Intravesical injections of botulinum neurotoxin A to treat overactive bladder and/or detrusor overactivity related to multiple sclerosis: 5-Year continuation rate and specific risk factors for discontinuation-A study from the neuro-urology committee of the French Association of Urology.

BACKGROUND: While intravesical injections of botulinum neurotoxin A (BoNT-A) are currently recommended for patients experiencing refractory neurogenic overactive bladder and/or detrusor overactivity (OAB/DO), it is unclear how much this therapy is effective and sustainable in the long-term in patients with multiple sclerosis (MS). OBJECTIVES: To assess the mid-term continuation rate of BoNT-A injections to treat neurogenic OAB/DO in MS patients and to investigate MS-specific risk factors for discontinuation. METHODS: This retrospective study involved 11 French university hospital centers. All MS patients who received BoNT-A to treat neurogenic OAB/DO between 2008 and 2013 and were subsequently followed up for at least 5 years were eligible. RESULTS: Of the 196 MS patients included, 159 (81.1%) were still under BoNT-A 5 years after the first injection. The combination of the Expanded Disability Status Scale (EDSS < 6 or ⩾ 6) and of the MS type (relapsing-remitting vs progressive) predicted the risk of discontinuation. This risk was 5.5% for patients with no risk factor, whereas patients presenting with one or two risk factors were 3.3 and 5.7 times more likely to discontinue, respectively. CONCLUSION: BoNT-A is a satisfying mid-term neurogenic OAB/DO therapy for most MS patients. Combining EDSS and MS type could help predict BoNT-A discontinuation.

Adrenalectomy for Pheochromocytoma: Complications and Predictive Factors of Intraoperative Hemodynamic Instability.

BACKGROUND: Surgery is the treatment of choice for pheochromocytoma. However, this surgery carries a risk of hemodynamic instability (HDI). The aim of this study was to report complications associated with this procedure, to identify risk factors for HDI during surgery, and its impact on postoperative outcomes. METHODS: The charts of all patients who underwent adrenalectomy for pheochromocytoma in two academic centers between 2006 and 2020 were retrospectively reviewed. The primary outcome was HDI defined by a systolic blood pressure >160 mmHg or a mean blood pressure <60 mmHg intraoperatively. The secondary outcomes of interest were the total duration of HDI, the occurrence of intraoperative arrhythmia, perioperative cardiovascular events, and postoperative complications. RESULTS: 205 patients were included. HDI occurred intraoperatively in 155 patients (75.6%) but only 6 (3.2%) experienced arrhythmia. Thirty-eight postoperative complications were reported (18.6%) but only nine were ≥3 according to Clavien-Dindo (4.4%). There were 10 postoperative cardiovascular events (5.7%). Patients with intraoperative HDI had higher rates of postoperative complications (21.3% vs 10%; P = .07), major postoperative complications (5.8% vs 0%; P = .12) and cardiovascular events (6.5% vs 0%; P = .12). Factors associated with intraoperative HDI in univariate analysis were age (OR = 8.14; P = .006), high blood pressure preoperatively (OR = 2.16; P = .04), tumor size (OR = 15.83; P = .0001), and urinary normetanephrine level (OR = 9.33; P = .04). DISCUSSION: In multidisciplinary centers, the overall morbidity of adrenalectomy for pheochromocytoma is low. HDI during adrenalectomy for pheochromocytoma is highly prevalent but rarely associated with major cardiovascular events. There might be a link between HDI and postoperative cardiovascular events.

Prospective Comparison of Thulium and Holmium Laser Lithotripsy for the Treatment of Upper Urinary Tract Lithiasis.

Background: Lithotripsy with holmium:yttrium-aluminum-garnet (Ho:YAG) laser is the current gold standard for treating stones of the upper urinary tract (UUT). The recently introduced thulium fiber laser (TFL) has the potential to be more efficient and as safe as Ho:YAG. Objective: To compare the performance and complications between Ho:YAG and TFL for UUT lithotripsy. Design setting and participants: This was a prospective single-center study of 182 patients treated between February 2021 and February 2022. In a consecutive approach, laser lithotripsy was performed via ureteroscopy with Ho:YAG for 5 mo, and then with TFL for 5 mo. Outcome measurements and statistical analysis: Our primary outcome was stone-free (SF) status at 3 mo after ureteroscopy with Ho:YAG versus TFL lithotripsy. Secondary outcomes were complication rates and results regarding the cumulative stone size. Patients were followed at 3 mo with abdominal imaging (ultrasound or computed tomography). Results and limitations: The study cohort comprised 76 patients treated with Ho:YAG laser and 100 patients treated with TFL. Cumulative stone size was significantly higher in the TFL than in the Ho:YAG group (20.4 vs 14.8 mm; p = 0.01). SF status was similar in both groups (68.4% vs 72%; p = 0.06). Complication rates were comparable. In subgroup analysis, the SF rate was significantly higher (81.6% vs 62.5%; p = 0.04) and the operative time was shorter for stones measuring 1-2 cm, whereas the results were similar for stones <1 cm and >2 cm. The lack of randomization and single-center design are the main limitations of the study. Conclusions: TFL and Ho:YAG lithotripsy are comparable in terms of the SF rate and safety for the treatment of UUT lithiasis. According to our study, for a cumulative stone size of 1-2 cm, TFL is more effective than Ho:YAG. Patient summary: We compared the efficiency and safety of two laser types for the treatment of stones in the upper urinary tract. We found that stone-free status at 3 months did not significantly differ between the holmium and thulium lasers.

Does a skeletonized internal thoracic artery give fewer postoperative complications than a pedicled artery for patients undergoing coronary artery bypass grafting?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'Does a skeletonized internal thoracic artery (ITA) give fewer postoperative complications than a pedicled artery for patients undergoing coronary artery bypass grafting?' Altogether, 98 papers were found using the reported search, of which 11 represented the best evidence to answer the clinical question. Papers about patency of skeletonized versus pedicled internal thoracic artery were excluded. The analysed complications were essentially mediastinitis, superficial sternal infection, wound infection, chest pain and pulmonary function. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Grafts used were either single ITA (LITA or RITA, left or right, respectively) or bilateral ITAs (BITAs). One prospective randomized controlled trial was identified, which found that benefits of skeletonized harvesting included increased graft length, increased graft flow and decreased incidence of mediastinitis. All of the six studies concerning wound infection demonstrate fewer complications when ITA is skeletonized. One of the three papers describing postoperative mortality demonstrated lower 30-day mortality, but there was no long-term analysis. Three studies describing postoperative chest pain reported a lower score on the visual analogue scale (VAS) within 30 days. One of them indicates that the pedicled group has a significantly greater VAS, pain disability index and short-form McGill Pain questionnaire score at 1 and 3 months. The hospital stay was shorter for three studies conducted on this subject. One study about pulmonary function reported a better ratio of pre- versus postoperative values of forced vital capacity. Despite longer operating times, skeletonization leads to fewer wound infections, reduced chest pain, allows a shorter hospital stay and better preserves pulmonary function.