Need For Secondary Intervention Research Articles

Early and Late Aortic-Related Mortality and Rupture After Fenestrated-Branched Endovascular Aortic Repair of Thoracoabdominal Aortic Aneurysms: A Prospective Multicenter Cohort Study.

Fenestrated-branched endovascular aortic repair (FB-EVAR) has been used as a minimally invasive alternative to open surgical repair to treat patients with thoracoabdominal aortic aneurysms (TAAAs). The aim of this study was to evaluate aortic-related mortality (ARM) and aortic aneurysm rupture after FB-EVAR of TAAAs. Patients enrolled in 8 prospective, nonrandomized, physician-sponsored investigational device exemption studies between 2005 and 2020 who underwent elective FB-EVAR of asymptomatic intact TAAAs were analyzed. Primary end points were ARM, defined as any early mortality (30 days or in hospital) or late mortality from aortic rupture, dissection, organ or limb malperfusion attributable to aortic disease, complications of reinterventions, or aortic rupture. Secondary end points were early major adverse events, TAAA life-altering events (defined as death, permanent spinal cord injury, permanent dialysis, or stroke), all-cause mortality, and secondary interventions. A total of 1109 patients were analyzed; 589 (53.1%) had extent I-III and 520 (46.9%) had extent IV TAAAs. Median age was 73.4 years (interquartile range, 68.1-78.3 years); 368 (33.2%) were women. Early mortality was 2.7% (n=30); congestive heart failure was associated with early mortality (odds ratio, 3.30 [95% CI, 1.22-8.02]; P=0.01). Incidence of early aortic rupture was 0.4% (n=4). Incidence of early major adverse events and TAAA life-altering events was 20.4% (n=226) and 7.7% (n=85), respectively. There were 30 late ARMs; 5-year cumulative incidence was 3.8% (95% CI, 2.6%-5.4%); older age and extent I-III TAAAs were independently associated with late ARM (each P<0.05). Fourteen late aortic ruptures occurred; 5-year cumulative incidence was 2.7% (95% CI, 1.2%-4.3%); extent I-III TAAAs were associated with late aortic rupture (hazard ratio, 5.85 [95% CI, 1.31-26.2]; P=0.02). Five-year all-cause mortality was 45.7% (95% CI, 41.7%-49.4%). Five-year cumulative incidence of secondary intervention was 40.3% (95% CI, 35.8%-44.5%). ARM and aortic rupture are uncommon after elective FB-EVAR of asymptomatic intact TAAAs. Half of the ARMs occurred early, and most of the late deaths were not aortic related. Late all-cause mortality rate and the need for secondary interventions were 46% and 40%, respectively, 5 years after FB-EVAR. URL: https://www.clinicaltrials.gov; Unique identifiers: NCT02089607, NCT02050113, NCT02266719, NCT02323581, NCT00583817, NCT01654133, NCT00483249, NCT02043691, and NCT01874197.

Aggressive Treatment Strategy at Index Thoracic Endovascular Aortic Surgery is Associated with Reduced Need for Short-Term Reintervention in Patients with Aortic Dissection

Thoracic endovascular aortic surgery (TEVAR) is the modern standard of treatment for patients with Type B aortic dissection, however it is unclear how the initial length of treated aorta affects long-term outcomes. This study aims to elucidate risk factors for secondary intervention after TEVAR for aortic dissection, focusing on length of aortic treatment at index operation. A retrospective multihospital chart review was completed for patients treated between 2011 and 2022 who underwent TEVAR for aortic dissection with at least 1year of post-TEVAR imaging and follow-up. Patient demographics and characteristics were analyzed. In this study, aortic zones treated only included those managed with a covered stent graft. The primary outcome measure was any need for secondary intervention. A total of 151 patients were identified. Demographics included a mean age of 57years, with 31.8% of the patients being female. Forty-three patients (28.5%) underwent secondary intervention after TEVAR, with a mean follow-up of 1.6years. The most common indication for secondary intervention was aneurysmal degeneration of the residual false lumen (76%). There was a significant difference in the number of aortic zones treated in patients who did and did not require secondary intervention (2.3 ± 1 vs. 2.7 ± 1, P=0.04). Additionally, patients with 3 or more aortic zones of treatment had a significant difference in the need for reintervention (32% secondary intervention versus 52% no secondary intervention, P=0.02). At least 3 zones of aortic treatment at index TEVAR is associated with a decreased need for overall reintervention. Modern treatment of acute and subacute type B dissection should stress an aggressive initial repair, balanced by the potential increased risk of spinal cord ischemia.

Thoracic irrigation for prevention of secondary intervention after thoracostomy tube drainage for hemothorax: A Western Trauma Association multi-center study.

