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PURPOSE: This study investigated late urinary adverse events (UAEs) in patients who underwent pelvic radiation therapy, with a focus on occurrence, diagnostic characteristics and the impact of subsequent extirpative surgery with the need of urinary diversion on quality of life. METHODS: A retrospective analysis of 20 patients after pelvic radiotherapy (2016-2022) was conducted. Data included demographics, perioperative details, oncological parameters, and patient-reported outcomes. Imaging (CT, MRI) was examined for early manifestations of late UAEs. RESULTS: In the study cohort, prostate cancer was the primary malignancy in 85% with a mean radiation dose of 84 Gray over 35 days. Time to diagnosis of late UAEs was 4.0 years post-radiation. Radiological assessment demonstrated a progressive increase in typical CT and MRI features of pubic bone osteomyelitis over time. Surgical interventions, mainly cystectomy, were required with variable outcomes in patient-reported post-surgery quality of life. CONCLUSION: Diagnosing and managing late UAEs after pelvic radiation necessitate an understanding of their occurrence, diagnostic features and appropriate management strategies. Early imaging, particularly MRI, is crucial for timely diagnosis and treatment planning. Variable post-surgery quality of life underscores the importance of a multidisciplinary approach in managing late UAEs. The study contributes to understanding these complications and emphasizes their consideration in post-radiation follow-up care.
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Osteomielite , Medidas de Resultados Relatados pelo Paciente , Osso Púbico , Fístula Urinária , Humanos , Masculino , Osso Púbico/diagnóstico por imagem , Estudos Retrospectivos , Idoso , Pessoa de Meia-Idade , Osteomielite/etiologia , Fístula Urinária/etiologia , Lesões por Radiação/etiologia , Neoplasias da Próstata/radioterapia , Idoso de 80 Anos ou mais , Radioterapia/efeitos adversos , Qualidade de VidaRESUMO
INTRODUCTION: Holmium laser enucleation of the prostate (HoLEP) is an established option in the surgical treatment of benign prostatic hyperplasia. Pulse modulation, such as MOSES® technology, has recently been introduced and may offer potential advantages in HoLEP. METHODS: Perioperative data from 117 patients who underwent MOSES® laser enucleation of the prostate (MoLEP) were collected. Propensity score matching using prostate volume, age, body mass index (BMI), and anticoagulant intake was performed using a database of 237 patients treated with HoLEP. In total, 234 patients were included in the analysis. RESULTS: Prostate volume (104 vs. 102 ml), age (70 vs. 71 years), BMI (27 vs. 27), and anticoagulant intake (34 vs. 35%) did not differ significantly between the groups. There were no significant differences in operation time (61.5 vs. 58.1 min, p = 0.42), enucleation efficiency (2.5 vs. 2.6 g/min, p = 0.74), hemostasis time (7.8 vs. 8 min, p = 0.75) and hemoglobin drop (0.9 vs. 0.7 mg/dl, p = 0.48). The complication rates were low in both groups (16.2% for HoLEP and 17.1% for MoLEP). No differences were noted in the Clavien-Dindo Classification (p = 0.63) and the Comprehensive Complication Index (p = 0.24). The rate of complications > CDC IIIa was 0.9% for HoLEP (endoscopic coagulation) and 1.7% for MoLEP (2 cases of endoscopic coagulation). No transfusions were administered. CONCLUSION: Overall, the enucleation efficiency was high in both groups and the procedure time was short. HoLEP is an efficient and safe treatment option in experienced hands, regardless of the use of pulse modulation technology.
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Terapia a Laser , Lasers de Estado Sólido , Hiperplasia Prostática , Ressecção Transuretral da Próstata , Masculino , Humanos , Hólmio , Pontuação de Propensão , Resultado do Tratamento , Lasers de Estado Sólido/uso terapêutico , Qualidade de Vida , Hiperplasia Prostática/complicações , Ressecção Transuretral da Próstata/métodos , Terapia a Laser/métodos , AnticoagulantesRESUMO
PURPOSE OF REVIEW: Percutaneous nephrolithotripsy (PCNL) is the first-line management option for large kidney stones (>2âcm). It remains, however, a demanding procedure with considerable morbidity. The present narrative review summarizes recent knowledge from original research studies investigating navigation systems/three-dimensional (3D) imaging in PCNL, particularly on publications during the past 12-18âmonths. RECENT FINDINGS: Navigation systems and 3D imaging are primarily used for preoperative planning, with few intra-operative applications. Patient management and residents' training could benefit from their use. SUMMARY: Navigation systems and 3D imaging technology have emerged as a potential game-changer in PCNL. Even though available evidence is currently scarce/inconclusive, the safety/efficacy of navigation systems and 3D dimensional imaging use in PCNL appears promising. This advanced technology offers precise anatomical mapping, improved visualization, and surgical accuracy. Enabling a comprehensive preoperative evaluation and improving guidance, navigation systems, and 3D imaging technology may improve the safety and efficacy of PCNL. With continuous technological evolution, it is expected that improvements/innovations will offer further aid in such demanding procedures. Familiarization and cost reduction are necessary for widespread application, while larger-scale prospective studies and well designed randomized controlled trials are still needed.
