Need For Secondary Procedures Research Articles

Intramedullary nailing versus percutaneous locked plating of distal extra-articular tibial fractures: a retrospective study

The aim of this study is to compare distal tibial fractures (4-10 cm proximal to the plafond) treated by intramedullary nailing with those treated by percutaneous locked plating and to assess the clinical and radiographic results, complication rates, and the need for secondary procedures. Thirty-six patients received percutaneous locked plate treatment and 25 patients received intramedullary nail treatment. The results obtained from these two treatment methods were assessed by comparing infection rates, starting time for wight-bearing, local implant irritation, union and malunion rates and along with secondary procedures. In the percutaneous locked plate group, two deep infections, four superficial infections, two nonunions, one malunion and 10 local implant irritations were observed. In the intramedullary nail group, one nonunion, four malunions and two local implant irritations were observed. The incidence of deep and superficial infections, local implant irritations and secondary procedures in the percutaneous locked plate group was greater than those in the intramedullary nail group. The time to full weight bearing was shorter in the intramedullary nail group. There was no significant statistical difference in malunion and nonunion rates between the two groups. The need for secondary procedures was more common in group receiving the percutaneous locked plate treatment and the time to full weight bearing was shorter in the intramedullary nail group.

Predictors for Secondary Procedures in Walking DDH

Persistent or recurrent hip dysplasia and/or loss of reduction can complicate the treatment of developmental dysplasia of the hip (DDH) in walking children. In this study, we identify predictors for secondary procedures after open reduction of the hip in walking children with DDH. We performed a retrospective study of walking children with idiopathic DDH treated with open reduction of the hip and followed up for >5 years. Perioperative factors were analyzed to investigate predictors of reoperation. Factors associated with the need for secondary procedures were identified. Acetabular remodeling was analyzed with a graphical plot of serial (0, 6 and 12 mo, and yearly) mean acetabular index and SD. There were 49 open reductions of the hip in 42 patients (34 female, 8 male) at a mean age of 31.3 months (range, 15.3 to 92.6 mo), with a mean follow-up of 9.7 years (5 to 16.9 y). Twelve (24%) patients had open reduction only, 15 (31%) had concurrent pelvic osteotomy, 4 (8%) had femoral osteotomy, and 18 (37%) had both femoral and pelvic osteotomy. Four (8%) patients required repeat open reduction at a mean of 5.1 months (range, 4 to 7.5 mo) after index surgery. Twenty-four (49%) patients had at least 1 secondary surgery for dysplasia at a mean of 3.2 years after index surgery. Six of the 24 (25%) had 2 and 2/24 (8.3%) had 3 additional operations. Of the 27 patients who did not have concurrent femoral osteotomy at index surgery, 19/27 (73%) required a secondary procedure; this significantly predicted the need for reoperation (P<0.001). Only 5/22 patients with femoral osteotomy at index surgery required a secondary procedure. Maximum acetabular remodeling was observed in the first 4 years after primary reduction, and the mean acetabular index remodeled from 43.9 to 20.3 degrees during this period. Forty-nine percent of the patients in this cohort required secondary procedures to treat hip dysplasia. Open reduction without concurrent femoral osteotomy strongly predicted the need for a secondary procedure. Maximum acetabular remodeling was observed in the first 4 years after open reduction. Retrospective case series, level IV.

Open Fractures of the Distal Radius: The Effects of Delayed Debridement and Immediate Internal Fixation on Infection Rates and the Need for Secondary Procedures

Open Fractures of the Distal Radius: The Effects of Delayed Debridement and Immediate Internal Fixation on Infection Rates and the Need for Secondary Procedures

Single-Center Experience with Pediatric Laparoscopic Extravesical Reimplantation: Safe and Effective in Simple and Complex Anatomy

