RESUMO
PURPOSE: Laparoscopic and robotic surgery have traditionally been performed with pneumoperitoneum of 12-15 mmHg. Based upon our previous retrospective study showing an advantage to using ultralow pneumoperitoneum during robotic prostatectomy (RP), we performed a randomized, double-blinded, controlled trial of RP at 6 mmHg vs 15 mmHg to assess postoperative pain and opioid use. MATERIALS AND METHODS: Patients undergoing RP with lymphadenectomy by a single surgeon were randomized to pneumoperitoneum pressures of 6 mmHg vs 15 mmHg. Pain scores and opioid use were recorded every 2 hours until discharge. Groups underwent intention-to-treat analysis on the primary outcome of pain scores up to 8 hours after post-anesthesia care unit. RESULTS: A total of 138 patients were randomized to RP at 6 mmHg or 15 mmHg (67 and 71, respectively). Mean console time was 7 minutes longer at 6 mmHg (135 vs 128 minutes, p=0.02). Mean estimated blood loss was similar (p=0.4) with no transfusions in either group. Most patients were discharged on the same day as surgery (88% vs 84%, p=0.5). There was no statistically significant difference observed in morphine equivalents administered during surgery or used postoperatively, yet 6 mmHg patients had lower immediate (0-4 hours) mean pain scores (2.1 vs 3.5, p <0.01) and lower maximum pain scores (3.0 vs 5.2, p <0.01). Shoulder pain was lower in 6 mmHg patients (0.03 vs 0.15, p=0.01), as was groin pain (0.6 vs 1.2 p=0.01). Patients reported flatus earlier with 6 mmHg (mean 1.0 day vs 1.3 days, p <0.01). CONCLUSIONS: Pneumoperitoneum pressure of 6 mmHg during RP has several advantages over the commonly used level of 15 mmHg without any identified disadvantages. Surgeons should consider using lower insufflation pressures.
Assuntos
Insuflação , Laparoscopia , Pneumoperitônio , Procedimentos Cirúrgicos Robóticos , Analgésicos Opioides , Humanos , Laparoscopia/efeitos adversos , Masculino , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/etiologia , Pneumoperitônio Artificial/efeitos adversos , Prostatectomia/efeitos adversos , Procedimentos Cirúrgicos Robóticos/efeitos adversosRESUMO
PURPOSE: Dehydration is a risk factor for kidney stone formation. Studying populations that may experience dehydration without a known increased incidence of stone formation may help understand stone formation and prevention. High-caliber athletes represent such a population. We characterized the urinary environment of high-caliber athletes utilizing 24-hour urine collections with comparison to non-athlete controls. MATERIALS AND METHODS: After Institutional Review Board (IRB) and National Collegiate Athletic Association (NCAA) compliance officer approval, 74 college-student athletes and 20 non-athletes were enrolled. Demographics, medical history, and sport of participation were recorded. Participants were asked to provide 24-hour urine collections as well as diet and activity logs at the time of urine collection. Standard stone risk parameters were assessed and compared to litholink reference standards. RESULTS: 34 athletes and 10 non-athletes provided at least one 24-hour urine specimen for evaluation. Athletes had a high prevalence of urinary risks for stone formation including low volume (median 1.46 L), low citrate, high sodium, high calcium (females), and high uric acid (males). However, athletes also had a high prevalence of known stone-protective factors such as high urine magnesium. Athletes had a lower urine pH but high supersaturation of uric acid and calcium oxalate compared to non-athletes. CONCLUSION: Student athletes appear to have a high prevalence of urinary risk factors for stone formation such as dehydration, high calcium, high uric acid, high sodium, and low citrate. Overall stone risk in this population may be offset by increased levels of stone-protective factors such as magnesium. Further study of this population may help generate hypotheses for effective stone prevention strategies in the general population.
