Somatosensory-evoked potential-guided intercostal artery reimplantation in thoracoabdominal aortic aneurysm surgery.

OBJECTIVE: This study was undertaken to evaluate the use of somatosensory-evokedpotential (SSEP) monitoring on intercostal artery reimplantation (IAR) and spinal cord ischemia rates during thoracoabdominal ortic aneurysm repair. METHODS: Fifty-two patients had thoracoabdominal aortic aneurysm repair with IAR under SSEP guidance and 79 patients had repair with routine IAR without SSEP guidance from 1999 to 2010. RESULTS: No differences were observed between the two groups in age (63.1 ± 11.6 vs 64.8 ± 9.8 years), sex (57.7% vs 50.6% men), chronic dissections (40.4% vs 44.3%), renal insufficiency (11.5% vs 10.1%), and Crawford type 1 and 2 aneurysms (53.9% vs 53.9%). There was one case (1.9%) of immediate paraplegia and one case (1.9%) of delayed paraplegia in the SSEP group versus 2 cases (2.5%) of immediate paraplegia in the non-SSEP group (P = 0.92). In the SSEP group, 38 patients (73.1%) had SSEP changes, but only 15 (28.8%) required reimplantation. There were fewer IARs in the SSEP group compared with the non-SSEP group (28.8% vs. 59.5%, P = 0.004). No difference was observed in 30-day mortality between the SSEP and the non-SSEP group (3.9% vs. 7.6%, P = 0.48). CONCLUSIONS: The use of SSEP monitoring led to a significant decrease in the need for IAR without increasing the paraplegia rate.

Perioperative outcomes of off-clamp vs complete hilar control laparoscopic partial nephrectomy.

OBJECTIVE: To evaluate perioperative and 6-month renal functional outcomes of patients undergoing off-clamp vs complete hilar control laparoscopic partial nephrectomy (LPN). PATIENTS AND METHODS: A retrospective review of 489 patients undergoing LPN was completed. Preoperative imaging assessed tumour characteristics. Patient demographics, perioperative parameters, and postoperative outcomes were documented. Multivariable regression analysis was used to assess factors contributing to changes in postoperative renal function between off-clamp and clamped LPN. RESULTS: In all, 289 LPNs were performed on-clamp and 150 were performed off-clamp. Tumours in the on-clamp group were larger than those in the off-clamp group (mean [range] 3.3 [0.5-13.5] vs 2.7 [0.4-9] cm, P = 0.003). Univariable analysis comparing off-clamp to on-clamp cohorts showed that estimated glomerular filtration rate (eGFR) was better preserved in the off-clamp cohort at 6 months (-5.8% vs -11.4%, P = 0.046). Multivariable analysis of the groups showed that estimate blood loss (P = 0.015) and warm ischaemia time (WIT, P < 0.001) were the only significant predictors of decreased eGFR in the postoperative period. Difference in eGFR at 6 months was not significant when WIT was limited to 30 min. The complication rate was greater in the clamped cohort (10% vs 20%, P = 0.012). There was no difference in transfusion rate or positive margin status. CONCLUSIONS: LPN without hilar clamping is feasible, safe and associated with less renal injury as assessed by postoperative GFR in select patients. With experience, it can be applied to complex renal lesions.

The impact of neuropathic pain in the chronic pelvic pain population.