Minimally invasive approaches to the surgical management of vesicoureteric reflux (VUR) have become more prominent over the last 10 years with progress in both endoscopic and laparoscopic/robotic surgery. We hypothesized that laparoscopic extravesical detrussoraphy (LED) for the management of VUR in children with complex bladders and/or bilateral VUR was safe and effective. Under institutional review board approval we evaluated the charts of all patients seen at our institution over the last 8 years who had undergone LED for the management of VUR. We evaluated demographic variables, surgical variables, and postoperative results. Postoperative bladder function was examined in the patients as well as need for secondary procedures. Patients with complex bladders included all patients who had previous surgery on the affected side, neurogenic bladders, and duplex or complex anatomy. Ninety-eight patients with 144 ureters were treated during this time period. The overall VUR resolution by voiding cystourethrogram was 95.2%. The average age was 6.74 years, with 13 children over the age of 12 years old. Average length of stay (LOS) was 1.7 days for children 5 years and older and 1.0 days for children less than 5 years old (P=.004). LOS was not affected by body mass index or complexity of the procedure. There were 46 bilateral procedures, and the incidence of urinary retention was 6.5% versus 0% in the unilateral group (P=.09). Of our patients, 27.6% had complex bladders, including 9 patients with complete ureteral duplications, 10 with periureteral diverticula, and 8 with prior surgery on the affected side. There were two complications requiring a second procedure in this group (7%). No patient with a complex bladder had persistent VUR. LED for the management of children with complex bladders and VUR is safe and effective. This technique is versatile and achieves high VUR resolution rates with minimal morbidity.

Long-term single institution comparison of endovascular aneurysm repair and open aortic aneurysm repair

Since the development of endovascular aneurysm repair (EVAR), there remains concerns regarding its durability, need for secondary procedures, and associated long-term morbidity. We compared these two approaches to evaluate secondary interventions and their respective long-term durability. All patients who had undergone endovascular and open abdominal aortic aneurysm (AAA) repair were identified from a prospectively maintained registry. Health system charts, medical communication, and national death indexes were reviewed. Secondary interventions were classified as vascular (aortic graft or remote) and nonvascular (incisional or gastrointestinal). Between July 1985 and September 2009, 1908 patients underwent 1986 AAA repair procedures (EVAR = 1066; open = 920). Patients were followed up to 290 months (mean 27.6 ± 35.9) and identified with 427 surgical encounters (EVAR 233% to 21.9%; open 194% to 21.1%). Most encounters (338% to 74.6%) were related to vascular disease: 178 (EVAR = 131; open = 47) related to the aortic graft; 160 (EVAR = 93; open = 67) were related to nonaortic vascular disease. The remaining 89 surgical encounters included incisional hernias, small bowel obstruction, intra-abdominal abscesses, and wound dehiscence requiring operation. Of these 89 encounters (EVAR = 9; open = 80), 44 patients required surgical intervention and 36 required hospitalization without surgical procedure. Over the period of 100 months, the all-cause mortality rate was 25.2% after EVAR and 39.1% after open repair. One-year survival was 88.0% (SE 0.01) and 85.0% (SE 0.01), while 5-year survival was 58.0% (SE 0.02) and 53.0% (SE 0.02) for EVAR and open repair, respectively (log-rank P value < .0164). Seven-year survival was 46% (SE 0.03) for EVAR and 36% (SE 0.03) for open AAA repair. EVAR requires more late secondary vascular interventions than open AAA repair, but patients who undergo open repair have more nonvascular long-term morbidity. Long-term survival is better after EVAR compared to open repair in this selected patient group.