Retained hemothorax (rHTX) requiring intervention occurs in up to 20% of patients who undergo chest tube (TT) placement for a hemothorax (HTX). Thoracic irrigation at the time of TT placement decreases the need for secondary intervention in this patient group but those findings are limited because of the single center design. A multi-center study was conducted to evaluate the effectiveness of thoracic irrigation. A multi-center, prospective, observational study was conducted between June 2018 and July 2023. Eleven sites contributed patients. Patients were included if they had a TT placed for a HTX and were excluded if: age < 18 years, TT for pneumothorax, thoracotomy or VATS performed within 6 hours of TT, TT >24 hours after injury, TT removed <24 hours, or death within 48 hours. Thoracic irrigation was performed at the discretion of the attending. Each hemithorax was considered separately if bilateral HTX. The primary outcome was secondary intervention for HTX-related complications (rHTX, effusion, or empyema). Secondary intervention was defined as: TT placement, instillation of thrombolytics, VATS, or thoracotomy. Irrigated and non-irrigated hemithoraces were compared using a propensity weighted analysis with age, sex, mechanism of injury, Abbreviated Injury Scale (AIS) chest and TT size as predictors. 493 patients with 462 treated hemothoraces were included, 123 (25%) had thoracic irrigation at TT placement. There were no significant demographic differences between the cohorts. Fifty-seven secondary interventions were performed, 10 (8%) and 47 (13%) in the irrigated and non-irrigated groups, respectively (p = 0.015). Propensity weighted analysis demonstrated a reduction in secondary interventions in the irrigated cohort (Odds Ratio 0.56 (0.34-0.85); p = 0.005). This Western Trauma Association multi-center study demonstrates a benefit of thoracic irrigation at the time of TT placement for a HTX. Thoracic irrigation reduces the odds of a secondary intervention for rHTX-related complications by 44%. Therapeutic Study, Level II.

Mid to Long-Term Outcomes of Grade III-B Open Tibial Fractures Definitively Managed With a Circular Frame: A 13-Year Prospective Database Study at a Major Trauma Center.

The aim of this study was to report experience of a major trauma center utilizing circular frames as definitive fixation in patients sustaining Gustilo-Anderson 3B open tibial fractures. A prospectively maintained database was retrospectively interrogated. Single major trauma center in the United Kingdom. All patients over the age of 16 sustaining an open tibial fracture with initial debridement performed at the study center. All patients also received orthoplastic care for a soft tissue defect (via skeletal deformation or a soft tissue cover procedure) and subsequent definitive management using an Ilizarov ring fixator. Patients who received primary debridement at another center, had preexisting infection, sustained a periarticular fracture, or those who did not afford a minimum of 12-month follow-up were excluded. Case notes and radiographs were reviewed to collate patient demographics and injury factors. The primary outcome of interest was deep infection rate with secondary outcomes including time to union and secondary interventions. Two hundred twenty-five patients met inclusion criteria. Mean age was 43.2 year old, with 72% males, 34% smokers, and 3% diabetics. Total duration of frame management averaged 6.4 months (SD 7.7). Eight (3.5%) patients developed a deep infection and 41 (20%) exhibited signs of a pin site infection. Seventy-nine (35.1%) patients had a secondary intervention, of which 8 comprised debridement of deep infection, 29 bony procedures, 8 soft tissue operations, 30 frame adjustments, and 4 patients requiring a combination of soft tissue and bony procedures. Bony union was achieved in 221 cases (98.2%), 195 (86.7%) achieved union in a single frame without the need for secondary intervention, 26 required frame adjustments to achieve union. Autologous bone grafts were used in 10 cases. Orthoplastic care including circular frame fixation for Gustilo-Anderson-3B fractures of the tibia resulted in a low rate of deep infection (3.5%) and achieved excellent union rates (98.2%). Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The value of ultrasound parameters in predicting the efficacy of transabdominal ultrasound-guided suction curettage alone in the treatment of cesarean scar pregnancy.

To investigate the value of ultrasound parameters in assessing the efficacy of transabdominal ultrasound (TAUS)-guided suction curettage alone for cesarean scar pregnancy (CSP). Secondary retrospective analysis of a prospective study consisted of 137 women diagnosed with CSP who were performed TAUS-guided suction curettage alone for the first time at Maternity and Child Health Care of Guangxi Zhuang Autonomous Region in China. Prior to surgery, an ultrasound examination was conducted. Based on the need for secondary intervention, the patients were categorized into failure group and success group, and the predictive factors for failure of TAUS-guided suction curettage alone were analyzed. Multivariate logistic regression showed that maximum diameter of the gestational sac>29 mm (odds ratio [OR] = 4.043, 95% CI: 1.100-14.862), residual myometrium thickness ≤1.8 mm (OR = 3.719, 95% CI: 1.148-12.048) and chorionic villi thickness at the scar >4.7 mm (OR = 15.327, 95% CI: 4.617-50.881) were independent predictors of failure in TAUS-guided suction curettage alone for CSP. Furthermore, the logistic regression model that was jointly constructed by these three predictors demonstrated an area under the curve, sensitivity, specificity, and Youden index of 0.913, 0.912, 0.864, and 0.776, respectively. The maximum diameter of the gestational sac, residual myometrium thickness, and chorionic villi thickness at the scar has certain predictive efficacy of TAUS-guided suction curettage alone for CSP. Nevertheless, it is more valuable to apply the model of this study, composed of the three ultrasound parameters, for this prediction purpose.

