Candidates For Open Surgery Research Articles

Surgical treatment of trigeminal neuralgia in adults.

Trigeminal neuralgia is a painful disorder of the face that negatively affects the functionality of those who suffer from it. Microvascular decompression remains the top choice for its short and long-term outcomes. In those who are not candidates for open surgery, ablative options become valuable, including radiosurgery, and radiofrequency, balloon, and glycerol rhizotomies. Radiosurgery can be useful in cases of trigeminal neuralgia associated with multiple sclerosis. A scheme is proposed to facilitate decision-making considering outcomes, predictors of response and complication rates.

Management of Calculus Anuria Using Ureteroscopic Lithotripsy as a First Line Treatment: Its Efficacy and Safety

Purpose: To present our experience with emergency ureteroscopic lithotripsy (URSL) on ureteral stones related with acute kidney injury (AKI). Place and Duration: In the Department of Urology for three years duration from January 2019 to January 2020. Material and methods: We retrospectively analysed 27 patients consisting of 54 ureteral units (UU) undergoing URSL. There were 9 females and 18 males with M: F of 2:1 The anuria cause was bilateral obstruction with calculi in 21 cases, and unilateral obstruction with calculi in 33 cases with contralateral nephrectomy. In the same session, bilateral ureteroscopy was performed for bilateral synchronous ureteral stones. The anuria duration ranged from 12hours to 3-days. After the procedure, all patients ureteral stent were systematically removed. The operation was accomplished 6-12 hours afterward hospitalization. After surgery; all individuals were followed for minimum one-month. Results: A total of 27 urgent URSL were performed in 9 (33.3%) females and 18 (66.7%) males with an average age of 51 (range 32 to 73). Percutaneous nephrostomy was performed in 2 (7.4%) patients and in 2 (9.5%) patients with bilateral stones, the ureteral units (UU), severely wedged distal hard stones. These patients were candidates for open surgery, ureterolithotomy, 6 to 8 weeks afterward the initial intervention (PCN+ URSL). The improvements in renal function as demonstrated by post-obstruction diuresis and serum creatinine were compared in the two groups of patients using the Fisher's exact test. In 20 (71.1%) patients, URSL proved to be an effective therapeutic approach for obstruction removal and stone removal. Repeat surgery was required in 3 (11.1%). In 3 (11.1%) patients, URSL caused significant damage to the mucosa with a guide wire in the area of the damaged ureteral calculus. Ureteral stenting was sufficient to treat this complication. Stone or fragment migration was observed in 5 (18.5%) patients, all of which were in the upper stone position, and this procedure was the main reason of failure. In the first 24 hours, mild macroscopic haematuria was detected which did not require treatment. Postoperatively, 6 (22.2%) patients had high fever. Body temperature reversed back to usual within four days after getting the high dose and intravenous injection of a third-generation cephalosporin antibiotic (ureteral stent culture for Escherichia coli and positive urine culture). Conclusion: Calculus anuria is a therapeutic emergency that necessitates timely analysis and decompression management. URSL is the appropriate technique for designated patients and can be accomplished securely and has a high achievement rate with insignificant incidence of morbidity. Key words: Ureteral stones, ureteroscopy; surgery; kidneys, anuria, abnormalities; outcome and treatment.

Endovascular therapy for patients with heritable thoracic aortic disease.