Open Fractures of the Distal Radius: The Effects of Delayed Debridement and Immediate Internal Fixation on Infection Rates and the Need for Secondary Procedures

There are few clinical data evaluating the outcome of surgery for open distal radius fractures based on treatment method. Specifically, the major contributing factors to infection are largely unknown. The purpose of this study is to determine the effect of early versus delayed debridement and the choice of initial external versus internal fixation on infection rates and the need for secondary procedures. Thirty-two patients with open distal radius fractures were identified from a database. Ten debridements were early (<6 h after hospital admission), and 22 debridements were delayed (>6 h after hospital admission). There were 10 treating surgeons for the 32 patients in this study. Based on the attending surgeon's preference and experience, 20 fractures were treated with external fixation, 7 with plating, and 5 with planned staged conversion from external fixation to plating. The cohort included 19 grade I, 11 grade II, and 3 grade IIIA open injuries. There were no infections, regardless of the time to debridement or the use of immediate plating. Other complications requiring secondary procedures occurred more frequently in patients treated with a planned staged conversion from external fixation to plating than in the patients treated with either external fixation or plating. We did not encounter infections for grade I and grade II open distal radius fractures, and infections do not appear to be related to either the time to debridement or the initial type of fracture fixation. Plating might be safe at the initial debridement, but temporary external fixation with a staged conversion to plating increases the risk of complications, which necessitates corrective secondary procedures. Therapeutic III.

2113 PROSTATE LASER VAPORIZATION USING THE 980 NANOMETER (NM) LASER: RESULTS OF FIRST 110 CASES AT THE CLEVELAND CLINIC FOUNDATION

You have accessJournal of UrologyBenign Prostatic Hyperplasia: Surgical Therapy and New Technology1 Apr 20112113 PROSTATE LASER VAPORIZATION USING THE 980 NANOMETER (NM) LASER: RESULTS OF FIRST 110 CASES AT THE CLEVELAND CLINIC FOUNDATION James Ulchaker, Shoskes Daniel, and Fareed Khaled James UlchakerJames Ulchaker Cleveland, OH More articles by this author , Shoskes DanielShoskes Daniel Cleveland, OH More articles by this author , and Fareed KhaledFareed Khaled Cleveland, OH More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.2309AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Many wavelengths of prostate laser vaporizations are currently available in the United States for the use in prostate laser vaporization. Each of these wavelengths has their own particular characteristics on tissue interaction and depth of penetration of energy. The 980nm wavelength is absorbed by both water and hemoglobin and has a deeper penetration of energy into prostatic tissue than some of the other used wavelengths. Herein, we report on the initial results and complications of the 980nm wavelength. METHODS Our first 110 cases of prostate laser vaporization (January 2009–June 2010) using the 980nm laser with either a side fire or end fire fiber were retrospectively evaluated. Data was recorded on intra, peri, and postoperative findings. RESULTS No major surgical complications were noted including any blood transfusions or extended hospital stays. The average prostate size=67cc. Comparable flow and PVR values to other energy forms. 14% of patients reported some urinary urgency and frequency at 4 weeks post procedure. 6% reported this urgency and frequency at 3 months post procedure. Complications included 9 patients with bladder neck contractures which required some form of dilation, and 6 patients required TURP. 4 additional patients were treated in the office for sloughed prostatic tissue. This sloughed prostatic tissue, usually occurred between 30 to 90 days postoperatively, and more commonly occurred in previously radiated patients for prostate cancer and with the use of the side fire fiber. CONCLUSIONS The 980nm wavelength is safe and effective for prostatic vaporization, but the need for secondary procedures and delayed slough are complications that need to be discussed during the consent process, especially in previously radiated patients. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e845 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information James Ulchaker Cleveland, OH More articles by this author Shoskes Daniel Cleveland, OH More articles by this author Fareed Khaled Cleveland, OH More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

