Functional evaluation of a spiral neobladder with an angled chimney; A prospective randomized comparative study.

OBJECTIVES: to assess the functional outcome of performing ureteric re-implantation to an angled short chimney in a modified spiral orthotopic ileal neobladder. PATIENTS AND METHODS: From January 2018 to December 2020, 90 male patients with bladder cancer underwent radical cystectomy and spiral ileal neobladder reconstruction with a chimney. Patients were randomly divided in two groups according to the position of the chimney [straight and angled] to which the ureters will be implanted. Postoperative evaluation included clinical, laboratory, radiographic and urodynamic studies. RESULTS: There were no perioperative deaths. The mean operative time for the procedure was 4.7 ± 1.2 h in group I and 4.9 ± 1.3 h in group II (p 0.456). No intraoperative complications occurred. Early postoperative complications occurred in 8 patients. In group I, according to the modified Clavien system, GII complication occurred in 2 (5%) patients in the form of DVT in 1 (2.5%) and surgical site infection in 1 (2.5%). GIIIa occurred in 3 (7.5%) patients in the form of wound dehiscence. In group II, GII occurred in 2 (4.8%) patients in the form of prolonged urinary leakage and myocardial infarction, each occurred in one patient. GIIIb occurred in 1 (2.4%) patient in the form of intestinal leak. Poucho-ureteral reflux occurred in 10 patients [3 (7.5%) in group I and 7 (16.8%) in group II (p 0.001)]. CONCLUSIONS: The preliminary results of the right sided angled chimney during neobladder reconstruction are safe, acceptable, without an extra time to develop an anti-reflux technique and without an increased incidence of reflux.

Effect of lidocaine infusion on intraoperative bleeding during functional endoscopic sinus surgery: a randomized controlled trial.

BACKGROUND: It is crucial to reduce bleeding during functional endoscopic sinus surgery (FESS). Our primary goal was to evaluate the effect of intravenous lidocaine infusion (ILI) as an adjunct to the enhanced recovery after surgery (ERAS) protocols on intraoperative bleeding during FESS. We hypothesized that ILI could improve the surgical field. METHODS: Forty-three adult patients ASA I-II, 20-50 years old, undergoing FESS under general anesthesia were randomly assigned to receive immediately after induction of anesthesia either ILI 1.5 mg/kg as a bolus followed by 1.5 mg/kg/ h until the end of surgery (Group L) or normal saline (Group NL). Intraoperative blood loss, bleeding and surgeon satisfaction scores, mean arterial pressure (MAP), heart rate (HR), extubation and eye-opening times, and time to first analgesic request were recorded. RESULTS: Intraoperative bleeding and bleeding scores in the first 45 min after ILI were decreased, with better surgeon satisfaction in Group L (P<0.05). MAP and HR values were lower after ILI in Group L during surgery (P<0.05). Extubation and eye-opening times were shorter (P=0.001) and the time to first analgesic request was prolonged (P=0.001) in Group L than in Group NL. CONCLUSIONS: ILI decreased intraoperative blood loss and improved the surgical field visibility in the first 45 min during FESS.

Usage of Intravenous Lidocaine Infusion with Enhanced Recovery Pathway in Patients Scheduled for Open Radical Cystectomy: A Randomized Trial.

BACKGROUND: Intravenous lidocaine infusion (IVLI) reduces postoperative pain and hastens the return of bowel function. OBJECTIVES: We aimed to compare the effects of adding lidocaine infusion to enhanced recovery pathway (ERP) on acute rehabilitation protocol. STUDY DESIGN: This study uses a double-blind, randomized design with allocation concealment in a 2-armed parallel group format among patients undergoing open radical cystectomy (RC). SETTING: The study was conducted at Assiut University Hospital, Asyut, Egypt. The study duration was March 2017 to July 2018. METHODS: After ethics committee approval, 111 patients, American Society of Anesthesiologists (ASA) physical status II-III, aged 45-65 years, scheduled for open RC with urinary diversion under an ERP, were randomly selected in a double-blind manner to receive IVLI 2 mg/minute for 4 hours or an equal volume of normal saline solution 0.9%. Postoperative pain scores, rescue analgesic consumption, times to return of bowel sounds, first flatus, first defecation, resuming of regular diet, length of hospital stay, in-hospital complications, and patient satisfaction were recorded. RESULTS: Patients in the lidocaine group experienced significantly lower pain scores after surgery at 6 hours (P = 0.005) and 12 hours (P = 0.001) at rest, and in the first 18 hours during mobilization (P < 0.05), with less paracetamol (P = 0.04) and meperidine (P = 0.02) consumption than in the control group. Between the lidocaine and the control group, mean times to return of bowel sounds (23.7 vs. 26.7 hours; P = 0.001), first flatus (76.5 vs. 86.5 hours; P = 0.001), first defecation (92.7 vs. 106.9 hours; P = 0.001) and resuming of regular diet (80.7 vs. 92.8 days; P = 0.001) were significantly shorter in the lidocaine group. Length of hospital stay, in-hospital complications, and patient satisfaction were similar in both groups. LIMITATIONS: Limitations of this study include lack of previous research that compare the additive effects of IVLI to ERP in patients undergoing open RC. Also, the inability to measure the serum lidocaine concentration in our patients. CONCLUSIONS: Adding IVLI to ERP improved postoperative analgesia and bowel function after open RC with urinary diversion. CLINICAL TRIAL REGISTRATION: NCT03047057. KEY WORDS: Lidocaine infusion, ileus, enhanced recovery pathway, acute rehabilitation, open radical cystectomy.

