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1.
Urology ; 135: 171-172, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31589882

RESUMO

OBJECTIVE: To demonstrate how bladder ultrasound can be useful in completing morcellation during difficult Holmium Laser Enucleation of the Prostate (HoLEP). As HoLEP has emerged as a standard of care for the treatment of benign prostatic hyperplasia, multiple studies have reported the potentially catastrophic complication of bladder injury during morcellation. This video aims to assist any urologist performing HoLEP by providing step-by-step instruction for using ultrasound to complete morcellation safely. METHODS: Enucleation is performed using a 26-French continuous flow scope, off-set laser bridge with a laser stabilization catheter, and a 550 µm holmium laser fiber. Once the median and lateral lobes have been enucleated, the outer sheath is removed and the nephroscope is inserted to facilitate morcellation. Under dual inflow irrigation, the Piranha morcellator (Richard Wolf, Knittlingen, Germany) is introduced and set to the manufacturer's recommended settings of 1500 rpm. A 3.5-MHz convex abdominal ultrasound transducer (Hitachi Prosound Alpha 7; Hitachi Aloka Medical America, Wallingford, CT) under B-mode is used to visualize the bladder, predominantly in the sagittal orientation. Morcellation proceeds under simultaneous ultrasound and direct cystoscopic guidance. RESULTS: The distended bladder is visualized concurrently with the ultrasound and via the nephroscope as the Piranha engages the adenoma and begins morcellation. Once the adenoma is engaged, the operator then drops their hands to place the morcellator in the center of the bladder. Ultrasound provides real-time feedback as to the location of the morcellator in relation to the adenoma and bladder. CONCLUSION: This video highlights the use of intraoperative bladder ultrasound as a visual aid to assist during the morcellation portion of HoLEP. This proof of concept demonstrates that ultrasound can be an additional tool to utilize during difficult cases when cystoscopic visualization during morcellation is limited.


Assuntos
Complicações Intraoperatórias/prevenção & controle , Terapia a Laser/métodos , Morcelação/métodos , Prostatectomia/métodos , Bexiga Urinária/diagnóstico por imagem , Humanos , Complicações Intraoperatórias/etiologia , Terapia a Laser/efeitos adversos , Terapia a Laser/instrumentação , Lasers de Estado Sólido/efeitos adversos , Lasers de Estado Sólido/uso terapêutico , Masculino , Morcelação/efeitos adversos , Morcelação/instrumentação , Estudo de Prova de Conceito , Próstata/diagnóstico por imagem , Próstata/cirurgia , Prostatectomia/efeitos adversos , Prostatectomia/instrumentação , Hiperplasia Prostática/cirurgia , Ultrassonografia , Bexiga Urinária/lesões
2.
Urology ; 133: 245-246, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31376473

RESUMO

INTRODUCTION: Ultrasound guidance for percutaneous nephrolithotomy (PCNL) has gained acceptance amongst urologists given its numerous advantages over fluoroscopy. While traditionally performed in the prone position, this video demonstrates a step-by-step approach to performing PCNL in the supine position, solely under ultrasound guidance. MATERIALS AND METHODS: Once in the modified supine (Galdakao-modified Valdivia) position, important anatomic landmarks are identified. It is important to first orient the ultrasound probe such that its cranial side corresponds to the left of the ultrasound screen. After optimizing a target calyx, keeping the needle in the imaging plane of the probe facilitates renal access. Tract dilation under ultrasound guidance is then achieved by keeping the wire and dilators in the same imaging plane. RESULTS: The 11th and 12th ribs, paraspinous muscle, iliac crest, midaxillary line, and costal margin are the anatomic landmarks that orient the probe to the location of the kidney. Placing the ultrasound probe in the midaxillary line, parallel to the 11th rib allows the operator to identify key renal landmarks: the renal cortex, peri-pelvic fat, collecting system, kidney stone with its associated postacoustic shadow, and the intended target calyx. Controlling the needle is easiest in the longitudinal view, as the needle can be visualized from skin to target. Dilation under ultrasound relies on keeping the wire in view. The tip of the 10-French dilator is based on the location where the wire image disappears as the dilator advances. The balloon dilator tip is visualized on ultrasound reaching the appropriate depth just inside the collecting system, at which time balloon inflation results in complete dilation of the tract. CONCLUSIONS: This video provides a step-by-step approach demonstrating that PCNL can be performed in the supine position using only ultrasound-guidance. This approach facilitates renal access in this position and obviates the need for radiation exposure.


