Patient In Lithotomy Position Research Articles

Transvaginal hybrid-NOTES appendectomy in routine clinical use: prospective analysis of 13 cases and description of the procedure

Access-related abdominal wall injury is part of the operative trauma in laparoscopic appendectomy and accounts for complications. Minimizing this trauma by entering the abdominal cavity by means of natural orifice transluminal surgery (NOTES) may be achieved by a hybrid-appendectomy procedure using the transvaginal route plus a single transumbilical trocar. Thirteen patients were prospectively analyzed following transvaginal-hybrid NOTES appendectomy. For the procedure, rigid instruments are used with the patient in lithotomy position. The procedure is performed with two transvaginal and one transumbilical access-points. The specimen is retrieved transvaginally. All procedures were performed without additional trocars. No conversions to standard laparoscopy or open surgery were necessary. All procedures were performed in acceptable time (mean 52min). No intraoperative complications and two (15%) postoperative complications, an infected hematoma and an abscess, occurred. They were smoothly treated with standard techniques including one laparoscopic reoperation (8%). Drain placement or resection of a Meckel's diverticulum was easily managed without conversion. Gynecological short-term follow-up revealed one complication, which was vaginal fungal infection. It occurred after a 7-day course of antibiotics. This method is found to be feasible intraoperatively and early postoperatively in terms of possibility to manage a variety of intraoperative findings that may occur during planned appendectomy, low intraoperative complications, and management of postoperative complications using established concepts. We, therefore, consider the procedure safe and continue to offer hybrid-NOTES appendectomy to suitable patients.

PD11-03 NEW APPROACH AND SET OF REFERENCE VALUES FOR QUANTITATIVE ELECTROMYOGRAPHIC ANALYSIS OF THE EXTERNAL URETHRAL SPHINCTER IN MEN

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Incontinence Evaluation1 Apr 2014PD11-03 NEW APPROACH AND SET OF REFERENCE VALUES FOR QUANTITATIVE ELECTROMYOGRAPHIC ANALYSIS OF THE EXTERNAL URETHRAL SPHINCTER IN MEN Francesca Bianchi, Matteo Ferrari, Giovanni La Croce, Marco Cursi, Andrea Salonia, Cristophe Germann, Giancarlo Comi, Ubaldo Del Carro, Hansjörg Danuser, and Agostino Mattei Francesca BianchiFrancesca Bianchi More articles by this author , Matteo FerrariMatteo Ferrari More articles by this author , Giovanni La CroceGiovanni La Croce More articles by this author , Marco CursiMarco Cursi More articles by this author , Andrea SaloniaAndrea Salonia More articles by this author , Cristophe GermannCristophe Germann More articles by this author , Giancarlo ComiGiancarlo Comi More articles by this author , Ubaldo Del CarroUbaldo Del Carro More articles by this author , Hansjörg DanuserHansjörg Danuser More articles by this author , and Agostino MatteiAgostino Mattei More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.536AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Aim of the present study is to evaluate the external urethral sphincter (EUS) function using a new approach to measure quantitative electromyography (EMG) in neurologically healthy men with prostatic pathology and to set reference values of EUS-EMG for men. METHODS 66 continent and neurologically healthy men (mean age: 64 range 51-86) were studied. With the patient in lithotomy position a concentric EMG needle was introduced transperineally in the EUS under triple guidance (transrectal ultrasound (TRUS), oscilloscopic and auditory). Motor Unit Potentials (MUPs) and Interference Pattern (IP) analysis were obtained using multi-MUP and turns/amplitude analysis. MUPs were collected at slight voluntary and reflex activation and only EUS with 15 or more MUPs sampled were included. IP samples were recorded from different sites in both parts of EUS, at different level of voluntary and reflex muscle activation. Patients, after prostate biopsies, were divided in benign prostatic hypertrophy (BPH) and Prostate cancer (PC). The mean values for individual MUP and IP parameters and the turn/amplitude cloud, obtained using the Stalberg's method, were determined for the 2 groups. RESULTS A mean of 22 (range: 15-40) different MUPs was collected from each EUS, for a total of 1290. No statistical differences were found between the 2 groups, therefore values from the BPH and PC groups have been joined to create a reference pool of data. A mean of 33 (range: 15-50) different IP samples were obtained from each patient, for a total of 2086. The regression analysis on log-transformed turns and amplitude values was performed for the 2 groups. The resulting regression lines had slope and intercept: bBPH=0.234, aBPH=1.962 and bPC=0.233, aPC=1.956 respectively. The statistical comparison between the 2 regression lines was not significant, so the distribution of the 2 clouds can be considered identical (Fig1). CONCLUSIONS Using a new approach, the largest consecutive series of male quantitative EUS-EMG is reported. Our data could be considered a valid reference to compare EMG parameters of patients developing urinary incontinence after prostatic surgery, in order to verify a possible involvement of EUS on continence status. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e287 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Francesca Bianchi More articles by this author Matteo Ferrari More articles by this author Giovanni La Croce More articles by this author Marco Cursi More articles by this author Andrea Salonia More articles by this author Cristophe Germann More articles by this author Giancarlo Comi More articles by this author Ubaldo Del Carro More articles by this author Hansjörg Danuser More articles by this author Agostino Mattei More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

