Outcome groups and a practical tool to predict success of shock wave lithotripsy in daily clinical routine.

PURPOSE: To improve outcome prediction of extracorporeal shock wave lithotripsy (SWL) by development of a model based on easily available clinical and radiographical predictors and suitable for daily clinical use. MATERIALS AND METHODS: We evaluated predictive factors for SWL success in 517 consecutive patients suffering from urinary calculi who underwent SWL between 2010 and 2018. Analyses included descriptive statistics, receiver operating characteristic statistics and logistic regression. Predictive value was improved by combining parameters using model selection and recursive partitioning. RESULTS: Of the 517 patients, 310 (60.0%) had a successful SWL. Best individual predictor of SWL success was mean attenuation (MAV), with an area under the curve (AUC) of 0.668, and an optimal cutpoint (OC) of 987.5 HU. The best multivariable model, including MAV, stone size, skin to stone distance (SSD), presence of an indwelling stent, and four interaction effects, yielded an AUC of 0.736. Recursive partitioning would categorize patients into three outcome groups with high (76.9%), intermediate (41%) and low (10%) success probability. High probability of SWL success (76.9%) was found for patients with a stone with MAV ≤ 987 HU or with MAV > 987 HU but stone size ≤ 11 mm and SSD (45°) ≤ 88 mm. CONCLUSION: A model based on four established predictors, and provided as an Excel®-Tool, can clearly improve prediction of SWL success. In addition, patients can be classified into three defined outcome groups based on simple cutpoint combinations. Both tools improve informed decision-making in daily clinical practice and might reduce failure rates.

Short- and long-term outcomes of laser haemorrhoidoplasty for grade II-III haemorrhoidal disease.

AIM: Laser haemorrhoidoplasty is associated with minimal postoperative pain and good symptom improvement in the short-term. However, less is known about its long-term efficacy. This study aims to determine the short- and long-term outcomes of laser haemorrhoidoplasty. METHOD: Between October 2010 and May 2012, 50 consecutive patients with grade II-III haemorrhoids were treated with laser haemorrhoidoplasty. Short-term follow-up was assessed on days 1, 30 and 60 and long-term follow-up was at 5 years (haemorrhoidal stage reduction, pain, patient satisfaction, symptom improvement, incapacity for work, continence, complications, recurrence). RESULTS: Short-term follow-up was achieved for all patients and long-term follow-up for 44/50 patients (88%). At short-term follow-up, haemorrhoidal stage reduction was documented in 49 (98%) patients. Complete or good symptom improvement was reported by 36/50 (72%) and 10/50 patients (20%) at 60 days. Postoperative complications occurred in 9/50 patients (18%) with three Clavien-Dindo grade IIIb complications (two fistulas, one incontinence), one grade IIIa (perianal thrombosis) and five grade I (one perianal thrombosis, two perianal eczema, one local bleeding, one anal fissure). Postoperative pain was low (visual analogue scale 0-1) at day 1 in 37/50 (74%), at day 30 in 47/50 (94%) and at day 60 in 50/50 patients (100%). After a mean follow-up of 5.4 years (SD 5.4 months) the recurrence rate was 34% (15/44 patients) with a median time to recurrence of 21 months (range 0.2-6 years). CONCLUSION: Although laser haemorrhoidoplasty achieves a high short-term success rate with respect to stage reduction and symptom improvement, it is associated with a high rate of minor postoperative complications and long-term recurrence. Therefore, laser haemorrhoidoplasty should be used with caution.

Successful grafting of tissue-engineered fetal skin.

PURPOSE: Fetal repair of spina bifida results in improved outcomes and has therefore become a standard clinical procedure in some highly specialized centers. However, optimization of the procedure technique and timing is needed. Both might be achieved by facilitating the procedure using laboratory-grown fetal skin substitutes. The aim of this study was therefore to test in vivo the suitability of such a fetal skin substitute for an in utero application. METHODS: Collagen-based hydrogels containing fetal ovine fibroblasts were seeded with fetal ovine keratinocytes and transplanted on immuno-incompetent nu/nu rats. After 3 weeks, grafts were harvested and analyzed histologically and by immunohistochemistry. RESULTS: Laboratory-grown fetal ovine dermo-epidermal skin substitutes showed successful engraftment at 3 weeks. Histologically, grafts revealed a neo-dermis populated by fibroblasts and with ingrowth of vessels, and an epidermis with an adult-like, mature appearance depicting clearly basal, spinous, granular, and a corneal layer. Immunostaining confirmed a physiologically organized epidermis. CONCLUSION: Fetal dermo-epidermal skin substitutes of ovine origin can successfully be grafted in vivo. In a next step, we will have to test whether favorable results can also be obtained when grafts are used in utero. If so, then human fetal spina bifida repair using laboratory-grown autologous fetal skin for defect closure may be envisaged.