Therapeutic use of tetrasodium ethylenediaminetetraacetic acid solution for treatment of subcutaneous ureteral bypass device mineralization in cats.

BACKGROUND: Subcutaneous ureteral bypass (SUB) device placement is an increasingly popular treatment option for decompression of ureteral obstruction in cats. Mineralization occlusion of the device occurs in a minority of cases but is the most common complication. OBJECTIVE: To evaluate a 2% tetrasodium ethylenediaminetetraacetic acid (tEDTA) solution for treatment of mineralization occlusion in cats with SUBs. ANIMALS: Six client-owned cats (8 obstructed devices). METHODS: Case series. Each cat was found to have device occlusion based on a combination of ultrasound examination, SUB irrigation, and failure to identify another cause of device obstruction. Each SUB was drained, irrigated using sterile saline, and infused with 1-2 mL of 2% tEDTA solution. Success was defined as normalization of flow during subsequent ultrasound visualization while irrigating. The volume and frequency of tEDTA instillations, time to achieve device patency, follow-up biochemical and ultrasound findings, and future reobstruction events were recorded. RESULTS: Resolution of mineralization was documented in all 8 SUBs. Reobstruction events occurred in 2 cats, all of which resolved after additional tEDTA infusions, but 1 cat ultimately required device exchange at 356 days from the first tEDTA infusion. In 1 cat, a single infusion was prematurely discontinued because of persistent pelvic dilatation after 1.25 mL of tEDTA had been instilled. No complications were observed. CONCLUSIONS AND CLINICAL IMPORTANCE: Tetrasodium EDTA infusions can be safely considered as a treatment option for mineralized SUB devices in cats. This solution was easily infused, well tolerated, and avoided the need for SUB device exchange in the majority of cats in which it was used.

Motor Response Matters: Optimizing Lead Placement Improves Sacral Neuromodulation Outcomes.

PURPOSE: We sought to determine the usefulness of motor responses during sacral neuromodulation lead placement by testing the hypothesis that a greater number of motor responses during intraoperative electrode testing would be associated with more durable therapy. MATERIALS AND METHODS: We retrospectively reviewed all sacral neuromodulation lead placements at a large academic center from 2010 to 2015. Included in study were all unilateral sacral lead placements for which the presence or absence of a motor response was documented discretely for each electrode. Motor responses were quantified into separate subscores, including bellows and toe response subscores (each range 0 to 4) for a possible maximum total score of 8 when combined. Revision surgery was the primary outcome. Univariate and multivariate analyses were performed for factors associated with lead revision. RESULTS: A total of 176 lead placements qualified for analysis. Mean ± SD cohort age was 58.4 ± 15.9 years, 86.4% of the patients were female and 93.2% had undergone implantation for overactive bladder. Median followup was 10.5 months (range 2 to 36). Overall 34 patients (19%) required lead revision. Revision was negatively associated with the total electrode response score (p = 0.027) and the toe subscore (p = 0.033) but not with the bellows subscore (p = 0.183). Predictors of revision on logistic regression included age less than 59 years at implantation (OR 5.5, 95% CI 2-14) and a total electrode response score less than 4 (OR 4.2, 95% CI 1.4-12.8). CONCLUSIONS: Fewer total electrode responses and specifically fewer toe responses were associated with sacral neuromodulation lead revision. These data suggest that placing a lead with more toe responses during testing may result in more durable sacral neuromodulation therapy.

Retropubic tissue fixation system tensioned mini-sling carried out under local anesthesia cures stress urinary incontinence and intrinsic sphincter deficiency: 1-year data.