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Cálculos Renais , Litotripsia , Humanos , Cálculos Renais/cirurgia , Imageamento Tridimensional/métodos , Estudos Prospectivos , Litotripsia/métodos , Cuidados Pré-OperatóriosRESUMO
INTRODUCTION AND OBJECTIVES: Challenging percutaneous renal punctures to gain access to the kidney requiring guidance by cross-sectional imaging. To test the feasibility of robotic-assisted CT-guided punctures (RP) and compare them with manual laser-guided punctures (MP) with Uro Dyna-CT (Siemens Healthcare Solutions, Erlangen, Germany). MATERIAL AND METHODS: The silicon kidney phantom contained target lesions of three sizes. RP were performed using a robotic assistance system (guidoo, BEC GmbH, Pfullingen, Germany) with a robotic arm (LBR med R800, KUKA AG, Augsburg, Germany) and a navigation software with a cone-beam-CT Artis zeego (Siemens Healthcare GmbH, Erlangen, Germany). MP were performed using the syngo iGuide Uro-Dyna Artis Zee Ceiling CT (Siemens Healthcare Solutions). Three urologists with varying experience performed 20 punctures each. Success rate, puncture accuracy, puncture planning time (PPT), and needle placement time (NPT) were measured and compared with ANOVA and Chi-Square Test. RESULTS: One hundred eighteen punctures with a success rate of 100% for RP and 78% for MP were included. Puncture accuracy was significantly higher for RP. PPT (RP: 238 ± 90s, MP: 104 ± 21s) and NPT (RP: 128 ± 40s, MP: 81 ± 18s) were significantly longer for RP. The outcome variables did not differ significantly with regard to levels of investigators' experience. CONCLUSION: The accuracy of RP was superior to that of MP. This study paves the way for first in-human application of this robotic puncture system.
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Procedimentos Cirúrgicos Robóticos , Humanos , Rim/diagnóstico por imagem , Rim/cirurgia , Punções/métodos , Tomografia Computadorizada de Feixe Cônico/métodos , Imagens de FantasmasRESUMO
BACKGROUND: The electrohydraulic high-frequency shock wave (Storz Medical, Taegerwilen, Switzerland) is a new way to create small fragments with frequencies up to 100 Hertz (Hz). This study evaluated the efficacy and safety of this method in a stone and porcine model. MATERIALS AND METHODS: BEGO stones were put in a condom in a specifically designed fixture treated with different modulations to see stone comminution. Standardized ex vivo porcine model with perfused kidneys with 26 upper and lower poles of 15 kidneys was treated with the following modulations: voltage 16-24 kV, capacitor 12 nF and frequency up to 100 Hz. 2000-20,000 shock waves were applied to each pole. The kidneys were perfused with barium sulfate solution (BaSO4) and x-ray was performed to quantify the lesions using pixel volumetry. RESULTS: There was no correlation between the number of shock waves and the powdering degree or the applied Energy and the grade of pulverization in the stone model. Regarding the perfused kidney model, the number of shock waves, applied voltage and frequency had no direct correlation with the occurrence of parenchymal lesions The detected lesions of the renal parenchyma were minimal, technical parameters had no significant impact and the lesions did not differ from the results of former experiments using 1-1.5 Hz in the same model. CONCLUSIONS: High-frequency shock wave lithotripsy can produce small stone fragments to pass in a very short time. The injury to the renal parenchyma is comparable to the results of the conventional SWL using 1-1.5 Hz.
