Shock wave lithotripsy success for renal stones based on patient and stone computed tomography characteristics.

OBJECTIVES: To determine the patient and noncontrast computed tomography (NCCT) stone characteristics that predict either of 2 extracorporeal shock wave lithotripsy (ESWL) outcomes: stone-free (SF) status or ESWL success. METHODS: The records of 200 consecutive patients with nephrolithiasis treated with ESWL were reviewed. Patient age, sex, stone laterality, body surface area, body mass index, maximal stone dimension, mean stone Hounsfield units (HU), stone Hounsfield density, skin-to-stone distance (SSD), and intrarenal stone location were studied as potential predictors. Patients with no calcifications on postoperative kidneys, ureters, and bladder (KUB) at 6 weeks were defined as SF. ESWL success was defined as SF or remaining stone fragments less than 4 mm. RESULTS: Intrarenal stone location was found to be the only predictor of SF status. Renal pelvic/ureteropelvic junction (UPJ) stones cleared better than calyceal stones, and upper/middle calyceal stones cleared better than lower calyceal stones. Stone size, mean HU, and location predicted ESWL fragmentation success. Smaller stones and stones with lower mean HU levels were more successfully fragmented. Higher SF and ESWL success rates were found with a shorter SSD among calyceal stones when renal pelvic/UPJ stones were excluded from analysis. CONCLUSIONS: Stone location is the most important factor in achieving SF status after ESWL. NCCT stone characteristics such as stone size, mean HU, and intrarenal location are important predictors of ESWL success.

Fibrin sealant as tissue glue: preliminary experience in complex genital reconstructive surgery.

OBJECTIVES: To report the outcomes of graft take and wound healing in the first reported series in which fibrin sealant was used as a tissue glue in the reconstruction of complex genital skin loss. METHODS: Between July 2001 and July 2005, 18 men requiring complex genital reconstruction underwent repair by two surgeons at our medical centers. Skin graft reconstruction was required in 6 men. Complete scrotal disassembly with extensive scrotal or thigh flaps was required for reconstruction of 12 others. In the skin graft cases, a thin layer of dilute fibrin sealant was sprayed on the recipient site immediately before graft apposition. In flap cases, fibrin sealant was injected beneath the flap to promote tissue adherence and prevent fluid accumulation. All wounds were followed up postoperatively and observed for evidence of graft take, seroma or hematoma formation, drainage, and infection. RESULTS: The 6 skin graft patients required a total of nine split-thickness skin grafts, all of which had 100% take. Of the 12 patients requiring flap reconstruction, 11 had excellent results. One flap case had a partial wound breakdown, but this reconstruction was performed immediately subsequent to a significant debridement and irrigation procedure in the same setting. Overall, 17 (94.4%) of 18 patients had no wound infection, seroma, hematoma, or other complications. CONCLUSIONS: Fibrin sealant performs very well as a tissue glue and appears to be a useful adjunct in cases of complex genital skin loss reconstruction.

Damage control management of experimental grade 5 renal injuries: further evaluation of FloSeal gelatin matrix.

BACKGROUND: We developed a porcine grade 5 renal laceration damage control model to evaluate the hemostatic efficacy of FloSeal gelatin matrix (Baxter Healthcare, Corp., Deerfield, Ill). METHODS: Ten commercial swine underwent celiotomy, contralateral nephrectomy, and cooling to 32 degrees C after a well-established hypothermia protocol to simulate a damage control scenario. Following prospective randomization, a complex grade 5 renal injury was uniformly produced on the remaining kidney. Control animals (group 1, n = 5) were treated with direct manual compression with a gelatin sponge. Experimental animals (group 2, n = 5) were treated by application of FloSeal gelatin matrix followed by direct compression with a gelatin sponge. Operative blood loss and efficacy of hemostasis were compared. Creatinine levels were obtained daily until postoperative day 7. Abdominal computed tomography was performed at 10 days. RESULTS: Use of FloSeal gelatin matrix hemostatic sealant resulted in significantly less mean blood loss than gelatin sponge bolster compression alone (202.4 mL vs. 540.4 mL, respectively, p = 0.016). Hemostasis was complete in 60% (three out of five) of experimental animals after 2 minutes, but was incomplete in all control animals. After an initial increase, serum creatinine approached baseline by postoperative day 7 in all animals. Axial imaging 10 days postoperatively revealed no evidence of significant delayed perirenal hemorrhage. CONCLUSIONS: FloSeal gelatin matrix performed well as a rapidly deployable, effective hemostatic agent in a hypothermic grade 5 renal injury damage control model. The absence of delayed bleeding and nephrotoxicity suggests a possible increased role for FloSeal in the treatment of devastating renal injuries in damage control surgery.

Gelatin matrix treatment of complex renal injuries in a porcine model.

PURPOSE: We developed a complex porcine renal laceration model at our laboratory to test the efficacy of an abbreviated, sutureless treatment regimen using FloSeal gelatin matrix hemostatic sealant (Baxter Healthcare Corp., Fremont, California). We evaluated the influence of preliminary renal arterial occlusion on hemostatic efficacy and assessed the risk of delayed hematoma or urinoma formation after treatment. MATERIALS AND METHODS: A total of 21 commercial swine underwent celiotomy with creation of a complex upper pole renal injury using a 4 x 4 cm cruciate press instrument. The injury was uniformly produced at the caudal extent of the upper third portion of the left kidney. Subjects were prospectively randomized into 3 treatment groups. Experimental animals were treated with the application of gelatin matrix with (7 in group 1) or without (7 in group 2) preliminary renal arterial occlusion. Control subjects (7 in group 3) were treated with conventional horizontal mattress sutured gelatin sponge bolsters over the capsular injury. Operative blood loss, time to hemostasis and volume of gelatin matrix required for hemostasis were compared among the groups. Abdominal computerized tomography with intravenous contrast medium was performed in each animal 7 days postoperatively. RESULTS: Gelatin matrix use resulted in significantly less mean blood loss (80.7 and 99.0 ml in groups 1 and 2, respectively) vs conventional suture treatment (191.8 ml in group 3, p = 0.036). Time to hemostasis was similarly decreased (1.1, 2 to 2.5 and 5.8 minutes in groups 1 to 3, respectively, p = 0.009). Followup abdominal computerized tomography with contrast medium revealed no clinically significant perinephric fluid collections (greater than 2 cm). CONCLUSIONS: FloSeal gelatin matrix hemostatic sealant provided effective hemostasis after complex renal injury with and without preliminary vascular control. No delayed bleeding or clinically significant urinoma formation was noted. These findings suggest a possible increased role for FloSeal gelatin matrix in renal salvage surgery.