OBJECTIVES: To assess the outcomes of the tissue fixation system midurethral sling for the treatment of intrinsic sphincter deficiency. METHODS: We retrospectively studied a total of 96 intrinsic sphincter deficiency patients treated with the tissue fixation system midurethral sling at Yokohama Motomachi Women's Clinic from 2006 to 2015. We evaluated intraoperative and 1-year postoperative results. Regarding the cure rate, we divided patients into three groups: (i) patients with maximum urethral closure pressure <20 and Valsalva leak point pressure <65 combined (n = 17); (ii) patients with maximum urethral closure pressure <20 (n = 55); and (iii) patients with Valsalva leak point pressure <65 (n = 47). RESULTS: The median age was 63 years (range 38-89 years). The median operating time including local anesthesia was 24 min (range 12-55 min) and median blood loss was 5.0 mL (range 3-69 mL). All operations were day surgery under local anesthesia. Postoperative pain was minimal. All patients were discharged the same day. There were no intraoperative complications except one bladder perforation. There were no tape rejections. The 1-year postoperative cure rates were: 88.2% among patients with maximum urethral closure pressure <20 and Valsalva leak point pressure <65, 90.9% for patients with maximum urethral closure pressure <20, and 85.1% among patients with Valsalva leak point pressure <65. CONCLUSIONS: The tissue fixation system midurethral sling operation is a simple, safe and effective operation for older women with intrinsic sphincter deficiency, and it can be carried out under local anesthesia.

[Using polypropylene mesh in surgery for stress urinary incontinence]. / Uso de malla de polipropileno en cirugías para incontinencia urinaria de esfuerzo.

BACKGROUND: Stress urinary incontinence (SUI) is defined as the involuntary leakage of urine while making an effort, such as coughing, sneezing or during activity. Since SUI generates high costs and affects the quality of life, it is important to make a proper diagnosis and, consequently, manage SUI efficiently. The objective was to know whether it is appropriate to use polypropylene mesh for SUI. METHODS: A historical cohort was conducted by reviewing records of patients with SUI treated with polypropylene mesh during 2013 with a follow-up of 12 months. RESULTS: Urinary continence was achieved in 98% of patients at one year. The complication rate was 2%. Only 12% of patients had normal weight. The most commonly used surgery was the placement of tension-free transobturator tape. CONCLUSION: The healing average reported worldwide is 90%, while the average for complications is 10%. In this study we achieved similar results. Using polypropylene mesh for surgical correction of SUI is a safe and effective alternative; however, studies with larger populations and more extensive monitoring to clarify this situation are required.

Introducción: la incontinencia urinaria de esfuerzo (IUE) se define como la pérdida involuntaria de orina con esfuerzos como toser, estornudar o realizar actividad física. Dado que la IUE genera costos elevados y afecta la calidad de vida, es importante el diagnóstico y el manejo adecuados. El objetivo fue conocer si es adecuado el uso de malla de polipropileno para la IUE. Métodos: se hizo un estudio de cohorte histórica que incluyó a pacientes con incontinencia urinaria de esfuerzo en los que se utilizó malla de polipropileno durante 2013 con un seguimiento a 12 meses. Resultados: se logró una corrección de la IUE en el 98% de las pacientes al año de seguimiento. La tasa de complicaciones fue del 2%. Solo el 12% de las pacientes tenía un peso normal. La cirugía más utilizada fue la colocación de cinta libre de tensión transobturadora. Conclusión: la curación que se reporta a nivel mundial en promedio es del 90%, mientras que para las complicaciones el promedio es del 10%. En este estudio tenemos resultados similares. Utilizar malla de polipropileno para la corrección quirúrgica de la IUE es una alternativa segura y eficaz; sin embargo, se requieren estudios con mayores poblaciones y un seguimiento más extenso para aclarar esta situación.

Laparoendoscopic single site surgery in pediatric urology: does it require specialized tools?