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Cálculos Renais , Litotripsia , Suínos , Animais , Cálculos Renais/patologia , Rim/diagnóstico por imagem , Rim/patologia , Litotripsia/métodos , Radiografia , SuíçaRESUMO
INTRODUCTION: Perioperative antibiotic prophylaxis (AP) is common in radical prostatectomy (RP). Yet there is no standard recommendation in international guidelines due to poor evidence. It is of great importance that these perioperative AP are sufficiently checked and systemically validated. The objective of this study was to determine whether a "single-shot" (single-use) perioperative AP yields equivalent results compared to a multiday prophylaxis in RP regarding postoperative wound infections and urinary tract infections. METHODS: 376 patients treated by RP at the University Medical Centre Mannheim, from 2014 to 2016, were included in this retrospective study. RP was performed either in a robotic-assisted or open manner. One group received an intravenous dose of perioperative AP with either ciprofloxacin or levofloxacin, continued by an oral dose of AP with ciprofloxacin or levofloxacin until catheter removal, while the other group received a single-shot intravenous perioperative AP with either ciprofloxacin or cefuroxime. RESULTS: There was no significant difference regarding the occurrence of postoperative infections between both AP regimes (p = 0.5). Age, body mass index, and ASA classification did not differ significantly between both groups (p > 0.25). Except for surgery time (p < 0.05), perioperative parameters, such as the preoperative presence of germ-free urine culture, length of hospital stay, catheter time, drain lay time, Gleason score, and TNM stadium, did not differ significantly. CONCLUSION: The present study shows that perioperative single-shot AP does not entail any disadvantage compared to the multiday AP in terms of postoperative infections after RP.
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Antibacterianos , Antibioticoprofilaxia , Masculino , Humanos , Antibioticoprofilaxia/métodos , Antibacterianos/uso terapêutico , Levofloxacino/uso terapêutico , Estudos Retrospectivos , Ciprofloxacina , Prostatectomia/efeitos adversos , Prostatectomia/métodosRESUMO
INTRODUCTION: The aim of this study was to investigate and compare clinical safety and efficiency of Thulium laser enucleation of the prostate (ThuLEP) and robot-assisted simple prostatectomy (RASP) for the treatment of large gland benign prostatic hyperplasia in a tertiary care center. METHODS: Perioperative data of 39 patients who underwent RASP in our institution from 2015 to 2021 was collected. Propensity score matching using prostate volume, patient age, and body mass index (BMI) was performed from a database of 1,100 Patients treated by ThuLEP from 2009 to 2021. A total of 76 patients were matched. Preoperative parameters such as BMI, age, and prostate volume, as well as intra- and postoperative parameters such as operation time, resection weight, transfusion rate, postoperative catheterization time, length of hospital stay (LoS), hemoglobin drop, postoperative urinary retention (PUR), Clavien-Dindo Classification (CDC), and the Combined Complication Index (CCI), were evaluated. RESULTS: There was no difference in mean hemoglobin drop (2.2 vs. 1.9 g/dL, p = 0.34), yet endoscopic surgery showed superiority in mean operation time (109 vs. 154 min, p < 0.001), mean postoperative catheterization time (3.3 vs. 7.2 days, p < 0.001), and mean LOS (5.4 vs. 8.4 days, p < 0.001). Complication rates evaluated by CDC (p = 0.11) and CCI (p = 0.89) were similar in both groups. Within the documented complications, transfusion rate (0 vs. 3, p = 0.08) and the occurrence of PUR (1 vs. 2, p = 0.5) showed no significant difference. CONCLUSION: ThuLEP and RASP show similar perioperative efficacy and a low rate of complications. ThuLEP had shorter operation times, shorter catheterization time, and a shorter LoS.
