Management of Total Transection of Nasoendotracheal Tube during LeFort I Osteotomy.

Transection of the nasoendotracheal tube during orthognathic surgery is a rare, but life-threatening complication. We present a case of complete nasoendotracheal tube transection during a LeFort 1 osteotomy and discuss appropriate preventative and management techniques.

In vivo factors influencing the freezing cycle during cryoablation of small renal masses.

PURPOSE: The aim of this study is to present a procedural analysis of the cryoablations performed in our department for small renal tumors and to try to identify clinical parameters or factors that influence the freezing rate during the procedure. PATIENTS AND METHODS: We collected all data from the procedures performed in our department until August 2007. Based on the intraoperative biopsy result, we grouped the cases in two groups: renal-cell carcinoma (RCC) and benign. We calculated the freezing rate in both groups and compared them. Finally, we performed a univariate and multivariate analysis to identify clinical parameters that significantly influence the freezing rate. RESULTS: A total of 70 cryoablations of small renal tumors in 67 patients were performed during this period. From these, 56 procedures met the inclusion criteria and were analyzed further. The RCC group consisted of 48 cases (39 RCC and 9 lesions with a nondiagnostic biopsy) while 8 formed the benign group. There was no difference in the freezing rate between these two groups. Preoperative creatinine levels above 120 IU, diabetes mellitus, American Society of Anesthesiologists score 3, and location of the tumor at the lower pole were found to increase the freezing rate. The only factor that significantly decreased the freezing rate was the presence of chronic obstructive pulmonary disease. The multivariate analysis showed that the location of the tumor and diabetes mellitus influence more significantly the temperature v time graph. CONCLUSIONS: The freezing rate during cryotherapy of small renal tumors is significantly influenced by various clinical factors, while there are no differences in the freezing rate of those proven small malignant tumors and the small benign lesions.

Beyond prone position in percutaneous nephrolithotomy: a comprehensive review.

CONTEXT: Percutaneous nephrolithotomy (PNL) is traditionally performed with the patient in the prone position. OBJECTIVE: To assess the efficacy and safety of the prone and supine positions, particularly in obese patients and in those with staghorn calculi. EVIDENCE ACQUISITION: A Medline search was conducted for articles published during the last 10 yr related to PNL in the prone and supine positions. EVIDENCE SYNTHESIS: This search revealed 9 published studies for supine and 25 for prone PNL. None of the supine PNL studies reported visceral injuries, while transfusion rates were 0.0-9.4% and stone-free rates were 69.6-95.0%. One study of supine PNL evaluated a significant proportion of obese patients. Prone PNL studies in obese patients report transfusion rates of 3.2-8.8% and stone-free rates of 79.0-89.2%. In the only randomized study, excluding obese patients and staghorn calculi, operative time favors the supine position. A nonrandomized comparative study demonstrated similar complication rates with insignificant improvement in treatment success for supine PNL; however, when comparing series with similar proportions of staghorn calculi cases, there are slightly improved outcomes for prone PNL. Moreover, comparison of weighted means favors prone PNL. CONCLUSIONS: For obese patients and staghorn calculi, prone PNL appears to be associated with decreased operative times with similar bleeding rates and slightly better stone-free rates than supine PNL.

Drug-induced urinary incontinence.

Physiological urinary continence depends on many factors that are potentially vulnerable to adverse drug effects, which may lead to incontinence. In principle, drugs could cause incontinence by lowering bladder outlet resistance and/or by increasing intravesical pressure, which disrupts the normal pressure relationship between the bladder and urethra and leads to urinary leakage; other possibilities include disturbances of central nervous control of voiding or an overproduction of urine. While many drug groups could theoretically induce urinary incontinence based upon pathophysiological considerations, evidence demonstrating a cause-effect relationship between drug usage and incontinence is sparse. Drug classes in which induction of incontinence has been proposed include alpha(1)-adrenoceptor antagonists, antipsychotics, benzodiazepines, antidepressants and hormone replacement therapy in postmenopausal women. However, other drug classes are not innocent in terms of causing urinary incontinence and physicians are well advised to closely monitor patients for the occurrence of incontinence after new prescriptions and/or major dosage changes.

The evolution of KTP laser vaporization of the prostate.