PURPOSE: To describe our experience utilizing Laparoendoscopic single site (LESS) surgery in pediatric urology. MATERIALS AND METHODS: Retrospective chart review was performed on LESS urologic procedures from November 2009 through March 2013. A total of 44 patients underwent 54 procedures including: nephrectomy (23), orchiopexy (14), varicocelectomy (9), orchiectomy (2), urachal cyst excision (3), and antegrade continence enema (3) (ACE). RESULTS: Median patient age was 6.9 years old. Estimated blood loss (EBL), ranged from less than 5cc to 47cc for a bilateral nephrectomy. Operative time varied from 56 mins for varicocelectomy to a median of 360 minutes for a bilateral nephroureterectomy. Incision length ranged between 2 and 2.5cm. In our initial experience we used a commercial port. However, as we progressed, we were able to perform the majority of our procedures via adjacent fascial punctures for instrumentation at the single incision site. One patient did require conversion to an open procedure as a result of bleeding. Three complications were noted (6.8%), with two Clavien Grade 3b complications. Two patients required additional procedures at 1-year follow-up. CONCLUSIONS: The use of LESS applies to many pediatric urologic procedures, ideally for ablative procedures or simple reconstructive efforts. The use of adjacent fascial puncture sites for instrumentation can obviate the need for a commercial port or multiple trocars.

Laparoendoscopic single site surgery in pediatric urology: does it require specialized tools?

ABSTRACT Purpose: To describe our experience utilizing Laparoendoscopic single site (LESS) surgery in pediatric urology. Materials and Methods: Retrospective chart review was performed on LESS urologic procedures from November 2009 through March 2013. A total of 44 patients underwent 54 procedures including: nephrectomy (23), orchiopexy (14), varicocelectomy (9), orchiectomy (2), urachal cyst excision (3), and antegrade continence enema (3) (ACE). Results: Median patient age was 6.9 years old. Estimated blood loss (EBL), ranged from less than 5cc to 47cc for a bilateral nephrectomy. Operative time varied from 56 mins for varicocelectomy to a median of 360 minutes for a bilateral nephroureterectomy. Incision length ranged between 2 and 2.5cm. In our initial experience we used a commercial port. However, as we progressed, we were able to perform the majority of our procedures via adjacent fascial punctures for instrumentation at the single incision site. One patient did require conversion to an open procedure as a result of bleeding. Three complications were noted (6.8%), with two Clavien Grade 3b complications. Two patients required additional procedures at 1-year follow-up. Conclusions: The use of LESS applies to many pediatric urologic procedures, ideally for ablative procedures or simple reconstructive efforts. The use of adjacent fascial puncture sites for instrumentation can obviate the need for a commercial port or multiple trocars.

Assessing visual control during simulated and live operations: gathering evidence for the content validity of simulation using eye movement metrics.

BACKGROUND: Although virtual reality (VR) simulators serve an important role in the training and assessment of surgeons, they need to be evaluated for evidence of validity. Eye-tracking technology and measures of visual control have been used as an adjunct to the performance parameters produced by VR simulators to help in objectively establishing the construct validity (experts vs. novices) of VR simulators. However, determining the extent to which VR simulators represent the real procedure and environment (content validity) has largely been a subjective process undertaken by experienced surgeons. This study aimed to examine the content validity of a VR transurethral resection of the prostate (TURP) simulator by comparing visual control metrics taken during simulated and real TURP procedures. METHODS: Eye-tracking data were collected from seven surgeons performing 14 simulated TURP operations and three surgeons performing 15 real TURP operations on live patients. The data were analyzed offline, and visual control metrics (number and duration of fixations, percentage of time the surgeons fixated on the screen) were calculated. RESULTS: The surgeons displayed more fixations of a shorter duration and spent less time fixating on the video monitor during the real TURP than during the simulated TURP. This could have been due to (1) the increased complexity of the operating room (OR) environment (2) the decreased quality of the image of the urethra and associated anatomy (compared with the VR simulator), or (3) the impairment of visual attentional control due to the increased levels of stress likely experienced in the OR. CONCLUSIONS: The findings suggest that the complexity of the environment surrounding VR simulators needs to be considered in the design of effective simulated training curricula. The study also provides support for the use of eye-tracking technology to assess the content validity of simulation and to examine psychomotor processes during live operations.

Trend, client profile and surgical features of vasectomy in Ghana.