PD11-10 LARGE DETRUSOR OVERACTIVITY PREDISPOSES URGENCY URINARY INCONTINENCE AFTER HOLEP IN PATIENTS WITH BENIGN PROSTATIC HYPERPLASIA

emerged at univariate analysis between EUS-EMG parameters (MUP and IP) and age, BMI, CCI, ICS-male SF, IPSS, and I-QoL scores, MRIderived prostate volume and membranous urethral length. CONCLUSIONS: Using a new TRUS-guided transperineal technique by patients in lithotomy position, the largest consecutive series of baseline male quantitative EUS-EMG is reported. EMG values did not correlate with age, BMI, CCI, ICS-male SF, IPSS and I-QoL scores, MRIestimated prostate volume and membranous urethra length.

1986 A NOVEL TECHNIQUE IN PLACEMENT OF THE MORBIDLY OBESE IN LITHOTOMY POSITION

You have accessJournal of UrologyStone Disease: SWL, Ureteroscopy or Percutaneous Stone Removal (IV)1 Apr 20131986 A NOVEL TECHNIQUE IN PLACEMENT OF THE MORBIDLY OBESE IN LITHOTOMY POSITION Patrick Irwin, Samay Jain, Natalie Singer, Adam Becker, and Khaled Shahrour Patrick IrwinPatrick Irwin Toledo, OH More articles by this author , Samay JainSamay Jain Toledo, OH More articles by this author , Natalie SingerNatalie Singer Toledo, OH More articles by this author , Adam BeckerAdam Becker Toledo, OH More articles by this author , and Khaled ShahrourKhaled Shahrour Toledo, OH More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.2405AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES There is a rising prevalence of morbid obesity in North America with obesity inflicting more than 30% of adults in USA. Moreover, morbid obesity is associated with increased incidence of nephrolithiasis with less successful treatment options. Theoretically, retrograde reno-ureteroscopy is done more frequently in morbidly obese patients as it is the least stone treatment to be adversely affected by morbid obesity. Nevertheless, special instruments, stirrups and operating tables for morbidly obese patients are expensive and may not be available in most operating rooms. We propose a fast and safe method in placing morbidly obese patients in lithotomy position using regular operating room tables. This technique can be used for patients with extensive leg size or weight that cannot be put in stirrups for lithotomy position. METHODS Three operating tables are positioned as in the figure. Once the patient is sedated, the two lower extremity tables (tables 2 and 3) are widened in a lambda formation and then elevated to achieve a modified dorsal lithotomy position. The patient is secured into position on the tables with cloth tape around each leg and the abdomen. Excessive fat can be retracted by cloth tape to improve access to the perineum. The table supporting the patient's trunk is then lowered, placing the patient in mild Trendelenburg position. RESULTS This positioning technique was used in two patients for 3 procedures each. The first patient is a 60-year-old male with symptomatic bilateral stones. He is 185.4 cm tall and weighs 217.7 kg with body mass index (BMI) of 63.3. The second patient is a 58-year-old female with right partial staghorn stone. She is 167.6 cm tall and weighs 225.9 kg (BMI 80.4). Mean positioning time in the 6 procedure was 9.8±3.2 minutes (range is 6-15 minutes). Mean operative time was 167.2±63.1 minutes (range is 84-240 minutes). No intra-operative or post operative adverse events were reported. CONCLUSIONS The three table technique is a fast and practical alternative to the use of expensive large capacity operative tables and stirrups for lithotomy position in patients with morbid obesity or other morbidities that do not allow for safe placement of legs in stirrups. There were no adverse events associated with this positioning technique in morbidly obese patients despite long operative duration due to extensive stone burden. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e815 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Patrick Irwin Toledo, OH More articles by this author Samay Jain Toledo, OH More articles by this author Natalie Singer Toledo, OH More articles by this author Adam Becker Toledo, OH More articles by this author Khaled Shahrour Toledo, OH More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Accessing the challenging pre-sacral abscess