The search for a minimally invasive approach to the treatment of Lower Urinary Tract Symptoms (LUTS) suggestive of Benign Prostatic Hyperplasia (BPH) is probably as old as Transurethral Resection of the Prostate (TURP). In an effort to overcome the limitations and morbidities of TURP, and in light of evidence suggesting that medical treatment for BPH has a limited life-span, laser-based treatments have emerged during the last decade. Photoselective Vaporization of the Prostate (PVP) by the "GreenLight" KTP laser is considered one of the most promising options, one that is constantly evolving new technologies in prostate surgery. In this overview of KTP laser usage in BPH treatment, we will briefly discuss the evolution of this modality since it was first introduced and focus on the available evidence regarding safety, efficacy and cost parameters of its application.

Transrectal high-intensity focused ultrasound devices: a critical appraisal of the available evidence.

Developments in the technology applied to the field of minimally invasive surgery have led to the exploration of high-intensity focused ultrasound (HIFU) for the treatment of localized prostate cancer. Extensive research and continuous evolution have resulted in two commercially available HIFU devices: the Ablatherm and the Sonablate500. These devices are conceptually the same; however, specific technical differences exist. This paper reviews the clinical outcomes obtained with these devices, evaluates the quality of the evidence from the individual trials, and provides the results of a head-to-head comparison in terms of oncologic outcomes and complication rates.

Pharmacologic treatment of male stress urinary incontinence: systematic review of the literature and levels of evidence.

OBJECTIVE: Stress urinary incontinence (SUI) occurs in men and women. Pharmacologic treatment of female SUI has been beneficiary but the role of drug treatment in male SUI is controversial. This review evaluates the drug classes, the effects of these drugs in trials with male SUI, and the levels of evidence of the individual trials. METHODS: A systematic literature review was conducted searching for studies on male SUI published between 1966 and 2007. In retrieved articles, reference lists were hand-searched to identify additional articles. The level of evidence was judged according to the Oxford classification. RESULTS: This search found nine articles providing evidence that alpha-adrenoceptor agonists (ephedrine, phenylpropanolamine, midodrine), beta2-adrenoceptor agonists (clenbuterol), and serotonin-noradrenaline reuptake inhibitors (imipramine, duloxetine) have a potentially beneficial effect on male SUI. Most trials used only small numbers of patients and a mixed study population (men and women). The evidence level of most studies was low due to the lack of randomisation (case series or cohort studies, level 4). In contrast, the first high-level study to provide evidence in the treatment of male SUI was with duloxetine, a selective serotonin and noradrenaline reuptake inhibitor (randomised controlled study, level 1b). However, only one well-designed study has been published so far. CONCLUSIONS: One high-level study with duloxetine in combination with pelvic floor muscle training shows preliminary but promising results in the treatment of male SUI. These results have to be confirmed in larger and well-designed trials to allow definite recommendations for the pharmacologic treatment of male SUI.

Age as a factor in the complication rate after removal of unerupted/impacted third molars at the time of mandibular sagittal split osteotomy.

PURPOSE: This study was designed to investigate the effect that the presence of an unerupted third molar has on the mandibular sagittal split osteotomy (SSO). PATIENTS AND METHODS: One operator performed 139 SSOs (70 right side and 69 left side) in 70 patients during a period of 6 months. Data related to gender, age, presence or absence of unerupted third molar teeth, split difficulty during SSO, fracture complications of the segment, neurovascular bundle involvement at surgery, removal of unerupted third molar teeth, and the postoperative recovery of nerve function were recorded. RESULTS: The SSOs evaluated as technically difficult were significantly more prevalent in mandibles with unerupted third molar teeth. All fractures (4) occurred in the younger age group (<20 years) with unerupted third molars present at the time of surgery. Although inferior alveolar nerve recovery was slower in the patients in whom the unerupted third molar teeth were present at the time of surgery due to increased frequency of neurovascular bundle manipulation, the recovery rates at 1 year were equal. CONCLUSIONS: The presence of unerupted third molar teeth increases the degree of difficulty of the SSO. Fracture of proximal and/or distal segments during SSO tend to occur more frequently in the younger age group (<20 years) with an unerupted third molar present.