RESUMEN
PURPOSE: Ureteral access sheaths are commonly used during ureteroscopy to facilitate stone removal, improve visibility and maintain low intrarenal pressures. However, the use of a ureteral access sheath can cause ureteral wall ischemia and ureteral tears, potentially increasing the risk of postoperative ureteral stricture and obstruction. We studied the impact of ureteral access sheath use on postoperative imaging studies. Secondary objectives included studying the impact of other intraoperative parameters on postoperative imaging studies. MATERIALS AND METHODS: A retrospective chart review was conducted of cases that underwent ureteroscopy for nephroureterolithiasis across 2 high volume institutions between January 2012 and September 2016. Patient demographics, cumulative stone size, operative time, use of ureteral access sheath, laser lithotripsy, basket extraction, preoperative ureteral stent and postoperative ureteral stent placement were extracted from the electronic medical record. Findings of followup renal ultrasound, kidney-ureter-bladder x-ray and/or computerized tomography at approximately 8 weeks after surgery were recorded. RESULTS: A total of 1,332 ureteroscopies were performed with 1,060 cases (79.6%) returning for routine upper tract imaging after ureteroscopy. Postoperative hydronephrosis was noted following 127 cases (12.0%). Factors predicting presence of hydronephrosis after ureteroscopy include lower body mass index (p=0.0016), greater cumulative stone size (p=0.0003), increased operative time (p <0.0001), preoperative ureteral stent (OR 1.49, p=0.0299) and postoperative ureteral stent placement (OR 6.43, p=0.0031). Postoperative hydronephrosis was not associated with use of ureteral access sheath, age, laser lithotripsy or basket extraction. CONCLUSIONS: Use of ureteral access sheath did not have a significant impact on development of postoperative hydronephrosis, suggesting ureteral access sheath is safe for use during ureteroscopy. Ureteral strictures remain rare following ureteroscopy, seen in only 1.0% of our cohort. With an observed prevalence of hydronephrosis of 12.0% on followup imaging at 8 weeks, routine upper tract imaging after ureteroscopy remains a valuable prognostic tool.
Asunto(s)
Hidronefrosis/epidemiología , Complicaciones Posoperatorias/epidemiología , Ureteroscopios/efectos adversos , Ureteroscopía/efectos adversos , Urolitiasis/cirugía , Adulto , Anciano , Índice de Masa Corporal , Femenino , Estudios de Seguimiento , Humanos , Hidronefrosis/diagnóstico por imagen , Hidronefrosis/etiología , Incidencia , Masculino , Persona de Mediana Edad , Tempo Operativo , Complicaciones Posoperatorias/diagnóstico por imagen , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Factores de Riesgo , Stents/efectos adversos , Tomografía Computarizada por Rayos X , Ureteroscopía/instrumentaciónRESUMEN
INTRODUCTION AND OBJECTIVE: Supracostal access in percutaneous nephrolithotomy (PCNL) may be avoided due to concern for thoracic complications. The objective of the study is to report the safety and efficacy of supracostal access utilizing a tubeless (stent only) PCNL technique. PATIENTS AND METHODS: Retrospective review of perioperative outcomes of 70 patients (76 renal units) who underwent a supracostal tubeless PCNL. No nephrostomy tubes were left. All patients had a 7F ureteral stent and Foley catheter placed. The nephrostomy sheath was removed with the patient held in end-expiration, and the incision closed. RESULTS: Median (IQR) age was 62 (48.3-67) years. Median stone size was 20 × 21 mm, and 14 (18%) patients had complete staghorn stones. The upper calyx was the site of access in 52 (68.4%) cases. Access was above the 12th and 11th rib in 63 (83%) and 12 (16%) cases, respectively. Median (IQR) length of stay was 30 (28-32) hours. Fifty (68.5%) patients had no residual fragments (< 2 mm) on postoperative imaging. Eight (11%) patients underwent an ancillary procedure (7 URS and 1 ESWL), with an additional seven patients becoming stone free after this procedure (78%). Thoracic complications occurred in two (2.6%) patients: one small pneumothorax, and one pleural effusion, both managed conservatively. Other complications occurred in nine patients (11.8%): bleeding requiring transfusion (1), fever (4), urinary retention (2), and syncope (2). CONCLUSION: Compared to historical controls, our approach to upper tract PCNL utilizing a nephrostomy tube-free approach resulted in an overall low thoracic complication rate and facilitated hospital discharge.
Asunto(s)
Cálculos Renales/cirugía , Nefrolitotomía Percutánea/métodos , Complicaciones Posoperatorias/epidemiología , Anciano , Femenino , Humanos , Cálices Renales/cirugía , Masculino , Persona de Mediana Edad , Derrame Pleural/epidemiología , Neumotórax/epidemiología , Estudios Retrospectivos , Cálculos Coraliformes/cirugía , Stents , Uréter , Cateterismo UrinarioRESUMEN
During laser lithotripsy, energy is transmitted to both the stone and the surrounding fluid. As the energy is delivered, the temperature will rise. Temperatures ≥60 ° C can cause protein denaturation. The objective of this study is to determine the time it takes from body temperature (37°C) to 60°C at various laser power settings. A Flexiva TracTip 200 optical fiber was submerged alongside a negative temperature coefficient-type thermistor in 4 mL of saline in a glass test tube. A Lumenis VersaPulse Powersuite 100-W holmium:yttrium aluminum garnet laser was activated at 0.2- to 1.5-J pulse energies, 6- to 50-Hz frequencies, and 2- to 22.5-W average power. Temperature readings were recorded every second from 37°C until 60°C. Time and heating rate were measured. The procedure was repeated three times for each setting. Average time from 37°C to 60°C for settings (1) 0.2 J/50 Hz, (2) 0.6 J/6 Hz, (3) 1 J/10 Hz, and (4) 1.5 J/10 Hz was 60.3, 172.7, 58, and 43.3 s, respectively. Time from 37°C to 60°C decreased as frequency increased for every given pulse energy. Average heating rate increased proportionally to power from 0.06°C/s at 2 W to 0.74°C/s at 22.5 W. During laser lithotripsy, there is a rapid increase in the temperature of its surrounding fluid and temperatures ≥60 ° C may be reached. This could have local tissue effects and some caution with higher power settings should be employed especially where irrigation is limited. Further studies incorporating irrigation and live tissue models may aid to further define the risks.