765 ANALYSIS OF ROBOTIC ASSISTED LAPAROSCOPIC PYELOPLASTY FOR PRIMARY VS. SECONDARY REPAIR IN 119 CONSECUTIVE CASES

You have accessJournal of UrologyTechnology & Instruments: Robotics/Laparoscopy1 Apr 2011765 ANALYSIS OF ROBOTIC ASSISTED LAPAROSCOPIC PYELOPLASTY FOR PRIMARY VS. SECONDARY REPAIR IN 119 CONSECUTIVE CASES Ben Niver, Ilir Agalliu, Romy Bareket, Patrick Mufarij, and Michael Stifelman Ben NiverBen Niver New York, NY More articles by this author , Ilir AgalliuIlir Agalliu Bronx, NY More articles by this author , Romy BareketRomy Bareket New York, NY More articles by this author , Patrick MufarijPatrick Mufarij Winston-Salem, NC More articles by this author , and Michael StifelmanMichael Stifelman New York, NY More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.1804AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Repair of secondary UPJ obstruction may pose additional challenges to surgeons. Robotic assistance may aid in these repairs. To evaluate this we analyzed the outcomes of our robotic-assisted primary pyeloplasty series and compared them to our series of robotic assisted secondary pyeloplasty. METHODS This study was HIPAA compliant and IRB approved. We reviewed 119 consecutive patients who underwent robotic assisted laparoscopic pyeloplasty (RALP) at our institution over an 8-year period (May 2002–February 2010). Data was collected in a combined retrospective and prospective manner. Patients were stratified into primary repair and secondary repair for primary analysis. Patients were also stratified into patients with stones and without stones for secondary analysis. We compared demographic, operative, postoperative and radiographic outcomes. Student-t test and Pearson chi-square were used for statistical analysis of continuous and categorical variables, respectively. A p-value <0.05 was considered significant. RESULTS Of the original 119 patients, data were unavailable on two patients. These patients were excluded from analysis. Ninety-seven patients underwent primary pyeloplasty repair and twenty patients underwent secondary pyleloplasty repair. Radiographic data were available for 84 patients with primary repair and 17 patients with secondary repair. Data are summarized in the accompanying tables. There were no statistical differences in patient demographic, operative, postoperative or radiographic outcomes for the primary analysis. There was a trend toward more intraoperative blood loss and more left sided repair in the secondary repair cohort. However, neither of these reached statistical significance. Additionally, there were no differences in outcomes for the secondary analysis. CONCLUSIONS This data represents the largest single center/single surgeon report of its kind with long-term follow up. This data strongly suggests that RALP is a safe and durable option for secondary pyeloplasty repair. Demographic, Operative, and Post-Operative Data Characteristic Primary Repair (n=97) Secondary Repair (n=20) p-value Mean age, years (SD) 39.4(17.4) 41.8(18.3) 0.60 Gender Males (%) 41(42) 9(45) 0.81 Females (%) 56(58) 11(55) Side Left (%) 41(42) 13(65) 0.08 Right (%) 56(58) 7(35) No. suspected crossing vessel etiology (%) 64(67.4) 16(80) 0.30 No. stones present (%) 11(11.3) 2(10) 0.86 Operative Time, minutes (SD) 218.7(55.3)⁎ 217.9(52.5)⁎ 0.95 Estimated Blood Loss, mL (SD) 62.8(77.2) 98.8(74.5) 0.06 Intra-Operative conversion rate 0 0 1.00 Length of Stay, days (SD) 2.5 2.8 0.47 Complications Minor 7(7.2) 1(5) 0.60 Major 4(4.1) 1(5) 0.85 No. need for secondary procedures (%) 3(3.1) 1(5) 0.78 Follow up, months (SD) 21.9(21.6) 26(17.4) 0.37 ⁎ In the primary cohort, OR time was unavailable for thirty-three patients. In the secondary cohort, OR time was unavailable for one patient. Radiographic Outcomes Characteristic Primary Repair (n=84) Secondary Repair (n=17) p-value No. pre-op radiographically obstructed (%) 76(90.4) 17(100) 0.18 No. post-op radiographically obstructed (%) 3(3.5) 1(5.9) 0.65 No. radiographic resolution of obstruction (%) 73 (96.0) 16(94.1) 0.72 © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e307-e308 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ben Niver New York, NY More articles by this author Ilir Agalliu Bronx, NY More articles by this author Romy Bareket New York, NY More articles by this author Patrick Mufarij Winston-Salem, NC More articles by this author Michael Stifelman New York, NY More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