Early and Mid-term Results of Endovascular Treatment of Abdominal Aortic Aneurysm in Patients Over 65 Years of Age

Objective: In patients over the age of 65, the most appropriate treatment modality for abdominal aortic aneurysms (AAA) is controversial, but the use of endovascular treatment methods is increasing. The aim of this study was to investigate the duration of intensive care unit stay, need for reintervention, and early and late mortality rates after endovascular treatment in octogenerians with abdominal aortic aneurysm.&#x0D; Material and Method: A total of 220 patients who underwent endovascular aneurysm repair for abdominal aortic aneurysm under elective conditions were included in the study. Patients over 70 years of age constituted Group-1 (n = 102) and those under 70 years of age constituted Group-2 (n = 118). The groups were analyzed in terms of postoperative intensive care stay, need for reintervention, and early and late mortality rates.&#x0D; Results: The ratio of males was higher in group 1 (94.5% vs. 84.9, p = 0.017). Length of ICU stay was higher in group 1 (12 hours vs. 8 hours, p = 0.014). All four cases of early mortality were in patients over 65 years of age (p = 0.031). There was no difference between the groups in terms of follow-up period (32 vs. 31 months, p = 0.859), late mortality (8% vs. 13%, p = 0.219), or the need for secondary intervention (6% vs. 7%, p = 0.770). There was no difference between the groups in terms of survival and the 3-year survival was 91% vs. 85%. (p = 0.199).&#x0D; Conclusion: In octogenerians, endovascular aneurysm repair can be performed with acceptable mortality rates and satisfactory mid-term outcomes.

Percutaneous nephrolithotomy vs retrograde intrarenal surgery for renal stones: a Cochrane Review.

To assess the effects of percutaneous nephrolithotomy (PCNL) vs retrograde intrarenal surgery (RIRS) for the treatment of renal stones in adults. We performed a comprehensive search of the Cochrane Library, MEDLINE, Embase, three other databases, trials registries, other sources of the grey literature, and conference proceedings up to 23 March 2023. We applied no restrictions on publication language or status. Screening, data extraction, risk-of-bias assessment, and certainty of evidence (CoE) rating using the Grading of Recommendations Assessment, Development and Evaluations (GRADE) approach were done in duplicate by two independent reviewers. This co-publication focuses on the primary outcomes of this review only. We included 42 trials that met the inclusion criteria. Stone-free rate (SFR): PCNL may improve SFRs (risk ratio [RR] 1.13, 95% confidence interval [CI] 1.08-1.18; I2 = 71%; 39 studies, 4088 participants; low CoE). Major complications: PCNL probably has little to no effect on major complications (RR 0.86, 95% CI 0.59-1.25; I2 = 15%; 34 studies, 3649; participants; moderate CoE) compared to RIRS. Need for secondary interventions: PCNL may reduce the need for secondary interventions (RR 0.31, 95% CI 0.17-0.55; I2 = 61%; 21 studies, 2005 participants; low CoE) compared to RIRS. Despite shortcomings in most studies that lowered our certainty in the estimates of effect to mostly very low or low, we found that PCNL may improve SFRs and reduce the need for secondary interventions while not impacting major complications. Ureteric stricture rates may be similar compared to RIRS. We expect the findings of this review to be helpful for shared decision-making about management choices for individuals with renal stones.

Reducing aneurysm sac growth and secondary interventions following endovascular abdominal aortic aneurysm repair by preemptive coil embolization of the inferior mesenteric artery and lumbar arteries

ObjectiveType II endoleak (EL-2) is the most common complication following endovascular aneurysm repair (EVAR), leading to continued sac growth and potential rupture. In this study, we examined the association between patency of the inferior mesenteric artery (IMA) and lumbar arteries (LAs) with respect to sac growth. The effect of preemptive embolization of the IMA and/or LAs on the need for secondary interventions for sac growth post-EVAR was also evaluated. MethodsA retrospective cohort study was performed on consecutive patients who underwent EVAR for non-ruptured, infrarenal abdominal aortic aneurysms (AAAs) from January 2012 to December 2020. A select group of patients underwent preemptive embolization of the IMA and/or LA. Patients with any types I, III, or IV endoleaks were excluded. Patency of the IMA and LA on preoperative computed tomography angiogram (CTA) was evaluated on TeraRecon workstation. All secondary interventions to treat EL-2 were recorded. Sac growth was defined as centerline axial diameter increase of ≥5 mm on follow-up CTA. ResultsA total of 300 patients (mean age, 74 ± 8.5 years; 83.7% male) underwent EVAR. Ninety-nine patients had preemptive embolization of the IMA and/or LA. Mean follow-up of the cohort was 59.3 ± 30.5 months. Thirty-six patients (12%) demonstrated sac growth on follow-up; 12 of these (33.3%) had preemptive embolization. The median time until detection of sac growth was 28.8 months (interquartile range, 15.2-46.5 months), with a mean growth of 10.1 ± 6.4 mm. Sac growth was significantly associated with presence of EL-2: 27 of 36 (75%) with EL-2 vs 9 of 36 (25%) without EL-2 (P < .001). Patients with sac growth had a higher mean total number (2.6 ± 1.5) of patent lower LAs (L3, L4) compared with those without (2.0 ± 1.4; P = .03). Patency of L1, L2, and L3 LAs were not associated with sac growth. However, patency of at least one L4 LA was significantly associated with sac growth (14.8% vs 7.7%; P = .04). The highest incidence of sac growth (17.6%) was seen when both IMA and L4 LA were patent; significantly different from the lowest incidence (5.3%) when both were occluded preoperatively (P = .018). Preemptive coiling of the IMA and/or LA significantly reduced the need for post-EVAR secondary intervention for sac growth. Freedom from post-EVAR secondary intervention was achieved in 92 of 99 (92.9%) pre-EVAR coiled patients vs 163 of 201 (81.5%) patients who did not undergo pre-EVAR coiling (P = .009). ConclusionsPreemptive coil embolization of the IMA and LAs, especially L4 LA, reduces the need for secondary interventions for sac growth, potentially improving the long-term durability of EVAR.

