Office Based Pediatric Urologic Procedures: A Safe and Effective Alternative to Interventions Under Anesthesia.

OBJECTIVE: To report on our experience performing office-based pediatric urologic procedures. We hypothesize that office-based interventions are safe and effective for children, avoiding unnecessary risk and cost associated with general anesthesia. METHODS: We retrospectively identified patients undergoing office-based interventions from 2014 to 2019, including lysis of penile or labial adhesions, division of skin bridges, meatotomy and excision of benign lesion. Success was defined as a completed attempt in the office. Failure includes any unsuccessful office attempts. Complications include 30-day ED visits/readmissions and recurrent skin bridge post division of skin bridge. RESULTS: We identified 1326 interventions: 491 lyses of penile adhesions (37%), 320 division of skin bridges (24%), 128 lyses of labial adhesions (10%), 348 meatotomies (26%), and 39 excisions of benign lesions (3%) [Table 1]. There was a >95% success rate reported in every procedure with an overall complication rate of 0.6%. Excision of benign lesion had 100% success rate. ED visits within 30 days are rare (0.2%), and no patients required admission after their procedure [Table 2]. The rate of recurrence was highest following lysis of labial adhesions (13.3%). Of the 54 patients who underwent retreatment, very few required general anesthesia (n = 6). CONCLUSION: Office-based urologic interventions in children are well tolerated with excellent safety and efficacy. Complications and recurrence are universally low. Ultimately, 99.5% of this cohort was managed under local anesthetics, thereby avoiding the risks of anesthesia use in the pediatric population.

Port Site Local Anesthetic Infiltration Vs Single-dose Intrathecal Opioid Injection to Control Perioperative Pain in Children Undergoing Minimal Invasive Surgery: A Comparative Analysis.

OBJECTIVE: To compare the efficacy of the intrathecal opiate vs wound site local anesthetic infiltration for perioperative pain control during and after surgery in patients undergoing minimally invasive pediatric urologic procedures. METHODS: Using an Institutional Review Board-approved registry database, we identified patients who underwent minimally invasive urologic procedures at our institution between 2009 and 2013. We collected all relevant preoperative variables and postoperative outcomes. Patients in intrathecal injection of opioids (ITO) group were matched with patients who received local anesthetic infiltration (LAI) based on age, diagnosis, and procedure. Perioperative analgesic requirements were converted to morphine equivalents standardized to body weight. Statistical analysis was performed using SPSS, and parametric comparisons were completed to determine difference in morphine equivalents between the 2 groups. RESULTS: One hundred thirty children (78 girls and 52 boys) were included in our study. Sixty-six patients underwent ITO and 66 received LAI. Sixty-six patients underwent ureteral reimplantation, 60 underwent pyeloplasty, and 4 underwent nephrectomy. Ages ranged from 0.5 to 19.9 years. There was no significant difference in cumulative morphine equivalents or weight administered between the ITO and LAI groups for the total period of hospitalization (0.76 units vs 0.79 units, P > .05). Multivariate regression analysis predicted that older age corresponds to higher analgesic requirements. CONCLUSION: ITO does not impact total analgesic requirements during the hospital stay compared to LAI following minimally invasive surgery. Considering the potential complications of ITO, LAI may be the preferred modality for pain management for minimally invasive surgery in children.

The use of complementary and alternative fertility treatments.

PURPOSE OF REVIEW: Complementary and alternative medicine (CAM) is widely used for the treatment of infertility; however, few reviews have evaluated the quality of evidence underlying the use of CAM fertility treatments. This review summarizes and evaluates the evidence underlying the use of these therapies for male and female infertility. RECENT FINDINGS: A wide range of CAM treatments are used by subfertile couples. Their use depends upon the region studied and the type of fertility problems encountered. Acupuncture, the most commonly used CAM fertility treatment in the USA, has the most literature-based support. Few randomized trials have been performed to evaluate other CAM fertility treatments. SUMMARY: CAM is used commonly to treat infertility; however, additional high-quality studies need to be conducted to demonstrate the safety and effectiveness of these therapies before clear recommendations can be made by physicians about their safety and effectiveness.

Acupuncture-induced blood oxygenation level-dependent signals in awake and anesthetized volunteers: a pilot study.

BACKGROUND: There are conflicting data regarding clinical efficacy of acupuncture applied while patients are under general anesthesia. We hypothesize that these conflicting data are a result of the inhibitory effect of anesthesia on acupuncture-induced central nervous system activity that can be demonstrated using magnetic resonance imaging. METHODS: Using a crossover study design, volunteers received standardized Stomach 36 manual acupuncture in two experimental conditions: while undergoing a propofol-based general anesthetic, and while awake. Functional magnetic resonance imaging was conducted during both experimental sessions. Paired-t-test analyses were performed to examine the differences in acupuncture-induced blood oxygenation level-dependent (BOLD) signals between awake and anesthesia conditions. A secondary analysis was performed to account for the changes in regional cerebral blood flow at six regions of interest (thalamus, red nucleus, insula, periaqueductal gray, retrosplenial cingular gyri, and the inferior temporal region). RESULTS: Using BOLD, we found significant differences between the two experimental sessions in brain areas, including postcentral gyri, retrosplenial cingular area, left posterior insula, bilateral precuneus, thalamus, red nuclei, and substantia nigra (cluster 100, P < 0.01). A secondary analysis correcting for background cerebral blood flow found that BOLD signal differences between experimental conditions were not directly caused by changes in regional blood flow. DISCUSSION: Propofol-based anesthesia reduces the neurophysiological response to acupuncture stimulation as measured by acupuncture-induced BOLD signals. Further work should be conducted to determine the clinical significance of these findings.

Acupuncture as an adjunct for sedation during lithotripsy.

OBJECTIVE: To determine whether a combination of auricular and body acupuncture is effective as an adjunct for the preprocedural anxiety and pain management in patients undergoing lithotripsy procedures. DESIGN: Randomized controlled study. SETTING AND LOCATION: Lithotripsy suite located at the Yale New Haven Hospital, New Haven CT. SUBJECTS: Adult patients who were scheduled to receive elective lithotripsy procedures. INTERVENTIONS: Acupuncture group: Preprocedural auricular acupuncture intervention combined with intraprocedural electroacupuncture stimulation (n = 29); Sham control group: Preprocedural sham auricular acupuncture intervention combined with intraprocedural sham electroacupuncture stimulation (n = 27). OUTCOMES MEASUREMENT: Preprocedural anxiety, intraprocedural alfentanil consumption, visual analogue scale for pain. RESULTS: Patients in the acupuncture group were less anxious preprocedure than those in the Sham Control Group 32 (29-34) versus 40 (35-45) (p = 0.029). Similarly, patients in the Acupuncture Group used a lesser amount of alfentanil than those in the sham control group (p = 0.040). The adjustable alfentanil consumption as expressed by median rate of alfentanil consumption of 1 (0.6-1.6) microg kg(-1) minute(-1) in the acupuncture group was lower than that of 1.5 (0.9-2.3) microg kg(-1) minute(-1) in the sham control group. Patients in the Acupuncture group also reported lower pain scores on admission to the recovery room (p = 0.014). CONCLUSIONS: A combination of auricular and body acupuncture can be used as an adjunct treatment to decrease preprocedural anxiety and intraprocedural analgesia in patients undergoing lithotripsy.