Use of preoperative embolization prior to Transplant nephrectomy.

INTRODUCTION: After a failed transplant, management of a non-functional graft with pain or recurrent infections can be challenging. Transplant nephrectomy (TN) can be a morbid procedure with the potential for significant blood loss. Embolization of the renal artery alone has been proposed as a method of reducing complications from an in vivo failed kidney transplant. While this does yield less morbidity, it may not address an infected graft or refractory hematuria or rejection. We elected to begin preoperative embolization to assess if this would help decrease the blood loss and transfusion rate associated with TN. MATERIALS AND METHODS: We performed a retrospective analysis of all patients who underwent non-emergent TN at our institution. Patients who had functioning grafts that later failed were included in analysis. TN was performed for recurrent infections, pain or hematuria. We evaluated for blood loss (EBL) during TN, transfusion rate and length of hospital stay. RESULTS: A total of 16 patients were identified. Nine had preoperative embolization or no blood flow to the graft prior to TN. The remaining 7 did not have preoperative embolization. The shortest time from transplant to TN was 8 months and the longest 18 years with an average of 6.3 years. Average EBL for the embolized patients (ETN) was 143.9cc compared to 621.4cc in the non-embolized (NETN) group (p=0.041). Average number of units of blood transfused was 0.44 in the ETN with only 3/9 patients requiring transfusion. The NETN patients had average of 1.29 units transfused with 5/7 requiring transfusion. The length of stay was longer for the ETN (5.4 days) compared to 3.9 in the NETN. No intraoperative complications were seen in either group and only one patient had a postoperative ileus in the NETN. CONCLUSION: Embolization prior to TN significantly decreases the EBL but does not significantly decrease transfusion rate. However, patients do require a significantly longer hospitalization with embolization due to the time needed for embolization. Larger studies are needed to determine if embolization before transplant nephrectomy reduces the transfusion rates and overall complications.

Use of preoperative embolization prior to transplant nephrectomy

ABSTRACT Introduction After a failed transplant, management of a non-functional graft with pain or recurrent infections can be challenging. Transplant nephrectomy (TN) can be a morbid procedure with the potential for significant blood loss. Embolization of the renal artery alone has been proposed as a method of reducing complications from an in vivo failed kidney transplant. While this does yield less morbidity, it may not address an infected graft or refractory hematuria or rejection. We elected to begin preoperative embolization to assess if this would help decrease the blood loss and transfusion rate associated with TN. Materials and Methods We performed a retrospective analysis of all patients who underwent non-emergent TN at our institution. Patients who had functioning grafts that later failed were included in analysis. TN was performed for recurrent infections, pain or hematuria. We evaluated for blood loss (EBL) during TN, transfusion rate and length of hospital stay. Results A total of 16 patients were identified. Nine had preoperative embolization or no blood flow to the graft prior to TN. The remaining 7 did not have preoperative embolization. The shortest time from transplant to TN was 8 months and the longest 18 years with an average of 6.3 years. Average EBL for the embolized patients (ETN) was 143.9cc compared to 621.4cc in the non-embolized (NETN) group (p=0.041). Average number of units of blood transfused was 0.44 in the ETN with only 3/9 patients requiring transfusion. The NETN patients had average of 1.29 units transfused with 5/7 requiring transfusion. The length of stay was longer for the ETN (5.4 days) compared to 3.9 in the NETN. No intraoperative complications were seen in either group and only one patient had a postoperative ileus in the NETN. Conclusion Embolization prior to TN significantly decreases the EBL but does not significantly decrease transfusion rate. However, patients do require a significantly longer hospitalization with embolization due to the time needed for embolization. Larger studies are needed to determine if embolization before transplant nephrectomy reduces the transfusion rates and overall complications.

Testosterone and the prostate: implications for the treatment of hypogonadal men.

Late-onset hypogonadism (LOH) and testosterone replacement therapy (TRT) are subjects of much recent research. Because aging men are at risk for benign prostatic hyperplasia (BPH) and prostate cancer, elucidating the relationship between testosterone and these diseases is crucial to ensure its safe administration. It is known that testosterone supplementation may worsen active prostate cancer and that its blockade or removal slows the disease's progression. However, recent studies have attempted to show that, in individuals in whom prostate cancer has been ruled out, TRT may simply restore serum testosterone levels to within normal limits without significant adverse affects on the prostate. Patients undergoing TRT should be monitored carefully for any evidence of prostatic disease.