Age Impacts Risk of Mixed Chimerism Following Reduced-Intensity Conditioning Hematopoietic Cell Transplantation for Non-Severe Combined Immune Deficiency Inborn Errors of Immunity

Alemtuzumab, fludarabine, and melphalan containing-reduced intensity conditioning (RIC) is commonly used in patients undergoing allogeneic hematopoietic cell transplantation (HCT) for definitive treatment of high-risk inborn errors of immunity (IEI). Although survival is favorable, there is an increased risk of mixed chimerism leading to secondary graft failure. This study evaluated factors associated with the risk of developing mixed chimerism, particularly the influence of age in patients undergoing allogeneic HCT for non-severe combined immune deficiency (SCID) IEI who received a uniform RIC regimen that included intermediate schedule alemtuzumab, fludarabine, and melphalan. We hypothesized that age would impact the incidence of mixed chimerism. We retrospectively reviewed records of patients who underwent HCT for non-SCID IEI with a uniform RIC regimen that included intermediate schedule alemtuzumab (1 mg/kg divided over days -14 to -10), fludarabine (150 mg/m2 or 5 mg/kg if weight <10 kg divided over days -9 to -4), and melphalan (140 mg/m2 or 4.7 mg/kg if weight <10 kg on day -3) between 2010 and 2020 at our institution. Mixed chimerism was defined as <95% donor chimerism on 2 or more consecutive occasions in whole blood. Ninety-three patients who underwent RIC-HCT for non-SCID IEI using intermediate schedule alemtuzumab, fludarabine, and melphalan were categorized into 3 groups: age <1 year, age 1 to 5 years, and age >5 years. Forty-nine patients (52.7%) developed mixed chimerism, at a median of 34 days post-HCT (range, 10 to 1396 days). Mixed chimerism developed in 88.9% (n=16/18) of the age <1 year group, in 57.1% (n=20/35) of the age 1 to 5 years group, and in 35% (n =14/40) of the age >5 years group. Patients age <5 years were significantly more likely to develop mixed chimerism (χ2(3,N=93)=14.8; P=.001). We observed a significantly increased cumulative incidence of developing mixed chimerism associated with age <1 year (P=.0002). Competing risk regression analysis showed a 3-fold higher risk of developing mixed chimerism for age <1 year (subdistribution hazard ratio (HR), 3.05; 95% confidence interval [CI], 1.11 to 8.38; P=.031,) compared to age >5 years and a significantly decreased risk of mixed chimerism in patients who developed acute GVHD prior to any intervention (OR, .24; 95% CI, .09 to .65; P=.005) There were no significant associations between mixed chimerism and graft source, graft type, CD34+ or CD3+ cell dose, HLA match, or underlying disease (hemophagocytic lymphohistiocytosis [HLH] versus non-HLH). Additionally, the need for secondary intervention was evaluated; 27 patients (29.0%) required 1 or more secondary interventions (donor lymphocyte infusion, CD34 boost, or second HCT). Patients age <1 year with mixed chimerism were significantly more likely than patients age >5 years to require secondary intervention for mixed chimerism (P=.004). Our study demonstrates that age <5 years, especially age <1 year, is associated with an increased risk of developing mixed chimerism in patients undergoing RIC-HCT for non-SCID IEI using intermediate-schedule alemtuzumab, fludarabine, and melphalan. Our data suggest tailoring regimen intensity based on age to reduce the incidence of mixed chimerism. Children age <5 years, particularly those age <1 year, require a higher-intensity regimen. Possible strategies include adding thiotepa or using a busulfan-based reduced toxicity regimen.

Propeller Perforator Flaps Used for Hand and Digit Reconstruction: A Systematic Review

BackgroundPropeller perforator flaps (PPFs) have increased in popularity due to the freedom in design and ability to cover a variety of defects without sacrificing the major vessels. Present reports of PPFs for upper limb reconstruction have not provided guidance for hand reconstruction, specifically. This study aims to review the current literature and evaluate techniques for use of PPFs in hand reconstruction. MethodsA comprehensive literature review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for articles published from 1991 to 2021. The database search was queried for records using appropriate Medical Subject Headings (MeSH) terms. Studies reporting PPFs were limited to English language and excluded lower extremity or upper extremity reconstruction not specific to defects in the hand or digits. Study characteristics, patient demographics, indications, preoperative testing, flap characteristics, flap survival, and complication rates were collected. ResultsOut of the initial 1,348 citations yielded, 71 underwent full-text review. Ultimately, 25 unique citations were included encompassing 12 retrospective reviews (48%), 3 prospective cohort studies (10%), and 10 case series (40%). In review, 525 patients underwent reconstruction with a total of 613 propeller flaps performed to repair defects of the hand, digits, or both with use of 18 unique flap types. Overall flap survival was 97.8%. Acute wounds accounted for 72.9% of performed reconstructions. The mean flap coverage was 14.7 cm2. Complications occurred in 19.8% of cases, with venous congestion and partial flap necrosis occurring in 5.5 and 6.5% of cases, respectively, leading to a flap failure rate of 2.1%. ConclusionPPFs are a reliable option for hand or digital reconstruction, allowing surgeons to cover a variety of defects without sacrificing local vasculature. Despite nearly a 20% reported complication rate, nearly all flaps with venous congestion and partial flap necrosis included in these articles resolved without the need for secondary intervention, retaining an excellent overall flap survival.