Patients with genetic or heritable aortic conditions and thoracic aortic aneurysm syndrome often develop cardiovascular abnormalities originating at the aortic root and affecting the entire thoracoabdominal aorta. Although thoracic endovascular aortic repair (TEVAR) is usually avoided in these patients, TEVAR may be worthwhile for those at high risk for surgical complications and in certain emergency circumstances. We explored indications for TEVAR in patients with suspected or confirmed genetic or heritable aortic conditions and investigated early and mid-term outcomes. Our institutional aortic surgery database was queried for patients with suspected or confirmed Marfan syndrome, Loeys-Dietz syndrome, Ehlers-Danlos syndrome, Turner syndrome, neurofibromatosis, or familial aortic aneurysm and dissection who underwent TEVAR between February 1, 2002 and October 31, 2020. We extracted operative details and in-hospital, follow-up, and survival data. Thirty-seven patients who underwent 40 endovascular interventions met the inclusion criteria; 25 previously underwent ascending aorta or aortic root surgery, and 21 previously underwent open thoracoabdominal surgery. Postoperative complications included respiratory failure (24.3%), cardiac complications (16.2%), renal failure (13.5%), tracheostomy (8.1%), and spinal cord ischemia (paraplegia/paraparesis) (8.1%). Follow-up ranged from 1.3 to 8.5 years (median: 3.6 years), with 15 deaths overall (three early/in-hospital). Thirteen patients (35.1%) had 22 repeat interventions (open and endovascular) post-TEVAR; five had the endograft removed. Despite consensus that thoracic aneurysms in patients with genetic or heritable aortic conditions should be treated with conventional open surgery, the outcomes from our study suggest that TEVAR might be suitable in emergency settings or for patients in this population who are not candidates for open surgery, who are at high risk for reintervention, or who have a previously implanted Dacron graft. Nonetheless, lifelong surveillance is important for these patients after TEVAR to monitor for new dissection at distal or proximal landing zones, as repeat interventions are frequent.

Renal Artery Coverage During Endovascular Aneurysm Repair for Ruptured Abdominal Aortic Aneurysm

Coverage of one or both renal arteries may be required to facilitate endovascular aneurysm repair (EVAR) in patients who are not candidates for open surgery in ruptured abdominal aortic aneurysms (rAAAs). We sought to understand the consequences of renal coverage during these emergent procedures. Using the VQI data set from 2013 to 2018, we selected patients who had undergone EVAR for rAAA. Patients were distinguished by whether they had none, unilateral, or bilateral renal artery coverage. Patients were excluded if they were previously on dialysis or had an intervention to preserve renal perfusion. Primary endpoints included inhospital mortality, composite permanent dialysis/30-day death, and 1-year survival. Overall, there were 2,278 patients presenting with ruptured aneurysms. Most patients had no renal artery coverage (n=2,230; 98%), followed by single renal artery coverage (n=30; 1.2%), and finally bilateral renal artery coverage (n=18, 0.8%). On multivariate regression, bilateral renal coverage was associated with increased odds of inhospital mortality (odds ratio [OR]=5.7, ±4; P=0.030), permanent dialysis/30-day death (OR=9.5, ±7; P=0.016), and permanent dialysis (OR=47.5, ±47; P<0.001). Two patients with bilateral renal coverage did not suffer permanent dialysis/death. Single renal artery coverage significantly increased the odds of permanent dialysis/30-day death (OR=2.8, ±1.6; P=0.044) driven mainly by its effect on the outcome of permanent dialysis (OR=12.3, ±6; P<0.001). Unadjusted Kaplan-Meier one-year survival estimates were significantly lower with bilateral renal coverage (hazard ratio [HR]=3.4, P=0.0002). Bilateral coverage remained a significant predictor on adjusted analysis (HR=3.5, P=0.002); however, single renal coverage did not significantly affect survival in unadjusted or adjusted models. Bilateral renal coverage in rAAA significantly increases inhospital mortality and lowers long-term survival. While single renal artery coverage increases the risk of permanent dialysis/30-day death driven mainly by its effect on permanent dialysis, it does not significantly affect inhospital mortality or one-year survival and may be a viable option for select patients with rAAAs.

Endovascular Repair of Complex Aortoiliac Aneurysm with the Sandwich Technique in Sixteen Patients

This study aimed to evaluate the safety and efficiency of the sandwich technique in endovascular repair of complex aortoiliac aneurysm. Sixteen patients (mean age 69.6years, ranging from 58 to 78years) with complex aortoiliac aneurysm were studied retrospectively from October 2013 to September 2017 in two vascular centers of teaching hospitals. Computed tomography angiography (CTA) was performed to make individual therapy. They were all performed endovascular repair with sandwich technique, including one with the sandwich, chimney, and fenestrated techniques during the same procedure. All patients were followed up at 1month, 3months, 6months, 12months, and yearly thereafter with X-ray, ultrasound, and/or CTA. The initial technical success was 81.25%, and the assisted technical success was 100%. At final angiography, little flow of a type I and a type III endoleak was found in two patients with observation. Two type II endoleaks were also detected. During the perioperative period, two patients suffered myocardial infarction. One pulmonary infection and one urinary infection happened. No death or cerebrovascular events occurred. During the follow-up (mean 18months, ranging from 2 to 45months), three stent occlusions were detected. One case got reintervened for his external iliac artery stent thrombosis in the first month postoperatively. The other two were under observation. A readmission happened to one man for his right brachial artery pseudoaneurysm in the third month postoperatively. One patient died of nonaneurysmal related reason in the eighth month. No aneurysmal related death, rupture, or new endoleak was found. No paralysis, claudication, or bowel ischemia was complained of. The primary patency of the preserved branches were 94.7%, 92.0%, 92.0%, 92.0%, 92.0% separately in first, sixth, 12th, 24th, and 36th month. For patients who are not candidates for open surgery or conventional endovascular repair with complex aortoiliac aneurysm, the sandwich technique is a feasible alternative to management.

