Predicting for postoperative incontinence following sling incision.

INTRODUCTION AND HYPOTHESIS: Our objective was to assess preoperative risk factors for developing recurrent stress urinary incontinence (SUI) following transvaginal sling incision (TVSI) for bladder outlet obstruction (BOO). METHODS: We identified 101 women who underwent TVSI and/or removal of a midurethral sling. Thirty-nine underwent TVSI for clinical and videourodynamic demonstrable BOO. Eighteen of 39 women demonstrated preoperative clinical SUI and urodynamic BOO. A comparative analysis was performed specifically looking at several clinical factors and the risk of the occurrence of postoperative SUI. RESULTS: Mean age, number of prior surgeries, parity, and pre- and postoperative PVRs did not predict for postoperative SUI. Nine of 18 (50%) of women with SUI and BOO preoperatively vs. only 2/21 (10%) of women with BOO alone developed postoperative SUI. This difference in the incidence of postoperative SUI was statistically significant (p<0.01). CONCLUSIONS: In patients with BOO, the presence of preoperative clinical SUI is a predictor for postoperative SUI following TVSI.

Laparoscopic cryoablation of renal masses: which lesions fail?

OBJECTIVE: To identify potential predictive characteristics of lesions which failed in laparoscopic renal cryoablation (LRC). We analyzed 47 lesions that underwent this approach. METHODS: We reviewed 45 consecutive patients who underwent LRC of a renal mass between 2003 and 2008 at a single institution. A total of 47 masses were identified; all were treated by 2 surgeons. We analyzed patient age, ASA, pre- and postoperative creatinine, tumor size, location, number of cryoprobes used, and histology of the lesions. We reviewed imaging to identify characteristics of those lesions which failed LRC management, defined as lesions that demonstrated persistent enhancement and/or did not decrease in size within 6 months of therapy. RESULTS: A total of 47 lesions in 45 patients were identified. The median follow-up was 13 months. Mean lesion size was 2.7 cm (range, 1.2-5.4), with 25 anterior and 22 lateral or posterior lesions. Of the biopsy samples from 40 of 47 lesions, renal cell carcinoma was found in 23, oncocytoma was found in 7, and 10 were benign or inconclusive. Treatment failure was noted in 8 of 47 lesions (17%), 7 of which (87.5% of failed lesions) had broad-based contact with the renal sinus. Broad-based lesions which made contact with the renal sinus were successfully treated 53.3% of the time, whereas lesions which lacked contact with the renal sinus were treated successfully 96.9% of the time (P <.01). CONCLUSIONS: Broad-based central location of a renal mass may predict a significantly increased risk of failure of LRC and should be considered in patient counseling.

Continuous infusion of local anesthetic decreases narcotic use and length of hospitalization after laparoscopic renal surgery.

PURPOSE: We sought to determine the efficacy of an extraction-incision infusion of local anesthetics through a continuous-infusion elastomeric pump (ON-Q) for the management of postoperative analgesia after laparoscopic nephrectomy and laparoscopic nephroureterectomy with intact specimen extraction. PATIENTS AND METHODS: We performed a retrospective comparative analysis of 38 consecutive patients undergoing either laparoscopic nephrectomy or laparoscopic nephroureterectomy between October 2006 and November 2007 by an experienced single surgeon. Postoperative pain management with an ON-Q pump providing continuous local anesthetic into the incisional area was compared with traditional intravenous and oral analgesic use. Data sources were reviewed for analgesia requirements (morphine equivalents), tumor size, American Society of Anesthesiologists scores, complications, and length of hospitalization. RESULTS: After laparoscopic procedures, 18 patients received the ON-Q Pain Relief System while 20 received the traditional subcutaneous injection of 0.25% bupivacaine at the end of the procedure and standard orders for oral and IV narcotics for pain. Mean morphine equivalents used by the ON-Q and control groups were 35.4 and 47.5 mg, respectively (P = 0.1). Average length of hospitalization was 1.8 days and 2.9 days (P < 0.01), while mean tumor size was 5.2 cm and 3.7 cm (P < 0.05) in the ON-Q and control group, respectively. CONCLUSION: A continuous infusion of 0.25% bupivacaine at 4 mL/hour through the ON-Q elastomeric infusion pump is a safe and effective adjunct in postoperative pain management after laparoscopy. Initial experience with the ON-Q Pain Relief System results in decreased narcotic use and decreased length of hospitalization compared with traditional postoperative pain management.