Assuntos
Nefrolitotomia Percutânea/métodos , Posicionamento do Paciente/métodos , Ultrassonografia de Intervenção , Dilatação , Humanos , Decúbito Dorsal
3.
J Endourol Case Rep ; 4(1): 133-135, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30131978

RESUMO

Background: Holmium laser enucleation of the prostate (HoLEP) has emerged as an accepted standard of care for the treatment of benign prostatic hyperplasia. This surgery relies on morcellation of the prostate adenoma once enucleation of the transition zone has been completed. Caution is required during this portion of the operation, as engaging bladder mucosa within the morcellator can result in bladder injury, a rare but potentially catastrophic complication of HoLEP. Morcellation of the prostatic tissue can be additionally challenging if visualization is poor from either equipment failure or increased bleeding from a highly vascularized prostate. Case Presentation: We report the case of a 66-year-old Caucasian man with an estimated 158 g prostate who underwent HoLEP at our institution. Enucleation was uneventful; however, upon placement of the nephroscope to begin morcellation, it was immediately evident that the lens of the nephroscope was damaged as there was extremely poor visualization. Without a replacement nephroscope available, this would have normally resulted in aborting the case and returning another day to complete the morcellation. Concurrent bladder ultrasonography was performed and allowed for additional visual feedback to the operator, helping guide the morcellator to safely engage the enucleated adenoma and complete the operation. Conclusion: This case report demonstrates the ability of performing the morcellation portion of HoLEP mainly with the visualization provided by concurrent bladder ultrasonography. By providing additional imaging feedback to the operator, ultrasound can be a complementary tool to assist in safely performing morcellation in situations of suboptimal cystoscopic visualization during HoLEP.

5.
J Urol ; 197(3 Pt 1): 710-714, 2017 03.
Artigo em Inglês | MEDLINE | ID: mdl-27773846

RESUMO

PURPOSE: In the emergency department ultrasonography is emerging as an alternative to computerized tomography for diagnosing patients with nephrolithiasis. In this multicenter randomized clinical trial we examined rates of urological referral and intervention to elucidate whether the initial diagnostic imaging modality affected the management of nephrolithiasis. MATERIALS AND METHODS: Patients 18 to 76 years old who presented to the emergency department with renal colic across 15 diverse treatment centers were randomized to receive abdominal ultrasonography by an emergency department physician or a radiologist, or abdominal computerized tomography. We analyzed the 90-day followup for patients diagnosed with nephrolithiasis to assess subsequent urological evaluation, procedure type and time to intervention. RESULTS: Of 1,666 patients diagnosed with nephrolithiasis in the emergency department 241 (14.5%) had a consultation with urology at initial presentation, 503 (30%) saw a urologist in followup and 192 (12%) underwent at least 1 urological procedure. Median time to outpatient procedure and type of procedure performed did not vary significantly among imaging groups. Most patients (78%) had computerized tomography performed before elective intervention. Patients with ultrasonography performed by an emergency department physician were 2.6 times more likely to undergo computerized tomography before intervention than those who had ultrasonography performed by a radiologist. CONCLUSIONS: Patients undergoing a urological intervention who had ultrasonography as initial imaging do not experience a significant delay to intervention or different procedure types, but the majority ultimately undergoes computerized tomography before surgery. Formal ultrasonography by a radiologist may encourage less computerized tomography preoperatively.