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Terapia a Laser , Lasers de Estado Sólido , Hiperplasia Prostática , Robótica , Masculino , Humanos , Próstata/cirurgia , Túlio , Prostatectomia , Pontuação de Propensão , Terapia a Laser/efeitos adversos , Resultado do Tratamento , Lasers de Estado Sólido/uso terapêutico , Hiperplasia Prostática/cirurgia , Complicações Pós-Operatórias/epidemiologia , HemoglobinasRESUMO
PURPOSE: Low-dose computer tomography (NCCT) is the standard imaging modality for patients with acute flank pain with a suspicion of urolithiasis. The stone size is usually measured 2D by a radiologist. We compared 3D stone measurement using different windows to the 2D measurement and evaluated the clinical impact on ureterorenoscopic stone removal (URS). METHODS: One hundred sixty-four patients (201 stones) with a preoperative NCCT, following a URS within 4 weeks, were included in this study. Stone location, number and size of stones, operating time, and laser lithotripsy were documented. Stones were measured in 3D using bone and soft tissue window. The maximum diameter was compared to the radiological report. The U test, Kruskal-Wallis, and regression were used for statistical analyses. RESULTS: Almost two-thirds (64.68%; 130 stones) of stone measurements in 3D with the bone window were lower than the radiologist reports in 2D. One-third (34.83%; 70 stones) of stone measurements were higher and 0.5% (1 stone) reported the same size. Using the 3D soft tissue window, 81.09% (163 stones), 17.91% (37 stones), and 1% (2 stones) of stones were measured bigger, smaller, or had the same measurement results, respectively. In the clinical setting, we could calculate a cutoff for laser lithotripsy at a maximum stone diameter of 5.70 mm (p < 0.01) with the 3D and 6.01 mm with the 2D measurements, respectively, and found a significant correlation between maximum stone diameter and operating time (p < 0.01) and number of stones and operating time (p < 0.01 with and p = 0.02 without laser). CONCLUSION: 3D stone measurement with bone window seems to be more accurate than 2D measurement, but 2D is sufficient for planning stone treatment.
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Cálculos Renais/diagnóstico por imagem , Cálculos Renais/cirurgia , Tomografia Computadorizada por Raios X/métodos , Cálculos Ureterais/diagnóstico por imagem , Cálculos Ureterais/cirurgia , Ureteroscopia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto JovemRESUMO
PURPOSE: To compare iPad-assisted (Apple Inc., Cupertino, USA) percutaneous access to the kidney to the standard puncturing technique for percutaneous nephrolithotomy (PCNL). METHODS: For the iPad-assisted PCNL, a computed tomography is performed prior to surgery, using fiducial radiopaque markers. The important anatomical structures (i.e. kidney, stones) are segmented using specific software enabling the superimposition of images semi-transparently on the iPad by marker-based navigation. Twenty-two patients underwent an iPad-assisted percutaneous puncture of the kidney for PCNL. Twenty-two patients of the clinical database from the Urological Department SLK Hospital Heilbronn, who underwent the standard puncturing technique, were matched to these patients. Matching criteria were age, gender, stone volume, body mass index, stone site and the absence of anatomical variation. Puncture time, radiation exposure and number of attempts for a successful puncture were evaluated. All procedures were performed by two experienced urologists. The standard puncturing method consisted of a combination of ultrasound and fluoroscopy guidance. Chi-square and t test were used to ensure that there was no difference in the matching criteria between the groups. To compare the two methods, U test, Kruskal-Wallis and Chi-square test were used. RESULTS: Examination of radiation exposure showed a significant difference between the two groups in favour of the standard puncturing method (p < 0.01) and puncture time (p = 0.01). However, there was no significant difference in puncturing attempts (p = 0.45). CONCLUSION: The iPad-assisted navigation, with the objective being to puncture the renal collecting system, represents a new technique (IDEAL criteria 2b), which proved to be applicable in clinical practice, but still has potential for technical improvement.
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Computadores de Mão , Cálculos Renais/cirurgia , Nefrolitotomia Percutânea/métodos , Cirurgia Assistida por Computador/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Análise por Pareamento , Pessoa de Meia-Idade , Ultrassonografia , Adulto JovemRESUMO
PURPOSE OF REVIEW: The aim of the article is to evaluate the actual role of extracorporeal shock-wave lithotripsy (ESWL) in the management of urolithiasis based on the new developments of flexible ureterorenoscopy (FURS) and percutaneous nephrolithotomy (PCNL). RECENT FINDINGS: In Western Europe, there is a significant change of techniques used for treatment of renal stones with an increase of FURS and a decrease of ESWL. The reasons for this include the change of indications, technical improvement of the endourologic armamentarium, including robotic assistance. Mostly relevant is the introduction of digital reusable and single-use flexible ureterorenoscopes, whereas micro-PCNL has been abandoned. Some companies have stopped production of lithotripters and novel ideas to improve the efficacy of shock waves have not been implemented in the actual systems. Promising shock-wave technologies include the use of burst-shock-wave lithotripsy (SWL) or high-frequent ESWL. The main advantage would be the very fast pulverization of the stone as shown in in-vitro models. SUMMARY: The role of ESWL in the management of urolithiasis is decreasing, whereas FURS is constantly progressing. Quality and safety of intracorporeal shock-wave lithotripsy using holmium:YAG-laser under endoscopic control clearly outweighs the advantages of noninvasive ESWL. To regain ground, new technologies like burst-SWL or high-frequent ESWL have to be implemented in new systems.