373 MODIFIED CLAVIEN CLASSIFICATION FOR COMPLICATIONS OF PERCUTANEOUS NEPHROLITHOTOMY (PCNL) IN PEDIATRIC PATIENTS: A COMPARATIVE STUDY

INTRODUCTION AND OBJECTIVES: To assess the morbidity and outcome of PCNL in pediatric patients using modified Clavien scale. METHODS: We retrospectively reviewed the computerized records of pediatric patients (ageiU 14 years) who underwent PCNL for treatment of renal stones between 1994 and 2010. All cases were performed by experienced endourologist. The patients were divided into two groups, group I; Simple stones (isolated renal pelvis or isolated calyceal stone) and group II; Complex stones (partial or complete staghorn stones, renal pelvis stones accompanied by calyceal stone). Modified Clavien complication scale was used to grade and compare the perioperative complications between both groups. Success rate of PCNL monotherapy and the need of secondary procedures were compared. RESULTS: During the study period, 122 PCNL procedures were performed for 97 children (61 males, 36 females) with mean age 7.1 (0.5–14) years. Group I included 57 procedures while group II included 65 procedures. There were no statistically significant differences between both groups with regard to age, gender, BMI, indications of the procedure, renal characteristics. Also, a comparable data were found for operative details such as number of PCNL sessions and mini-Perc procedures. However, multiple puncture tracts were created in 4 (7%) procedures in group I and in 21 (32%) procedures in group II (P-value 0.001). Perioperative complications were 35 (28.7%) in 122 procedures. Low grade complications (G1–G3a) were 33 (27%) and high grade complications (G3b-G5) were 2 (1.6%). Table 1 shows the sort and distribution of complications. 2nd session PCNL was needed in 6 and 13 procedures in group I &II respectively (P-value 0.21). Stone free rate for PCNL monotherapy was 94.7% and 72.3% in group I &II respectively (Pvalue 0.013). Secondary procedures were needed once (1.7%) in group I and in 10 procedures (15.3%) in group II (P-value 0.017). CONCLUSIONS: High grade complications during PCNL in pediatric patients were seldom occurring. Complexity of the stone is not a risk of complications as long as the procedure is done by experienced surgeon Table 1. Perioperative complications according to modified Clavien scale. Grades Types of complications Group 1 Group 2 Grade 1 fever for antipyretics 5 2 haematuria 2 3 Grade 2 bleeding or haematuria requiring blood transfusion 2 1

Locking Plates for Distal Femur Fractures: Is There a Problem With Fracture Healing?

Fractures of the distal femur are severe injuries that present many clinical challenges. Nonunion, delayed union, implant failure, and the need for secondary procedures can reflect complications of healing. This article reviews the literature on distal femur fractures treated with locking plates to determine the reported rate of healing difficulties. The PubMed database and the Orthopaedic Trauma Association and American Academy of Orthopedic Surgeons abstract archives were searched for studies including the key words distal femur fracture, supracondylar femur fracture, or locking plate from the year 2000 to the present. Reports were included when distal femur fractures were treated with locking plates and when the number of healed fractures was identified in the study. The reported healing rates and the rate of healing complications were determined from the studies. The time to implant failure was recorded. Those articles that included periprosthetic fractures were separated from those only including acute distal femur fractures. Fifteen full-length publications and three abstracts were included. The rate of complications related to healing ranged from 0% to 32% in these studies. Implant failures occurred late with 75% of the failures occurring after 3 months and 50% occurring after 6 months. Complications of healing including nonunion, delayed union, and implant failure are not infrequent and represent ongoing problems with distal femur fracture treatment. Further clinical research combined with innovation in surgical techniques and implant design will be necessary to improve the results of the last decade.