MP35-01 A SINGLE CENTRE PROSPECTIVE RANDOMIZED CONTROLLED STUDY TO ASSESS OUTCOMES AND COMPLICATIONS OF CONVENTIONAL STENT PLACEMENT VERSUS NO STENT PLACEMENT AFTER URETEROSCOPY FOR DISTAL URETERIC CALCULUS OF SIZE &lt; 1 CMS

You have accessJournal of UrologyCME1 Apr 2023MP35-01 A SINGLE CENTRE PROSPECTIVE RANDOMIZED CONTROLLED STUDY TO ASSESS OUTCOMES AND COMPLICATIONS OF CONVENTIONAL STENT PLACEMENT VERSUS NO STENT PLACEMENT AFTER URETEROSCOPY FOR DISTAL URETERIC CALCULUS OF SIZE <1 CMS Arun Chawla, Suraj Jaidev Reddy, and Jean de la Rosette Arun ChawlaArun Chawla More articles by this author , Suraj Jaidev ReddySuraj Jaidev Reddy More articles by this author , and Jean de la RosetteJean de la Rosette More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003269.01AboutAbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Abstract INTRODUCTION AND OBJECTIVE: Most Endo-urologists routinely insert ureteric stents, justified by the hypothetical fact that stent placement promotes the passage of residual stone fragments and clots, presumably lowers the risk of stricture formation, and prevents ureteric obstruction and renal colic induced by ureteric oedema We aimed to compare the efficacy, safety and morbidity of No stent placement with the conventional stent placement after uncomplicated retrograde semi rigid URSL for distal ureteric calculus of size <1 cm pertaining to Lower Urinary tract symptoms and Sexual function using validated questionnaires. In addition, to compare complication rate, emergency visits, secondary interventions and pain at the time of follow up using visual analog scale (VAS) between the two groups. METHODS: 104 patients were randomized following an uncomplicated ureteroscopic lithotripsy into Conventional stented Group (CSG) and non-stented group (NSG). Lower urinary tract symptoms and sexual function were evaluated using validated questionnaires (IPSS+IIEF-5+MSHQ-EjD/FSFI) preoperatively and at 4 weeks during follow up/ stent removal based on the group. Pain scores at follow up/ stent removal were recorded using a visual analogue scale (VAS). Patients who had emergency room visits, need for secondary interventions before the recommended time of follow up were noted. Generalized Estimating Equations method was used to explore the difference in change in the domains of IPSS, IIEF-5, MSHQ-EjD and FSFI between the two groups over time. RESULTS: Significant difference was noted in the following IPSS domains: Frequency, Urgency, Nocturia, Storage symptoms, Total IPSS Score (p=<0.001) and QoL (p=0.002), IIEF-5 domains: Overall Score (p=0.004), MSHQ-EjD domains, Ejaculation Bother/ Satisfaction (p=<0.001) and FSFI domains: Lubrication (p=<0.001), Satisfaction (p=0.006) and Overall Score (p=0.004). There was no significant difference between the various groups in terms of distribution of Emergency Visits, Readmission and Secondary Interventions, pain at follow-up (VAS) and long-term analgesia. CONCLUSIONS: Non placement of stents after uncomplicated URS decreases stent related symptoms, improves QoL without jeopardizing for an increased postoperative risk. Header Variable CSG Group (n=49) NSG Group (n=43) p-Value χ2 Header Emergency visits 7(14.3%) 5 (11.6%) 0.706 0.143 Header Readmissions 4 (8.2%) 1 (2.3%) 0.367 1.519 Secondary Interventions Conservative Management 0 (0.0%) 1 (2.3%) 0.467 1.152 Early stent removal 3 (6.1%) NA - - PCN Insertion 0 (0.0%) 0 (0.0%) - - Relook URS 1 (2.0%) 0 (0.0%) 1.000 0.887 Analgesia requirement (> 5 days) 11 (22.4%) 5 (11.6%) 0.172 1.867 Variable CSG Group (n=49) NSG Group (n=43) p-Value χ2 Emergency visits 7(14.3%) 5 (11.6%) 0.706 0.143 Readmissions 4 (8.2%) 1 (2.3%) 0.367 1.519 Secondary Interventions Conservative Management 0 (0.0%) 1 (2.3%) 0.467 1.152 Early stent removal 3 (6.1%) NA - - PCN Insertion 0 (0.0%) 0 (0.0%) - - Relook URS 1 (2.0%) 0 (0.0%) 1.000 0.887 Analgesia requirement (> 5 days) 11 (22.4%) 5 (11.6%) 0.172 1.867 Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e468 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Arun Chawla More articles by this author Suraj Jaidev Reddy More articles by this author Jean de la Rosette More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

The Fate of Hemodialysis Vascular Access After Kidney Transplantation: Why Ligation Should Not Be Systematically Performed?

