Surgical Repair of Late Complications in Patients Having Undergone Primary Hypospadias Repair during Childhood: A New Perspective

Background. The repair of complications in patients who had undergone hypospadias repair is still an open problem. Patients and Methods. We conducted a retrospective study of patients treated for late complications after hypospadias repair. Study inclusion criteria were patients presenting urethral, corpora cavernosa deformity, and/or penile defects due to previous hypospadias repair. Exclusion criteria were precancerous or malignant lesions and incomplete data on personal medical charts. Preoperative evaluation included clinical history, physical examination, urine culture, residual urine measurement, uroflowmetry, urethrography, urethral sonography, and urethroscopy. The patients were classified into four different groups. Success was defined as a normal functional urethra, with apical meatus, no residual penile curvature or esthetic deformity of the genitalia. Results. A total of 1,176 patients were entered in our survey. Out of the 1,176 patients, 301 patients (25.5%) underwent urethroplasty (group 1), 60 (5.2%) corporoplasty (group 2), 166 (14.1%) urethroplasty and corporoplasty (group 3), and 649 (55.2%) complex genitalia resurfacing (group 4). Mean followup was 60.4 months. Out of the 1,176 cases, 1,036 (88.1%) were considered successful and 140 (11.9%) failures. Conclusion. The majority of patients (55.2%) with failed hypospadias repair require surgical reconstruction to fully resurfacing the glans and penile shaft

Managing female urinary incontinence: A regional prospective analysis of cost-utility ratios (curs) and effectiveness

Introduction: To evaluate the cost-utility of incontinence treatments, particularly anticholinergic therapy, by examining costs and quality-adjusted life years. Materials and methods: A prospective cohort study of women who were consecutively referred by general practitioners (GPs) to the Urology Department because of urinary incontinence. The primary outcome was evaluation of the cost-utility of incontinence treatments (surgery, medical therapy and physiotherapy) for stress and/or urgency incontinence by examining costs and quality-adjusted life years. Results: 137 consecutive female patients (mean age 60.6 ± 11.6; range 36-81) were enrolled and stratified according to pathologies: SUI and UUI. Group A: SUI grade II-III: 43 patients who underwent mid-urethral sling (MUS); Group B: SUI grade I-II 57 patients who underwent pelvic floor muscle exercise and Group C: UUI: 37 patients who underwent antimuscarinic treatment with 5 mg solifenacin daily. The cost utility ratio (CUR) was estimated as saving more than €1200 per QALY for surgery and physiotherapy and as costing under € 100 per QALY for drug therapy. Conclusions: This study shows that appropriate diagnosis and treatment of a patient with incontinence lowers National Health Service costs and improves the benefits of treatment and quality of life

Pelvic Organ Prolapse Repair with and without Concomitant Burch Colposuspension in Incontinent Women: A Randomised Controlled Trial with at Least 5-Year Followup

The aim of this study was to reevaluate and update the followup of a previously published randomized controlled trial (RCT) on the impact of Burch Colposuspension (BC), as an anti-incontinence procedure, in patients with UI and POP, who underwent POP repair. Forty-seven women were randomly assigned to abdominal POP repair and concomitant BC (24 patients; group A) or POP repair alone without any anti-incontinence procedure (23 patients; group B). Median followup was 82 months (range 60–107); from over 47 patients, 30 reached 6-year followup. Two patients were lost at followup. In group A, 2 patients showed a stage I rectocele. In group B, 2 patients had a stage I rectocele and 1 a stage II rectocele. In group A, 13/23 (56.5%) were still incontinent after surgery compared with 9/22 patients (40.9%) in group B (P = 0.298). No significant changes were observed between the first and the current followup. The update of long-term followup confirmed that BC did not improve outcome significantly in incontinent women when they undergo POP repair

