The effect on outcome of peribulbar anaesthesia in conjunction with general anesthesia for vitreoretinal surgery.

The purpose of this study was to evaluate peri-operative outcome after vitreoretinal surgery when peribulbar anaesthesia is combined with general anaesthesia. Sixty adult patients undergoing elective primary retinal detachment surgery with scleral buckling or an encircling procedure received either peribulbar anaesthesia in conjunction with general anaesthesia or general anaesthesia alone. For peribulbar anaesthesia a single percutaneous injection of 5-7 ml of local anaesthetic solution (0.75% ropivacaine with hyaluronidase 15 iu.ml(-1)) was used. The incidence of intra-operative oculocardiac reflex and surgical bleeding interfering with the surgical field, postoperative pain and analgesia requirements, and postoperative nausea and vomiting were recorded. In the block group there was a lower incidence of oculocardiac reflex and surgical bleeding intra-operatively. Patients in the block group also had better postoperative analgesia and a lower incidence of postoperative nausea and vomiting compared with the group without a block. The use of peribulbar anaesthesia in conjunction with general anesthesia was superior to general anaesthesia alone for vitreoretinal surgery with scleral buckling.

Posterior urethral valves with persistent high serum creatinine: the value of percutaneous nephrostomy.

PURPOSE: In patients with posterior urethral valves and persistent high serum creatinine irrespective of vesical drainage proximal urinary diversion is done for presumed concomitant ureterovesical junction obstruction. We retrospectively evaluated whether such management is justified. MATERIALS AND METHODS: Between 1982 and 1995 we reviewed the records of all patients with posterior urethral valves and serum creatinine persistently higher than 1.5 mg./dl. Patient characteristics, treatment method and eventual outcome were determined as well as the results of radiological and Whitaker pressure studies done to exclude obstruction at the ureterovesical junction. RESULTS: Of the 48 patients evaluated 28 underwent primary valve ablation, 16 high loop ureterostomy and 4 vesicostomy. After an average of 78 months (range 37 to 135) chronic renal failure developed in 31% and 25% of those treated with and without high loop ureterostomy, respectively. However, in patients who underwent ureterostomy initially there was a significantly higher rate of decreased bladder capacity, urinary incontinence and augmentation cystoplasty. Obstruction at the ureterovesical junction was noted at surgery and after an average of 2 weeks of diversion in 7 (32%) and 1 (5%) of the 22 cases of percutaneous nephrostomy, respectively. However, after an average of 18 months of ureterostomy drainage we noted evidence of obstruction in 2 of the 27 ureterovesical units (7%). Early in our series 15 of 34 patients (44%) underwent ureterostomy. Subsequently, according to a treatment algorithm including percutaneous nephrostomy, only 1 of 14 boys (7%) underwent such diversion. CONCLUSIONS: Based on our findings high loop ureterostomy does not prevent progression to renal insufficiency and is associated with more complications than primary valve ablation or vesicostomy. Unresolved ureterovesical junction obstruction is rare. Before performing formal supravesical diversion short-term percutaneous nephrostomy drainage helps to identify patients who require diversion.

One-stage hypospadias repair. Experience with 544 cases.

PURPOSE: We evaluated one-stage hypospadias repairs in providing a normal looking penis with a normal functioning urethra. Also we looked critically at the effects of the severity of hypospadias, the type of repair and the experience of the surgeon on the outcome. MATERIALS AND METHODS: From 1987 to 1996 we performed 578 primary hypospadias repairs. The type and surgical results as well as the effects of certain variables on outcome were reviewed retrospectively. RESULTS: 544 single-stage hypospadias repairs have been followed up for a mean of 19 months (range 12-49). They included: MAGPI (92), ARAP (78), Mathieu (205), Mustarde (12), Duckett's tubularized preputial flap (142) and Onlay preputial flap (15). Despite an initial overall complication rate of 19%, the final success rate was 96%, after a mean of 1.3 procedures. Complications included fistula in 48 (9%) cases, meatal stenosis or retraction in 28 (5%), residual chordee in 17 (3%), stricture in 14 (2.5%), tubal abnormality in 10 (2%), and flap necrosis in 9 (2%). Complication rates were significantly higher (p < 0.05) when the meatus was proximal, the degree of chordee was moderate or severe and in the early series. Complication rates were also significantly higher with flap procedures and when the urethral plate was resected. Cosmetic defects occurred mainly with meatal advancement procedures. CONCLUSIONS: A repertoire of different types of single stage procedures has allowed the successful treatment of most hypospadias cases presenting to one surgeon. Complication rates increases with the severity of hypospadias or transection of the urethral plate. A cumulative experience allows for better results via a proper selection of the procedure and a perfection of a few techniques.