OZONE THERAPY IN JOINT PATHOLOGY

AIM: Ozone therapy is minimally invasive procedure for the treatment of various medical problems including osteoarthritis, frozen shoulder etc .We report the treatment on a series of patients affected by joint pathology, treated by injection of oxygen-ozone gas mixture. This is an experience of treating acute and chronic disease of the large joints (knee, shoulder, hip) by intra and peri-articular injections of an oxygen- ozone gas mixture. The patients were assessed before and after treatment. In addition to a resolution of joint pain, patients had a good functional recovery of their daily activities and the treatment was well-tolerated METHODS: Forty – three patients, ages ranging from 32 years through 76 years were treated with the injection of oxygen-ozone mixture. Indications for treatment were hip and knee osteoarthritis, and frozen shoulder .All patients were treated with multiple, intermittent injections at regular intervals. Under local anesthesia approximately 20 ml of an ozone-oxygen mixture of 10ug/ml ozone was injected with1a 22G needle puncture under C –arm guidance where necessary. After 2 and 6 weeks patients were asked to rate the treatment success on a numeric pain scale from 0 to 10.Patients were put on a rehabilitative physiotherapy program at 2 weeks. RESULTS: After 2 weeks, most patients had satisfactory pain relief of various degrees. Four patients reported no change (all had advanced stages of osteo arthritis). On follow up, 2 of those had effective pain relief while the remaining 2 had no change, and went on for surgery. At a 6 week follow up pain relief was still satisfactory for all. CONCLUSION: Joint disorders can very successfully be treated by means of oxygen-ozone mixture locally administered. The medical ozone injection is thought to affect both the mechanical and inflammatory components of pain. Ozone therapy is a promising treatment option for patients with symptomatic joint pathology, failed conservative therapies, and are not considered candidates for open surgery.

Large proximal ureteral stones: Ideal treatment modality?

Background and Purpose:Ideal treatment modality for patients with large impacted proximal ureteral stone remains controversial. We compared laparoscopic transperitoneal ureterolithotomy (Lap-TPUL) and semirigid ureteroscopy for large proximal ureteric stones to evaluate their efficacy and safety.Patients and Methods:From November 2012 to December 2014, we enrolled 122 patients with large (≥1.5 cm) proximal ureteral stone in the study. Patients were randomly divided into two groups: Group A (60 patients), retrograde ureteroscopic lithotripsy using a semirigid ureteroscope; Group B (62 patients), transperitoneal LU (Lap-TPUL).Results:The overall stone-free rate was 71.6% and 93.5% for Group A and Group B respectively (P = 0.008). Auxiliary procedure rate was higher in Group A than in Group B (27.3% vs. 5.6%). The complication rate was 11.2% in Group B versus 25% in Group A. Mean procedure time was higher in laparoscopy group as compared to ureterorenoscopy (URS) groups (84.07 ± 16.80 vs. 62.82 ± 12.71 min). Hospital stay was 4.16 ± 0.67 days in laparoscopy group and 1.18 ± 0.38 days in URS group (P < 0.0001).Conclusion:Laparoscopic transperitoneal ureterolithotomy is a minimally invasive, safe and effective treatment modality and should be recommended to all patients of impacted large proximal stones, which are not amenable to URS or extracorporeal shock-wave lithotripsy or as a primary modality of choice especially if patient is otherwise candidate for open surgery.