Assuntos
Cálculos Renais , Atletas , Oxalato de Cálcio , Citratos , Feminino , Humanos , Cálculos Renais/diagnóstico , Cálculos Renais/epidemiologia , Cálculos Renais/etiologia , Masculino , Fatores de Risco , EstudantesRESUMO
OBJECTIVES: To demonstrate how using a standardised dosing strategy of indocyanine green (ICG) dye with near-infrared fluorescence (NIRF) imaging can be used to differentiate renal tumours from normal renal parenchyma during robot-assisted partial nephrectomy (RAPN). PATIENTS AND METHODS: We reviewed a prospectively collected database of 361 consecutive RAPNs using NIRF between June 2011 and March 2018, and determined the rate at which differential fluorescence was achieved. Tumour and kidney fluorescence or afluorescence were recorded intraoperatively and compared to histological results on final pathology. RESULTS: Of 330 tumours, after 31 exclusions for nonvisible tumours due to adherent fat, completely intrarenal location or for incomplete data, 288 (87.3%) successfully exhibited differential fluorescence. Among the predominant histologies, 249 of 277 (89.9%) renal cell carcinomas did not fluoresce, as well as 23 of 32 (71.9%) oncocytomas. Real-time gross assessment of resection margin for fluorescence yielded a positive margin rate on final pathology of 0.30%. CONCLUSION: When administered with a standardised ICG-dosing strategy, NIRF successfully achieved differential fluorescence in a large majority of tumours during RAPN with an exceedingly low positive margin rate.
Assuntos
Corantes , Verde de Indocianina , Neoplasias Renais/diagnóstico por imagem , Neoplasias Renais/cirurgia , Margens de Excisão , Nefrectomia/métodos , Imagem Óptica/métodos , Procedimentos Cirúrgicos Robóticos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Período Intraoperatório , Masculino , Pessoa de Meia-Idade , Espectroscopia de Luz Próxima ao Infravermelho , Adulto JovemRESUMO
PURPOSE: The typical mean length of stay following robot-assisted laparoscopic prostatectomy is 24 to 48 hours. We began routinely offering same day discharge from the hospital after robot-assisted laparoscopic prostatectomy. We evaluated the success rate, safety and cost implications in what is to our knowledge the only large series of same day discharge to date. MATERIALS AND METHODS: Beginning in September 2016 all patients were given the option of same day discharge without it being mandated. After allowing 3 months to solidify the protocol we evaluated our prospective database for the next 500 patients. RESULTS: Of the 500 consecutive men who underwent robot-assisted laparoscopic prostatectomy performed by 1 surgeon in 18 months 246 (49.2%) were discharged home the day of surgery and all of the remaining 254 were discharged the next day for a mean 0.51-day length of stay. Mean patient age was 62 years (range 42 to 81) and mean body mass index was 29.7 kg/m2 (range 20 to 53). Of the patients 34 (6.8%) had a Clavien-Dindo grade I-III complication within 90 days but there were no grade IV-V complications. Only 5 patients (1%) required an emergency department visit and only 8 (1.6%) required readmission. Only 1 of the patients who elected same day discharge was rehospitalized and only 1 presented to the emergency department. The estimated charge for an overnight stay at our institution is $2,109. The approximate reduction in charges was $518,814 during 18 months ($345,876 per year) with no increased cost due to emergency department visits or hospital readmissions compared with that of overnight patients. In the most recent 100 patients the rate of same day discharge improved to 65%. CONCLUSIONS: Same day discharge following robot-assisted laparoscopic prostatectomy can be safely routinely offered with no increase in readmissions or emergency visits. It may lead to significant savings in health care costs.
