Double Cuff Research Articles

Rat liver transplantation without preservation of "phrenic ring" using double cuff method.

To develop a double cuff method for rat liver transplantation without preservation of "phrenic ring" to shorten the portal vein clamping time. "Phrenic ring" was completely excluded from the donor liver, and end to end anastomosis of suprahepatic inferior vena cava was performed. The portal vein clumping time was shortened to 10.6 min, the successful rate was 83.1%. This method can simplify the operation and shorten the portal vein clumping time.

Comparison of outcomes after single or DOUBLE-CUFF artificial urinary sphincter insertion

Objectives To assess the effectiveness and complications associated with single and double-cuff artificial urinary sphincter (AUS) implantation for postprostatectomy stress urinary incontinence. Methods A retrospective study of 56 men with postprostatectomy stress urinary incontinence who underwent either single (28 patients) or double (28 patients) cuff AUS placement was performed. Patients in each cohort were matched on the basis of preoperative pad use, risk factors for complications, and age. Patient selection was blinded relative to outcome. Continence, quality of life, and complications were assessed using the Incontinence Impact Questionnaire Short Form (IIQ-7), postoperative pad use, and chart review. Results The mean age was 67 years for each group. Daily pad use decreased from 7.7 to 1.1 in patients treated with a single-cuff AUS and from 7.8 to 0.7 in patients with a double-cuff AUS ( P = 0.25). Complete continence (0 pads daily) was reported in 3 (11%) of 28 men with single-cuff and 12 (43%) of 28 men with double-cuff sphincters ( P = 0.008). The IIQ-7 scores improved from 14.8 to 3.1 after single-cuff placement and from 16.3 to 2.5 after double-cuff placement ( P = 0.03). With an average follow-up of 41.3 and 21.2 months for the single and double-cuff cohorts, respectively, five complications were reported in the single-cuff recipients and four in the double-cuff patients. Conclusions A significantly greater rate of complete continence and improvement in the IIQ-7 were seen in men with double-cuff AUS compared with single-cuff devices. Additional study is needed to confirm the relative advantages of double-cuff insertion.

Salvage Procedure For Infected Noneroded Artificial Urinary Sphincters

We report our experience with removal, antiseptic irrigation and immediate reimplantation of infected noneroded artificial urinary sphincters. From April 1996 to October 2000, 8 patients with an infected artificial urinary sphincter underwent a total of 9 salvage operations. All patients underwent cystoscopy before salvage to ensure nonerosion of the sphincter cuff. All previously implanted material was removed, the wounds were copiously irrigated according to a 7 solution protocol and an identical new system was implanted. All patients were discharged home the following morning on oral antibiotics. Followup was 5 to 66 months (mean 33). The predominant organisms cultured at salvage were gram-positive cocci. Time from implantation to salvage was from 2 weeks to 64 months (mean 13.7 months). Prostatectomy was the etiology of incontinence in all except 1 case. In 5 of the 8 men a double cuff system was placed and 3 underwent concurrent 3-piece inflatable penile prosthesis salvage. The salvage procedure was done twice in 1 patient 5 months apart. The system was removed 16 months later secondary to urethral erosion. At the most recent followup the other 7 patients were free of infection with a functioning artificial urinary sphincter. Salvage and immediate reimplantation of an infected, noneroded single or double cuff artificial urinary sphincter appears to be a valid option. Our overall success rate was 87%. The usual offending organisms are gram-positive skin flora. An associated inflatable penile prosthesis does not prohibit simultaneous salvage of the 2 devices.

Spatial and temporal aspects of deep tissue pain assessed by cuff algometry.