Clinical analysis of hybrid treatment for extensive aortic disease

To evaluate the effect of extensive aortic diseases (EAD) after hybrid repair with supra-arch branches or visceral arterial debranching and endovascular repair. A total of 24 EAD patients (19 male and 5 female) underwent hybrid repair in Department of Vascular Surgery, Zhongshan Hospital, Fudan University between March 2005 and April 2015. The clinical data was analyzed retrospectively. The mean age was (49±12) years (from 29 to 69 years). The high-risk candidates for open surgery were enrolled in the study. The patients, including 14 cases with thoracic aortic aneurysms and 10 cases with aortic dissection, were treated by one or two stages. Post-operative follow-up with CT angiography was performed at 3, 6 and 12 months and then annually thereafter. A total of 74 branches, including 63 with visceral arteries and 11 with supra-arch arteries, were recanalized. Nine patients were treated in two-stage hybrid procedure and fifteen were repaired by one stage. The perioperative mortality was 12.5% (3/24), whereas the aneurysm-related mortality was 8.3% (2/24). The 30-day patency of the grafts was 95.9% (71/74). There was no endoleak, paralysis, and intestinal ischemia at 30 days post-hybrid procedures. Four cases (16.6%) suffered acute renal dysfunction. During the follow-up (3 to 123 months), there were two deaths and one endoleak (type Ia and III) which emerged at 4 months post-procedure. The 1-year and 3-year survival rates were 81.7% and 73.5%, respectively. Hybrid treatment is safe and effective for complex EAD patients in the midterm follow-up. It is especially suitable for the high-risk patients with comorbidities, re-intervention, or little tolerance to open surgery repair.

Initial experiences with Corevalve® for transcatheter aortic valve implantation in Turkey: two case reports

Transcatheter aortic valve implantation (TAVI) has become an alternative treatment modality in patients with severe aortic stenosis who are not candidates for open surgery. We performed two of the initial procedures in our center with the CoreValve® Revalving System, which has been recently introduced to the market. In this article, we report the outcomes of this procedure after a nine-month followup and discuss the different aspects of the two prostheses commercially available in Turkey.

Bioprosthetic Mitral Valve Endocarditis After Percutaneous Device Closure of Severe Paravalvular Leak

A large mitral paravalvular leak in a 63-year-old patient was closed by percutaneous placement of 2 Amplatzer Septal Occluder (AGA Medical Corporation, Plymouth, MN) devices. The patient had a residual paravalvular leak and subsequently developed infective endocarditis that was successfully treated by removal of all hardware and implantation of a new valve. Transcatheter treatment of paravalvular leaks may be useful in select patients who are poor candidates for open surgery; however, one must be aware of the potential complications. This report underscores the risk of device infection that may be increased if there is turbulence related to residual paravalvular leaks.

Aortoesophageal fistula: an uncommon complication after stent-graft repair of an aortic thoracic aneurysm

To report the incidence and management of aortoesophageal fistula (AEF) secondary to endovascular stent-graft repair of the descending thoracic aorta. We analyze a case of AEF as a late complication of stent-graft repair of a thoracic aortic aneurysm in a 74-year-old male. We also include a discussion on alternatives of treatment based on a review of the literature currently available in MEDLINE. This patient was admitted to our hospital because of constitutional symptoms. The diagnosis was established by computed tomography and upper gastrointestinal endoscopy. The patient died 50 days after admission. AEF is a catastrophic complication of endovascular stent-graft placement. Treatment options are very limited, as these patients are usually not candidates for open surgery. Conservative treatment is often associated with fatal results.

Replacement of the Descending Aorta: Recent Outcomes of Open Surgery Performed with Partial Cardiopulmonary Bypass