Assuntos
Procedimentos Cirúrgicos Ambulatórios/métodos , Alta do Paciente/estatística & dados numéricos , Prostatectomia/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Ambulatórios/economia , Serviço Hospitalar de Emergência/economia , Utilização de Instalações e Serviços/economia , Utilização de Instalações e Serviços/estatística & dados numéricos , Estudos de Viabilidade , Custos Hospitalares/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Ohio , Avaliação de Resultados em Cuidados de Saúde , Alta do Paciente/economia , Readmissão do Paciente/economia , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/epidemiologia , Prostatectomia/economia , Procedimentos Cirúrgicos Robóticos/economiaRESUMO
OBJECTIVES: To evaluate the feasibility of performing robot-assisted laparoscopic prostatectomy (RALP) at an ultra-low pressure of 6 mmHg and to assess the potential impact on its clinical outcomes, as compared to those of a historical cohort of patients in which RALP was performed at a pressure of 15 mmHg. PATIENTS AND METHODS: We evaluated 600 consecutive RALP procedures, performed by a single surgeon, including 300 procedures performed at 6 mmHg and the previous 300 performed at 15 mmHg. We compared preoperative patient characteristics and outcomes including pain scores, morphine equivalents, length of stay (LOS) and complications. After implementing the adjustment to 6 mmHg, we began allowing same-day discharge in patients meeting established criteria. RESULTS: All 300 consecutive RALP procedures were completed at 6 mmHg with no pressure adjustments for the entirety of the case. There were no significant differences in patient or pathological features between groups. Body mass index was 19.5-44.3 kg/m2 in the 6 mmHg group. The mean operating time was 10.5-min longer and mean estimated blood loss 20-mL higher at 6 mmHg, with no blood transfusions in either group. The mean LOS was shorter in the 6-mmHg group (0.57 vs 1.00 days; P < 0.001), with 43.3% of patients in the 6-mmHg group discharged home the day of surgery. There were no differences in morphine equivalents or maximum pain scores in the first 4 h after surgery, but there was a small improvement (18%) in pain scores at 5-12 h postoperatively (3.2 vs 3.9; P < 0.001). The 30-day complication rate was 8.7% vs 4.0%, with 30-day hospital readmissions of 5.7% vs 1.0% for the 15 vs 6 mmHg groups. CONCLUSION: Robot-assisted laparoscopic prostatectomy at a pneumoperitoneum pressure of 6 mmHg was uniformly feasible without increasing complications. Ultra-low pneumoperitoneum may confer a pain benefit, which may contribute to safe same-day discharge.
Assuntos
Laparoscopia/métodos , Pneumoperitônio Artificial/métodos , Prostatectomia/métodos , Neoplasias da Próstata/cirurgia , Procedimentos Cirúrgicos Robóticos/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Viabilidade , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Resultado do TratamentoRESUMO
PURPOSE: Vitamin D deficiency is often detected during metabolic evaluation in the nephrolithiasis population. Multiple vitamin D repletion protocols exist, although their differing impact on urinary stone formation risk factors is unclear. MATERIALS AND METHODS: Patients with a history of calcium stones and vitamin D deficiency (less than 30 ng/ml) were randomized to receive either 1,000 IU daily or 50,000 IU weekly of vitamin D supplementation for 6 weeks. Patients completed a pretreatment and posttreatment serum vitamin D level evaluation and 24-hour urine collections to assess the response and any changes in urine stone formation risk parameters. RESULTS: A total of 21 patients completed the study, including 8 who received 1,000 IU daily and 13 who received 50,000 IU weekly. The 50,000 IU weekly group showed a significant increase in median serum vitamin D levels of 23 ng/ml (135%, p <0.01), while the 1,000 IU daily group showed a nonsignificant median increase of 9 ng/ml (49%, p = 0.12). Post-repletion 24-hour urine analysis demonstrated no significant change in urine calcium between the groups, including a median change of -11 mg (IQR -143-29) in patients receiving 1,000 IU and -16 mg (IQR -42-66) in those receiving 50,000 IU. Between the groups there was no significant difference in the supersaturation of calcium oxalate or calcium phosphate. CONCLUSIONS: High dose and low dose vitamin D repletion had no effect on urine calcium excretion or the supersaturation of calcium salts in known stone formers. The higher dosing regimen, which had superior repletion, may be the optimal protocol in patients with vitamin D deficiency.