Assuntos
Serviço Hospitalar de Emergência , Cálculos Renais/diagnóstico por imagem , Cálculos Renais/cirurgia , Encaminhamento e Consulta , Tomografia Computadorizada por Raios X , Ultrassonografia , Adolescente , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Tempo para o Tratamento , Adulto Jovem
6.
J Urol ; 192(2): 524-9, 2014 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-24518769

RESUMO

PURPOSE: This study was designed to assess perceptions of untreated hypospadias and quality of life in culturally disparate low or middle income countries, to highlight the demographic and care differences of patient groups treated for hypospadias in the surgical workshop context, and to evaluate the long-term outcomes achieved by these workshop groups. MATERIALS AND METHODS: Family member perceptions of hypospadias, perioperative process measures and urethrocutaneous fistula rates were compared between 60 patients from Vietnam and Senegal treated for hypospadias through training workshops by local surgeons and pediatric urologists from the U.S. between 2009 and 2012, of whom approximately 42% had previously undergone repair attempts. RESULTS: More than 90% of respondents surveyed believed that untreated hypospadias would affect the future of their child at least to some degree. Patient cohorts between the 2 sites differed from each other and published high income country cohorts regarding age, weight for age and frequency of reoperation. Telephone based outcomes assessment achieved an 80% response rate. Urethrocutaneous fistula was reported in 39% and 47% of patients in Vietnam and Senegal, respectively. CONCLUSIONS: Family members perceived that the social consequences of untreated hypospadias would be severe. Relative to patient cohorts reported in practices of high income countries, our patients were older, presented with more severe defects, required more reoperations and were often undernourished. Urethrocutaneous fistula rates were higher in cohorts from low or middle income countries relative to published rates for cohorts from high income countries. Our study suggests that outcomes measurement is a feasible and essential component of ethical international health care delivery and improvement.


Assuntos
Atitude Frente a Saúde , Hipospadia/cirurgia , Qualidade de Vida , Adolescente , Criança , Pré-Escolar , Estudos de Coortes , Características Culturais , Humanos , Lactente , Internacionalidade , Masculino , Resultado do Tratamento
7.
PLoS One ; 7(4): e34595, 2012.
Artigo em Inglês | MEDLINE | ID: mdl-22558089

RESUMO

BACKGROUND: Although advances in the reduction of maternal mortality have been made, up to 273,000 women will die this year from obstetric etiologies. Obstructed labor (OL), most commonly treated with Caesarean delivery, has been identified as a major contributor to global maternal morbidity and mortality. We used economic and epidemiological modeling to estimate the cost per disability-adjusted life-year (DALY) averted and benefit-cost ratio of treating OL with Caesarean delivery for 49 countries identified as providing an insufficient number of Caesarean deliveries to meet demand. METHODS AND FINDINGS: Using publicly available data and explicit economic assumptions, we estimated that the cost per DALY (3,0,0) averted for providing Caesarean delivery for OL ranged widely, from $251 per DALY averted in Madagascar to $3,462 in Oman. The median cost per DALY averted was $304. Benefit-cost ratios also varied, from 0.6 in Zimbabwe to 69.9 in Gabon. The median benefit-cost ratio calculated was 6.0. The main limitation of this study is an assumption that lack of surgical capacity is the main factor responsible for DALYs from OL. CONCLUSIONS: Using the World Health Organization's cost-effectiveness standards, investing in Caesarean delivery can be considered "highly cost-effective" for 48 of the 49 countries included in this study. Furthermore, in 46 of the 49 included countries, the benefit-cost ratio was greater than 1.0, implying that investment in Caesarean delivery is a viable economic proposition. While Caesarean delivery alone is not sufficient for combating OL, it is necessary, cost-effective by WHO standards, and ultimately economically favorable in the vast majority of countries included in this study.