PURPOSE: Patients with chronic pelvic pain disorders often present with neuropathic features. We examined a cohort of patients with a primary complaint of chronic pelvic pain for the presence of neuropathic pain symptoms. MATERIALS AND METHODS: Patients with chronic pelvic pain disorders from 2 tertiary referral centers were prospectively evaluated. The validated S-LANSS (Self-Administered Leeds Assessment of Neuropathic Symptoms and Signs) survey was used to examine pain symptoms of neuropathic origin. Patients completed SF-12v2™ to assess mental/physical health domains. The 2-tailed t test and chi-square analysis were used to compare physical and mental component summaries in patients with vs without neuropathic symptoms. RESULTS: A total of 142 patients mean age of 45 years were included in analysis. Of the patients 72.5% with chronic pelvic pain carried more than 1 primary diagnosis. The S-LANSS survey identified symptoms suggestive of neuropathic pain in 44 patients (31%). A greater proportion of patients with a neuropathic component had altered sensation in the affected area (86.4% vs 24.5%). Patients with neuropathic pain scored 4.28 and 5.45 points lower on the physical and mental component summaries (p = 0.053 and 0.008, respectively). CONCLUSIONS: A large proportion of patients with chronic pelvic pain present with neuropathic features and report decreased quality of life compared with the general population. Those with neuropathic symptoms have significantly lower quality of life than those without such symptoms. Clinicians can identify patients to use targeted therapies and use a multidisciplinary approach to care.

Symptom profile variability of interstitial cystitis/painful bladder syndrome by age.

UNLABELLED: Study Type--Diagnostic (symptom prevalence). Level of Evidence 2b. What's known on the subject? And what does the study add? Symptom variability is profound in the population of patients diagnosed with interstitial cystitis and painful bladder syndrome because these diagnoses represent a very heterogeneous patient population. Recently, younger patients are being diagnosed with these pain syndromes, without any specific investigation into the symptoms they experience. We identified that patients diagnosed with interstitial cystitis and painful bladder syndrome have variable clinical symptom profiles depending on the age at the time of their diagnosis. Dyspareunia, external genitalia pain, urgency, frequency and dysuria were more common in younger patients whereas nocturia, urinary incontinence and the presence of Hunner's ulcers were more common in older patients. Better defining symptom profiles for patients at the time of evaluation may potentially aid in more accurate and expedited diagnosis of these conditions, particularly in the youngest patient population which is being recognized more commonly in recent times. OBJECTIVE: • To investigate the clinical profile differences among patients with interstitial cystitis/painful bladder syndrome (IC/PBS) based upon age at the time of diagnosis from childhood into the geriatric age group. METHODS: • An analysis of 268 patients with IC/PBS seen between 1990 and 2008 was performed. • Three age cohorts were analysed: <30 years, ≥30 years but <60 years, and ≥60 years of age at time of diagnosis. • Patient demographics, disease characteristics and IC/PBS-associated symptoms were compared across the three groups. RESULTS: • Of the 268 patients, 60 were <30 years of age at the time of IC diagnosis (median 22, range 11-29), 105 were ≥30 but <60 years (median 48, range 30-59) and 103 patients were ≥60 years of age (median 69, range 60-88). • Of the patients in the youngest, middle and oldest age cohorts: 12.0, 42.0 and 39.8% had Hunner's ulcers, respectively (P<0.001). • Dyspareunia and external genitalia pain were more common in the youngest age cohort, P<0.001 and P=0.001, respectively. • Urinary urgency (P=0.033), frequency (P=0.006) and dysuria (P<0.001) were also more common in patients diagnosed before 30 years of age. • The reported rate of nocturia and urinary incontinence increased with age, P=0.002 and P<0.001, respectively. CONCLUSIONS: • Patients with IC/PBS analysed across a wide spectrum of ages at time of diagnosis portrayed a unique symptom profile pattern. • Patients diagnosed at the youngest ages experienced significantly more urinary urgency, frequency, dysuria, dyspareunia and pain in their external genitalia. • Older patients had higher rates of nocturia, urinary incontinence and Hunner's ulcer disease.

Reproducibility and fidelity of the R.E.N.A.L. nephrometry score.