Assuntos
Cálculos Renais/complicações , Deficiência de Vitamina D/complicações , Deficiência de Vitamina D/tratamento farmacológico , Vitamina D/uso terapêutico , Vitaminas/uso terapêutico , Adulto , Feminino , Humanos , Cálculos Renais/urina , Masculino , Pessoa de Meia-Idade , Deficiência de Vitamina D/urinaRESUMO
This study examined the possibility that pudendal nerve stimulation (PNS) or tibial nerve stimulation (TNS) inhibits the excitatory pathway from the pontine micturition center (PMC) to the urinary bladder. In decerebrate cats under α-chloralose anesthesia, electrical stimulation of the PMC (40 Hz frequency, 0.2-ms pulse width, 10-25 s duration) using a microelectrode induced bladder contractions >20 cmH2O amplitude when the bladder was filled to 60-70% capacity. PNS or TNS (5 Hz, 0.2 ms) at two and four times the threshold (2T and 4T) to induce anal or toe twitch was applied to inhibit the PMC stimulation-induced bladder contractions. Propranolol, a nonselective ß-adrenergic receptor antagonist, was administered intravenously (1 mg/kg i.v.) to determine the role of sympathetic pathways in PNS/TNS inhibition. PNS at both 2T and 4T significantly (P < 0.05) reduced the amplitude and area under the curve of the bladder contractions induced by PMC stimulation, while TNS at 4T facilitated the bladder contractions. Propranolol completely eliminated PNS inhibition and TNS facilitation. This study indicates that PNS, but not TNS, inhibits PMC stimulation-induced bladder contractions via a ß-adrenergic mechanism that may occur in the detrusor muscle as a result of reflex activity in lumbar sympathetic nerves. Neither PNS nor TNS activated a central inhibitory pathway with synaptic connections to the sacral parasympathetic neurons that innervate the bladder. Understanding the site of action involved in bladder neuromodulation is important for developing new therapies for bladder disorders.
Assuntos
Ponte/fisiologia , Nervo Pudendo/fisiologia , Nervo Tibial/fisiologia , Bexiga Urinária/fisiologia , Micção/fisiologia , Antagonistas Adrenérgicos beta/farmacologia , Animais , Gatos , Estado de Descerebração/fisiopatologia , Estimulação Elétrica , Feminino , Masculino , Microeletrodos , Contração Muscular/efeitos dos fármacos , Contração Muscular/fisiologia , Músculo Liso/efeitos dos fármacos , Músculo Liso/fisiologia , Sistema Nervoso Parassimpático/fisiologia , Propranolol/farmacologia , Raízes Nervosas Espinhais/fisiologiaRESUMO
INTRODUCTION: Horseshoe kidney is the most common congenital renal fusion anomaly, with an estimated incidence of 1.7 to 2.5 cases per 1000 live births. In these patients, nephron-sparing surgical management of renal tumors may be complicated by abnormal renal location, aberrant vasculature, and the presence of a renal isthmus. We present the largest known series of patients with renal malignancy in horseshoe kidneys managed by partial or hemi-nephrectomy with associated outcomes. MATERIALS AND METHODS: A retrospective review of our institution's electronic medical record was conducted to identify consecutive cases over an 11 year period. Pediatric patients and those who underwent surgery for benign indications were excluded from analysis. RESULTS: Eight patients with horseshoe kidney who underwent partial or hemi-nephrectomy for renal malignancy were identified. Median tumor size was 6.0 cm (IQR 3.7 cm-9.5 cm). Six patients had clear cell renal cell carcinoma (RCC), 1 patient had papillary RCC, and 1 patient had a renal carcinoid tumor with concurrent adenocarcinoma. Median length of stay was 4 days (IQR 2-.5.5 days). Median perioperative change in eGFR was -6 mL/min/1.73² (IQR -2.6-8.6 mL/min/1.73m²). One patient developed postoperative urine leak requiring percutaneous drainage and ureteral stent placement. Median follow up was 38.5 months, with a cancer-specific survival of 87.5% and an overall survival of 62.5%. CONCLUSION: Partial and hemi-nephrectomy for renal malignancy can safely be performed in patients with horseshoe kidney with acceptable operative and oncologic outcomes.