This study assessed spatial and temporal aspects of pressure pain during increasing and constant compressions using a cuff algometer and during adaptive compressions using a closed-loop feedback system for maintaining stable pain. Experimental setup consisted of a pneumatic tourniquet cuff, a computer-controlled air compressor, and a 10-cm electronic visual analogue scale (VAS). The first experiment assessed spatial summation for cuff pain by recording the pressure-pain stimulus-response (SR) function during increasing compressions with single and double cuffs. The second experiment assessed temporal profile of cuff pain during constant compression for 10 min beginning at pain intensities of 2, 4, and 6 cm on the VAS. The third experiment assessed temporal pressure profile when pain was maintained for 10 min by a close-loop system within target zones of +/-0.5 cm VAS at pain intensities of 2, 4, and 6 cm on the VAS.Doubling the tissue volume under the cuff shifted the SR function to the left, demonstrating spatial summation. The constant cuff pressure evoked typical biphasic response consisting of an overshoot in pain intensity, followed by decreasing pain, or adaptation. The pain intensity was significantly correlated to the time of constant stimulation, showing time-dependency of pain encoding. Both overshoot magnitude and adaptation rate were dependent on the starting pain intensity. The pain decrease rate was lowest for a pain intensity of 2 cm on the VAS. The overshoot magnitude was lowest for a pain intensity of 6 cm on the VAS. Both the overshoot and the adaptation were maximal for a pain intensity of 4 cm on the VAS. The oscillating pressure generated by closed-loop system led to constant rather than adapting pain at intensities of 2, 4, and 6 cm on the VAS. The cuff algometer is highly configurable tool for assessment of pain sensitivity by pressure-pain and time-pain functions. The presented models are useful additions to a researcher's armamentarium for further pharmacological and clinical studies on deep tissue pain and related mechanisms.

Transcorporal Artificial Urinary Sphincter Cuff Placement in Cases Requiring Revision for Erosion and Urethral Atrophy

A distal cuff location is often required in patients undergoing artificial urinary sphincter reimplantation after previous erosion or in those requiring revision because of urethral atrophy at the original cuff site. Dissecting the urethra at a more distal site increases the risk of urethral injury and erosion, and often the urethral circumference is so small that a 4 cm. cuff is too large. We present a novel technique for distal cuff placement using transcorporal dissection that leaves corporal tunica albuginea on the dorsal surface of the urethra, allowing for its safer mobilization and adding to its bulk. We reviewed the charts of 31 men who underwent this technique and contacted 26 by telephone. The indications for distal transcorporal cuff placement varied. In 7 men with inadequate urethral coaptation with a 4 cm. proximal cuff at initial implantation a primary transcorporal tandem cuff was implanted distal. In 8 men persistent or recurrent incontinence despite a 4 cm. proximal cuff led to secondary distal reimplantation. Previous artificial urinary sphincter erosion and/or infection in 10 cases, previous urethral surgery at the optimal cuff site in 5 and radiation changes at the optimal cuff site in 1 led to selection of the more distal site and technique. Of the transcorporally placed cuffs 18 were 4 cm. and 13 were 4.5 cm. Preoperatively 5.2 pads were used daily. Of the 31 patients 27 were impotent preoperatively, 1 had normal erections, 1 had partial erections with the MUSE drug delivery system (Vivus, Inc., Menlo Park, California) and 2 had a previously placed penile prosthesis. At a mean followup of 17 months 26 of the 31 patients (84%) had occasional or no stress incontinence requiring 0 to 1 pad daily, 2 with pure urge incontinence used 1 to 2 pads daily and 3 had mixed incontinence requiring 0 to 3 pads daily. Of the 26 men surveyed 25 were very satisfied with the postoperative level of incontinence. Postoperatively erectile function deteriorated in 1 patient and was unchanged in the remainder. There was no erosion or infection of the transcorporally placed cuffs, although 3 were replaced for malfunction. This technique offers significant advantages in cases of revision. The technique protects the urethra from intraoperative dissection injury and decreases the risk of erosion because the urethra is buttressed at its vulnerable location. In addition, bulk is added to the urethra, allowing for better cuff sizing, which is usually a problem at this location where the urethra is small, thereby, improving continence in revised cases. Our success has recently led us to abandon tandem cuff placement altogether. There is a potential for deteriorating erectile function in potent men who undergo implantation in this fashion.

MANAGEMENT OF CUFF EROSION OF THE DOUBLE CUFF ARTIFICIAL URINARY SPHINCTER

We report on a series of patients with erosion of 1 cuff of an AMS800 double cuff artificial urinary sphincter and determine the success rate of removing the eroded cuff, leaving the other components behind and converting the device to a single cuff system. In 9 patients with a double cuff artificial sphincter 1 eroded cuff was removed and the system was converted to a single cuff sphincter. Followup was based on an incontinence scoring system. In 1 patient the remaining cuff was removed because it also eroded. In another patient a wound infection developed 5 months after placement and the entire device was removed. The remaining 7 patients had better continence scores than before artificial sphincter placement but each remarked that continence was better with 2 cuffs. An eroded cuff of a double cuff artificial urinary sphincter system can be successfully removed and the device can be converted to a single cuff system.

