is frequently accompanied by bacterial invasion and stimulation of acute inflammatory response (3, 4). Toxin-induced epithelial damage and bladder hemorrhage contribute further to the pathogenicity of uropathogens in the kidney, with progression leading to renal damage including renal scarring and in extreme cases septicemia (5, 6). Ultimately, renal scarring is a cause of substantial morbidity (7, 8).Leukocyte infiltration in response to bacterial invasion is an important contributor to renal tissue damage (9, 10). Production and extracellular release of reactive oxygen species (ROS) by infiltrating leukocytes can lead to kidney injury and dysfunction (11, 12). Consequently, oxidative stress in renal cells may be a critical factor in the pathogenesis of pyelonephritis whereas pharmacological management of the oxidative stress response may provide a therapeutic effect in preventing renal pathologies (13–18). However, the issue is complicated by the diversity of ROS-generating mechanisms and their differential contribution to host defense from infection and collateral tissue damage. Mitochondria and NADPH oxidases (19) are the two principle sources of ROS although their relative contribution to inflammatory pathologies is not well-defined. A new class of antioxidants that specifically target mitochondrial ROS (hereafter referred to as SkQ1 and SkQR1) have been recently developed and shown to have a beneficial effect in a number of cell pathologies (20–28).In this study, we explored mechanisms of APN progression considering various aspects of interaction of renal cells with leukocytes and bacterial pathogens. The goal was to gain insight into the role and mechanisms of induction of oxidative stress in eukaryotic components of the system and find an approach of directed correction of the pathological oxidative changes in renal tissue. We analyzed the relevance of the strategy of protecting the kidney based on the activation of prosurvival and blockage of prodeath signaling pathways involving mitochondria. We evaluated chimeric compounds carrying an antioxidant moiety as potential agents to efficiently alleviate the deleterious consequences of APN. To facilitate the future design of directed pharmacologic interventions to normalize renal function subsequent to APN, we explored the role of mitochondria and oxidative stress in this pathology using positively charged membrane-permeable, mitochondrial-targeted compounds (29). We demonstrated that specific targeting of mitochondrial ROS by antioxidant resulted in a significant protective effect in animal models of APN. These results illustrate the role of mitochondrial ROS in renal tissue damage in the context of acute infection and suggest a therapeutic potential of mitochondrial antioxidants.     

Zinc and cadmium plasma and erythrocyte levels in prostatic carcinoma, BPH, urological malignancies, and inflammations

Zinc and cadmium in both serum and erythrocytes from patients with prostatic carcinoma of different histologies, BPH, other urological tumors, and pyelonephritis were analyzed by atomic absorption spectrometry. The variance of the results obtained was very high for each group. No significant differences in the Zn or Cd concentration in either the blood plasma or the erythrocytes could be found between any of the different groups of patients. There were also no trends to be seen in the concentrations of these elements in human blood over a period of months. We conclude that the concentration of Zn and Cd in serum or erythrocytes are not an index for the diagnosis or therapy of prostatic carcinoma, BPH, urological malignancy, or inflammations.     

Late caliceal fistula after kidney transplantation

Caliceal fistula is a rare urological complication that can occur usually shortly after kidney transplantation (KTx). The occlusion of the renal accessory artery with subsequent necrosis of the kidney pole is the most common cause of the fistula development. We report a case of a 57-year-old man with reconstruction of two accessory renal arteries by anastomosis to the side of the main artery during graft placement complicated by late caliceal fistula, managed surgically. Directly after KTx good kidney graft function (serum creatinine concentration 151 micromol/L) was observed. The patient noticed protuberance and pain in the kidney graft area 5 months later. Diagnostic imaging revealed moderate urostasis and liquid collection in the region of the lower graft pole. Administration of a contrast medium through the inserted drain visualized a fistula of a lower renal calyx and ureteric stenosis. Percutaneous drainage was applied with subsequent stop of diuresis through the urethral catheter. During the surgery, the resection of a lower kidney graft pole necrosis was performed, with the closure of caliceal fistula. Simultaneously double pigtail ureteric stent was inserted. After the next two months the pigtail catheter was removed, and neither urostasis in the kidney graft nor liquid collection in the perigraft area were observed. The exceptionality of the case is the late caliceal fistula occurrence. We may only speculate, why it happened 5 months after KTx. The thrombosis of stenosed accessory artery is the most probable cause.     

Predictors of surgical site infection in dirty urological surgery

Objectives:   Risk factors for surgical site infection (SSI) following urologic dirty operations have not been clearly identified. This study was conducted to describe incidence, potential risk factors and common causative pathogens of the SSI in such operations.
Methods:   Medical records of patients who had undergone simple nephrectomy or lumbotomy for suppurative renal infection at our institutions from 1999 to 2006 were retrospectively evaluated. The following data were retrieved: presence of SSI, demographic data, laboratory findings, comorbidities, microbiological data, type of renal suppuration, type of urological surgery and antibiotic regimen. Risk factors for SSI were evaluated using the multiple logistic regression model.
Results:   Sixty-five patients (mean age 55.6 ± 13.1 years) were eligible for data analysis. In 20 of them (30.8%) a SSI was identified. The most common isolated pathogens were gram-negative bacteria. At univariate logistic regression analysis risk factors significantly associated with SSI included: presence of emphysematous infection, hypoalbuminemia, number of predisposing conditions, emergency operations, isolation of Enterobacteriaceae, positive pus culture. The use of trimethoprim/sulfamethoxazole was associated with a decreased risk for SSI. Multiple logistic model identified only the emergency operations and isolated Enterobacteriaceae as independent predictors of SSI (odds ratio [OR] = 11.1) (95% confidence interval [CI] = 3.0–40.8) and OR = 3.9 (1.0–14.8), respectively.
Conclusions:   Patients with suppurative renal infections are submitted to life-saving emergency surgery. Urological surgeons should keep in mind that this carries a high risk for subsequent SSI. Effective preventive measures in these circumstance cannot be identified. Further research in this area is necessary to clarify this issue.     

Integrating metastasectomy in the management of advanced urological malignancies-where are we in 2005?

PURPOSE: In the past patients with metastatic cancer were considered incurable and they were not candidates for surgical management of metastases. However, experience with testicular cancer has shown that metastasectomy can often be the final, critical step in achieving disease-free status. We summarized the most current data on metastasectomy for advanced urological malignancies. MATERIALS AND METHODS: We performed an extensive review of the literature from 1990 to the present using MEDLINE. Only original reports were included with an emphasis on specific malignancies and specific sites of metastasis. RESULTS: There is increasing evidence that patients with metastatic renal cell carcinoma and bladder carcinoma can be cured by surgical resection of metastases, usually combined with systemic therapy. The ideal patient has responded to systemic therapy and has few metastatic sites. CONCLUSIONS: Metastasectomy should frequently be done in patients with advanced testicular cancer and it should increasingly be considered in patients with metastatic renal cell carcinoma or bladder carcinoma. This technique may be used for cure and palliation. Specific patient factors determine the likelihood and degree of potential benefit.