Assuntos
Rim Fundido/cirurgia , Neoplasias Renais/cirurgia , Nefrectomia , Rim Fundido/complicações , Humanos , Neoplasias Renais/complicações , Neoplasias Renais/patologia , Estudos RetrospectivosRESUMO
This study examined the role of the brain stem in inhibition of bladder reflexes induced by tibial nerve stimulation (TNS) in α-chloralose-anesthetized decerebrate cats. Repeated cystometrograms (CMGs) were performed by infusing saline or 0.25% acetic acid (AA) to elicit normal or overactive bladder reflexes, respectively. TNS (5 or 30 Hz) at three times the threshold (3T) intensity for inducing toe movement was applied for 30 min between CMGs to induce post-TNS inhibition or applied during the CMGs to induce acute TNS inhibition. Inhibition was evident as an increase in bladder capacity without a change in amplitude of bladder contractions. TNS applied for 30 min between saline CMGs elicited prolonged (>2 h) poststimulation inhibition that significantly (P < 0.05) increased bladder capacity to 30-60% above control; however, TNS did not produce this effect during AA irritation. TNS applied during CMGs at 5 Hz but not 30 Hz significantly (P < 0.01) increased bladder capacity to 127.3 ± 6.1% of saline control or 187.6 ± 5.0% of AA control. During AA irritation, naloxone (an opioid receptor antagonist) administered intravenously (1 mg/kg) or directly to the surface of the rostral brain stem (300-900 µg) eliminated acute TNS inhibition and significantly (P < 0.05) reduced bladder capacity to 62.8 ± 22.6% (intravenously) or 47.6 ± 25.5% (brain stem application). Results of this and previous studies indicate 1) forebrain circuitry rostral to the pons is not essential for TNS inhibition; and 2) opioid receptors in the brain stem have a critical role in TNS inhibition of overactive bladder reflexes but are not involved in inhibition of normal bladder reflexes.
Assuntos
Tronco Encefálico/fisiologia , Reflexo/fisiologia , Nervo Tibial/fisiologia , Micção/fisiologia , Ácido Acético , Animais , Gatos , Estado de Descerebração/fisiopatologia , Estimulação Elétrica , Feminino , Masculino , Naloxona/farmacologia , Antagonistas de Entorpecentes/farmacologia , Nervo Pudendo/efeitos dos fármacos , Bexiga Urinária/inervação , Bexiga Urinária/fisiopatologia , Bexiga Urinária Hiperativa/induzido quimicamente , Bexiga Urinária Hiperativa/fisiopatologiaRESUMO
In α-chloralose anesthetized cats, we examined the role of opioid receptor (OR) subtypes (µ, κ, and δ) in tibial nerve stimulation (TNS)-induced inhibition of bladder overactivity elicited by intravesical infusion of 0.25% acetic acid (AA). The sensitivity of TNS inhibition to cumulative i.v. doses of selective OR antagonists (cyprodime for µ, nor-binaltorphimine for κ, or naltrindole for δ ORs) was tested. Naloxone (1 mg/kg, i.v., an antagonist for µ, κ, and δ ORs) was administered at the end of each experiment. AA caused bladder overactivity and significantly (P < 0.01) reduced bladder capacity to 21.1% ± 2.6% of the saline control. TNS at 2 or 4 times threshold (T) intensity for inducing toe movement significantly (P < 0.01) restored bladder capacity to 52.9% ± 3.6% or 57.4% ± 4.6% of control, respectively. Cyprodime (0.3-1.0 mg/kg) completely removed TNS inhibition without changing AA control capacity. Nor-binaltorphimine (3-10 mg/kg) also completely reversed TNS inhibition and significantly (P < 0.05) increased AA control capacity. Naltrindole (1-10 mg/kg) reduced (P < 0.05) TNS inhibition but significantly (P < 0.05) increased AA control capacity. Naloxone (1 mg/kg) had no effect in cyprodime pretreated cats, but it reversed the nor-binaltorphimine-induced increase in bladder capacity and eliminated the TNS inhibition remaining in naltrindole pretreated cats. These results indicate a major role of µ and κ ORs in TNS inhibition, whereas δ ORs play a minor role. Meanwhile, κ and δ ORs also have an excitatory role in irritation-induced bladder overactivity.
Assuntos
Receptores Opioides delta/metabolismo , Receptores Opioides kappa/metabolismo , Receptores Opioides mu/metabolismo , Nervo Tibial , Estimulação Elétrica Nervosa Transcutânea , Bexiga Urinária Hiperativa/terapia , Ácido Acético , Animais , Gatos , Feminino , Masculino , Morfinanos/farmacologia , Morfinanos/uso terapêutico , Naloxona/farmacologia , Naltrexona/análogos & derivados , Naltrexona/farmacologia , Naltrexona/uso terapêutico , Receptores Opioides delta/antagonistas & inibidores , Receptores Opioides kappa/antagonistas & inibidores , Receptores Opioides mu/antagonistas & inibidores , Bexiga Urinária Hiperativa/induzido quimicamente , Bexiga Urinária Hiperativa/metabolismo , Bexiga Urinária Hiperativa/fisiopatologiaRESUMO
Prolonged exposure to immunosuppressive medication is a known risk factor for the development of post-transplant malignancies. De novo angiosarcoma in the post-transplant population is extremely rare. We present an 81-year-old female who developed an angiosarcoma at the site of a functioning renal allograft and review contemporary treatment strategies for this devastating disease. The report underscores the importance of periodic surveillance for the development of malignancy in the immunosuppressed population.