Dear Editor: Drainage of pre-sacral collections transrectally or percutaneously can be challenging due to difficulty of access. Transanal endoscopic surgery is a well-established technique used to resect benign or early malignant rectal tumours, either using a binocular stereoscopic operating rectoscope or a monocular laparoscopic equivalent, and a number of additional indications have been described for their use, including pelvic anastomotic stricturoplasty, excision of extraluminal pre-sacral tumours as well as drainage of pre-sacral abscesses which may otherwise be inaccessible. Transanal endoscopic microsurgery uses the stereoscopic equipment (Richard Wolf Medical Instruments Corporation), while the alternative produced by Storz is less expensive and fully compatible with standard laparoscopic equipment, and is referred to as transanal endoscopic operation (TEO). Patients can expect minimal effect on anorectal function despite the use of a large diameter rectoscope. TEO equipment was used to successfully drain an inaccessible pre-sacral abscess in a 53-year-old man with a bodymass index of 28. He had undergone reversal of a Hartmann's procedure which had been performed 7 months earlier for complicated diverticular disease with a pelvic abscess, and a tight anastomotic stricture at 10 cm from the anal verge was subsequently diagnosed another 7 months later after he complained of pelvic discomfort and obstructive symptoms. Imaging ruled out recurrent pelvic sepsis and he underwent three anastomotic balloon dilatations over a 12-month period, resulting in a widely patent anastomosis and a significant improvement in symptoms. Two years after the last dilatation, he developed new symptoms of coccygeal pain on prolonged sitting, which worsened over 5 months, and he subsequently developed additional symptoms of night sweats. A magnetic resonance imaging (MRI) scan confirmed a 4-cm pre-sacral abscess postero-superior to the anastomosis which remained widely patent. Long-term antibiotics did not improve his symptoms and little change in size was evident on repeat imaging, and transanal drainage was attempted under general anaesthesia. This was unsuccessful due to access difficulties related to the distance of the abscess from the anal canal and the patient's body habitus. The procedure was abandoned when no pus was able to be aspirated and a submucosal haematoma obscured the operative view. Symptoms persisted over 18 months despite repeated courses of antibiotics, until drainage was successfully achieved using TEO equipment. With the patient in lithotomy position, the 4.0-cm diameter, 7.5-cm long operating rectoscope facilitated access, providing a magnified view of the extraperitoneal anastomosis which was incised posteriorly using an ultrasonic dissector, deroofing a pre-sacral cavity which contained pus and was lined with granulation tissue. He was discharged on oral antibiotics 1 day after surgery and was reviewed in an outpatient setting 1month later. He described post-operative symptoms of faecal urgency and increased frequency, associated with ongoing night sweats and discharge of pus per rectum with minor bleeding, but all of these symptoms had fully resolved on further review 4 months later. The coccygeal pain also resolved post-operatively, and no incontinence was experienced. An MRI scan performed 5 months after surgery confirmed resolution of the chronic collection which measured 39 mm on imaging prior to the procedure. This case illustrates chronic sepsis with a delayed presentation after anastomotic balloon dilatation and highlights the ease of access achievable using laparoscopic equipment via an operating rectoscope to manage pelvic pathology which would otherwise be inaccessible using alternative modalities.