Conclusion: Descending thoracic aortic replacement performed with partial cardiopulmonary bypass (CPB) has compatible risks to that associated with thoracic endovascular aneurysm repair (TEVAR). Summary: Endovascular treatment of descending thoracic aortic aneurysms (TAA) has drastically changed the treatment of this disease. Results are generally favorable, and endovascular treatment can be used even in high-risk patients not considered candidates for open surgery. The authors note that there are several strategies for open treatment of descending TAA. These include a single-clamp technique, distal perfusion with left heart bypass, hypothermic circulatory arrest, and partial CPB. Their technique uses partial CPB with hypothermic circulatory arrest when there is no room for a distal aortic cross-clamp. They compared their results of open distal thoracic aortic repair using partial CPB with literature results for TEVAR. There were 113 patients (75 men) with a mean age of 68 ± 12 years who underwent graft placement for descending TAA not associated with dissection; of these, 16 (14.2%) were emergencies. Operations were performed through a left thoracotomy with partial CPB and segmental clamping of the aorta. The authors also used magnetic resonance angiography preoperatively in elective cases to detect the artery of Adamkiewicz. Intraoperative motor evoked potentials were measured. The early mortality rate was 5.3%, with a 1% mortality rate in elective cases and 31.3% in emergencies. Spinal cord dysfunction was 2.7% overall, 1% in elective cases, and 12.5% in emergency cases. Stroke rates were 7.6% overall, 4.1% in elective cases, and 25% in emergency cases. Respiratory failure rates were 9.7% overall, 9.2% in elective cases, and 12.5% in emergency cases. During follow-up, no patient underwent reoperation secondary to problems with the original open repair. Overall survival estimates using Kaplan-Meier techniques were 92.3% at 3 years, 90.6% at 5 years, and 70.2% at 10 years. Comment: At first glance, one questions the relevance of this article. Although certainly the results presented are excellent, no one can argue that there is a huge difference between a thoracotomy and a small incision in the groin. Therefore, although the results the authors presented may be compatible with those reported for endovascular repair of TAA, morbidity is not. However, not everyone who has a TAA can have an endovascular repair. In cases where there are short or wide proximal or distal landing zones, severe neck angulation, or tortuous or stenotic access arteries, an open TAA repair can certainly be justified based on the results presented here and by others (Ann Thorac Surg 2004;77:1298-303; Ann Thorac Surg 2001;72:481-6).

Laparoscopic anatrophic nephrolithotomy for managing large staghorn calculi

To evaluate the efficacy of a laparoscopic approach for managing large staghorn renal calculi. Laparoscopic transperitoneal anatrophic nephrolithotomy was used to duplicate open anatrophic nephrolithotomy in five patients (three men) with large staghorn renal stones unsuitable for percutaneous nephrolithotomy. Only the renal artery was clamped, using a bulldog clamp. The stone was removed through a nephrotomy incision on the Brodel line, which was closed using 3/0 polyglactin continuous sutures, and sutures were buttressed by haemostatic clips instead of knots. Intraoperative ultrasonography was used in the last two patients to evaluate residual stones. The mean (range) stone size was 53 (45-65) mm, the patient age was 53 (45-58) years, and the warm ischaemia and operative duration were 32 (29-35) and 170 (120-225) min, respectively. No blood transfusion was needed during or after surgery. All of the procedures were uneventful and there was no urine leakage after surgery. Only an 8-mm and a 6-mm residual stone remained in the first and third patients, in the lower and middle calyces, respectively. Both of them were subsequently treated with shock wave lithotripsy. An intravenous pyelogram after surgery showed a functional corresponding renal unit, with a significant improvement in obstruction in all patients. Laparoscopic anatrophic nephrolithotomy is a promising alternative for patients who are candidates for open surgery, with an acceptable stone-free rate. While offering a minimally invasive approach, it can minimize the need for secondary invasive interventions. Further patients and a longer follow-up are needed before this is suggested as the preferred method in selected patients in the future.

Cold saline irrigation of the renal pelvis during Radiofrequency Ablation of a central renal neoplasm: a case report

IntroductionThermal destruction mediated by radiofrequency ablation (RFA) is gaining attention as an alternative treatment for patients with renal cell carcinoma (RCC), particularly in those who are not candidates for open surgery. Treatment of central tumours is occasionally associated with complications such as ureteric stricture, injury to the psoas muscle, haematuria and vascular laceration.Case presentationWe have used infusion of cold saline during RFA, through a retrograde ureteric catheter with its tip in the renal pelvis, in a patient with a central renal tumour.ConclusionWe believe this process to have successfully avoided the risk of thermal injury.

