RESUMEN
Klinefelter syndrome (KS) is a common disorder and almost every clinician in almost every sub-specialty of medicine will knowingly or unwittingly treat boys or men with a 47,XXY chromosomal constitution. Although there are numerous aspects of KS worthy of discussion, this contribution will focus specifically on the controversial, and as yet unresolved, issue of whether it is advantageous to harvest testis tissue from peri-pubertal or adolescent boys with KS in a heroic effort to preserve that child's chances of reproduction in his future adult life. What would be the rationale for that, how does the biology of spermatogenesis in the Klinefelter testis impact that decision, and what does the data show? The answer, assembled from a selection of seemingly disparate sources and directions, appears to be "No". We do not have to advocate for an aggressive approach, we do not have to preemptively preserve future fertility. We can justifiably wait until adulthood with equivalent chances of success.
RESUMEN
INTRODUCTION: We surveyed U.S. urology trainees to determine current prescribing practices after common endourological procedures. METHODS: An institutional review board approved, 22-item survey was distributed to all U.S. urology residents through the Society of Academic Urologists. The survey was divided into demographics including American Urological Association section, prescribing patterns after ureteroscopy, shockwave lithotripsy, percutaneous nephrolithotomy and transurethral prostate procedures, as well as attitudes surrounding opioid prescription. RESULTS: A total of 148 U.S. urology residents completed the survey (response rate 13%). All American Urological Association sections were represented, including Northeastern (12.8%), New England (8.1%), New York (6.1%), Mid-Atlantic (3.4%), Southeastern (19.6%), North Central (29.05%), South Central (10.1%) and Western (10.8%). By procedure, 72.3% of respondents prescribe opioids after ureteroscopy, 37.8% after shockwave lithotripsy, 93.9% after percutaneous nephrolithotomy, and 53.4% after transurethral prostate procedures. By procedure, the average number of tablets prescribed, were 7.5 (range 0-30) for ureteroscopy, 4.2 (0-20) for shockwave lithotripsy, 14.1 (0-40) for percutaneous nephrolithotomy and 6.7 (0-30) for transurethral prostate procedures. The average number of tablets prescribed by region varied significantly for ureteroscopy, percutaneous nephrolithotomy and transurethral prostate procedures (all p <0.0001), but did not vary significantly for shockwave lithotripsy (p=0.067). CONCLUSIONS: Opioid prescribing practices among U.S. urology residents for common urological procedures varied by regional American Urological Association section, and attitudes surrounding opioid dispensing influenced prescription patterns. While attitudes regarding opioid prescriptions after urological surgery are improving, residents may benefit from additional training, best practice policies and/or society guidelines.
RESUMEN
INTRODUCTION: Classic surgical teaching advocates for closure of the mesenteric defect (MD) after bowel anastomosis but the necessity is controversial. We sought to evaluate the necessity of MD closure at the time of harvest of ileum for genitourinary reconstructive surgery (GURS) by analyzing the incidence of early and late gastrointestinal adverse events (GIAE) in patients with and without MD closure. MATERIALS AND METHODS: A retrospective review was conducted on patients undergoing urologic reconstruction with ileum to identify incidence of ileus, small bowel obstruction (SBO), gastrointestinal (GI) fistula and stoma complications. Patient and procedure variables were analyzed to identify risk factors for GIAE. RESULTS: A total of 288 patients met inclusion criteria and 93% of GURS was for urinary diversion following cystectomy. MD was closed in 194 cases (67%). Median follow up was 19 months. Early (< 30 day) GIAE rates were 16.5% (n = 32) and 21.3% (n = 20) in the closure and non-closure groups, respectively (p = 0.22). The rate of early ileus/SBO requiring nasogastric tube decompression or laparotomy were similar after closure (15.0%) and non-closure (21.3%) (p = .18). The late GIAE rates were 5.7% (n = 11) and 6.4% (n = 6) in the closure and non-closure cohorts, respectively (p = 0.56). The rate of late SBO were similar and no cases of early or late SBO in either cohort were due to internal herniation. On multivariate analysis, increasing BMI was associated with both early and late GIAE. CONCLUSIONS: After harvesting ileum for urologic reconstruction, the MD can safely be left open as we found no association between non-closure and early or late GIAE..