OBJECTIVE: To examine the socio-demographic and reproductive characteristics of vasectomy acceptors and surgical features of vasectomy in Ghana. METHODS: Retrospective review of 271 vasectomies performed between 1 January 2000 and 31 December 2009 in three healthcare facilities. RESULTS: Less than 0.5% of family planning clients opt for vasectomy in Ghana; acceptors are both professional and semi-skilled workers. The mean age of vasectomy acceptors was 40.7 years, and their mean number of children four. All clients had two children or more; there was a trend towards a greater number of children with increasing age (p trend <0.001) or a lower educational level of the clients (p trend =0.01). Most clients obtained their information on vasectomy through the media and healthcare workers. Nearly all vasectomies were performed under local anaesthesia using the no-scalpel technique. The operating time of gynaecologists was significantly shorter than that of urologists (median operating time 10 minutes vs. 25 minutes; p <0.001). The reported vasectomy failure rate was about 1%. CONCLUSIONS: The prevalence of vasectomy is low in Ghana. The factors influencing utilisation of male sterilisation services must be identified in order to improve uptake of this method of contraception in the country.

Cutting for stone: Roman lithotomy instruments in the Museo Nazionale Romano.

Bladder stones, one of the scourges of the past, have been recorded as far back as 6,500 BC. Lithotomy was famously proscribed in the Hippocratic Oath, but it was certainly being undertaken in Hellenistic Alexandria by the 3rd century BC. However, the earliest surviving description of the operation is that of Celsus in the early 1st century AD, while identifiable instrumentation currently dates between the 2nd and early 5th century AD. Finds from Rimini, Marcianopolis, Ephesus and Cyrene illustrate how widespread the operation was at the time of the Roman Empire, but the majority of lithotomy instruments, of which those in the Museo Nazionale Romano are an important part, have been discovered in Rome itself doubtless a reflection of the size of the city's medical 'market'.

Open retropubic colposuspension for urinary incontinence in women: a short version Cochrane review.

BACKGROUND: Urinary incontinence is a common and potentially debilitating problem. Open retropubic colposuspension is a surgical treatment which involves lifting the tissues near the bladder neck and proximal urethra in the area behind the anterior pubic bones to correct deficient urethral closure. OBJECTIVES: To assess the effects of open retropubic colposuspension for the treatment of urinary incontinence. SEARCH STRATEGY: We searched the Cochrane Incontinence Group Specialized Register (searched June 30, 2008) and reference lists of relevant articles. We contacted investigators to locate extra studies. SELECTION CRITERIA: Randomized or quasi-randomized controlled trials in women with symptoms or urodynamic diagnoses of stress or mixed urinary incontinence that included open retropubic colposuspension surgery in at least one trial group. DATA COLLECTION AND ANALYSIS: Studies were evaluated for methodological quality/susceptibility to bias and appropriateness for inclusion and data extracted by two of the reviewers. Trial data were analyzed by intervention. Where appropriate, a summary statistic was calculated. MAIN RESULTS: This review included 46 trials involving a total of 4,738 women. Overall cure rates were 68.9-88.0% for open retropubic colposuspension. Two small studies suggest lower failure rates after open retropubic colposuspension compared with conservative treatment. Similarly, one trial suggests lower failure rates after open retropubic colposuspension compared to anticholinergic treatment. Evidence from six trials showed a lower failure rate for subjective cure after open retropubic colposuspension than after anterior colporrhaphy. Such benefit was maintained over time (RR of failure 0.51; 95% CI 0.34-0.76 before the first year, RR 0.43; 95% CI 0.32-0.57 at 1-5 years, RR 0.49; 95% CI 0.32-0.75 in periods beyond 5 years). In comparison with needle suspensions there was a lower failure rate after colposuspension in the first year after surgery (RR 0.66; 95% CI 0.42-1.03), after the first year (RR 0.48; 95% CI 0.33-0.71), and beyond 5 years (RR 0.32; 95% CI 15-0.71). Evidence from 12 trials in comparison with suburethral slings found no significant difference in failure rates in all time periods assessed. Patient-reported failure rates in short, medium and long-term follow-up showed no significant difference between open and laparoscopic retropubic colposuspension, but with wide confidence intervals. In two trials failure was less common after Burch (RR 0.38 95% CI 0.18-0.76) than after the Marshall-Marchetti-Krantz procedure at 1-5-year follow-up. There were few data at any other follow-up time. In general, the evidence available does not show a higher morbidity or complication rate with open retropubic colposuspension, compared to the other open surgical techniques, although pelvic organ prolapse is more common than after anterior colporrhaphy and sling procedures. AUTHORS' CONCLUSIONS: The evidence available indicates that open retropubic colposuspension is an effective treatment modality for stress urinary incontinence especially in the long term. Within the first year of treatment, the overall continence rate is approximately 85-90%. After 5 years, approximately 70% of patients can expect to be dry. Newer minimal access procedures such as tension free vaginal tape look promising in comparison with open colposuspension but their long-term performance is not known and closer monitoring of their adverse event profile must be carried out. Laparoscopic colposuspension should allow speedier recovery but its relative safety and effectiveness is not known yet.

