RESUMO
BACKGROUND: The Global increase in colonization by multidrug-resistant (MDR) bacteria poses a significant concern. The precise impact of MDR colonization in solid organ transplant recipients (SOTR) remains not well established. OBJECTIVES: To assess the impact of MDR colonization on SOTR's mortality, infection, or graft loss. METHODS AND DATA SOURCES: Data from PROSPERO, OVID Medline, OVID EMBASE, Wiley Cochrane Library, ProQuest Dissertations, Theses Global, and SCOPUS were systematically reviewed, spanning from inception until 20 March 2023. The study protocol was registered with PROSPERO (CRD42022290011) and followed the PRISMA guidelines. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, INTERVENTIONS, AND ASSESSMENT OF RISK OF BIAS: Cohorts and case-control studies that reported on adult SOTR colonized by Methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), extended-spectrum ß-lactamase (ESBL) or carbapenem-resistant Enterobacteriaceae. (CRE), or MDR-pseudomonas, and compared to noncolonized, were included. Two reviewers assessed eligibility, conducted a risk of bias evaluation using the Newcastle-Ottawa Scale, and rated certainty of evidence using the GRADE approach. METHODS OF DATA SYNTHESIS: We employed RevMan for a meta-analysis, using random-effects models to compute pooled odds ratios (OR) and 95% confidence intervals (CI). Statistical heterogeneity was determined using the I2 statistic. RESULTS: 15,202 SOTR (33 cohort, six case-control studies) were included, where liver transplant and VRE colonization (25 and 14 studies) were predominant. MDR colonization significantly increased posttransplant 1-year mortality (OR, 2.35; 95% CI, 1.63-3.38) and mixed infections (OR, 10.74; 95% CI, 7.56-12.26) across transplant types (p < 0.001 and I2 = 58%), but no detected impact on graft loss (p 0.41, I2 = 0). Subgroup analysis indicated a higher association between CRE or ESBL colonization with outcomes (CRE: death OR, 3.94; mixed infections OR, 24.8; ESBL: mixed infections OR, 10.3; no mortality data) compared to MRSA (Death: OR, 2.25; mixed infection: OR, 7.75) or VRE colonization (Death: p 0.20, mixed infections: OR, 5.71). CONCLUSIONS: MDR colonization in SOTR, particularly CRE, is associated with increased mortality. Despite the low certainty of the evidence, actions to prevent MDR colonization in transplant candidates are warranted.
RESUMO
OBJECTIVE: To describe a single-stage urethroplasty for fossa navicularis strictures using a "sliding-T" dorsal inlay technique with buccal mucosa. Strictures of the fossa navicularis are challenging. Endoscopic treatments typically offer only temporary relief and necessitate lifelong instrumentation. Reconstruction should provide an unobstructed urethra, slit-like meatus, preserve sexual function, and create a cosmetically appealing glans. The ideal urethroplasty technique has not yet been elucidated despite various described single-stage and multistaged approaches. METHODS: A retrospective review from January 2013 to May 2018 was performed to identify patients undergoing single-stage urethroplasty for fossa navicularis strictures. The primary outcome was urethroplasty success defined as the ability to easily pass a 16 Fr flexible cystoscope with a minimum of 12-month follow-up. Secondary outcome measures included 90-day complications, de novo erectile dysfunction, chordee, and patient satisfaction assessed at ~6-months postoperatively with the question, "Overall, are you satisfied with the result of your operation for urethral stricture?" RESULTS: Twenty-seven patients underwent reconstruction of fossa navicularis strictures using buccal mucosa with a "sliding-T" dorsal inlay urethroplasty technique. Stricture etiology was most commonly lichen sclerosus (70.4%; n = 19), iatrogenic (18.5%; n = 5), or idiopathic (11.1%; n = 3). Mean stricture length was 3.2 cm ± 1.2 [1-4] and mean patient age was 47.3 years [19-71]. Around 92.6% (n = 25) of patients failed prior endoscopic treatment while 7.4% (n = 2) failed prior urethroplasty. At a mean follow-up of 29.6 (12-60) months the success rate was 92.4% (n = 25). Both recurrences were managed successfully with meatotomy. 90-day complications (Clavien ≥2) occurred in 2 patients (7.4%) (surgical site infection treated with antibiotics). Functionally, 1 patient (3.7%) experienced de novo erectile dysfunction, 1 (3.7%) reported mild chordee, and 96.3% (26/27) of patients were satisfied with the outcome of surgery. CONCLUSION: Reconstruction of fossa navicularis strictures using buccal mucosa with a single-stage "sliding-T" dorsal inlay technique provides satisfying anatomic and functional outcomes with a low rate of associated complications.