V861 LAPAROSCOPIC TRANSVESICAL URETERIC RESECTION AND RE-IMPLANTION

You have accessJournal of UrologyReconstruction, Transitional Cell Carcinoma & Adrenal1 Apr 2011V861 LAPAROSCOPIC TRANSVESICAL URETERIC RESECTION AND RE-IMPLANTION Philippe Grange, Amrith Rao, Davinder Sharma, Christian Brown, and Angelika Zang Philippe GrangePhilippe Grange London, United Kingdom More articles by this author , Amrith RaoAmrith Rao London, United Kingdom More articles by this author , Davinder SharmaDavinder Sharma London, United Kingdom More articles by this author , Christian BrownChristian Brown London, United Kingdom More articles by this author , and Angelika ZangAngelika Zang London, United Kingdom More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.683AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Segmental excision and ureteric re-implantation is an accepted surgical option for benign stricture or localised transitional cell carcinoma (TCC) affecting the lower 1/3rd of the ureter. Most often, the operation is performed by an open approach, but increasingly laparoscopic approach is favoured because of the obvious advantages. One of the difficulties with the laparoscopic approach is dealing with the ureteric orifice & the intra-mural part of the ureter. Although we have performed this technique for benign ureteric strictures, this particular video is about a 62 year old lady with recurrent high-grade superficial TCC in the right lower ureter. With this high definition video, we demonstrate a transvesical laparoscopic lower ureteric excision and re-implantation. METHODS With the patient in lithotomy position, ureteroscopy is performed to look at the length that requires excision. Cystoscopic dismembering of the intramural ureter is carried out upto the perivesical fat using a Collin's knife. The bladder is then distended using the gas insufflation connected to the urethral catheter. A 10 mm VisiportTM along with the camera allows access to the bladder under direct vision. Further two 5 mm ports were inserted under the camera guidance. Bladder was also suspended using two percutaneous stitches, which allowed sufficient working space. Entire operation was performed with gas insufflation of the bladder. Ureter is mobilized further till the desired length of excision. A neo-orifice is created distally and the ureter is brought through this opening into the bladder. The site of the old ureteric orifice is then closed. The diseased distal segment is useful to manipulate the ureter and spatulation is carried out. The ureter is then anchored to the neo-orifice using interrupted sutures. The diseased segment is excised and retrieved urethrally. The guide-wire is passed via the urethra and directed into the ureter. JJ stent is subsequently inserted. RESULTS The total operative time was 180 minutes with blood loss < 50 mL. There were no intra- or post-operative complications. The in-hospital stay was 3 days. The patient was discharged home with a urethral catheter on free drainage, which was removed in 2 weeks after cystogram showing no evidence of leak. At the last follow-up ureteroscopy and multiple biospies, there was no evidence of stricture or disease recurrence. CONCLUSIONS We demonstrate in this video our technique of transvesical laparoscopic excision and ureteric re-implantation. We demonstrate that the short-term functional and oncological outcome is equivalent to the established open approach. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e345 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Philippe Grange London, United Kingdom More articles by this author Amrith Rao London, United Kingdom More articles by this author Davinder Sharma London, United Kingdom More articles by this author Christian Brown London, United Kingdom More articles by this author Angelika Zang London, United Kingdom More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

The role of hemorrhoidopexy in the management of 3rd degree hemorrhoids

Hemorrhoidopathy is a very common benign surgical pathology. Hemorrhoids are divided into 4 stages, depending on symptoms and degree of prolapse. Hemorrhoidopexy is a technique developed for the treatment of 3rd degree hemorrhoids, but its application has been extended to the treatment of 4th degree hemorrhoids as well. Nevertheless, recent studies identify weaknesses of the PPH in the treatment of 4th degree hemorrhoids. One hundred and twenty-six consecutive patients with 3rd degree hemorrhoids underwent stapled hemorrhoidopexy. All procedures were performed under general anesthesia with the patient in lithotomy position. A phosphate enema was given to the patient 2 h before the procedure, and cephalosporine and metronidazole were administered at anesthesia induction. Most patients were discharged the day after the operation. All patients were reassessed at 1, 6 weeks, 6 and 12 months after the procedure. The mean operating time was 16.3 min. Of all patients, 5.8% complained of mild rectal pain for a post-operative period of 5-12 days, 5.8% developed post-operative urinary retention, managed with catheterization, 13.3% experienced fecal urgency while 5.8% experienced gas incontinence, which subsided 2-8 weeks from surgery. The mean hospital stay was 1.2 days. Most patients returned to daily activities within 2-5 days. Ninety-five percent of patients returned for their follow-up visits. Recurrence of the disease occurred in 8 patients (6.6%). It was managed conservatively in 2 patients, 3 underwent redo hemorrhoidopexy and 3 underwent classic hemorrhoidectomy. According to our results, stapled hemorrhoidopexy seems to be a safe, pain-free and, in the long-term, effective technique for the treatment of 3rd degree hemorrhoids.