Locoregional intravenous anesthesia

To analyse current data on intravenous regional anaesthesia (IVRA), its benefits and drawbacks. Articles were obtained from a Medline search using the following search terms: 'intravenous regional anaesthesia', alone or combined with 'local anaesthetic agents', 'toxicity'. Following articles in English and in French have been selected: main articles, original articles, update and review articles, letters to the editor and recent editorials. Physiopathological and pharmacological data were extracted for involved mechanisms and means for improving this technique. IVRA is a reliable and efficient technique with a lower cost than general anaesthesia and well adapted for limb surgery in the ambulatory patient. Depending on the site of the surgical field, the pneumatic tourniquet is set either on the arm, forearm or wrist for the upper limb or thigh, calf or ankle for the lower limb. When set in periphery, less local anaesthetic agent is required. A wide tourniquet requires a lower inflation pressure than a double cuff tourniquet. A single cuff is as efficient as a dual cuff if shape, size and inflating pressure are appropriate. The limb occlusion pressure (LOP) is the minimal pressure required to occlude blood flow. It is assessed with either a pulse oximeter or Doppler for determination of the lowest cuff inflating pressure. The cuff is inflated to 50 mmHg above LOP. Oozing in the surgical field can be decreased by the re-exsanguination technique. Currently, lidocaine is the only local anaesthetic released in France for IVRA. Addition of a muscle relaxant, a NSAID or clonidine allows the dose of local anaesthetic agent to be decreased and improves postoperative analgesia.

The Italian Registry of Pediatric Chronic Peritoneal Dialysis: A Ten-Year Experience with Chronic Peritoneal Dialysis Catheters

To analyze the data from 347 peritoneal catheters implanted in 249 pediatric patients aged < or = 15 years at start of chronic peritoneal dialysis (CPD). Restrospective study of the data collected between 1986 and 1995, in 20 dialysis centers, from the Italian Registry of Pediatric Chronic Peritoneal Dialysis. Data collection for each pediatric catheter included: catheter type, site and technique of insertion, complications, duration, and reason for removal or replacement. Fifty catheters were inserted in patients under 2 years of age, 50 in patients aged 2 - 5 years and 247 in patients over 5 years of age. Catheter types included 307 (88.5%) Tenckhoff (286 double cuff, 21 single cuff) and 40 (11.5%), double-cuff, Valli-type catheters. All catheters were surgically implanted and omentectomy was performed in 83.5% of cases; the entry-site was in the midline in 136 cases (39.2%) and paramedian in 211 (60.8%). During 6076 CPD months we observed 274 catheter-related complications: 182 catheter infections (exit-site and/or tunnel infection), 23 leakages, 19 obstructions, 19 cuff-extrusions, 14 dislocations, 6 hemoperitoneum, 10 other (incidence of one complication every 21.8 dialysis-months). A significant reduction of catheter-related complications occurred in the last five years, compared with the first 5 years. One hundred and six catheters were removed due to catheter-related causes: infection (83 cases), obstruction (11), dislocation (4), outer-cuff extrusion (3), leakage (2), bowel incarceration (2), and bowel infarction (1). Catheter survival was 72.2% at 12 months, 52.3% at 24 months, 32.8% at 36 months, and 25.7% at 48 months. Significantly lower catheter survival was found in younger children (0 - 2 years) compared with two other age groups (2 - 5 years, and > 5 years). No significant correlation was found between catheter survival and catheter entry-site (midline vs paramedian). Catheter-related infections were confirmed to be the most common complication and most frequent cause of peritoneal catheter removal. In addition, catheter survival rate was worse in younger children, indicating that more effort should be made to improve peritoneal catheter survival particularly in this age group.