After renal transplant, the haemodialysis (HD) vascular access (VA) is often maintained in the event of graft failure but evidence to recommend the systematic ligation/maintenance are lacking. We investigate the effects of VA preservation/ligation in successfully transplanted patients. A retrospective analysis of all patients undergoing successful renal transplantation after HD were conducted. Patients with a functioning VA, those undergoing ligation or presenting with post-transplantation spontaneous thrombosis were included. Demographics, comorbidities, reasons for ligation, need for secondary interventions, complications and return in dialysis were assessed. Out of 542 HD patients, 114 (76, 66.7% male, median age 50 years, range 20-70) were included. Eight (7%) accesses thrombosed in a mean of 1.4 days (range 1-3) after transplant; 42 (36.8%) fistulas were ligated and 64 (56.1%) preserved. The reasons for ligation were patient's request (35, 83.3%), steal syndrome (5, 11.9%), heart failure (1, 2.4%) and aneurysmal degeneration (1, 2.4%).During a mean follow-up of 724.9 days (range 80-1082) 25 patients developed complications over the maintained access (40% of stenosis; 32% high flow and 28% thrombosis); 18 (15.8%) needed reoperation; 17 (15%) required further HD. Multivariate analysis showed that coronary artery disease (OR= 12.566 [2.056-76.805], P < 0.06) or age >60 years (OR=0.181 [0.044-0.735], P = 0.017) were risk factor for complications over unused VA. The ligation of a functioning VA after renal transplant should evaluated on an individualized basis. Patients with pre-existing cardiovascular disease or aged >60 years should be monitored closely up as they are at higher risk of complications.

The Clinical Outcomes of Operative Treatment Versus Conservative Treatment for Dancer's Fractures: Protocol for a Retrospective Cohort Study.

BackgroundFifth metatarsal fractures are one of the most common foot fractures, and 11% to 25% of such fractures are Dancer’s fractures (distal spiral fractures). Conservative therapy while wearing a cast and operative treatment have been used as preferred modes of treatment in the limited literature available. However, we often see healing problems, such as delayed union and nonunion, when Dancer’s fractures are treated nonoperatively, resulting in a need for secondary intervention. In our institution, treatment has changed over the years from predominantly conservative treatment to mostly operative treatment. To investigate whether our hypothesis holds true that primary surgical treatment is beneficial, a retrospective study was designed.ObjectiveThe objective of the study is to compare differences between outcomes (delayed union and nonunion) of conservative and operative treatments for Dancer’s fractures.MethodsA retrospective comparative cohort study will be conducted in a level II trauma center (Zaandam Medical Center). Patients who experienced a Dancer’s fracture in the period of 2012 to 2021 will be included and divided into 2 cohorts—the conservative (2012-2015) and operative (2016-2021) treatment cohorts. The primary outcome will be the differences in percentages of delayed union and nonunion between the two groups. The secondary outcomes will be the percentage of primary conservative treatment failure, the need for secondary operative treatment, complications (infection and hardware failure), and functional outcomes. If 118 patients are included in each group, sufficient power is expected to be reached, depending on the age distribution of patients. The percentages of delayed union and nonunion among the two groups will be calculated and statistically compared via chi-square statistics. A logistic regression analysis will be used to investigate possible associations between patient characteristics and failed conservative treatment. A Mann-Whitney U test will be used to compare functional outcomes between groups. An independent, 2-tailed t test will be used to compare mean 12-Item Short Form Survey scores if they are normally distributed, and a Wilcoxon rank sum test will be used if they are nonnormally distributed.ResultsIn total, 2134 potentially relevant health insurance codes have been extracted from the hospital’s register. We expect to find a total of 236 Dancer’s fractures in this data set.ConclusionsOur study has limitations due to it being a single-center study and data collection being performed retrospectively. However, it covers a large time period and may provide the possibility to show treatment outcome differences (delayed union and nonunion, complications, and functional outcomes) in 2 reasonably large cohorts (conservative and operative treatment cohorts), which has not been done before in literature on Dancer’s fractures. If our hypothesis that surgery is beneficial for Dancer’s fractures is proven true by our study, we plan to further corroborate it by conducting a prospective randomized controlled trial.International Registered Report Identifier (IRRID)PRR1-10.2196/37171

Пересадка культи трехфалангового пальца противоположной кисти на микрососудистых анастомозах у больных с последствиями отморожений кистей и стоп (случаи из практики)

in frostbite patients. Material and methods Medical histories and long-term results of treatment of two frostbite patients with finger stumps of both hands were reviewed. The triphalangeal finger and the thumb were reconstructed by transplanting the opposable finger stump together with the metacarpophalangeal joint using microvascular and microneural anastomoses. The stumps were mobilized and transplanted to the distal ulnar artery with the venous drainage performed using the dorsal saphenous vein of the hand. Long-term results were examined at 10 years and 2.5 years of surgery. Clinical, radiological, biomechanical and biophysical investigations were produced. Results The bilateral gripping function was restored in recipient stumps without functional damage to the donor stumps. Discriminatory sensitivity of reconstructed fingers was 6mm and 8 mm, the range of active motion in the transplanted joint was 55 and 66 degrees. Discussion Opposable digital stump transplantation with microvascular anastomoses has significant advantages over the classical surgery. The technique allows for one-stage restoration of a finger to have sufficient length, function, adequate blood supply and innervation due to a short digital stump being transplanted with the metacarpophalangeal joint. The advantage over a toe transplant consists of the use of digital structures of the hand that are identical in functionality and the anatomy reducing the need for secondary interventions. Conclusion The method of management can be successfully applied for frostbite patients with hand stumps according to indications.