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Endoscopia , Cálculos Renais/cirurgia , Litotripsia , Procedimentos Cirúrgicos Robóticos , Endoscopia/métodos , Endoscopia/tendências , Humanos , Terapia a Laser , Lasers de Estado Sólido/uso terapêutico , Litotripsia/métodos , Litotripsia/tendências , Nefrolitotomia Percutânea/métodos , Nefrolitotomia Percutânea/tendências , Procedimentos Cirúrgicos Robóticos/métodos , Procedimentos Cirúrgicos Robóticos/tendências , Resultado do Tratamento , Ureteroscopia/instrumentação , Ureteroscopia/métodos , Ureteroscopia/tendências , Urolitíase/cirurgiaRESUMO
INTRODUCTION: Urinary tract infections (UTI) represent the most frequent complications after transrectal focal ablation of prostate cancer. Single-shot antibiotic prophylaxis for prevention has not yet been described. METHODS: In this cohort study of patients who received a high-intensity focused ultrasound (HIFU) ablation of prostate cancer within a registered prospective single-arm trial, we analyzed posttreatment UTI (≤30 days after HIFU) related to perioperative antibiotic management in an exploratory analysis: single-shot prophylaxis or targeted treatment for bacteriuria. Potential risk factors associated with UTI were evaluated by uni- and multivariate regression analyses. RESULTS: In total, 55 patients were eligible for analysis. Of these, 76.4% received antibiotic single-shot prophylaxis. UTI occurred in 10.7% of all patients, 5.4% developed fever, 3.6% required hospitalization. An antibiotic single-shot prophylaxis helped to protect 90.5% of men from infectious complications. Estimated effects indicate that a longer posttreatment catheterization (OR 3.38, 95% CI 0.47-27.08) and larger ablation volume (OR 4.85, 95% CI 0.61-107.49) might be associated with the highest risk for UTI after treatment. CONCLUSION: Single-shot antibiotic prophylaxis compared to a targeted antibiotic treatment showed a similar effectivity to prevent patients from infectious complications and should be considered as an element of antibiotic stewardship. Further research on risk factors and antibiotic strategies is required.
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Antibacterianos/administração & dosagem , Antibioticoprofilaxia/métodos , Complicações Pós-Operatórias/prevenção & controle , Neoplasias da Próstata/cirurgia , Ultrassom Focalizado Transretal de Alta Intensidade , Infecções Urinárias/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Estudos de Viabilidade , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , RetoRESUMO
BACKGROUND: Urinary bladder tamponade is a urological emergency that is part of the clinical routine of every urologist and requires immediate and adequate diagnosis and therapy. OBJECTIVES: Presentation of the clinical picture of urinary bladder tamponade including etiology, diagnostics, and therapy as well as formulation of recommendations for action for clinical routine. MATERIALS AND METHODS: Structured presentation of the diagnosis and therapy of urinary bladder tamponade with practical recommendations for action based on a current literature search and a clinical case study. RESULTS: Urinary bladder tamponade is a usually painful filling of the urinary bladder with blood clots as part of gross hematuria. The central pillars of diagnostics are anamnesis, targeted physical examination, and sonography. Therapy involves the rapid insertion of a flushing catheter with manual evacuation of the tamponade. A flushing catheter with at least 20 French should be used here. CONCLUSION: Timely diagnosis and prompt treatment are crucial. This usually includes transurethral catheter insertion with manual evacuation. If the tamponade is unsuccessfully removed, further measures such as endoscopic evacuation or, as a last resort, sectio alta or radical cystectomy are available.