Total and Free PSA, PCA3, PSA Density and Velocity

Since the late 1980s, the diagnosis and follow-up of prostate cancer (PCa) has relied on the use of prostate-specific antigen (PSA), a blood laboratory measurement that was shown to be associated with pathological diagnosis of cancer and had both diagnostic and prognostic clinical validity and utility. In 1986 the Food and Drug Administration approved the test to monitor those men already diagnosed with cancer, and in 1994 it went further, authorizing the test to help detect cancer in men aged 50 and older. Through the years, PSA has provided significant advancements in diagnosis and prognosis of PCa, although it was counterbalanced by its low sensitivity and specificity. PSA clinical availability triggered a frenzied hunt for the tumor, but its indiscriminate use let critics of the testing, once regarded as heretics, gain credibility. In 2004 the World Health Organization arranged an international consultation to assess new markers recognizing the limitation of PSA testing. Recently, PSA has been thrust into the public spotlight after several publications showed the risk of overdiagnosis and overtreatment of low-risk PCa in particular, which showed that nonperformance of PSA testing would not have affected the longevity or the quality of life. Such shortcoming led urologists to optimized the use of PSA (PSA density and velocity), to investigate some isoforms of PSA (free PSA, [−2]proPSA) and to develop novel molecular markers (PCA3 or molecular markers, i.e., cell cycling processing genes)

Feasibility of inter-hospital transportation using extra-corporeal membrane oxygenation (ECMO) support of patients affected by severe swine-flu(H1N1)-related ARDS

<p>Abstract</p> <p>Background</p> <p>To describe the organization of an ECMO-centre from triage by telephone to the phase of inter-hospital transportation with ECMO of patients affected by H1N1-induced ARDS, describing techniques and equipment used.</p> <p>Methods</p> <p>From September 2009 to January 2010, 18 patients with H1N1-induced ARDS were referred to our ECMO-centre from other hospitals. Six patients had contraindications to treatment with ECMO and remained in the local hospital. Twelve patients were transported to our centre and were included in this study. Four patients were transported on ECMO (Group A) and eight on conventional ventilation (Group B). The groups were compared on the basis of adverse events during transport, clinical characteristics and outcome.</p> <p>Results</p> <p>The PaO2/FiO2 ratio was lower in the patients of Group A (46.8 vs 89.7 [median]) despite the PEEP values being higher (15.0 vs 8.5 [median]). The Murray score was higher in Group A (3.50 vs 2.75 [median]). During the transfer there were no significant complications noted in Group A, whereas two patients in Group B were reported with hypoxia (SpO2 < 90%). One patient in Group A died. All the other patients of the two groups have been discharged from hospital.</p> <p>Conclusions</p> <p>The creation of an ECMO team, with various experts in the treatment of ARDS, assured a safe transfer of patients with severe hypoxia, over long distances, when in other cases they wouldn't have been be transportable.</p

Diabetes, ankle joint mobility, aging, and foot ulcer

In diabetic patients the evaluation of how ankle joint mobility (AJM) can be useful in the identification of connective tissue alteration and risk of foot ulcer (FU). Plantar and dorsal flexion of foot were evaluated using an inclinometer in 87 patients (54 type 2 and 33 type 1), and 35 healthy sex- and age-matched control subjects. Patients with diabetes were followed up for diagnosis of FU over the next 8 years and subsequently, patients were subdivided into: those without a history of FU (18 type 1 and 33 type 2), those who had a history of FU detected before baseline evaluation (14 type 2) and those who had history of first ulceration detected by the 8th year of the evaluation period (7 type 2). Aging and diabetes caused a significant reduction in mobility of each of the movements investigated (p &lt; 0.001), whereas after adjusting for the confounding effect of age, diabetes specifically reduced plantar flexion (p &lt; 0.0001). AJM was significantly lower in those with history of previous FU compared to all the other groups (p &lt; 0.001). The first ulceration was detected in the same foot presenting lower AJM in 17 of the 22 subjects with diabetes with history of ulcer (77.27%). Diabetes and aging reduce AJM although diabetes seems to reduce plantar flexion to a more specific extent. Reduced AJM is mostly associated with a previous history of FU. The evaluation of AJM is a valid and reliable ulcer risk scale that indicates which foot is at higher ulcer risk

Preoperative Valsava leak point pressure may not predict outcome of mid-urethral slings: analysis from a randomized controlled trial of retropubic versus transobturator mid-urethral slings