BACKGROUND AND PURPOSE: The R.E.N.A.L nephrometry score (NS) was developed to characterize renal tumor anatomy to facilitate standardized reporting and ultimately clinical decision making. Up to three points are assigned for each of the following criteria: Tumor size (R), exophytic vs endophytic nature (E), nearness to the collecting system (N), anterior vs posterior (A), and polar location (L), with more complex lesions receiving higher scores. There are no independent studies to date that validate the reproducibility of this scoring system. Our aim was to validate the R.E.N.A.L. NS system by assessing interobserver variability, and therefore reproducibility and fidelity of this proposed assessment tool. PATIENTS AND METHODS: We reviewed our prospectively collected laparoscopic partial nephrectomy (LPN) database and identified 306 patients with available preoperative CT or MRI. Of these, 149 were independently read by two urology residents who assigned NS. The Pearson test was used to assess interobserver variability of total NS as well as each of the five components of the scoring system. RESULTS: Interobserver correlation of total NS calculated by the Pearson test was found to be 0.92 (P<0.001). Concordance rates for each of the individual nephrometry components R.E.N.A.L (hilar) were 96%, 92%, 86%, 96%, 89%, and 99% respectively. A t test showed no significant difference between final NS assigned by two different observers. CONCLUSION: The R.E.N.A.L. NS system is a comprehensive and reproducible tool that may aid surgeons in communicating tumor characteristics effectively. Interobserver correlation is high, rendering it a high fidelity assessment tool.

Surgical site infection rates following laparoscopic urological procedures.

PURPOSE: Surgical site infections have been categorized by the Centers for Medicare and Medicaid Services as "never events". The incidence of surgical site infection following laparoscopic urological surgery and its risk factors are poorly defined. We evaluated surgical site infection following urological laparoscopic surgery and identified possible factors that may influence occurrence. MATERIALS AND METHODS: Patients who underwent transperitoneal laparoscopic procedures during a 4-year period by a single laparoscopic surgeon were retrospectively reviewed. Surgical site infections were identified postoperatively and defined using the Centers for Disease Control criteria. Clinical parameters, comorbidities, smoking history, preoperative urinalysis and culture results as well as operative data were analyzed. Nonparametric testing using the Mann-Whitney U test, multivariable logistic regression and Spearman's rank correlation coefficient were used for data analysis. RESULTS: In 556 patients undergoing urological laparoscopic procedures 14 surgical site infections (2.5%) were identified at mean postoperative day 21.5. Of the 14 surgical site infections 10 (71.4%) were located at a specimen extraction site. Operative time, procedure type and increasing body mass index were significantly associated with the occurrence of surgical site infections (p = 0.007, p = 0.019, p = 0.038, respectively), whereas history of diabetes mellitus (p = 0.071) and intraoperative transfusion (p = 0.053) were found to trend toward significance. Age, gender, positive urine culture, steroid use, procedure type and smoking history were not significantly associated with surgical site infection. Body mass index and operative time remained significant predictors of surgical site infection on multivariate logistic regression analysis. CONCLUSIONS: Surgical site infection is an infrequent complication following laparoscopic surgery with the majority occurring at the specimen extraction site. Infection is associated with prolonged operative time and increasing body mass index.

Evaporative isotope enrichment as a constraint on reach water balance along a dryland river.

Deuterium and oxygen-18 enrichment in river water during its transit across dryland region is found to occur systematically along evaporation lines with slopes of close to 4 in (2)H-(18)O space, largely consistent with trends predicted by the Craig-Gordon model for an open-water dominated evaporating system. This, in combination with reach balance assessments and derived runoff ratios, strongly suggests that the enrichment signal and its variability in the Barwon-Darling river, Southeastern Australia is acquired during the process of evaporation from the river channel itself, as enhanced by the presence of abundant weirs, dams and other storages, rather than reflecting inherited enrichment signals from soil water evaporation in the watershed. Using a steady-state isotope mass balance analysis based on monthly (18)O and (2)H, we use the isotopic evolution of river water to re-construct a perspective of net exchange between the river and its contributing area along eight reaches of the river during a drought period from July 2002 to December 2003, including the duration of a minor flow event. The resulting scenario, which uses a combination of climatological averages and available real-time meteorological data, should be viewed as a preliminary test of the application rather than as a definitive inventory of reach water balance. As expected for a flood-driven dryland system, considerable temporal variability in exchange is predicted. While requiring additional real-time isotopic data for operational use, the method demonstrates potential as a non-invasive tool for detecting and quantifying water diversions, one that can be easily incorporated within existing water quality monitoring activities.