RESUMEN
PURPOSE: Studies have shown that encountering an inguinal hernia during robotic radical prostatectomy is not uncommon. We reviewed our experience with simultaneous robotic prostatectomy and mesh hernia repair to identify variables predictive of a hernia. MATERIALS AND METHODS: Our cohort consisted of 693 consecutive men who underwent robotic radical prostatectomy as performed by 1 surgeon. Hernias were repaired with mesh composed of equal parts of absorbable polyglecaprone-25 and nonabsorbable polypropylene monofilament. Preoperative variables potentially predictive of an inguinal hernia were evaluated. RESULTS: Inguinal hernias were encountered in 55 of 639 patients (8.6%), of which 22.3% were bilateral for a total of 68 hernia sides. Only 26 of 55 hernias (47.2%) were evident preoperatively. Men with a preoperative I-PSS (International Prostate Symptom Score) of 15 or greater had a 22.4% chance (30 of 134) of requiring a hernia repair compared with 5% in those without such a score (OR 5.54, 95% CI 3.13-9.81, p <0.0001). There were no differences between the hernia and nonhernia groups in prostate size, body mass index, age, blood loss, transfusions, operative time, length of stay or any Clavien grade II-V complication. In 47 patients there was 1 recurrence at a median followup of 27.9 months. There were no cases of mesh associated pain or erosion. CONCLUSIONS: Independent of prostate size, men with preoperative lower urinary tract dysfunction were at 5 times the risk of a hernia at robotic radical prostatectomy (22.4% vs 5%). Given that half of the hernias were subclinical, patients with an I-PSS of 15 or greater should be counseled about the potential need for hernia repair at robotic radical prostatectomy.
Asunto(s)
Hernia Inguinal/cirugía , Herniorrafia/métodos , Prostatectomía/métodos , Neoplasias de la Próstata/cirugía , Procedimientos Quirúrgicos Robotizados/métodos , Anciano , Hernia Inguinal/complicaciones , Hernia Inguinal/diagnóstico , Herniorrafia/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Estudios Prospectivos , Próstata/patología , Próstata/cirugía , Prostatectomía/efectos adversos , Neoplasias de la Próstata/complicaciones , Procedimientos Quirúrgicos Robotizados/efectos adversos , Mallas Quirúrgicas/efectos adversosRESUMEN
INTRODUCTION: The management of patients with upper urinary tract obstruction who are not candidates for definitive reconstruction often presents a challenge. We report our initial experience with the Resonance (Cook Urological, Spencer, IN) metallic ureteral stent for the management of benign ureteral obstruction and present a comparative cost analysis of metallic to standard polymer stent use. METHODS: Data were retrospectively gathered on all patients undergoing metallic ureteral stent placement for benign causes from July 2007 to February 2009. Baseline demographics, previous method of drainage, pre- and postoperative creatinine levels, procedural complications, stent-related side effects, and metallic stent dwell time were recorded. The cost of stent maintenance for polymer and metallic stents for a 12-month interval was calculated for each patient. RESULTS: Fifteen stents were placed in 13 patients to manage obstruction due to a variety of benign etiologies. Metallic stents provided adequate drainage in 12/13 patients, but were discontinued prematurely in 3 patients (2 for voiding symptoms, 1 for hematuria). Eight patients had their metallic stents changed after a mean time of 11.6 months, with no encrustation. The yearly cost associated with polymer and metallic stent use was $23,999 and $11,183, respectively. This amounted to a $10,394 annual cost reduction (43%) for each patient. CONCLUSIONS: Metallic ureteral stents provide effective upper tract drainage for the majority of patients with benign upper tract obstruction, with significant cost benefit, largely because of the shorter exchange interval.
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Metales/economía , Stents/economía , Uréter/patología , Obstrucción Ureteral/economía , Obstrucción Ureteral/terapia , Adulto , Anciano , Anciano de 80 o más Años , Análisis Costo-Beneficio , Humanos , Persona de Mediana EdadRESUMEN
The Resonance metallic stent is a new wire-based ureteral stent that was initially developed for patients with malignant ureteral obstruction. Potential advantages over traditional stents include resistance to encrustation and to external compression, allowing for increased dwell times and the maintenance of upper tract drainage when traditional polymer stents have failed. We present a comparative cost analysis of Resonance metallic and standard polymer stent use in patients with benign urinary obstruction and review the literature regarding the Resonance stent.