Ontogenetic structural and material variations in ovine calcanei: a model for interpreting bone adaptation.

Experimental models are needed for resolving relative influences of genetic, epigenetic, and nonheritable functionally induced (extragenetic) factors in the emergence of developmental adaptations in limb bones of larger mammals. We examined regional/ontogenetic morphologic variations in sheep calcanei, which exhibit marked heterogeneity in structural and material organization by skeletal maturity. Cross-sections and lateral radiographs of an ontogenetic series of domesticated sheep calcanei (fetal to adult) were examined for variations in biomechanically important structural (cortical thickness and trabecular architecture) and material (percent ash and predominant collagen fiber orientation) characteristics. Results showed delayed development of variations in cortical thickness and collagen fiber orientation, which correlate with extragenetic factors, including compression/tension strains of habitual bending in respective dorsal/plantar cortices and load-related thresholds for modeling/remodeling activities. In contrast, the appearance of trabecular arches in utero suggests strong genetic/epigenetic influences. These stark spatial/temporal variations in sheep calcanei provide a compelling model for investigating causal mechanisms that mediate this construction. In view of these findings, it is also suggested that the conventional distinction between genetic and epigenetic factors in limb bone development be expanded into three categories: genetic, epigenetic, and extragenetic factors.

The orthopedist as clinical densitometrist: cost- and time-effectiveness.

We tested the hypothesis that an orthopedic surgeon and his or her staff can efficiently and economically provide a bone densitometry service. This hypothesis reflects a philosophy that orthopedists should take a more active role in identifying patients at risk for osteoporosis. We evaluated the cost- and time-effectiveness of an orthopedic surgeon and his medical assistant in completing reports and related correspondence for dual-energy x-ray absorptiometry scans conducted in an orthopedic subspecialty clinic. Cost analysis showed that completing 14 or 15 reports per month was required to break even and that completing up to 40 reports per month was a highly efficient and economic use of the surgeon's time.

Knowledge and opinions of orthopaedic surgeons concerning medical evaluation and treatment of patients with osteoporotic fracture.

BACKGROUND: With the exponential increase in osteoporotic fractures, orthopaedic surgeons are in a logical position to become more involved in the medical treatment of this disease. However, it has been hypothesized that surgeons may not be inclined to initiate such treatment if they do not view medical interventions as an extension of their surgical opportunities. The objective of this study was to determine the knowledge and opinions of orthopaedic surgeons with regard to their opportunities for initiating medical treatment of patients with an osteoporotic fracture. METHODS: A survey consisting of twenty-two questions was administered to 171 orthopaedic surgeons in Utah, Idaho, and Wyoming. RESULTS: Of the 171 surveys that were mailed, 107 usable surveys were returned (a 63% response rate). A majority of the orthopaedic surgeons thought that it was appropriate to expand their orthopaedic practice to include prescribing pharmacological treatments for osteoporosis (68% agreed or strongly agreed with that statement). However, 47% were concerned enough about adverse events related to some conventional pharmacological treatments that they would rather avoid prescribing them. Of the surgeons who were willing to prescribe these treatments, 74% felt most comfortable prescribing bisphosphonates and >77% felt most comfortable prescribing calcium and vitamin-D supplements. Fifty-one percent considered an apparent osteoporotic fracture and several other clinical risk factors for osteoporosis as sufficient evidence for initiating pharmacological treatments, whereas 72% thought that a bone-density scan should be made before initiating treatment. Although 32% thought that all nonoperative treatment should be the responsibility of a primary care provider, 63% thought that the orthopaedic surgeon should initiate a workup to look for secondary causes of the osteoporosis and should begin medical treatment of patients with an osteoporotic fracture before referring them. CONCLUSIONS: Although a majority of orthopaedic surgeons believe that they should expand their role in the medical treatment of patients with an osteoporotic fracture, many do not institute medical treatment and think that the patient's primary care providers should be responsible for medical care.