Nucleoplasty in the Treatment of Lumbar Diskogenic Back Pain: One Year Follow-Up

The spine is an important source of pain and disability, affecting two thirds of adults at some time in their lives. Treatment in these patients is mainly conservative medical management, based on medication, physical therapy, behavioral management, and psychotherapy, surgery being limited to elective cases with neurologic deficits. This study was carried out to evaluate the efficacy of percutaneous nucleoplasty in patients affected by painful diskal protrusions and contained herniations. From February 2004 to October 2005, 72 patients (48 men, 24 women; mean age 48 years) affected by lumbar disk herniation were treated with nucleoplasty coblation. All patients were evaluated clinically and with radiography and MRI in order to confirm the presence of lumbalgic and/or sciatalgic pain, in the absence of major neurologic deficit and with lack of response after 6 weeks of conservative management. Average preprocedural pain level for all patients was 8.2 (on a visual analog scale of 1 to 10), while the average pain level at 12 months follow-up was 4.1. At the 1 year evaluation, 79% of patients demonstrated a statistically significant improvement in numeric pain scores (p < 0.01): 17% (12 patients) were completely satisfied with complete resolution of symptoms, and 62% (43 patients) obtained a good result. Our data indicate that nucleoplasty coblation is a promising treatment option for patients with symptomatic disk protrusion and herniation who present with lumbalgic and/or sciatalgic pain, have failed conservative therapies, and are not considered candidates for open surgery.

11C-Methionine Positron Emission Tomography for Preoperative Evaluation of Suggestive Low-Grade Gliomas

The treatment regimen for cerebral gliomas is different, depending on the histological grade of the lesion. The therapeutic strategy for anaplastic gliomas and glioblastomas is more aggressive, including microsurgical removal, radiation and chemotherapy. The management for low-grade gliomas is still under discussion, operation or "wait and see" tactics are possible options. Therefore the diagnostic imaging procedures are crucial for further treatment planning. Although most of the low-grade gliomas appear as hypointense lesions without contrast medium (CM) enhancement on magnetic resonance images, in some cases lesions without CM enhancement can be anaplastic tumours as well. 11C-Methionine positron emission tomography (MET-PET) was performed for preoperative evaluation of non or low CM enhancing intracerebral lesions, so-called suggestive low-grade gliomas. 20 patients harbouring suggestive low-grade gliomas were included. Seventeen patients were found to be candidates for open surgery and 3 patients were planned for stereotactic biopsy due to the localisation of the lesions. MET-PET studies were performed a few days prior to surgery. On the day of surgery MRI sequences for neuronavigation planning were carried out (MPRAGE and FLAIR sequences). All image data were fused for operation with neuronavigation-guided microsurgery or stereotactic biopsy (BrainLAB Neuronavigation system, VectorVision 6.1). Biopsies were taken from the MET uptake areas as well as from areas without MET uptake. 2/20 patients showed sparse CM enhancement on MRI T (1) images, 18/20 patients had lesions without CM enhancement. MET uptake was found in 16/20 cases (T/N ratio 1.5 or more) and no MET uptake was documented in 4/20 cases (T/N ratio <1.5). Histologically the 2 patients with sparse CM enhancement and MET uptake were glioblastoma multiforme, 10/14 patients with MET uptake and without CM enhancement had an anaplastic astrocytoma WHO III, 3/14 with MET uptake and no CM enhancement had an anaplastic oligoastrocytoma WHO III, and 1/14 had an oligoastrocytoma grade II. The lesions of the 4 patients without MET uptake and without CM enhancement were classified as astrocytoma grade II in 2 cases, as astrocytoma grade I in 1 case and as astrocytoma III in one case. According to the results of this study, we find MET-PET to be a helpful tool for pretreatment evaluation of non-CM enhancing, suggestive low-grade intracerebral lesions. MET-PET adds valuable information for the decision-making for surgery or stereotactic biopsy.

When is open ureterolithotomy indicated for the treatment of ureteral stones?