Editorial Comment.

No AccessJournal of UrologyAdult Urology1 Apr 2022Editorial CommentThis article comments on the following:Urethroscopic Findings following Urethroplasty Predict the Need for Secondary Intervention in the Long Term: A Multi-Institutional Study from Trauma and Urologic Reconstructive Network of Surgeons Reynaldo G. Gomez Reynaldo G. GomezReynaldo G. Gomez Chief of Urology, Hospital del Trabajador, Santiago, Chile More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002353.02AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Editorial Comment." The Journal of Urology, 207(4), p. 865 © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsRelated articlesJournal of Urology2 Dec 2021Urethroscopic Findings following Urethroplasty Predict the Need for Secondary Intervention in the Long Term: A Multi-Institutional Study from Trauma and Urologic Reconstructive Network of Surgeons Volume 207Issue 4April 2022Page: 865-865 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Reynaldo G. Gomez Chief of Urology, Hospital del Trabajador, Santiago, Chile More articles by this author Expand All Advertisement PDF downloadLoading ...

Editorial Comment.

No AccessJournal of UrologyAdult Urology1 Apr 2022Editorial CommentThis article comments on the following:Urethroscopic Findings following Urethroplasty Predict the Need for Secondary Intervention in the Long Term: A Multi-Institutional Study from Trauma and Urologic Reconstructive Network of Surgeons Christopher Chapple Christopher ChappleChristopher Chapple Sheffield Teaching Hospitals NHS Foundation Trust, University of Sheffield Sheffield Hallam University, Sheffield, UK More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002353.01AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Editorial Comment." The Journal of Urology, 207(4), pp. 864–865 Reference 1. : Flexible cystourethroscopy in the follow-up of posturethroplasty patients and characterisation of recurrences. Eur Urol 2015; 68: 523. Google Scholar © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsRelated articlesJournal of UrologyDec 2, 2021, 12:00:00 AMUrethroscopic Findings following Urethroplasty Predict the Need for Secondary Intervention in the Long Term: A Multi-Institutional Study from Trauma and Urologic Reconstructive Network of Surgeons Volume 207Issue 4April 2022Page: 864-865 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Christopher Chapple Sheffield Teaching Hospitals NHS Foundation Trust, University of Sheffield Sheffield Hallam University, Sheffield, UK More articles by this author Expand All Advertisement PDF DownloadLoading ...

Urethroscopic Findings following Urethroplasty Predict the Need for Secondary Intervention in the Long Term: A Multi-Institutional Study from Trauma and Urologic Reconstructive Network of Surgeons.

Postoperative surveillance urethroscopy has been shown to be an effective tool to predict reoperation within 1 year after urethroplasty. We aimed to evaluate early surveillance urethroscopy findings and long-term outcomes among urethroplasty patients in order to define the value of surveillance urethroscopy to predict failure. We evaluated 304 patients with at least 4 years of followup after urethroplasty performed at 10 institutions across the United States and Canada. All patients were surveilled using a flexible 17Fr cystoscope and were categorized into 3 groups: 1) normal lumen, 2) large-caliber stricture (≥17Fr) defined as the ability of the cystoscope to easily pass the narrowing and 3) small-caliber stricture (<17Fr) that the cystoscope could not be passed. Failure was stricture recurrence requiring a secondary intervention. The median followup time was 64.4 months (range 55.3-80.6) and the time to initial surveillance urethroscopy was 3.7 months (range 3.1-4.8) following urethroplasty. Secondary interventions were performed in 29 of 194 (15%) with normal lumens, 11 of 60 (18.3%) with ≥17Fr strictures and 32 of 50 (64%) with <17Fr strictures (p <0.001). The 1-, 3- and 9-year cumulative probability of intervention was 0.01, 0.06 and 0.23 for normal, 0.05, 0.17 and 0.18 for ≥17Fr, and 0.32, 0.50 and 0.73 for <17Fr lumen groups, respectively. Patient-reported outcome measures performed poorly to differentiate the 3 groups. Early cystoscopic visualization of scar recurrence that narrows the lumen to <17Fr following urethroplasty is a significant long-term predictor for patients who will eventually undergo a secondary intervention.

Iterative Methods for the Biomechanical Evaluation of Corneal Response. A Case Study in the Measurement Phase

The number of corneal surgeries steadily grew in recent years and boosted the development of corneal biomechanical models. These models can contribute to simulating surgery by reducing associated risks and the need for secondary interventions due to ectasias or other problems related to correcting other diseases. Biomechanical models are based on the geometry obtained with corneal topography, which is affected by intraocular pressure and material properties. Knowledge of stress distribution in the measurement phase is a key factor for improving the accuracy of in silico mechanical models. In this work, the results obtained by two different methods: prestress method and displacements method were compared to evaluate the stress and strain distribution in a general geometric model based on the Navarro eye geometry and two real corneal geometries. The results show that both methods are equivalent for the achievement of the stress distribution in the measurement phase. Stress distribution over the corneal geometry in the measurement phase is a key factor for accurate biomechanical simulations, and these simulations could help to develop patient-specific models and reduce the number of secondary interventions in clinical practice.

