Over the years, Dorsal Inlay Graft (DIG) urethroplasty has gained worldwide acceptance for primary hypospadias repair. However, its safety and effectiveness for revision surgery are yet to be proven.
...The aim of the study is to assess and compare complication rates and functional outcomes of DIG surgery in revision versus primary hypospadias repair.
We carried out a retrospective analysis of data collected from 53 consecutive DIG urethroplasties performed by a single surgeon at our institution. Patients were stratified in two groups – primary repair and redo-urethroplasty. For each group, we recorded standard pre-operative characteristics, surgical technicalities, complication rates and uroflowmetry parameters.
Out of 53 DIG urethroplasties, 21 (39.6 %) where primary and 32 (60.4 %) were re-do. As expected, the two groups differed for median age at surgery: 20 months for primary and 68.5 months for revision surgery (p < 0.001). Additionally, all 21 (100 %) primary interventions were performed with a preputial graft, whereas among revision DIG urethroplasties only 2 (6.3 %) where preputial and 30 (93.8 %) were buccal (p < 0.001). Catheterization time (7 vs 8 days, p = 0.155) and postoperative complication rates (14.3 % vs 9.4 %, p = 0.581) were comparable between the primary and revision surgery group, respectively (all p > .05). Forty-two of the 53 patients underwent uroflowmetry during follow-up. Of these, 19 (63 %) patients presented with abnormal uroflowmetry and 11 (37 %) had equivocal parameters with no difference between the two groups.
Dorsal Inlay Graft urethroplasty has long been known to be safe and effective for primary hypospadias repair. On the other hand, data on dorsal inlay graft urethroplasty as a salvage surgery after primary hypospadias repair failure is scarce. Surprisingly, according to our findings, surgical outcomes and complication rates are comparable between primary and revision hypospadias cases. Additionally, our results in the redo group are absolutely encouraging if compared to those reported in the literature for the same subset of patients.
According to our findings, DIG urethroplasty is a safe and effective option to treat revision hypospadias repair.
Endoscopic retrograde cholangiopancreatography (ERCP) is usually performed with the patient lying in the prone position, on the assumption that this position is optimal for cannulation of the papilla ...and for obtaining good-quality radiographic images. The supine position, however, may be more comfortable for the patient and may facilitate airway management, and this study aimed to compare the two positions in terms of procedure outcome, safety, and patient tolerance.
Consecutive patients who were undergoing ERCP were randomized to start the procedure in either the prone position or the supine position. Patients under the age of 18 years, intubated patients, and those who had already undergone endoscopic sphincterotomy were excluded. The difficulty of cannulation was assessed using the Freeman score (1=one to five attempts; 2=six to 15 attempts; 3=more than 15 attempts; 4=failure of cannulation). Total procedure time, patient tolerance, willingness to undergo ERCP in the future, and procedure-related adverse cardiorespiratory events (oxygen desaturation, tachycardia, bradycardia) were also recorded.
A total of 34 patients were evaluated (21 men, 13 women; mean age 68, range 20-96), 17 patients in each group. Demographic and clinical features, and the indications for the procedure were similar for the two patient groups. The median Freeman score was significantly lower in the prone group compared with the supine group (1 vs. 3, P=0.0047, rank sum test). Biliary cannulation was achieved in all patients in the prone group, but was not achieved in five patients (29%) in the supine group (P=0.052). In four of these five patients, biliary cannulation was successfully achieved after turning the patient into the prone position. The percentage of patients unwilling to repeat the ERCP procedure in the future was higher in the supine group (29% vs. 6%, P=0.087); the mean tolerance score and mean total procedure time were similar in the two groups. Seven patients in the supine group experienced at least one adverse cardiorespiratory event, compared with only one patient in the prone group (41% vs. 6%, P=0.039).
ERCP performed with the patient in the supine position is technically more demanding for operators used to working with patients in the prone position and carries a greater risk of adverse cardiorespiratory events in nonintubated patients.
Robotic technology has gained popularity allowing performance of several complex and difficult reconstructive procedures. This video demonstrates the advantages of the robotic approach for a “keel” ...bladder neck construction in an obese patient.