Assuntos
Hemangiossarcoma , Neoplasias Renais , Transplante de Rim , Complicações Pós-Operatórias , Idoso de 80 Anos ou mais , Evolução Fatal , Feminino , Hemangiossarcoma/diagnóstico , Humanos , Falência Renal Crônica/cirurgia , Neoplasias Renais/diagnóstico , Complicações Pós-Operatórias/diagnósticoRESUMO
Serious complications of shock wave lithotripsy (SWL) are rare, but can have significant long term effects. We present a case of acute renal vein thrombus following SWL leading to subsequent renal atrophy and loss of renal function. To our knowledge this is a newly reported complication of SWL.
Assuntos
Cálculos Renais/terapia , Rim/patologia , Litotripsia/efeitos adversos , Veias Renais , Trombose Venosa/etiologia , Doença Aguda , Atrofia/diagnóstico por imagem , Atrofia/etiologia , Feminino , Humanos , Pessoa de Meia-Idade , RadiografiaRESUMO
Ureteroarterial fistula (UAF) is a rare but potentially fatal cause of hematuria seen in patients with prolonged ureteral stenting in the setting of surgery or abdominal radiation. It presents as episodic, transfusion-dependent hematuria with formation of clots. There is no current consensus for the optimal way to diagnose or treat UAF. We report two cases of UAF that required repeated studies and provocative testing to confirm the diagnosis. Both were successfully managed by endovascular stenting. Clinicians must recognize the diagnostic difficulties involved and maintain a high index of suspicion for UAF in stented patients with intermittent, severe hematuria.
Assuntos
Hematúria/etiologia , Doença Arterial Periférica/complicações , Doenças Ureterais/complicações , Fístula Urinária/complicações , Adulto , Angiografia , Procedimentos Endovasculares , Feminino , Hematúria/diagnóstico , Humanos , Artéria Ilíaca/cirurgia , Stents , Resultado do TratamentoRESUMO
Androgen suppression therapy (AST) was first described in 1941 as a treatment of prostate cancer (PCa) and remains the mainstay of therapy in patients with hormone-naïve metastatic disease. It also is used in locally advanced or recurrent disease and in combination with radiation therapy in patients with higher-risk features. Several approaches to AST have been developed as a result of increased understanding of the pathways controlling testosterone production. Increased recognition of the side effects has resulted in strategies to minimize complications associated with AST. Attempts to reduce AST adverse effects include intermittent hormonal therapy and methods to reduce amount of intracellular androgens without reducing the circulating testosterone levels.
Assuntos
Antagonistas de Androgênios/uso terapêutico , Antineoplásicos Hormonais/uso terapêutico , Recidiva Local de Neoplasia/mortalidade , Antígeno Prostático Específico/sangue , Neoplasias da Próstata/tratamento farmacológico , Neoplasias da Próstata/mortalidade , Antagonistas de Androgênios/efeitos adversos , Antineoplásicos Hormonais/efeitos adversos , Intervalo Livre de Doença , Relação Dose-Resposta a Droga , Esquema de Medicação , Humanos , Masculino , Recidiva Local de Neoplasia/patologia , Estadiamento de Neoplasias , Prognóstico , Neoplasias da Próstata/patologia , Medição de Risco , Análise de Sobrevida , Testosterona/sangue , Resultado do TratamentoRESUMO
This mini review article summarizes the many clinical applications of near-infrared fluorescence with indocyanine green in urologic robotic-assisted surgery with a focus on robotic partial nephrectomy.