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Cateterismo Urinário , Idoso de 80 Anos ou mais , Humanos , Masculino , Emergências , Hematúria/etiologia , Hematúria/terapia , Hematúria/diagnóstico , Doenças da Bexiga Urinária/terapia , Doenças da Bexiga Urinária/diagnóstico , Cateterismo Urinário/métodosRESUMO
Surgical approaches for benign prostatic hyperplasia have evolved and diversified over the past decades. While numerous studies document the efficacy of surgical procedures for moderate prostate sizes, there remains insufficient data for large prostate volumes >200 ml, leaving important questions unanswered regarding their effectiveness and safety. Consequently, selecting and adapting suitable therapeutic options for this specific patient group often poses a significant challenge. In this context, this review comprehensively summarizes and discusses current insights into surgical treatment options for large prostate volumes (>200 ml) following an extensive literature review.In summary, the surgical treatment of prostate volumes >200 ml is a challenge regardless of the chosen surgical method. Minimally invasive approaches should be considered standard practice today. Anatomical endoscopic enucleation of the prostate is a size-independent method and has the lowest morbidity. As it may be performed in spinal anaesthesia, endoscopic enucleation is feasible in patients with an increased anaesthetic risk. In extremely large prostate glands, the procedure poses challenges even for highly experienced surgeons. Especially in obese patients, the surgeon should be familiar with different exit strategies. Robot-assisted simple prostatectomy provides a minimally invasive alternative that may also treat pathologies such as diverticula or large bladder stones in the same surgical session. Due to its transabdominal approach, the morbidity and anaesthetic risk is comparatively higher. Each centre and surgeon should individually decide in which method they have the greatest expertise and which option is best suited for the specific case. In cases of limited expertise, it is advisable to refer patients to a centre with appropriate specialization.
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Endoscopia , Prostatectomia , Hiperplasia Prostática , Procedimentos Cirúrgicos Robóticos , Humanos , Masculino , Hiperplasia Prostática/cirurgia , Procedimentos Cirúrgicos Robóticos/métodos , Prostatectomia/métodos , Endoscopia/métodos , Próstata/cirurgia , Próstata/patologia , Procedimentos Cirúrgicos Minimamente Invasivos/métodosRESUMO
Introduction: Before holmium laser enucleation of the prostate (HoLEP), many patients have undergone short-term prostate biopsy (PB) to rule out the presence of prostate cancer. The aim of this study is to determine whether a short-term PB before HoLEP has an impact on the perioperative outcomes or complications of HoLEP. Methods: In total, 734 consecutive patients treated with HoLEP at a tertiary care university hospital between January 2021 and July 2023 were retrospectively enrolled. Patients who had PB within 6 months before HoLEP were matched to patients who underwent PB more than 6 months or had no PB before HoLEP using propensity score matching (PSM) based on age, prostate volume (PV), prostate-specific antigen (PSA), preoperative urinary tract infection (UTI), and surgeon. Perioperative parameters, such as operation time (OT), enucleation efficiency (EF), as well as complications according to the Satava classification, the Clavien-Dindo classification (CDC), and the Comprehensive Complication Index (CCI) were evaluated. Results: In total, 206 patients were matched. Age, PV, PSA, as well as the presence of a preoperative UTI and surgeons did not differ significantly between both groups after PSM. There were no significant differences in mean OT (75 vs. 81 minutes, p = 0.28) and EF (2.13 vs. 2.13 g/min, p = 0.99). No differences were noted regarding intraoperative (16 vs. 25, p = 0.16) or postoperative complications graded by CDC (p = 0.53) and CCI (p = 0.92). Conclusion: PB within 6 months preoperatively before HoLEP showed no effect on perioperative outcomes or intra- and postoperative complications.
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Lasers de Estado Sólido , Complicações Pós-Operatórias , Pontuação de Propensão , Próstata , Neoplasias da Próstata , Humanos , Masculino , Lasers de Estado Sólido/uso terapêutico , Idoso , Próstata/cirurgia , Próstata/patologia , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Neoplasias da Próstata/cirurgia , Neoplasias da Próstata/patologia , Biópsia/efeitos adversos , Resultado do Tratamento , Terapia a Laser/efeitos adversos , Terapia a Laser/métodosRESUMO
We report on postoperative management of wound healing in four cases of Fournier's gangrene successfully treated with low-intensity shockwave therapy (LI-ESWT). In three cases, LI-ESWT (3 sessions per week with 2000 shockwaves at 3 Hz applied at 0.25 mJ/mm2) was able to close wound dehiscence secondary to plastic surgery with skin flaps. In one patient, LI-ESWT resulted in complete closure of an extensive wound with restoration of the local scrotal and penile skin. This is the first report of successful application of LI-ESWT for this indication. Restoration of local skin rather than wound closure by fibrous tissue could be related to promotion of stem cells, which has been discussed previously for other indications, such as treatment of chronic ulcers and restoration of the pelvic floor.