Improvements in extracorporeal shock wave lithotripsy (ESWL) and ureteroscopy have almost eradicated the need for open surgery in ureteral stones. The aim of this study was to assess characteristics of patients who underwent open ureterolithotomy. During a 5-year period, a total of 654 patients with ureteral stones were treated. Initial management consisted of ureteroscopy in 524 patients, ESWL in 62 patients and percutaneous nephrolithotomy (PCNL) in 12 patients. Open surgery was performed in 56 patients. Stone location, size and success rates were retrospectively analyzed. Ureteroscopy resulted in successful stone removal in 94%, 98% and 98.5% of proximal, mid and distal ureteral stones, respectively. A total of 14 patients with ureteroscopy failure were referred for open surgery. ESWL treatment resulted in success in 55 patients (88%), and those with ESWL failure were referred for either ureteroscopy (n = 3) or open surgery (n = 4). Open surgery was performed in a total of 56 patients, 38 of whom had been referred from other centers. Stone location was proximal ureter in 25 (44.6%) patients (stone size: 2-12 cm(2)), mid ureter in five (8.9%) patients (stone size: 2-6 cm(2)) and distal ureter in 26 (46.4%) patients (stone size: 4-9 cm(2)). A history of previous unsuccessful endourological procedure was observed in 33 (58%) of 56 patients. Children under age 16 (range 1-15 years) comprised 17.8% of patients undergoing open surgery. Open surgery, which is nowadays being replaced with laparoscopic techniques, is generally indicated for failed endourological procedures (58%), particularly in centers that do not have flexible ureteroscopy or laser lithotriptor, and in patients with larger stones (>3 cm). Children (17.8%) are also candidates for open surgery, if specifically designed endourological equipment is not available.

Endourologic treatment of upper urinary tract transitional cell carcinoma

The traditional treatment for upper tract transitional cell carcinoma (UTTCC) consists of radical nephroureterectomy. A more conservative approach, however, was required in cases of bilateral UTTCC and in patients with disease in a solitary kidney but who had underlying comorbidities that made them unsuitable candidates for open surgery. Minimally invasive treatment methods were developed for these select groups of patients. Because of technological advancements and refinement in endoscopic techniques, most patients with UTTCC, even those with normal contralateral kidneys, can now be offered minimally invasive treatment with single or multimodal approaches involving ureteroscopy or percutaneous resection. For patients with low-stage, low-grade UTTCC, five-year survival rates are comparable for those treated endourologically and those treated by nephroureterectomy. High-grade lesions have much higher recurrence and progression rates than lower-grade lesions, and nephroureterectomy is therefore recommended in patients with high-grade disease. The use of adjuvant instillation in the treatment of UTTCC, administered via antegrade and retrograde methods, has been shown to improve outcomes. For recurrences to be diagnosed and treated in a timely manner, and acceptable cancer-free survival rates maintained, long-term rigorous follow-up after endourologic treatment, with regular surveillance ureteroscopy, is crucial.

Stent-Graft Repair of Thoracic Aortic Aneurysms

Endovascular treatment of aortic disease has emerged as an alternative mode of treatment that is particularly attractive for patients with severe comorbidities who would not be ideal candidates for open surgery. Actually, short-term morbidity and mortality rates, of large series, compare favorably with those from surgery, and stent-graft placement is proving to be a safe, minimally invasive, and effective treatment for thoracic aortic diseases. However, although endoluminal interventions are minimally invasive, they are associated with complications, as are surgical methods. In this article, indications, technical aspects, and results of endovascular TAA repairs will be reviewed. We will also examine the advantages and limitations of stent-graft treatment. Finally, we will discuss the management of complications following aortic stent-graft implantation. We intentionally do not cover the topic of thoracic dissection, as it is being covered in another article in this volume.

Aortoesophageal fistula secondary to stent-graft repair of the thoracic aorta.

To report the incidence and management of aortoesophageal fistula (AEF) secondary to endovascular stent-graft repair of the descending thoracic aorta. A retrospective review was conducted of patients treated at our facility between July 1999 and June 2003. During this interval, 60 patients (46 men; average age 66+/-10 years) underwent thoracic aortic stent-graft placement for a variety of pathologies. AEF occurred in 3 (5%) patients. One 62-year-old man presented with recurrent back pain and fever and died suddenly due to fatal exsanguination; the AEF was revealed at necropsy. The other 2 patients (both women) presented with hematemesis after endovascular repair of thoracic aortic aneurysms. AEF was detected by esophagogastroduodenoscopy. Both patients were treated conservatively, as open surgical repair was refused because of their general condition. Both patients developed severe mediastinitis and died after 5 weeks and 10 months, respectively. Aortoesophageal fistula is, in our experience, a catastrophic complication of endovascular stent-graft placement. Treatment options are very limited, as these patients are usually not candidates for open surgery. Outcome under conservative management is, however, almost invariably fatal.