Asunto(s)
Calor , Cálices Renales/efectos de la radiación , Láseres de Estado Sólido , Litotripsia por Láser/métodos , Modelos Biológicos , Calorimetría , Humanos , Cálculos RenalesRESUMEN
PURPOSE: Testosterone replacement therapy is commonly used to treat men with hypogonadism. However, there has been caution in using testosterone replacement therapy in men with moderate to severe lower urinary tract symptoms for fear of worsening the symptoms. In this study we examine the effect of testosterone replacement therapy on lower urinary tract symptoms in hypogonadal men. MATERIALS AND METHODS: We retrospectively reviewed our outpatient database and identified patients with a diagnosis of hypogonadism who received testosterone replacement therapy from 2002 to 2012. Lower urinary tract symptoms were assessed using the AUASI (American Urological Association symptom index) before and after testosterone replacement therapy. Testosterone and prostate specific antigen were also continuously measured, and all patients were closely monitored for side effects of testosterone replacement therapy. Patients who had progression of lower urinary tract symptoms to the point of requiring surgery were included in the study. RESULTS: We identified 120 hypogonadal men who received testosterone replacement therapy, the majority of whom had topical therapy or a combination of topical and pellet based therapy (57.5% and 20.8%, respectively). Mean baseline AUASI (±SD) was 10.8 (±7.8) and mean duration of testosterone replacement therapy was 692 days (±773). Mean change in AUASI was -1.07 (±6.06). Mean baseline prostate specific antigen was 1.6 ng/dl (±1.9) and mean change in prostate specific antigen was 0.44 (±2.2). Of the patients 8.1% had a baseline prostate specific antigen greater than 4.0 ng/dl, and these patients had greater improvement in AUASI than those with a baseline prostate specific antigen less than 4.0 ng/dl (-1.9 vs -1.0, p not significant). Overall 45.8% of patients had a less than 3-point change in AUASI in either direction. Of the 120 patients 38 (31.7%) had improvement in AUASI 3 or more points while 27 (22.5%) had worsening of AUASI 3 or more points. Patients with an improved AUASI had a mean prostate specific antigen change of 0.3 (±3.4), while those who had worsening of AUASI had a mean prostate specific antigen change of 0.7 (±2.2) (p not significant). Approximately 9 of 120 (7.5%) of these men initiated new medications for lower urinary tract symptoms during the course of the study. There was no significant change in AUASI compared to patients without any use of lower urinary tract symptoms medications. In addition, 4 (3.3%) patients had progression of lower urinary tract symptoms and required transurethral resection of the prostate. CONCLUSIONS: We demonstrate that initiating testosterone replacement therapy in hypogonadal men involves a low risk of worsening lower urinary tract symptoms. In fact, many men experience symptom improvement while changes in prostate specific antigen appear minor. Future research should focus on larger patient population studies to further examine this relationship.
Asunto(s)
Terapia de Reemplazo de Hormonas/efectos adversos , Síntomas del Sistema Urinario Inferior/inducido químicamente , Testosterona/efectos adversos , Progresión de la Enfermedad , Humanos , Hipogonadismo/tratamiento farmacológico , Masculino , Persona de Mediana Edad , Antígeno Prostático Específico , Estudios Retrospectivos , Testosterona/uso terapéuticoRESUMEN
OBJECTIVES: Timely transfer of injured children to pediatric trauma centers (PTCs) that can address their unique needs is important. This study was designed to understand the characteristics of transferred injured children. METHODS: Data from our level I PTC over 5 years (2002-2006) were reviewed. Transferred patients were divided based on time from injury to arrival at our PTC: early (<2 hours) and late (>2 hours). Data collected included demographics, Injury Severity Scale score, Glasgow Coma Scale score, mode of transportation, referring hospital information including pretransfer imaging, and disposition from our emergency room. RESULTS: Seven hundred forty-eight patients were included. Eighty-two percent (n = 612) were in the late group and arrived, on average, 6 hours after those transferred early (420 vs 69.9 minutes, P < 0.05). Seventy-nine percent (n = 147) of transfers with severe injuries (Injury Severity Scale score >15) and 47% (n = 15) of those with severe head injuries (Glasgow Coma Scale score <8) arrived late. The disproportionate number of late transfers was consistent among all transferring hospitals regardless of distance and only slightly improved in the group transferred by air ambulance. In addition, those transferred late had significantly more pretransfer imaging (49% vs 23%, P = 0.0025). CONCLUSIONS: Despite the advantages of care in trauma centers, a significant number of severely injured children are transferred well beyond 2 hours after injury. This study has demonstrated that this pattern of delayed transfer is a systemic problem occurring among all transferring hospitals regardless of distance or mode of patient transfer and is associated with increased use of imaging before transfer.