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Metales/química , Stents , Obstrucción Ureteral/terapia , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Costos y Análisis de Costo , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Polímeros/química , Stents/economía , Adulto JovenRESUMEN
The removal of encrusted ureteral stents typically necessitates secondary treatment modalities, such as ureteroscopy, extracorporeal shock wave lithotripsy, or antegrade nephroscopy. We present a novel technique for the removal of minimally encrusted stents using a suture and a ureteral access sheath.
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Remoción de Dispositivos/métodos , Stents/efectos adversos , Uréter/cirugía , Femenino , Humanos , SuturasRESUMEN
PURPOSE: The aim of the study was to analyze the frequency and certain epidemiological characteristics of a consecutive series of conjoined twins born in Spain. MATERIAL AND METHODS: We used data from the Spanish Collaborative Study of Congenital Malformations for the period April 1976 to 2006. Because the Spanish law permitting voluntary termination of pregnancies (TOP) when the fetus presented malformations was effective by the end of 1985, we analyzed the data in 4 periods, 2 before 1986 and 2 after. During the first period (1976-1979) only live births were recorded, whereas both still and live births were included in the other three (1980-1985, 1986-1995, and 1996-2006). In the present study, the cases were classified as symmetrical (16 pairs) and asymmetrical (1 pair) conjoined twins. Each pair of conjoined twins was considered as only one case for calculations, regardless of the type of union. RESULTS: Among a total of 2,281,604 consecutive births between 1980 and 2006, there were a total of 15 cases of symmetrical conjoined twins giving a frequency of 0.70 per 100,000 (1/152,107), whereas there was only 1 stillborn asymmetrical conjoined twin pair (0.04/100,000). Among the 13,418 consecutive stillborns surveyed, 6 cases of conjoined twins were identified (either symmetrical or asymmetrical) giving a frequency of 44.72 per 100,000, and 11 pairs were identified among the 2,425,583 total live births surveyed during the first period 1976 to 1979, a frequency of 0.45 per 100,000. Thus, the frequency among stillborn infants is 99.34 times higher than that observed among live births. However, the frequency for the total births (3 last periods) showed a decreasing trend from 1.47 per 100,000 birth in the first period (1980-1985) when TOP was illegal, to a value of 0.09 per 100,000 in the last period, more than 16-fold lower, probably because of the TOP of affected fetuses. Therefore, we consider that the frequencies observed in the period 1980 to 1985 are the basal values in our population. The most frequent type observed was thoracopagus, with an overall prevalence at birth of 0.44 per 100,000 (1/228,160) from 1980 to 2006, representing 58.82% of the total population of symmetric conjoined twin pairs. Diprosopus pairs were the next most common group (11.76%). Most of the cases were females (4 males/11 females), and although this appeared to be mainly because of the thoracopagus pairs (males-females, 2:8), in such a small number of cases, it is not possible to determine the ratios for the other groups. Gestational age was significantly shorter than in control twins for each type studied. CONCLUSIONS: We conclude that it is incorrect to consider that all types of conjoined twins have the same epidemiological characteristics, such as the frequency at birth. The differences observed may be related with the distinct embryo-fetal mortality of each type of conjoined twins in different populations, and the sex ratio, among others.
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Anomalías Múltiples/epidemiología , Causas de Muerte , Mortinato/epidemiología , Gemelos Siameses/patología , Anomalías Múltiples/diagnóstico , Anomalías Múltiples/cirugía , Aborto Terapéutico , Femenino , Humanos , Incidencia , Recién Nacido , Masculino , Diagnóstico Prenatal , Sistema de Registros , Estudios Retrospectivos , España/epidemiología , Análisis de Supervivencia , Gemelos Siameses/fisiopatologíaRESUMEN
Achondroplasias are the most common genetic forms of dwarfism in humans. They are associated with activating mutations in FGFR3, which signal through the Stat and MAPK pathways in a ligand-independent manner to impair chondrocyte proliferation and differentiation. Snail1 has been implicated in chondrocyte differentiation as it represses Collagen II and aggrecan transcription in vitro. Here we demonstrate that Snail1 overexpression in the developing bone leads to achondroplasia in mice. Snail1 acts downstream of FGFR3 signaling in chondrocytes, regulating both Stat and MAPK pathways. Moreover, FGFR3 requires Snail1 during bone development and disease as the inhibition of Snail1 abolishes its signaling even through achondroplastic- and thanatophoric-activating FGFR3 forms. Significantly, Snail1 is aberrantly upregulated in thanatophoric versus normal cartilages from stillborns. Thus, Snail activity may likely be considered a target for achondroplasia therapies.