Ty-Raps in Trauma: A Novel Closing Technique of Extremity Fasciotomy Wounds

The challenge of closing extremity fasciotomy wounds is well known to every trauma and orthopedic surgeon. We developed a new, easy, and inexpensive dermatotraction technique based on the simple use of Ty-Raps and report on the first pilot study using this novel technique for the closure of 23 extremity fasciotomy wounds. The Ty-Rap system consists of several combinations of two Ty-Raps and four surgical staples. Immediately after fasciotomy, the system is secured to the skin by the surgical staples, and once the swelling of the affected limb is subsided, the Ty-Raps are tightened every 24 hours to 48 hours until full approximation of the skin edges is achieved. We recorded the time to closure of the wound, the time to removal of the Ty-Raps, and the complications related to the procedure. Also, a cost analyses was calculated. The mean time of approximation of the skin was 6.3 days, and after a further 9.4 days, the Ty-Raps could be removed. The majority of the wounds (91%) healed without complications, and only one patient in our series required a secondary surgical procedure for the closure of one fasciotomy wound. The total cost to close a fasciotomy wound of 30 cm with the use of Ty-Raps is US dollar 23.33. We regard the use of Ty-Raps a good alternative for the current closing techniques of extremity fasciotomy wounds. We value its low cost, general availability, effectiveness, and the fact that, in this pilot study, both the application and the tightening of the Ty-Raps were well tolerated by our patients with a minimal need for secondary procedures. Knowledge of this technique is a useful adjunct to the existing surgical array for every trauma and orthopedic surgeon for the closure of extremity fasciotomy wounds, especially in austere or military environments.

Synchronous Twin-Tract Percutaneous Nephrolithotomy

Introduction: Percutaneous nephrolithotomy (PCNL) is the standard technique for management of large renal calculi. Our main goal is to achieve complete stone clearance, which can be attained in single stage or multiple stages. Large bulk stone clearance by PCNL has considerable morbidity, namely, prolonged operative times, increased intraoperative blood loss, and need for secondary procedures. Therefore, to further minimize morbidity and to achieve maximum stone clearance for these difficult stones, we investigated the feasibility of a synchronous twin-tract approach. Patient and Methods: Thirty-six-year-old man presented with right ureteric and left complete staghorn calculus. He underwent right pushbang for the ureteric stone earlier and underwent synchronous twin-tract PCNL for the left complete staghorn calculus. Initial ultrasound-guided localization and puncture was achieved in the upper and lower calix, and both the tracts were dilated synchronously. PCNL was performed by two operative surgeons simultaneously. Results: Complete stone clearance was achieved. Total operative time was 80 mins and hemoglobin drop was 1.5 gm%. There were no intra- or perioperative complications noted. Postoperative X-ray confirmed complete clearance. Conclusion: Synchronous twin-tract PCNL is a potentially ideal operation for complete clearance of large bulk renal calculi with minimal morbidity. There is a need for two experienced operating teams working in tandem with two sets of endoscopic equipment, energy sources, and television monitors, which would limit this technique to hospitals where these logistics can be met. No competing financial interests exist. Runtime of video: 5 mins 46 secs

Primary Tracheoesophageal Puncture in Stapler-Assisted Total Laryngectomy

Background/Aims: The purpose of this article was to present a novel technique for primary tracheoesophageal puncture (TEP) in patients undergoing stapler-assisted laryngectomy. Methods: A case series of 10 consecutive patients treated with stapler-assisted laryngectomy that underwent primary TEP at the time of the initial surgery was conducted. The technique involves the use of a flexible esophagoscope and a modified Seldinger technique to safely create the TEP under direct visualization without disrupting the stapler closure. This series was performed at a single academic institution. The primary outcome measured was ability of alaryngeal speech. Results: A total of 10 consecutive patients had the procedure done. All patients achieved alaryngeal speech and there were no complications. Conclusion: This method allows for a safe and efficient TEP creation at the time of stapler-assisted laryngectomy, obviating the need for secondary procedures, either in the office or operating room.

Reconstruction of the burned hand using a super-thin abdominal flap, with donor-site closure by an island deep inferior epigastric perforator flap

A pedicled super-thin superficial inferior epigastric artery flap can provide a thin and pliable skin coverage for the hand dorsum, and debulking of the flap during elevation limits the need for secondary procedures. Simultaneously, an island deep inferior epigastric perforator flap transferred to reconstruct the flap donor site in the abdomen subsequently minimises donor-site morbidity.