Hypospadias repair by skin flaps: a comparison of onlay preputial island flaps with either Mathieu's meatal-based or Duckett's tubularized preputial flaps.

OBJECTIVES: To evaluate the success of different skin flaps in the one-stage correction of primary hypospadias, with particular emphasis on comparing onlay preputial island flaps with Mathieu's meatal-based and Duckett's preputial tubularized flaps. PATIENTS AND METHODS: During a 12-year period, 418 patients underwent single-stage primary hypospadias repair using skin flaps, carried out by one surgeon. The surgical techniques used included Mathieu's repair in 216 (52%), Duckett's in 148 (35%), onlay preputial flaps in 42 (10%) and the Mustarde flap procedure in 12 (3%). The surgical results were reviewed, assessing complications and the functional and cosmetic outcome. RESULTS: At a mean follow-up of 23 months the initial overall complication rate for flap procedures was 22%; however, after a mean of 1.4 procedures, the final success rate was 95%. The complication rate was significantly (P<0.05) higher in patients with a proximal urethral meatus, with severe chordee or in repairs involving transection of the urethral plate. However, the complication rates were not significantly different when the patients underwent repair when aged <2 years or >2 years. Despite no significant difference in overall complication rates, onlay procedures tended to be used in more severe hypospadias than was Mathieu's repair. Duckett's repair caused a significantly higher overall complication rate as fistulae, strictures, meatal stenoses and tubular abnormalities than did onlay procedures. The use of double-faced preputial island flaps resulted in an inferior cosmetic appearance than the use of single-faced flaps, but the overall complication rates did not differ significantly between these techniques. CONCLUSIONS: Hypospadias repair using skin flaps offered a reliable and durable outcome. However, complication rates were greater in patients with severe hypospadias and with techniques requiring transection of the urethral plate. The onlay preputial island-flap technique was more widely applicable than was Mathieu's repair and had a lower complication rate than Duckett's procedure.

Ureteric injuries: diagnosis, management, and outcome.

OBJECTIVES: To define the current causes and the optimal methods of early diagnosis and management of ureteric injuries, both iatrogenic (excluding endourologic) and traumatic, and to determine the outcome of these injuries and which identifiable factors affect this outcome. METHODS: A retrospective analysis was performed of all the 35 patients who sustained 40 ureteric injuries over a 5-year period (1991-1996). The methods used for diagnosis and management were reviewed. The outcome was assessed in terms of preservation of renal function. RESULTS: The study group was composed of 28 patients with 32 iatrogenic injuries and 7 patients with 8 injuries caused by external trauma. Gynecologic procedures accounted for 63% (20 of 32) of the iatrogenic injuries, whereas motor vehicle crashes accounted for 75% of the external injuries (6 of 8 injuries). The successful diagnostic rate for direct inspection (intraoperatively), intravenous urogram, retrograde pyelogram, and anterograde pyelogram were 33% for the former two and 100% for the latter two. Treatment consisted of primary open repair in 26 cases, a staged procedure in 7 cases, and endoscopic stenting in 5 cases. Of 36 cases with follow-up, complications developed in 9 cases (25%), 7 cases of which were corrected surgically. Overall incidence of nephrectomy was 8%, and the factors that seemed to affect the outcome adversely were pediatric age (< or =12 years), injury to upper ureter, delay in recognition, the presence of a urinoma, and/or associated organ injury. CONCLUSION: Iatrogenic trauma is the leading cause of ureteric injuries. The single controllable factor adversely affecting the outcome of this rather uncommon injury seems to be delayed diagnosis. Wound inspection and intravenous urogram are not reliable for early and accurate diagnosis, and a retrograde pyelogram or an anterograde pyelogram may be needed. Uncontrollable factors adversely affecting the outcome include young age, injury to upper ureter, and associated injuries all seen in association with external trauma rather than iatrogenic injuries.

Cost-effective emergency diagnosis plan for urinary stone patients presenting with ureteric colic.