Treatment of the neurogenic bladder in spina bifida.

Renal damage and renal failure are among the most severe complications of spina bifida. Over the past decades, a comprehensive treatment strategy has been applied that results in minimal renal scaring. In addition, the majority of patients can be dry for urine by the time they go to primary school. To obtain such results, it is mandatory to treat detrusor overactivity from birth onward, as upper urinary tract changes predominantly start in the first months of life. This means that new patients with spina bifida should be treated from birth by clean intermittent catheterization and pharmacological suppression of detrusor overactivity. Urinary tract infections, when present, need aggressive treatment, and in many patients, permanent prophylaxis is indicated. Later in life, therapy can be tailored to urodynamic findings. Children with paralyzed pelvic floor and hence urinary incontinence are routinely offered surgery around the age of 5 years to become dry. Rectus abdominis sling suspension of the bladder neck is the first-choice procedure, with good to excellent results in both male and female patients. In children with detrusor hyperactivity, detrusorectomy can be performed as an alternative for ileocystoplasty provided there is adequate bladder capacity. Wheelchair-bound patients can manage their bladder more easily with a continent catheterizable stoma on top of the bladder. This stoma provides them extra privacy and diminishes parental burden. Bowel management is done by retrograde or antegrade enema therapy. Concerning sexuality, special attention is needed to address expectations of adolescent patients. Sensibility of the glans penis can be restored by surgery in the majority of patients.

First clinical experience with new transurethral bipolar prostate electrosurgery resection system: controlled tissue ablation (coblation technology).

BACKGROUND AND PURPOSE: Bipolar transurethral resection of the prostate (TURP) can allow transurethral debulking of the adenoma with a lower potential for complications from systemic absorption of hypotonic irrigant. We evaluated a new bipolar double-loop resection system with a dedicated controlled ablation (Coblation) generator in this context. PATIENTS AND METHODS: In our series of 36 patients, 32 underwent transurethral bipolar loop resection, of whom 12 had prostates >50 cc (range for entire series 30-126 cc) on transrectal ultrasonography. Ten men had indwelling catheters because of urinary retention. The four other patients underwent transurethral resection of bladder tumors. After an initial learning curve of eight TURPs, some minor technical modifications were made, both to the bipolar-loop resection technique and to the hardware. The modified Vista Coblation system was subsequently evaluated by 18 other urologists in 17 other centers throughout the U.S. RESULTS: The median resected dry weight was 22 g, and the median operating-room time was 48 minutes, giving a median resection rate of approximately 1 g every 2 minutes. Two of the eight men in our learning curve required treatment for delayed bleeding problems (clot obstruction of catheter), and one of these received a blood transfusion. Transfusion was not required subsequently regardless of prostate size, even in men with larger glands. One of the patients treated for bladder tumor had a minor perforation of the posterior bladder wall, which healed with conservative management. In the multicenter experience in the U.S., there were 59 evaluable patients. The median resected weight was 23 g, and the median resection time was 55 minutes. Two men required conversion to monopolar roller coagulation for intraoperative bleeding. Most patients (80%) were discharged from hospital within 24 hours. No adverse neuromuscular stimulation occurred. CONCLUSION: This first single-center and international multicenter experience with Coblation technology for bipolar double-loop saline TURP confirms the feasibility and safety of this procedure. Subjective evaluation showed the four most important perceived benefits of bipolar over monopolar TURP to be smoother cutting action, elimination of TUR syndrome, less tissue burning (and no smell), and reduced bleeding. The results of randomized studies with this technology are awaited, while its role in bladder tumor resection remains unclear.