Prophylactic granisetron for post-spinal anesthesia shivering in cesarean section: A randomized controlled clinical study.

BACKGROUND: The serotonergic system is known to be involved in control of post-anesthetic shivering. Our hypothesis was that prophylactic granisetrone (serotonin antagonist) might reduce incidence of post-spinal anesthesia shivering in cesarean section. METHODS: Parturient scheduled for elective cesarean delivery under spinal anesthesia were allocated to receive 0.9% saline (Group I, n = 71), 1 mg granisetron (Group II, n = 69), or 0.7 mg granisetron (Group III, n = 72) before the spinal block. Assessment parameters included; hemodynamics, tympanic membrane temperature, neonatal Apgar score, shivering score, patient satisfaction scores about shivering prophylaxis and adverse effects. RESULTS: Clinically significant shivering was recorded in 55/71 patients (77.5%) in group I, 11/69 (15.9%) in group II and 21/72 (29.2%) in group III (P = 0.000). The intensity of shivering was significantly lower in patients who received granisetron 1 mg compared with granisetron 0.7 mg or saline (P = 0.000). Patients who received prophylactic granisetron 1 mg reported lower mean intraoperative arterial pressure and heart rate values and consumed higher doses of iv ephedrine compared with 0.7 mg granisetron or saline placebo (P < 0.05). Pruritus significantly decreased from (22.5%) in control group to (0%) in granisetron groups (P = 0.000). Nausea was reported in 8 vs 10 and four in group I, II and III, respectively (P < 0.03). Sixteen vs eight and six patients vomited in group I, II, and III, respectively (P < 0.03). Higher patient satisfaction scores were recorded in group II (9.83 ± 0.29, P < 0.03) and III (9.14 ± 1.04, P < 0.04), compared with control group (8.23 ± 1.14). CONCLUSION: Prophylactic granisetron effectively reduced incidence and severity of perioperative shivering in a dose dependent manner, compared to placebo controls.

Health related quality of life after urinary diversion. Which technique is better?

OBJECTIVE: To compare quality of life (QoL) after urinary diversion (UD) following radical cystectomy (RC) using validated questionnaires. PATIENTS AND METHODS: Between January 2011 and June 2016, 150 patients (121 men [80.7%] and 29 women [19.3%]) with invasive bladder cancer who underwent RC and UD were included in this prospective study. Patients were divided into 2 groups; group I included the orthotopic neobladder 50 (33.3%) and uretro-sigmoidostomy 41 (27.3%) and group II included uretero-cutanoustomy 33 (22.1%) and ileal conduit 26 (17.3%) patients. QOL was evaluated using the Functional Assessment of Cancer Therapy-Bladder Cancer. The erectile function (EF) was assessed using the Sexual Health Inventory for Men Questionnaire. Evaluation was done before and after one year postoperatively. RESULTS: The mean ±â€¯SD patient age was 55.0 ±â€¯7.9 and 59.5 ±â€¯8.5 years in both groups, respectively (p = 0.001). There was a significant difference in the physical, social/family, emotional and functional statuses that were significantly higher in group I. One year postoperatively, the emotional well-being became insignificantly different, but other QoL parameters remained significantly different between both groups. Regarding EF, there was a significant difference between patients who underwent nerve-sparing (No. 29) and non nerve-sparing RC (No. 59) (p < 0.001). CONCLUSIONS: Which type of diversion is the best is still a controversial topic. Egyptian patients may prefer the continent UD to avoid the urostomy appliance and its associated daily-life constraints. Detailed patient counseling and active participation of the patient in selecting the treatment methods are important for better postoperative QoL.

Does the site of the orthotopic neobladder outlet matter? A prospective randomized comparative study.