OBJECTIVE: To test the hypothesis that preoperative Valsalva leak point pressure (VLPP) predicts long-term outcome of mid-urethra slings for female stress urinary incontinence (SUI). MATERIALS AND METHODS: One hundred and forty-five patients with SUI were prospectively randomized to two mid-urethra sling treatments: Tension free vaginal tape (TVT) or transobturator tape (TOT). They were followed-up at 3, 6, 12 months post-operatively and then annually for the primary outcome variable, i.e. dry or wet and secondary outcome variables such as scores on the urogenital distress inventory (UDI-6) and the impact of incontinence on quality of life (IIQ-7) questionnaire as well as patient satisfaction as scored on a visual analogue scale (VAS). Preoperative VLPP was correlated with primary and secondary outcome variables. RESULTS: Mean follow-ups were 32 + 12 months (range 12-55) for TVT and 31 + 15 months (range 12-61) for TOT. When patients were analyzed according to VLPP stratification, 95 (65.5%) patients showed a VLPP > 60 cm H2O and 50 (34.5%) patients had a VLPP 60 cm H2O and 72% for those with VLPP 60 cm H2O (82 % vs. 68.9% p of 60 cm H2O), preoperative VLPP was not linked to outcome after TVT or TOT procedures

γEpithelial Na+ Channel and the Acid-Sensing Ion Channel 1 expression in the urothelium of patients with neurogenic detrusor overactivity

Both Epithelial Na+ Channel (γENaC) and the Acid-Sensing Ion Channel 1 (ASIC1) belong to Degenerin/Epithelial Na+ channel family that represents a new class of cation channels [1]. Increasing evidences show an involvement of these channels in the control of bladder afferent excitability under physiological and pathological conditions [2]; however, data available on their expression in human urothelium are controversial. Pathogenesis of the neurogenic detrusor overactivity (NDO), one of the most severe disabilities reported in patients with spinal cord lesions (SCL), has been attributed to bladder afferent dysfunction. Therefor, the aim of the present study was to investigate the expression of γENaC and ASIC1 in control urothelium and NDO patients. Controls and SCL patients with a clinical diagnosis of NDO underwent to urodynamic measurements and cystoscopy. Cold cup biopsies were processed for immunohistochemistry and western blots. In controls, γENaC and ASIC1 were expressed in the urothelium with different cell distribution and intensity. In NDO patients, both markers showed consistent changes in their cell distribution and intensity. Moreover, a significant correlation between the higher intensity of γENaC expression in urothelium of NDO patients and lower values of bladder compliance was found. In conclusion, the present findings show important changes in the expression of γENaC and ASIC1 in NDO human urothelium. Of note, while the changes in γENaC might impair the mechanosensory function of urothelium, the increase of the ASIC1 might represent an attempt to compensate excess in local sensitivity

Extracorporeal life support for management of refractory cardiac or respiratory failure: initial experience in a tertiary centre

<p>Abstract</p> <p>Introduction</p> <p>Extracorporeal Life Support (ECLS) and extracorporeal membrane oxygenation (ECMO) have been indicated as treatment for acute respiratory and/or cardiac failure. Here we describe our first year experience of in-hospital ECLS activity, the operative algorithm and the protocol for centralization of adult patients from district hospitals.</p> <p>Methods</p> <p>At a tertiary referral trauma center (Careggi Teaching Hospital, Florence, Italy), an ECLS program was developed from 2008 by the Emergency Department and Heart and Vessel Department ICUs. The ECLS team consists of an intensivist, a cardiac surgeon, a cardiologist and a perfusionist, all trained in ECLS technique. ECMO support was applied in case of severe acute respiratory distress syndrome (ARDS) not responsive to conventional treatments. The use of veno-arterial (V-A) ECLS for cardiac support was reserved for cases of cardiac shock refractory to standard treatment and cardiac arrests not responding to conventional resuscitation.</p> <p>Results</p> <p>A total of 21 patients were treated with ECLS during the first year of activity. Among them, 13 received ECMO for ARDS (5 H1N1-virus related), with a 62% survival. In one case of post-traumatic ARDS, V-A ECLS support permitted multiple organ donation after cerebral death was confirmed. Patients treated with V-A ECLS due to cardiogenic shock (N = 4) had a survival rate of 50%. No patients on V-A ECLS support after cardiac arrest survived (N = 4).</p> <p>Conclusions</p> <p>In our centre, an ECLS Service was instituted over a relatively limited period of time. A strict collaboration between different specialists can be regarded as a key feature to efficiently implement the process.</p