Randomized clinical trial of concomitant or sequential phlebectomy after endovenous laser therapy for varicose veins

The management of residual varicosities following endovenous laser therapy (EVLT) for varicose veins is contentious. Ambulatory phlebectomy may be performed concomitantly with the initial EVLT, or sequentially as a secondary procedure. This randomized trial compared these two approaches. Fifty patients with great saphenous varicose veins were randomized to EVLT alone or EVLT with concomitant ambulatory phlebectomies (EVLTAP). Principal outcomes were procedure duration, pain scores, requirement for secondary procedures and quality of life after 3 months. EVLTAP took longer, but significantly decreased the requirement for subsequent interventions. There was no impairment in immediate postprocedural pain, Short Form 36 or EuroQol 5D scores with EVLTAP. Median (i.q.r.) Venous Clinical Severity Score (VCSS) at 3 months was lower for EVLTAP than for EVLT alone (0 (0-1) versus 2 (0-2); P < 0.001), with lower Aberdeen Varicose Vein Questionnaire (AVVQ) scores at 6 weeks (7.9 (4.1-10.7) versus 13.5 (10.9-18.1); P < 0.001) and 3 months (2.0 (0.4-7.7) versus 9.6 (2.2-13.8); P = 0.015). At 1 year, there were no differences in VCSS or AVVQ scores. Concomitant phlebectomy with EVLT prolonged the procedure, but reduced the need for secondary procedures and significantly improved quality of life and the severity of venous disease.

EVAR in Small Versus Large Aneurysms: Does Size Influence Outcome?

To determine whether there is a difference in outcome between endovascular repair of abdominal aortic aneurysm (EVAR) of small versus large aneurysms. A total of 192 patients from the Power-link trial were subdivided into small abdominal aortic aneurysms (AAA; </=5 cm) and large AAA (>5 cm) groups. Demographics, perioperative morbidity, mortality, overall survival, and freedom from major adverse events, endoleak, aneurysm-related death, migration, and secondary procedures were assessed. Aneurysmal involvement of the iliacs as well as neck length and angulation was compared between groups. Perioperative morbidity (P = 1.000), mortality (P = .4603), and extent of iliac involvement did not differ between groups (P = .2260). The necks in small AAA were longer (P = .0028) and less angulated (P < .0001). There was no difference in overall survival (P = .6066), freedom from major adverse events (P = .7842), endoleak, (P = .1832), migration (P = .5765), aneurysm-related death (P = .4728), or need for secondary procedures (P = .2323). Under controlled conditions of patient and device selection, there is no significant difference in outcome for EVAR of small versus large AAA.

Clinical Trials of the Surgical Management of Urolithiasis: Current Status and Future Needs

We reviewed the literature on the surgical treatment of urolithiasis. All prospective, randomized trials on the surgical treatment of stone disease were reviewed. Percutaneous nephrolithotomy (PNL) is superior to shockwave lithotripsy (SWL) or open surgery in the treatment of staghorn calculi. For ureteral stones, ureteroscopy appears to result in a higher stone-free rate and lower need for retreatment compared with SWL but has a higher complication rate and increased hospital stay. For lower pole renal calculi, PNL results in a higher stone-free rate and lower need for retreatment compared with SWL but has a higher complication rate and increased hospital stay. Most areas of surgical stone treatment have been addressed by a randomized controlled trial; however, most trials were of poor quality. Trials tend to focus only on radiologic outcomes. No study to date has been able to show a measurable quality of life benefit to patients, possibly because no condition-specific quality of life instruments have been developed. In addition, economic impact, both direct and indirect, has been rarely characterized. The surgical treatment of kidney stones is poorly researched. Future trials should be performed with adequate funding and patient-focused outcomes.