Clinical Model for Diagnosis of Urinary Tract Infection in Young Women

To the Editor .—I was, to say the least, quite surprised that the authors of the article entitled A Clinical Model for Diagnosis of Urinary Tract Infection in Young Women 1 have only recently discovered the fact that bacterial counts of less than 100 000 per milliliter obtained from midstream urine specimens may indicate a true urinary tract infection in women. We, and others, have, starting in 1963, repeatedly and exhaustingly proven that, in view of the relatively high percentage of bacterial counts of less than 100 000 per milliliter obtained from the midstream urine specimens in women in the presence of urinary tract infection, 2-6 the criteria for a correct diagnosis of urinary tract infection vs bacterial contamination in midstream urine specimens carefully collected by a trained nurse with the patient in lithotomy position after adequate preparation is 1000 and not 100 000 colonies of a single species per

Mini-Laparotomy for Bilateral Tubal Ligation in Lithotomy Position

Two hundred consecutive cases of mini-laparotomy for nonpuerperal bilateral tubal ligation done by a single gynecologist with the patient in lithotomy position are presented here. Technical aspects of the procedure, some innovative and some old, are presented in an effort to demonstrate a simple, low-risk alternative to laparoscopic sterilization.

Single stage Anterior Sagittal Anorectoplasty (ASARP) for Anorectal Malformations with Vestibular Fistula and Perineal Ectopic Anus in Females: A New Approach

Introduction: Despite a better understanding of the embryology, anatomy of anorectal malformations and of the physiology of continence, the management of children born with imperforate anus continues to be a surgical challenge and is still fraught with numerous complications and often leads to less than perfect qualitative results. Pediatric patients with recto-vestibular fistula have good prognoses in terms of bowel function when properly treated. Aim &amp; Objective: The study was designed to assess the surgical morbidity of single stage Anterior Sagittal Anorectoplasty (ASARP). Methodology: This prospective study was carried for a period of 26 months. It included a total of 48 female patients (aged 0 - 14 years) with diagnosis of Anorectal Malformations (ARM) with vestibular fistula or perineal ectopic anus. In ASARP, Patient in lithotomy position, the anterior portion of sphincter muscles were cut through a midline perineal skin incision, rectum was separated from the vagina &amp; then rectum was pulled through the center of these muscles. The perineal body was reconstructed and the normal appearance of perineum was achieved. Results: Short-term surgical outcome was satisfactory in all cases. No one needed colostomy. Conclusion: Single-stage ASARP is a good approach in experience hands for ARM with vestibular fistula and perineal ectopic anus in females and thereby complications and time involved in staged procedures including colostomy can be avoided. Key words: Anterior sagittal anorectoplasty, anorectal malformations, perineal ectopic anus, vestibular fistula. DOI: 10.3126/jnps.v30i1.2458 Journal of Nepal Paediatric Society Vol.30(1) 2010 37-43

Nerve block in painless childbirth.

Pudendal nerve block in obstetrics is not new. King 1 described its use in 1916. DeLee made this statement in 1937: Local anesthesia is very simple and can be used by any doctor with ordinary ability. 2 More recent authors have written of its use in cervical dystocia 3 and breech as well as normal deliveries. 4 The early accounts of the procedure described two or four sites of injection. The technic here described is a modification which is simpler, gives better results and is suitable in the present concept of painless labor and deliveries. TECHNIC With the patient in lithotomy position, prepared and draped for delivery, a wheal is raised in the midline of the perineum about 1.5 cm. posterior to the vagina. All injections are carried out through this site with a 4 inch (10 cm.) 20 gage or spinal needle attached to a 30 cc. syringe filled