Addition of a Second Urethral Cuff to Enhance Performance of the Artificial Urinary Sphincter

Purpose Stress urinary incontinence may persist in approximately 15 percent of men following implantation of a standard artificial urinary sphincter. The ability of a second urethral cuff to provide satisfactory continence without additional operative complications was investigated. Materials and Methods A second urethral cuff was placed to enhance performance of the artificial urinary sphincter in 5 men with stress urinary incontinence following radical prostatectomy. A stainless steel 3-way tubing connector allowed for addition of a second cuff to the standard artificial urinary sphincter without the kinking problems previously observed with a flexible 3-way connector. In 4 consecutive men a second cuff was added at operative revision of an existing artificial urinary sphincter that had failed to produce satisfactory continence. A double cuff artificial sphincter was placed initially in 1 man. Results Of 5 men 4 had satisfactory and 1 had improved continence with the double cuff artificial urinary sphincter. The stainless steel 3-way tubing connector eliminated kinking complications. Conclusions Implantation of a second urethral cuff can provide satisfactory urinary continence in men with an artificial urinary sphincter and persistent incontinence. Placement of a double cuff artificial urinary sphincter may also represent appropriate initial intervention in men with significant stress urinary incontinence.

Erosion Rate of the Double Cuff AMS800 Artificial Urinary Sphincter

Erosion Rate of the Double Cuff AMS800 Artificial Urinary Sphincter

Erosion Rate of the Double Cuff AMS800 Artificial Urinary Sphincter: Long-Term Followup

Purpose We reviewed the erosion rate of the double cuff artificial urinary sphincter. Materials and Methods Charts of 95 patients were evaluated for erosions and underlying etiology. Results Ten patients had erosion of the cuffs, for an erosion rate of 10.5 percent. Of the 10 erosions 4 (40 percent) were secondary to iatrogenic injuries. Conclusions Addition of a second cuff to the artificial urinary sphincter remains a safe alternative for patients with severe urinary stress incontinence.

Comparison of the Effect of EMLA Cream, Subcutaneous Ring Anaesthesia and a Double Cuff Technique in the Prevention of Tourniquet Pain

Comparison of the Effect of EMLA Cream, Subcutaneous Ring Anaesthesia and a Double Cuff Technique in the Prevention of Tourniquet Pain

Comparison of the Effect of Emla Cream, Subcutaneous Ring Anaesthesia and a Double Cuff Technique in the Prevention of Tourniquet Pain

We have examined the effect of EMLA on tourniquet pain and compared it with those of subcutaneous ring anaesthesia (SRA), a double cuff technique and a single cuff (control) during i.v. regional anaesthesia. The durations of analgesia (mean 57.3 (SD 16.6) min) and tolerance (72.3 (13.9) min) to tourniquet inflation in the EMLA group were comparable to those in the SRA group (54.1(16.2) min and 68.3(19.0) min), but significantly (P

COMPARISON OF THE EFFECT OF EMLA CREAM, SUBCUTANEOUS RING ANAESTHESIA AND A DOUBLE CUFF TECHNIQUE IN THE PREVENTION OF TOURNIQUET PAIN

We have examined the effect of EMLA on tourniquet pain and compared it with those of subcutaneous ring anaesthesia (SRA), a double cuff technique and a single cuff (control) during i.v. regional anaesthesia. The durations of analgesia (mean 57.3 (SD 16.6) min) and tolerance (72.3 (13.9) min) to tourniquet inflation in the EMLA group were comparable to those in the SRA group (54.1 (16.2) min and 68.3 (19.0) min), but significantly (P < 0.05) greater than those in the control group (30.0 (10.7) min and 45.6 (14.0) min). The double cuff technique was the most effective method, with 91.5 (14.9) min duration of analgesia. We conclude that EMLA provided a significant analgesic effect on tourniquet pain compared with the control group, but a relatively limited analgesic effect compared with a double cuff technique.

Use of a Double Cuff AMS800 Urinary Sphincter for Severe Stress Incontinence

Stress urinary incontinence in the male patient has been successfully treated with the artificial urinary sphincter. However, approximately 15% of the patients treated are still significantly wet despite some improvement with this device. These patients usually are almost totally incontinent before artificial sphincter implantation. Of 15 such patients 80% were rendered satisfactorily dry by adding a second sphincter cuff around the bulbous urethra. This double cuff technique increases the success rate with the AMS800 sphincter to greater than 95%.

A New Noninvasive Blood Pressure Recorder Employing a Liquid-Filled Cuff.