Assuntos
Carcinoma de Células Renais/cirurgia , Rim/cirurgia , Nefrectomia/instrumentação , Procedimentos Cirúrgicos Robóticos/métodos , Administração Intravenosa , Carcinoma de Células Renais/irrigação sanguínea , Carcinoma de Células Renais/patologia , Corantes , Fluorescência , Humanos , Verde de Indocianina/administração & dosagem , Cuidados Intraoperatórios , Isquemia , Rim/irrigação sanguínea , Rim/patologia , Nefrectomia/métodos , Avaliação de Resultados em Cuidados de Saúde , Artéria Renal/cirurgia , Instrumentos CirúrgicosRESUMO
Intraoperative cell salvage (IOCS) has been used in urologic surgery for over 20 years to manage intraoperative blood loss and effectively minimize the need for allogenic blood transfusion. Concerns about viability of transfused erythrocytes and potential dissemination of malignant cells have been addressed in the urologic literature. We present a comprehensive review of the use of IOCS in urologic oncologic surgery. IOCS has been shown to preserve the integrity of erythrocytes during processing and effectively provides cell filtration to mitigate the risk of tumor dissemination. Its use is associated with reduction in the overall need for allogenic blood transfusion, which clinically reduces the risk of hypersensitivity reactions and disease transmission, and may have important implications on overall oncologic outcomes. In the context of a variety of urologic malignancies, including prostate, urothelial, and renal cancer, the use of IOCS appears to be safe, without risk of tumor spread leading to metastatic disease or differences in cancer-specific and overall survival. IOCS has been shown to be an effective intraoperative blood management strategy that appears safe for use in urologic oncology surgery. The ability to reduce the need for additional allogenic blood transfusion may have significant impact on immune-mediated oncologic outcomes.
RESUMO
OBJECTIVE: To evaluate the effect of a novel at-home approach to electrical foot stimulation of peripheral tibial nerve branches on the frequency of nocturnal enuresis episodes in children. MATERIALS AND METHODS: Children aged 5 to 18 having 2 or more bedwetting episodes per week for at least 3 consecutive months were eligible. The study was a total of 6 weeks. Participants completed a baseline nighttime voiding diary during the first 2 weeks. This was followed by 2 weeks of foot stimulation for 60 minutes each night. During the stimulation period, and the following 2 weeks poststimulation, participants completed the nighttime voiding diary. RESULTS: Twenty-two patients with a mean age of 11.4 years (range 7-16) completed the study. Overall, there was a significant reduction in mean total wet nights from 9.0 ± 4.0 to 6.8 ± 4.8 during the stimulation period (P < .01) and a sustained significant reduction to 7.2 ± 5.0 wet nights during the poststimulation period (P = .02). Sixteen patients (72.7%) showed improvement of at least 1 less wet night during stimulation, demonstrating a significant improvement from a mean of 7.9 ± 3.7 to 4.8 ± 3.5 wet nights during the 2-week stimulation (P < .01) and maintained an improved mean of 5.1 ± 4.0 wet nights during the poststimulation period (P < .01). There were no adverse events experienced by any child. CONCLUSION: Transcutaneous foot stimulation is a well-tolerated, noninvasive, at-home treatment that may reduce the number of wet nights in children with nocturnal enuresis.
Assuntos
Serviços de Assistência Domiciliar , Enurese Noturna/terapia , Estimulação Elétrica Nervosa Transcutânea/métodos , Micção/fisiologia , Adolescente , Criança , Pré-Escolar , Feminino , Seguimentos , Pé/inervação , Humanos , Masculino , Enurese Noturna/fisiopatologia , Estudos Prospectivos , Nervo Tibial , Fatores de Tempo , Resultado do Tratamento , UrinaRESUMO
OBJECTIVE: To determine whether children discharged with prophylactic antibiotics following laparoscopic pyeloplasty with indwelling ureteral stent have a decrease risk of postoperative urinary tract infections (UTIs) compared to those discharged without antibiotics. MATERIALS AND METHODS: A retrospective review of all minimally invasive pyeloplasties performed at our institution from January 2009 to March 2015 was conducted. Patients were discharged home with or without daily prophylactic-dose antibiotics continued until 3 days after ureteral stent removal per surgeon preference. The primary outcome was incidence of culture-positive UTI. Secondary outcomes included bacteriuria at time of stent removal and adverse events associated with extended antibiotic therapy. RESULTS: Of 163 pyeloplasties (106 robotic and 57 pure laparoscopic) performed over the study period, 126 patients were discharged on prophylactic antibiotics whereas 37 patients were discharged without prophylaxis. Groups were different with respect to median age (7.1 vs 12.0 years, P = .03) and median duration of ureteral stent (35 days vs 28 days, P = .02). The incidence of culture-positive UTI between the time of discharge and stent removal was comparably low between groups; 2/126 (1.6%) in the prophylaxis group and 1/37 (2.7%) in the group not on prophylaxis. At time of stent removal, perioperative urine culture was positive in 2/20 (10.0 %) patients who received prophylactic antibiotics and in 1/25 (4.0%) patients who did not (P = .54). CONCLUSION: The administration of extended prophylactic antibiotics showed no significant impact on the rate of UTI following minimally invasive pyeloplasty.