The Results of The Interposition Graft-Technique in Treatment of High Flow Vascular Access

High-flow (HF) vascular access (VA) is a fearsome condition potentially responsible for cardiac or pulmonary complications, steal syndrome and hand ischemia. The present study was conducted to report the results achieved in a group of patients undergoing interposition-graft technique to treat HF. An analysis of clinical, ultrasound and echocardiography data collected from the review of medical charts was performed. Flow reduction, complications and need for secondary interventions were investigated. Among a total 498 hemodialysis access interventions performed during a 6-years period, 30 patients (n 15, 50% male, median age 63.5, range 42-91 years) presented with high-flow (median flow 1.9 L/min, range 1.5-4 L/min). 18 patients were asymptomatic (60%); 6 (20%) suffered from a severe distal hand ischemia; 5 (16.6%) developed signs of congestive heart failure and 1 patient (3.3%) presented with pulmonary hypertension. In twenty patients (66.7%) the access was preserved by the interposition of a 6 mm polytetrafluroethylene (PTFE) prosthesis. This approach was used as a primary flow reduction technique in 16 patients (80%) or the failure of a previously attempted procedure in 4 cases. No intraoperative complications were observed. Post-operative median VA flow was 1.1 L/min (range 0.900-2 L/min), with a median flow reduction of 0.770 L/min (range 0.100-2.8 L/min). At a median follow-up of 9 months (range 1-42), 95% (n 19) of patients were free from recurrences. In treatment of HF-VA graft interposition demonstrated satisfactory results at the mid-term follow-up. More data are needed to affirm this technique as the preferential one.

MP64-12 SALVAGE PELVIC LYMPH NODE DISSECTION OF LOCALLY RECURRENT PROSTATE CANCER AFTER RADICAL PROSTATECTOMY CAN DELAY THE NEED FOR SYSTEMIC INTERVENTIONS

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy VI (MP64)1 Sep 2021MP64-12 SALVAGE PELVIC LYMPH NODE DISSECTION OF LOCALLY RECURRENT PROSTATE CANCER AFTER RADICAL PROSTATECTOMY CAN DELAY THE NEED FOR SYSTEMIC INTERVENTIONS Erica Huang, Karren Liang, Linda Huynh, Whitney Zhang, and Thomas Ahlering Erica HuangErica Huang More articles by this author , Karren LiangKarren Liang More articles by this author , Linda HuynhLinda Huynh More articles by this author , Whitney ZhangWhitney Zhang More articles by this author , and Thomas AhleringThomas Ahlering More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002104.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: With the advent of the 68-Ga PSMA PET/CT scan, recurrences following radical prostatectomy (RP) can be localized to pelvic lymph nodes, soft pelvic tissue, and/or distant metastases. In our experience, 55% of patients with a biochemical recurrence (BCR) following surgery recur locally in the pelvic lymph nodes (PLN). Standard therapies such as radiation and/or hormonal therapy are known to negatively affect patients’ quality of life (QOL) and, in this regard, the present study introduces salvage pelvic lymph node dissections (sPLND) of local recurrence as a potential treatment for local recurrences. METHODS: Following RP, 87 patients underwent 68 Gallium PSMA/PET CT scan, of which 64 scans were positive, with 35 (40.2%) demonstrating radiographic evidence of localized recurrence in the PLN. Amongst the PLN positive group, 15 patients proceeded with sPLND by a single surgeon. The primary outcome evaluated was PSA kinetics, and secondary outcome evaluated was need for secondary treatment. RESULTS: All surgeries were completed outpatient without complication. Patients were discharged with <24 hours hospitalization with <1 week recovery time. Of the 15 patients who underwent sPLND, 6 (40.0%) patients had a stable rise in PSA with no secondary intervention at mean follow-up time of 2.3 (±0.8) years following sPLND. 4 (26.7%) patients experienced a stable rise in PSA with secondary intervention, and 5 (33.3%) patients experienced BCR immediately, with immediate hormonal therapy as a secondary intervention. In 10/15 (33.33%) of the patients, PSA decreased by an average of 58% following sPLND. 6/15 (40.0%) patients did not require secondary systemic interventions such as radiation and hormonal therapy thus far (Table 1). CONCLUSIONS: This case series explores the utility of PSMA/PET scan imaging and subsequent dissection of pelvic lymph node recurrences, demonstrating its potential to slow PSA progression and delay or eliminate the need for secondary intervention. Future studies with additional patients and greater follow-up are required to evaluate PSA progression and secondary intervention post-sPLND further. Source of Funding: Self-Funded © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e1114-e1115 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Erica Huang More articles by this author Karren Liang More articles by this author Linda Huynh More articles by this author Whitney Zhang More articles by this author Thomas Ahlering More articles by this author Expand All Advertisement Loading ...