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Context: Recently developed concepts for higher efficacy extracorporeal shockwave lithotripsy with low-pressure wide focus systems resulting in finer fragmentation of the calculi. Objective: To compare two different electromagnetic shockwave sources (low-pressure wide focus [Xinin Lithotripter, XL] vs high-pressure small focus [Siemens Lithoskop, SL]) by sound field measurements and in vitro fragmentation. Evidence Acquisition: The CS-2012A XX-ES lithotripter (self-focusing electromagnetic shockwave generator with concave spherical curved electrical coil; XL) was compared to the (SL) (electromagnetic generator with a flat electric coil with an acoustical lens). Different sound field measurements were performed using a fiber-optic hydrophone. Measurements at three different power settings (XL: 8.0, 9.3, and 10.3 kV and SL: Level 1, 5, and 8). Ten AST stones and 15 BegoStones (9.3 kV, Level 3) with a frequency of 90/minute (SL) and 20/minute (XL). Number of impulses to the first crack and for complete stone comminution (residual fragments <2 mm) was documented. Results: The median number of shockwaves for the first crack in AST stones with the XL was 12 (10-14) and 7 with the SL (6-9). Complete disintegration was accomplished after 815 (782-824) shockwaves with XL and 702 (688-712) with SL. The difference was not statistically significant. The median number of shockwaves to produce the first crack in BegoStones was 524 (504-542) with XL and only 151 (137-161) with SL. Numbers of shockwaves for complete disintegration did not differ significantly (XL: 2518 vs SL: 2287). Using a wide focus with low pressure shows more homogeneous disintegration. Conclusion: Two stone models showed significant differences regarding form and time of the initial fragmentation. Impulses for stone comminution did not differ significantly. The advantages of a low-pressure wide-focus system include minimal trauma and a homogeneous fragment size but is more time consuming. High-pressure small-focus systems are clinically effective.
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Cálculos Renais , Litotripsia , Fenômenos Eletromagnéticos , Tecnologia de Fibra Óptica , Humanos , Cálculos Renais/terapia , Litotripsia/métodos , Imagens de FantasmasRESUMO
Objective: To evaluate perioperative parameters, clinical outcomes, and the learning curve of holmium laser enucleation of the prostate (HoLEP) in surgeons with experience in thulium laser enucleation of the prostate (ThuLEP). Materials and Methods: The learning curves for HoLEP of the first 50 consecutive patients of two surgeons experienced in ThuLEP were analyzed. In addition, demographic parameters, clinical outcomes, and adverse events (AEs) were evaluated. Results: Mean operation time was 70.9 ± 29.7 minutes (standard deviation) (Surgeon 1) and 74.4 ± 35.4 minutes (Surgeon 2), the mean enucleation efficiency was 1.5 ± 0.6 g/min (Surgeon 1) and 1.5 ± 0.7 g/min (Surgeon 2). The hemoglobin loss was 0.9 ± 0.8 and 0.8 ± 0.8 g/dL. For both surgeons, there was a significant learning curve in enucleation efficiency within the first 50 cases (Surgeon 1: p = 0.034, Surgeon 2: p = 0.006, both: p = 0.0003, Spearman's ρ = 0.351). Both surgeons started with an enucleation efficiency of around 1 g/min in their first 10 cases. No significant correlation between hemoglobin loss and experience could be found (p = 0.823, ρ = 0.025). While there was no significant learning curve for morcellation efficiency (p = 0.785, ρ = 0.028), a significant progress was found for one of the two surgeons regarding laser energy efficiency (p = 0.014). The overall incidence of all grade treatment-related AEs was low at 10.0%, and extremely low for significant complications with Clavien-Dindo Grade >II at 1%. Conclusions: In our analysis, switching to HoLEP is uncomplicated and safe for experienced ThuLEP surgeons. The enucleation efficiency was high from the beginning, but a learning curve was present for both surgeons. No learning curve was noticeable in hemoglobin loss and the incidence of complications, both of which were low throughout the study.
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Terapia a Laser , Lasers de Estado Sólido , Hiperplasia Prostática , Cirurgiões , Masculino , Humanos , Túlio , Lasers de Estado Sólido/uso terapêutico , Próstata , Hiperplasia Prostática/cirurgia , Hólmio , Resultado do Tratamento , Estudos RetrospectivosRESUMO
PURPOSE: To analyze and share our experience with ultra-mini-PCNL using the urological Dyna-CT in small infants. METHODS: A retrospective analysis was performed on all infants younger than 3 years of age who underwent ultra-mini-PCNL at our institution since 2016. Operating time, fluoroscopy time, dose area product (DAP), stone-free status, intra- and postoperative complications and the duration of hospital stay were analyzed. RESULTS: A total of nine interventions conducted on eight children were evaluated. The mean age of infants was 22.8 ± 11.9 months. The mean operation time and the mean fluoroscopy time were 119.2 ± 51.8 min, and 190.4 ± 93.8 s, respectively. The mean DAP was 11.4 ± 6.9 µGym2 and the stone clearance at 3 months was 87.5%. No major postoperative complications were assessed, and no transfusion was given. The mean hospital stay was 4 (IQR 3-6) days. CONCLUSION: Ultra-mini-PCNL utilizing the urological Dyna-CT can safely and effectively be performed in small infants with kidney stones. In this setting, the urological Dyna-CT allows for a very low radiation exposure.