BACKGROUND: To compare the results of urethral anastomosis to a button hole and to the lowest part of the anterior suture line during orthotopic neobladder substitution. METHODS: From January 2012 to December 2015, 87 consecutive male patients with invasive bladder cancer underwent radical cystectomy and Hautmann ileal neobladder. Patients were randomly divided into two groups; group I (44 patients), the outlet was created as a button-hole at the most dependent part of the pouch, group II (43 patients), the lowest 1 cm of the anterior suture line of the pouch was left open as an outlet. Patients were randomly assigned to either group using computer-generated random numbers (JMP, Version 12.0.1; SAS Institute, Cary, NC, USA) via a sealed envelope. The functional outcomes of both groups were compared especially at the urethro-enteric anastomosis. RESULTS: There were no intraoperative complications. Early postoperative complications occurred in 9 patients (5 in group I and 4 in group II, p = 0.484). Prolonged urinary leakage persisted for 11 and 14 days in 2 patients in group I and 10 and 16 days in 2 patients in group II. Delayed postoperative complications occurred in 11 patients (5 [12.5%] in group I and 6 [15.6%] in group II) (p = 0.711). Three patients developed urethro-enteric strictures (2 in group I and 1 in group II) (p = 0.571). CONCLUSION: The "non-hole" technique of urethral anastomosis was not associated with a significant increase in the complication rate when compared to the commonly performed "hole" technique.

Dexamethasone and Dexmedetomidine as an Adjuvant to Intraarticular Bupivacaine for Postoperative Pain Relief in Knee Arthroscopic Surgery: A Randomized Trial.

BACKGROUND: Knee arthroscopy causes minimal trauma, however, good analgesia is required for early rehabilitation and return to normal life in the patients. OBJECTIVE: We aimed to compare the analgesic effects of intraarticular dexamethasone and dexmedetomidine added to bupivacaine with those of bupivacaine alone. STUDY DESIGN: This study uses a double-blind, randomized, controlled design with allocation concealment in a 3-armed parallel group format among patients undergoing arthroscopic meniscal surgery. SETTING: The study was conducted at Assiut University Hospital in Asyut, Egypt. The study duration was from July 2016 to February 2017. METHODS: After the ethics committee approval, 60 patients, with the American Society of Anesthesiologists (ASA) physical status of I or II, 20 - 50 years old, and scheduled for arthroscopic meniscal surgery were randomized in a double-blind manner to receive 18 mL intraarticular bupivacaine 0.25% with either dexamethasone 8 mg (group I), dexmedetomidine 1 ug/kg (group II), or 2 mL of normal saline (group III). The total volume of injectate used in each group was 20 mL. All of the patients received spinal anesthesia. Postoperatively, oral paracetamol 1000 mg was given every 8 hours, and oral tramadol 50 mg was administered, as needed, for rescue analgesia. The visual analog scale (VAS) pain scores, time to first analgesic request, and total dose of postoperative analgesics were recorded for 3 days postoperatively. RESULTS: The VAS scores were lower in groups I and II compared with group III. The time to the first analgesic was significantly shorter in group III compared with groups I and II (P = 0.001). The total dose of rescue paracetamol was higher in group III compared with groups I and II (P = 0.001). No need for tramadol rescue analgesia was recorded in any of the groups. No significant differences between groups I and II were noticed. LIMITATIONS: The limitations of this study include the lack of previous research to compare the effect of both intraarticular dexamethasone and dexmedetomidine added to bupivacaine for postoperative analgesia in arthroscopic knee surgery. Additionally, there was a short observation period for the detection of chondrotoxicity, if occurred. CONCLUSION: The addition of dexamethasone or dexmedetomidine to a solution of bupivacaine 0.25% provided better analgesia than using bupivacaine alone. CLINICAL TRIAL REGISTRATION: NCT02818985. KEY WORDS: Intraarticular, knee arthroscopy, bupivacaine, dexmedetomidine, dexamethasone, postoperative pain.

Could acupuncture be an adequate alternative to dexamethasone in pediatric tonsillectomy?

BACKGROUND: Usage of nonpharmacological treatment contributes to an overall patient well-being, assisting in physical and emotional healing. Acupuncture has been reported to be useful in reducing early postoperative vomiting (POV) and attenuating postoperative pain. AIM: The aim of this study was to compare the effect of dexamethasone vs acupuncture at P6 bilaterally and CV13 on the incidence and severity of POV in children undergoing tonsillectomy with or without adenoidectomy. METHOD: One hundred and twenty children, ASA I-III aged 2-8 years undergoing elective tonsillectomy were included in this prospective randomized double-blind study. Children were randomly divided into two equal groups (60 each). At induction of anesthesia, the dexamethasone group received 0.15 mg·kg(-1) dexamethasone IV plus sham acupuncture, and the acupuncture group received acupuncture at P6 bilaterally and CV13 plus 2 ml of normal saline IV. Vomiting was recorded at 0-6, 6-24, and 0-24 h postoperatively. RESULTS: There was no difference in the incidence of vomiting between the acupuncture and dexamethasone groups. The mean difference in time to first oral intake (95% CI) was 4.3 (0.5-8.6) min between dexamethasone group and acupuncture group; P = 0.426. The mean difference in time until first vomit (95% CI) was 12 (9.5-13.8) min between both groups. No significant differences between Kaplan-Meier curves for time until first vomit (log-rank test) were obtained (P = 0.697). CONCLUSION: Acupuncture at P6 bilaterally and CV13 provided similar antiemetic effect to dexamethasone in children undergoing tonsillectomy.