Maggot therapy for problematic wounds: uncommon and off-label applications.

OBJECTIVE: To identify off-label uses for maggot therapy that may be worthy of further clinical evaluation. DESIGN: Clinician surveys and invitations to submit unusual and off-label uses of maggot therapy. SETTING: All levels of inpatient, outpatient, extended care, and home care. PARTICIPANTS: More than 350 clinicians known to use maggot therapy were invited to participate in the survey. Twelve returned the survey. MAIN OUTCOME MEASURE: Indications for maggot therapy other than simple debridement of wounds listed on product labeling. MAIN RESULTS: A total of 544 wounds were treated by the 12 respondents; 131 (24%) were rare or off-label applications, including stimulation of epithelialization in clean but nonhealing wounds; disinfection, odor, and drainage control; determination of tissue viability; debridement of acute burns, necrotic tumors, and ischemic ulcers; and debridement of unusual sites (ie, glans penis, joints, pleural space, and peritoneal cavity). Noted drawbacks included the time and effort needed to train personnel and convince administrators of the need for treatment. CONCLUSION: Medicinal maggots are frequently being used as an adjunct to other methods of surgical and nonsurgical wound care and often for off-label indications, including debridement, disinfection, and stimulation of healing. Further study is warranted to evaluate the efficacy and safety of maggot therapy for these indications, and better education is needed for administrative and clinical staff to make maggot treatment more accessible.

Laparoscopic urethrovesical anastomosis: a model to assess surgical competency.

PURPOSE: To create a model for the evaluation of resident competency and performance of laparoscopic skills in compliance with Accreditation Council for Graduate Medical Education (ACGME) outcome assessment guidelines for urology residency programs. MATERIALS AND METHODS: A model of laparoscopic interrupted urethrovesical anastomosis was developed using chicken skin from a local supermarket. Eight residents at various training levels utilized a simulator with a camera-operating assistant to practice placing interrupted stitches. The time necessary for completion of an anastomosis and the quality of the anastomosis were documented. RESULTS: The time required to recreate a simulated urethrovesical anastomosis by placing six interrupted stitches declined from an initial mean of 60.75 minutes to 20.5 minutes after each resident had performed 20 anastomoses each. The mean improvement was 39.5 minutes, with one postgraduate year-3 resident demonstrating an improvement of 50 minutes. CONCLUSION: This model can be used by ACGME-certified urology residency programs to assess the laparoscopic skills of residents.

Reversible infertility in a man with 21-hydroxylase deficiency congenital adrenal hyperplasia.

OBJECTIVE: To report a case of an azoospermic man diagnosed with 21-hydroxylase deficiency congenital adrenal hyperplasia who successfully conceived with intrauterine insemination (IUI) after hormonal and clomiphene citrate (CC) treatment. DESIGN: Case report. SETTING: Outpatient practice and academic hospital. PATIENT(S): A 32-year-old azoospermic man who presented for evaluation of male factor infertility. INTERVENTION(S): Semen analysis, ultrasonography, endocrinologic assays, hormonal treatment, CC, and IUI. MAIN OUTCOME MEASURE(S): Semen analysis demonstrating increased sperm count and motility, ultrasonography demonstrating persistent nodules in bilateral testes, endocrinologic assays demonstrating elevated FSH and LH after CC treatment. RESULT(S): Successful intrauterine pregnancy after IUI using the patient's sperm. CONCLUSION(S): Clomiphene citrate treatment in addition to hormonal manipulation in azoospermic patients with congenital adrenal hyperplasia can be successful in improving sperm count and motility to allow for successful conception using IUI. The presumed adrenal rests in the testes may not involute after adrenal suppression.

Tubeless percutaneous renal surgery in obese patients.

OBJECTIVES: To assess the outcome and safety of tubeless percutaneous renal surgery in overweight and obese patients. METHODS: A single urologist performed tubeless percutaneous renal surgery on a total of 138 renal units in 133 patients from March 1996 to January 2003. The tubeless procedures consisted of either nephrolithotripsy or endopyelotomy. We analyzed the clinical data of a subset of these patients who were of considered normal weight (body mass index [BMI] 18.5 kg/m2 or greater but less than 25 kg/m2), overweight (BMI 25 kg/m2 or greater but less than 30 kg/m2), obese (BMI 30 kg/m2 or greater but less than 40 kg/m2), and morbidly obese (BMI 40 kg/m2 or greater). RESULTS: Of the 133 patients, 5 (3.8%) were considered morbidly obese, 28 (21.1%) were considered obese, 55 (41.4%) were considered overweight, and 45 (34%) were considered to be of normal weight. Of the 133 patients, 104 underwent percutaneous stone extraction and 29 underwent percutaneous antegrade endopyelotomy. Using unpaired t testing, BMI was compared with the transfusion rates, days of hospitalization, and stone-free outcome. The stone group did not demonstrate statistically significant relationships between BMI and transfusion rate, length of hospitalization, and stone-free outcome (P = 0.423, P = 0.105, and P = 0.127, respectively). A stone-free rate of 94.5% was achieved. In the endopyelotomy group, 29 patients were analyzed. Follow-up showed 24 patients (82.8%) had successful resolution of the ureteropelvic junction obstruction 1 year postoperatively. Two patients required readmission for gross hematuria and low hematocrit. One patient required selective angiographic embolization of a pseudoaneurysm. CONCLUSIONS: Tubeless percutaneous renal surgery is a safe and effective procedure in overweight, obese, and morbidly obese patients.

Radiation protection during percutaneous nephrolithotomy: a new urologic surgery radiation shield.

BACKGROUND AND PURPOSE: As endourology becomes an important part of the practice of urology, the use of fluoroscopic guidance has increased the exposure of urologists to the possibly deleterious effects of radiation. There is a need for a method of radiation protection for percutaneous nephrolithotomy (PCNL), as the exposure from radiation scatter may be significant, depending on the difficulty of establishing access. PATIENTS AND METHODS: We ascertained the effectiveness of a newly modified radiation shield during PCNL. Exposure readings were taken using a thermoluminescent dose monitor placed different distances from the radiation source during six PCNLs. We compared the exposure readings with and without the shield. RESULTS: The shield was able to reduce the radiation by an average of 96.1% at a distance of 25 cm and 71.2% at a distance of 50 cm from the source. CONCLUSION: The shield can be used as one step toward the goal of reducing surgeon radiation exposure. Other methods, such as dose-minimizing imaging protocols and adaptation of equipment optimized to reduce exposure, are also important measures in creating a safe environment for both the urologist and the patient.