Assuntos
Cálculos Renais , Nefrostomia Percutânea , Criança , Pré-Escolar , Fluoroscopia , Humanos , Lactente , Cálculos Renais/diagnóstico por imagem , Cálculos Renais/cirurgia , Complicações Pós-Operatórias , Estudos Retrospectivos , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
The Clavien-Dindo Classification (CDC) lacks a combined score of multiple complications in one patient. The comprehensive complication index (CCI) circumvents this problem making it a valuable instrument to optimize quality control. We aimed to introduce and validate CCI in the treatment of urolithiasis. 60 day postoperative complications of 327 consecutive patients undergoing percutaneous nephrolitholapaxy (PNL) and ureterorenoscopy (URS) between 2017 and 2019 were retrospectively assessed and graded according to CDC. CCI was calculated for each patient. Overall morbidity scores of CCI and CDC were compared. Correlation analyses between the two scores and length of hospital stay (LOS) were performed. A multivariate analysis was performed to identify predictive factors for complications. Sample size calculation for an imaginary clinical trial was compared between CCI and CDC. A significant difference in overall morbidity between CCI and CDC was revealed for PNL (p < 0.001) and URS (p = 0.001). There was no statistically significant difference in comparing correlations between cumulative CCI and LOS versus non-cumulative CDC and LOS for both cohorts. Operating time > 90 min, maximum stone size, positive preoperative urine culture and PNL type (p < 0.001) were predictive factors for postoperative complications in PNL, while urine culture (p = 0.02) was for URS. Sample size calculation based on CCI resulted in a significant reduction of required patients for PNL (- 48%) and URS (- 84%) compared to CDC. CCI could successfully be validated in endourological stone treatment with the advantage of assessing complications in their entirety compared to CDC. CCI can significantly reduce the required sample size in future clinical trials.
Assuntos
Litotripsia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Controle de Qualidade , Ureteroscopia/efeitos adversos , Urolitíase/cirurgia , Adulto , Idoso , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Litotripsia/métodos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
To prevent postoperative infectious complications, a urinary tract infection should be either diagnostically excluded or treated prior to ureterorenoscopy (URS). URS is a frequently performed endoscopic surgery for urological stone removal. Although the urinary dipstick test represents a simple and cost-effective method to gain information about the presence of urinary tract infection, the prevailing procedure is the more expensive and more time-consuming method of urine culture. The aim of this retrospective single-center study was to compare two strategies of perioperative prophylaxes prior to URS and to evaluate their impact on postoperative infectious complications: I) Obtaining a urine culture in every patient prior to URS or II) only in case of a positive dipstick test. Therefore, we retrospectively compared 201 patients in two cohorts undergoing URS. In one cohort a urine culture was obtained only in case of a positive dipstick test of midstream urine sample and in the second cohort a urine culture was prepared for every patient regardless of the dipstick's test results. The study's end point was determined as "infectious failure" (IF), if more than one of the following criteria are fulfilled: postoperative fever, elevation of inflammation laboratory values, significant prolongation of hospital stay and readmission within short-notice. Simple and multiple logistic regressions were performed to evaluate the influence of patient characteristics and preoperative urine analysis strategy on the occurrence of IF. Patients with a score of the American Society of Anesthesiologists (ASA)â¯>â¯2 had a nearly statistically higher risk (pâ¯=â¯.09) to develop an IF than healthier patients with an ASA scoreâ¯≤â¯2. Prestenting was determined as a significant predictive factor (pâ¯=â¯.04) for a postoperative IF. No difference in patients with or without IF was detected regarding the two preoperative urine analysis strategies. Sensitivity of dipstick test was 87.5% and the negative predictive value was 89.66%. We found that a negative urine dipstick test result obtained prior to URS eliminated the need for urine culturing in predicting postoperative infectious complication. This approach can reduce preoperative preparation-time and costs without affecting postoperative complication outcomes.