OBJECTIVE: To develop a cost-effective plan for the accurate diagnosis of urinary stone patients presenting with ureteric colic based on an assortment of investigations which are less invasive and more economical than intravenous urography (IVU). PATIENTS AND METHODS: 143 consecutive emergency patients presenting with ureteric colic were admitted to hospital and prospectively studied by history recording, physical examination, laboratory tests and imaging procedures according to a preset format. Significant association of the final diagnosis of urinary stones (which was made by actual stone retrieval) with various diagnosis variables obtained from the results of investigation (including IVU) was statistically studied using bivariate correlation and multivariate logistic regression analysis. Algorithms for reaching an accurate diagnosis of urinary tract stones were formulated using the most significant diagnostic variables and the accuracy of each of those plans was compared with that of emergency IVU. RESULTS: 18 patients were excluded for various reasons. Of the remaining 125 patients 82 (66%) were confirmed as having urinary stones. A positive IVU had the strongest correlation with the final diagnosis of urinary tract stones. Other findings associated with eventual stone retrieval in a descending order of significance were: calcular sonographic features; radio-opacities on a plain abdominal film of the kidney, ureter and bladder (KUB), and microhaematuria. Based on these findings two algorithms could be formulated to reach as accurate a diagnosis as possible. Algorithm A in which an initial ultrasound is mandatory had a sensitivity of 89%, a specificity of 88% and an overall accuracy of 88% for urinary stone detection compared with 91, 77, and 86%, respectively, for algorithm B in which ultrasonography was employed selectively after initial KUB and urinalysis for microhaematuria. This compares with 94, 79, and 89%, respectively, for IVU. CONCLUSION: Both plans are viable alternatives which could replace routine emergency IVU.

Does gland histopathology correlate with mode of presentation and surgical complications in benign prostatic hyperplasia?

The histopathology specimens from 256 consecutive prostatectomies were retrospectively analysed and classified into three categories namely BPH alone, BPH and an inflammatory lesion and adenocarcinoma. Mode of presentation (acute urine retention versus prostatism) as well as short term post-operative complications, namely, haemorrhage and genitourinary infection were compared in the three histological categories to study the impact of histology on clinical presentation and complications. There were no significant differences between the three categories neither in presentation nor in complications. We conclude that prostate gland histology neither correlates with the onset of acute urine retention nor with the surgical complications studied in this report.

Clinical features and surgical outcome of benign prostatic hyperplasia.

The clinical features and outcome of surgery for benign prostatic hyperplasia (BPH) were studied retrospectively in Asir during the period between 1987 and 1993. Two hundred and fifty-three patients were included. The mean and median ages were both 70 years. The main presentation were acute retention (54%), prostatism (39%), and chronic retention (6.8%). Thirty-five and five-tenths percent of the patients had one or more pre-existing medical problems. Two hundred and forty-eight patients underwent prostatectomy. Open surgery constituted 26.6%, while transurethral resection of the prostate (TURP) was carried out in 73.4%. There was neither intraoperative death nor postoperative failure of voiding. The perioperative mortality rate was 0.8%. The main perioperative complications were bacteriuria in 48%, and significant bleeding requiring blood transfusion of three units or more in 20.6%. Histopathology revealed benign disease in 93.2% of the specimens and adenocarcinoma in 6.8%. It is concluded that the Saudi BPH patient in Asir presents late with acute retention of urine more often than in other places and so noninvasive therapeutic modalities may be less helpful.

Effect of age, comorbidity and type of surgery on perioperative complications and mortality of prostatectomy.

OBJECTIVE: To study the effect of age, type of surgery and comorbidities (cardiovascular diseases, chronic lung diseases, diabetes mellitus and renal impairment) on the peri-operative complications and mortality of prostatectomy. PATIENTS AND METHODS: A series of 236 consecutive patients who underwent prostatectomy (171 by transurethral resection, TUR, and 65 by open procedure) were reviewed. Ninety patients at risk with one or more of the comorbidities were grouped together and compared with the remaining 146 fit patients. Also, 148 patients aged < or = 70 years were compared with 88 patients aged > 70 years. The peri-operative morbidity variables compared were haemorrhage, > or = 3 units of blood transfusion, bacteriuria, orchitis, pyrexia, uraemia and bed-stay. RESULTS: Mean post-operative bed-stay for patients at risk was significantly longer than that for fit patients (12 +/- 7 and 9.7 +/- 6 days, respectively). Mortality and the other morbidity variables, apart from post-operative bacteriuria which was more frequent in diabetics, were not significantly different between the groups. Similarly, comparing age groups revealed no significant differences. However, open surgery was associated with more haemorrhage, blood transfusion, post-operative pyrexia and a longer bed-stay. CONCLUSION: The comorbidities studied and age did not significantly influence the complications and mortality of prostatectomy. However, comorbidities prolonged post-operative bed-stay. Open surgery was associated with more bleeding and pyrexia and a longer bed-stay than TUR.