The systolic and diastolic blood pressures (BP) measured by the conventional auscultatory method tend to be lower and higher respectively than the corresponding values obtained with invasive direct measurement. This study aims to develop a new, noninvasive device employing a liquid-filled cuff to mea sure BP accurately. The new BP recorder employs hydraulic pressure instead of air pressure in a double cuff (outer cuff and inner cuff with an implanted pressure transducer) surrounding the upper arm. The basic principle of this method is based on evidence that the pulsatile pattern of the pressure tracings obtained changes when the inner-cuff pressure reaches diastolic BP and changes again when it exceeds systolic BP. BP values measured directly from the brachial artery were compared with those obtained simultaneously by the conventional auscultatory method or by our new method in 7 normotensives and 14 hypertensive patients. The differnce in systolic BP between the auscultatory and direct methods was -6.8±4.0 (SD) mmHg and the diastolic BP difference was 1.1±6.5mmHg. In contrast, the systolic BP difference between the new method and the direct method was -0.6±2.0mmHg and that for diastolic BP was 0.6±1.9mmHg. These values were significantly smaller than the differences obtained with the auscultatory method (p<0.05). Improved conduction of brachial artery pulsation through the liquid-filled cuff to the transducer apparently improved the analysis of arterial pulsation. This new device employing a liquid-filled cuff could be useful for assessing hypertension. (Hypertens Res 1992; 15: 163-169)

Continuous Ambulatory Peritoneal Dialysis in Children in Saudi Arabia

Over a period of 5 years, 26 children with end-stage renal disease were started on maintenance continuous ambulatory peritoneal dialysis (CAPD) program in King Khalid University Hospital, Riyadh. A...

Cardiovascular effects of inhaled adenosine

To increase the signal-to-noise ratio (S/N) of H₂¹⁵O bolus PET activation images, we designed and tested a data acquisition protocol that alters the relative distribution of tracer in the uptake and washout phases of the input function. This protocol enhances the S/N gains obtained with conventional switched protocols by combining task switching and the use of a large bolus of blood free of tracer (cold bolus). The cold bolus is formed by sequestering blood in the lower limbs with a double cuff before tracer injection. <b>Methods:</b> The effect of a combined cold-bolus, switched protocol on the signal from activation images was first simulated using a compartmental model of the uptake of H₂¹⁵O into the brain. Then, the effectiveness of the protocol was investigated in 4 healthy volunteers performing a language task. Each volunteer underwent scanning 12 times: 3 activation/ baseline and 3 baseline/activation scans using the conventional switched protocol and 3 activation/baseline and 3 baseline/ activation scans using the combined cold-bolus, switched protocol. The S/N changes introduced when using the cold bolus were analyzed by comparing, across protocols, the magnitude and statistical significance of the activation foci associated with the execution of the language task identified in the averaged subtracted images, and by comparing image noise levels. <b>Results:</b> In the simulated datasets, the combined protocol yielded a substantial increase in the activation signals for scan durations greater than 60 s, in comparison with equivalent signals yielded by the switched protocol alone. In the PET experiments, activation foci obtained using the combined protocol had significantly higher <i>t</i> statistic values than did equivalent foci detected using the conventional switched protocol (mean improvement, 36%). Analysis of the S/N in the averaged subtracted images revealed that the improvements in statistical significance of the activation foci were caused by increases in the signal magnitudes and not by decreases in overall image noise. <b>Conclusion:</b> We designed a data acquisition protocol for H₂¹⁵O bolus PET activation studies that combines the use of a tracer-free bolus with a switched protocol. Simulated and experimental data suggest that this combined protocol enhances the S/N gains obtained with a conventional switched protocol. Implementation of the combined protocol in H₂¹⁵O bolus activation studies was easy.

Echec d'une anesthésie locorégionale intraveineuse chez une hypertendue

A case is reported of a congested arm occurring during intravenous regional anaesthesia with a double cuff tourniquet in a female elderly patient suffcring from hypertension. The proximal cuff was apparently inflated adequately to 300 mmHg. Recent studies showed that the use of only the proximal tourniquet was associated with a risk of venous leakage. In elderly hypertensive patients, when intravenous regional anaethesia was necessary, one would be justified in inflating the two cuffs before injection of the local anaesthetic.

Failure of intravenous regional analgesia using a double cuff tourniquet

A case is presented of an elderly, obese patient with calcified peripheral vessels in whom an intravenous regional analgesic technique failed because arterial occlusion could not be achieved safely with a double cuff tourniquet. The possible causes and precautions are discussed.