A 13 year-old-girl (BMI = 28) already treated elsewhere for a uro-genital sinus (Total Urogenital Mobilization) has been evaluated for disturbing persistent total urinary incontinence. Cisto-colposcopy revealed an extremely short and tortuous urethra. Bladder neck was wide open and incompetent. Video-Urodynamic evaluation showed a bladder with a capacity of 280 mL with low voiding pressures (14–16 cmH20) and continuous urinary leakage. MAG3 scan confirmed normal renal function. Thus, the girl underwent a laparoscopic robotic-assisted “keel” bladder neck construction.
The patient was discharged on 5th post-operative day without complications. After 4 years she is voiding spontaneously (300 cc) without post-void residuals. She has presented a persistent mild stress incontinence successfully treated with subsequent endoscopic bulking agent injection.
Robotic access to the bladder neck region is an excellent option with ideal anatomical exposure compared to conventional open surgery, especially in obese patients. The “keel” procedure allows to reconfigure and tubularize a wide and incompetent bladder neck creating a continent funnel without the absolute need of concomitant ureteric reimplantation.
Abstract Background and aim Inadequate disinfection of endoscopes and associated instrumentation can result in transmission of infections to patients. The aim of this study is to assess cleaning and ...disinfection practice in gastrointestinal endoscopy units in public and private institutions in the Lombardy region. Methods We drafted a questionnaire which we e-mailed to all gastrointestinal centers in Lombardy. Results A total of 79 centers responded (77%). All endoscopy units perform manual cleaning before disinfection. Automated endoscope reprocessors are available in 84.4% of the centers. Glutaraldehyde-based disinfectants are the most common employed (67% of centers). The time of exposure to the disinfectant is of 10 min in only 9.8% of the centers. The majority of endoscopy units modify their disinfection procedures in the case of infectious disease patients. In 59% of centers disposable material is only used once. In 37% of the endoscopy units instruments are dried with propanol. Conclusions The data collected suggest that cleaning and disinfection practices have improved in recent years, and that there is a good compliance with standard guidelines. There is still room for improvement in equipment, disinfection protocols, and traceability of instruments in order to improve safety for patients and staff.
We performed a long-term follow-up study of patients with segmental colitis associated with diverticula, in order to clarify the natural history of this disease.
We identified 15 patients who were ...diagnosed as having segmental colitis associated with diverticula during 1997. We assessed these patients by means of periodic follow-up visits from 1997 to 2004.
Eight of the 15 patients had no clinical recurrence during follow-up. Five patients had sporadic recurrences that were clinically mild (on average, one in 5 years), which responded to topical therapy and often to self-medication. Only two patients were diagnosed during the follow-up period as having Crohn's disease; notably, these were the only patients who did not have hematochezia as the main symptom at onset.
The course of this disease appears to be substantially benign.
Background and aim. To record prospectively, in a multi-centre survey, the adherence to some quality parameters of lower digestive endoscopy in everyday practice, focusing in particular on sedation ...and monitoring; choice of extension of endoscopic examination by the operator and relative performance in incubation of the caecum; behaviour, in some particular clinical circumstances, such as fresh haematochezia, screening and surveillance situations, functional symptoms, management of polyps.
Patients and Methods. Twenty-five centres located in Lombardia, Italy took part in the study; the duration of the survey was 2 weeks. 1406 consecutive cases were recorded.
Results. The main indications to colonoscopy were fresh haematochezia (21%), abdominal pain (11.7%) and surveillance after surgery for tumours or endoscopic polyp removal (24.3%). Screening examinations accounted for 7.1 % of all examinations. Conscious sedation was administered in 63.9% of patients; pulse oxymetry and cardiac frequency monitoring was used in 44.2% of cases. Total colonoscopy was planned in 84.2% of cases; the actual rate of intubation of the caecum in the cases submitted to the procedure was 84.1 %. Normal results were obtained in 24.3%. In 24.3% of patients, one or more polyps were identified; 84.2% of these were removed during the first examination. Four complications (accounting for 0.28% of cases) were recorded, all after polypectomy and all successfully treated conservatively.
Conclusions. The present study has shown that some attitudes in lower digestive endoscopy are sub-optimal: in particular, screening examinations are still infrequent; conscious sedation and monitoring have probably been used too rarely; intubation of the caecum was achieved in <90% of cases; the endoscopic removal of many polyps has been delayed for unexplained reasons. On the other hand, timing of surveillance after surgery for tumours or endoscopic removal of polyps has, overall, been adequate; the rate of normal examinations and the rate of complications have been satisfactorily low.