Assuntos
Antibioticoprofilaxia , Pelve Renal/cirurgia , Laparoscopia , Complicações Pós-Operatórias/prevenção & controle , Stents , Infecções Urinárias/prevenção & controle , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Procedimentos Cirúrgicos Minimamente Invasivos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos , Ureter , Infecções Urinárias/epidemiologia , Infecções Urinárias/etiologia , Procedimentos Cirúrgicos Urológicos/métodosRESUMO
PURPOSE: Primary ureteroscopic intervention for kidney or ureteral stones occasionally encounters difficulty with passage of the ureteroscope in the initial procedure. These patients require a second procedure after stenting. We aim to define the contemporary failure rate of primary ureteroscopy (URS) and identify predictive factors that necessitate prestenting. This will assist in preoperative patient counseling, informed consent, and clinical decision-making. MATERIALS AND METHODS: We conducted a multi-institutional retrospective review of 535 unstented patients undergoing primary URS from August 2011 to August 2013. The primary outcome was gaining access to the unstented ureter. RESULTS: The failure rate for accessing the unstented ureter was 7.7% (41/535). The median age of females with primary ureteroscopic failure was significantly lower than in females who had successful ureteroscopic access (34 vs 52 years; p = 0.0041). There was no difference in the median age of males with access vs failure (58 vs 57 years; p = 0.3683). Proximal ureteral stones had the highest failure rate for ureteral access at 18.28% (p = 0.006). On multivariable logistic regression, proximal ureteral stone location remained a significant predictor of failure when compared to renal stones (odds ratio [OR] 3.14, p = 0.006). When including only ureteral stones in the multivariable analysis, stone location in the proximal ureter compared to the distal ureter remained the only significant predictor of access failure (OR 0.24, p = 0.015). CONCLUSIONS: A low overall rate of ureteral access failure in unstented patients is shown. Young female patients and proximal ureteral stones were less likely to be accessed primarily. This study provides information that will help urologists counsel their patients preoperatively regarding their likelihood of failing primary URS necessitating a second procedure. This will also help the patient to make an informed decision during the consent process and may guide urologists on selective prestenting in higher risk patients.
Assuntos
Cálculos Renais/cirurgia , Cálculos Ureterais/cirurgia , Ureteroscopia/métodos , Adulto , Fatores Etários , Idoso , Feminino , Humanos , Cálculos Renais/patologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores Sexuais , Stents , Falha de Tratamento , Resultado do Tratamento , Cálculos Ureterais/diagnóstico , Cálculos Ureterais/patologia , UreteroscópiosRESUMO
Asymptomatic bacteriuria (ASB) is a common finding and frequently detected in premenopausal nonpregnant women, institutionalized patients, patients with diabetes mellitus, and the ambulatory elderly population. Despite clear recommendations regarding diagnosis and management of ASB in these populations from the Infectious Diseases Society of America (IDSA), there remains an alarming rate of antimicrobial overuse. This article reviews definitions of ASB, epidemiology of ASB, literature surrounding ASB in diabetic patients, risk factors of ASB, microbiologic data regarding bacterial virulence, use of ASB strains for treatment of symptomatic urinary tract infection, and approaches to addressing translational barriers to implementing IDSA recommendations regarding diagnosis and management of ASB.