Assuntos
Cesárea/economia , Modelos Econômicos , Complicações do Trabalho de Parto/epidemiologia , Complicações do Trabalho de Parto/cirurgia , Análise Custo-Benefício , Países em Desenvolvimento , Feminino , Humanos , Gravidez
9.
Blood ; 114(8): 1553-62, 2009 Aug 20.
Artigo em Inglês | MEDLINE | ID: mdl-19542300

RESUMO

Human immunodeficiency virus-1 subtypes A and C differ in the highly conserved Gag-TL9 epitope at a single amino acid position. Similarly, the TL9 presenting human leukocyte antigen (HLA) class I molecules B42 and B81 differ only at 6 amino acid positions. Here, we addressed the influence of such minor viral and host genetic variation on the TL9-specific CD8 T-cell response. The clonotypic characteristics of CD8 T-cell populations elicited by subtype A or subtype C were distinct, and these responses differed substantially with respect to the recognition and selection of TL9 variants. Irrespective of the presenting HLA class I molecule, CD8 T-cell responses elicited by subtype C exhibited largely comparable TL9 variant cross-recognition properties, expressed T-cell receptors that used almost exclusively the TRBV 12-3 gene, and selected for predictable patterns of viral variation within TL9. In contrast, subtype A elicited TL9-specific CD8 T-cell populations with completely different, more diverse TCRBV genes and did not select for viral variants. Moreover, TL9 variant cross-recognition properties were extensive in B81(+) subjects but limited in B42(+) subjects. Thus, minor viral and host genetic polymorphisms can dramatically alter the immunologic and virologic outcome of an epitope-specific CD8 T-cell response.


Assuntos
Linfócitos T CD8-Positivos/imunologia , Epitopos de Linfócito T/genética , HIV-1/genética , HIV-1/imunologia , Antígenos de Histocompatibilidade Classe I/genética , Polimorfismo Genético/fisiologia , Sequência de Aminoácidos , Linfócitos T CD8-Positivos/metabolismo , Análise Mutacional de DNA , DNA Viral/análise , DNA Viral/genética , Epitopos de Linfócito T/imunologia , Feminino , Infecções por HIV/genética , Infecções por HIV/imunologia , Interações Hospedeiro-Patógeno/genética , Interações Hospedeiro-Patógeno/imunologia , Humanos , Receptores de Antígenos de Linfócitos T/genética , Homologia de Sequência de Aminoácidos , Especificidade do Receptor de Antígeno de Linfócitos T/genética , Especificidade do Receptor de Antígeno de Linfócitos T/imunologia , Proteínas Virais/genética , Proteínas Virais/imunologia
10.
J Exp Med ; 206(4): 923-36, 2009 Apr 13.
Artigo em Inglês | MEDLINE | ID: mdl-19349463

RESUMO

Despite the pressing need for an AIDS vaccine, the determinants of protective immunity to HIV remain concealed within the complexity of adaptive immune responses. We dissected immunodominant virus-specific CD8(+) T cell populations in Mamu-A*01(+) rhesus macaques with primary SIV infection to elucidate the hallmarks of effective immunity at the level of individual constituent clonotypes, which were identified according to the expression of distinct T cell receptors (TCRs). The number of public clonotypes, defined as those that expressed identical TCR beta-chain amino acid sequences and recurred in multiple individuals, contained within the acute phase CD8(+) T cell population specific for the biologically constrained Gag CM9 (CTPYDINQM; residues 181-189) epitope correlated negatively with the virus load set point. This independent molecular signature of protection was confirmed in a prospective vaccine trial, in which clonotype engagement was governed by the nature of the antigen rather than the context of exposure and public clonotype usage was associated with enhanced recognition of epitope variants. Thus, the pattern of antigen-specific clonotype recruitment within a protective CD8(+) T cell population is a prognostic indicator of vaccine efficacy and biological outcome in an AIDS virus infection.


Assuntos
Linfócitos T CD8-Positivos/imunologia , Produtos do Gene gag/imunologia , Síndrome de Imunodeficiência Adquirida dos Símios/imunologia , Animais , Produtos do Gene gag/genética , Variação Genética , Imunização , Macaca mulatta , Fenótipo , Vírus da Imunodeficiência Símia , Linfócitos T/imunologia , Vacinação/veterinária , Vacinas Virais/imunologia
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