Randomized comparison of local versus epidural anesthesia for tension-free vaginal tape operation.

PURPOSE: We determine the difference between local anesthesia and epidural blockade for the tension-free vaginal tape operation. MATERIALS AND METHODS: Between November 1995 and November 1997, 73 women who had genuine stress incontinence in the absence of pelvic prolapse underwent a prospective randomized study. The study was conducted using a standardized protocol for different types of anesthesia for the tension-free vaginal tape procedure. A formal pain scale was used to determine the pain score for the patients during the operation. Additionally an anxiety scale was used to measure the anxiety level of the subjects immediately after admission to the ward and before discharge from the hospital. RESULTS: One woman was excluded from study due to loss at followup. The comparisons of pain score, duration of procedure and anxiety level of the 2 different types of anesthesia were not significantly different in the 72 study subjects. There was no significant difference in the amount of blood loss, while initial spontaneous voiding occurred significantly earlier (3.5 +/- 2.3 versus 5.8 +/- 0.1 hours, p <0.01), the number of patients in whom initial spontaneous voiding occurred more than 6 hours postoperatively was fewer (2 versus 10, p =0.01), amount of post-void residual during hospitalization was significantly less (98 +/- 63 versus 155 +/- 56 ml., p <0.01) and length of hospital stay was significantly shorter (3.4 +/- 1.4 versus 5.5 +/- 1.6 days, p <0.01) in the local anesthesia compared to epidural group. Subjective and objective success rates were not significantly different in these 2 groups. CONCLUSIONS: Both anesthetic methods can be equally effectively used for the tension-free vaginal tape operation. Local may be better than epidural anesthesia but its clinical significance needs to be proved by further study.

A three-year follow up of tension free vaginal tape for surgical treatment of female stress urinary incontinence.

OBJECTIVE: To study the long term results of tension-free vaginal tape, a new ambulatory surgical procedure for treatment of female stress urinary incontinence. STUDY DESIGN: A prospective open study using a standardised protocol for pre- and post-operative evaluation. PARTICIPANTS: Fifty consecutive women participated in the study. All suffered from genuine stress incontinence. The mean age was 57 years (SD 11), 42 women (84%) were multiparous, 8 (16%) nulliparous. SURGICAL METHOD: Tension-free vaginal tape implies the implantation of a prolene tape around mid-urethra via a minimal vaginal incision. The procedure is carried out under local anaesthesia, allowing the surgeon to check intra-operatively that continence has been obtained. RESULTS: All the women except one could be operated on an ambulatory basis under local anaesthesia. Mean operation time was 29 minutes (range 1647). Ninety percent of the women were able to micturate spontaneously within 24 hours with insignificant residual volumes. In another 10% of the women an in-dwelling catheter had to be used temporarily. There was no need for long term postoperative catheterisation (> 14 days). Post-operative evaluation was carried out after 2 to 6, 12, 24 and 36 months. According to the protocol, 86% of the women were completely cured and another 11% were significantly improved. No signs of deterioration of the results over time were observed. No defect in healing or rejection of the tape occurred. CONCLUSION: We consider the tension-free vaginal tape operation to be a safe and effective surgical procedure for the treatment of female urinary stress incontinence. The technique can be considered as an ambulatory procedure performed under local anaesthesia, allowing the majority of the women to be discharged from the clinic the same day or the day after the procedure.