Does reflux in orthotopic diversion matter? A randomized prospective comparison of the Studer and T-pouch ileal neobladders

Orthotopic neobladder reconstruction has become a standard form of urinary diversion in many centers for patients undergoing radical cystectomy for bladder cancer. There is still controversy about the best technique for construction of the neobladder, and especially whether it is necessary to include an antireflux mechanism. We designed a prospective randomized clinical trial comparing two forms of ileal neobladder: the Studer pouch and the T-pouch. The latter includes an extraserosal tunneled afferent limb which prevents reflux from the pouch to the kidneys. The primary endpoint of the study is renal function and anatomy at 3 years following surgery, with secondary endpoints including early and late postoperative complications, renal infections and need for secondary procedures. To date we have randomized 462 patients over approximately 6 years, with a planned full enrollment of 550 patients. Ten percent of patients have been withdrawn because they did not undergo the planned orthotopic diversion due to a positive urethral margin on frozen section. We expect approximately 70% of patients to be alive and available for follow-up at 3 years, which will give us ample power to detect clinically meaningful differences in the outcome of these two diversions. This trial has been feasible and randomization has been acceptable to most patients. Long-term follow-up of the patients on this trial should be able to definitively answer the question of the importance of an antireflux mechanism in the orthotopic neobladders construction.

Early Limited Internal Fixation of Diaphyseal Extensions in Select Pilon Fractures: Upgrading AO/OTA Type C Fractures to AO/OTA Type B

Fractures of the tibial pilon may present an array of problems and potential complications. Staged treatment with initial spanning external fixation of the ankle has proven to be a successful strategy for the treatment of these difficult fractures in many cases. A subset of the tibial pilon fractures, with an oblique extension to the diaphysis may constitute a treatment problem, as these long fractures may be difficult to reduce at the time of definitive fixation, often 1-3 weeks post-injury due to interposed soft tissues, hematoma and/or early callus. Anatomic reduction of this fracture may thus require more extensive dissection than might be desirable in this injury. We offer a technique to assist in the treatment of the subset of these difficult fractures. In appropriate cases, a small fragment plate may be applied to the diaphyseal component of the fracture in an anti-glide type plate application, through a small incision proximal to the area of greatest injury. This re-establishes the length, rotation and alignment of this fragment which is commonly attached to either the Chaput anterolateral or the Volkmann posterolateral fragment. It additionally provides the intimate contact that may favor early union or minimize the need for secondary procedures. The fracture is thereby converted from a complete articular AO/OTA 43-C type pattern to a partial articular, or AO/OTA 43-B type pattern.

Prospective Randomized Trial Comparing Shock Wave Lithotripsy and Ureteroscopy for Lower Pole Caliceal Calculi 1 cm or Less

Purpose The optimal management of lower pole renal calculi is controversial. We compared shock wave lithotripsy (SWL) and ureteroscopy (URS) for the treatment of patients with small lower pole stones in a prospective, randomized, multicenter trial. Materials and Methods A total of 78 patients with 1 cm or less isolated lower pole stones were randomized to SWL or URS. The primary outcome measure was stone-free rate on noncontrast computerized tomography at 3 months. Secondary outcome parameters were length of stay, complication rates, need for secondary procedures and patient derived quality of life measures. Results A total of 67 patients randomized to SWL (32) or URS (35) completed treatment. The 2 groups were comparable with respect to age, sex, body mass index, side treated and stone surface area. Operative time was significantly shorter for SWL than URS (66 vs 90 minutes). At 3 months of followup 26 and 32 patients who underwent SWL and URS had radiographic followup that demonstrated a stone-free rate of 35% and 50%, respectively (p not significant). Intraoperative complications occurred in 1 SWL case (unable to target stone) and in 7 URS cases (failed access in 5 and perforation in 2), while postoperative complications occurred in 7 SWL and 7 URS cases. Patient derived quality of life measures favored SWL. Conclusions This study failed to demonstrate a statistically significant difference in stone-free rates between SWL and URS for the treatment of small lower pole renal calculi. However, SWL was associated with greater patient acceptance and shorter convalescence.