Ultra-Mini Percutaneous Nephrolithotomy (UMP) with Strict Lower Irrigation Pressure Control: Correlation with Post Operative Febrile Urinary Tract Infection Rate.

BACKGROUND: Ultra-mini PCNL (UMP) is a device that removes stones by using 7.5 Fr. nephroscope and 11/12 Fr. working sheath. The stone free rate (SFR) does not lag behind the convetional PCNL, but due to the diameter of the small device, UMP has many disadvantages; Irrigation pressure increases easily during surgery and post operative febrile urinary tract infection (UTI) is relative common. The purpose of this study is to present the surgical results of UMP with strict irrigation pressure control using a pressure control irrigator. METHODS: 70 consecutive patients who underwent UMP surgery for kidney stones were enrolled retrospectively. All surgeries proceeded with the shoulder rotated supine position. Of these, initial 35 patients underwent surgery using 100 mmHg irrigation power previously and later 35 patients underwent surgery below 40 mmHg irrigation power. RESULTS: The stone size of the UMP 100 mmHg group was 2.52 ± 1.05 and that of the UMP 40 mmHg group was 2.79 ± 1.32 respectively. Operative time was also slightly shorter in the UMP 40 mmHg group, but there was no statistical difference between the two groups. There was no statistical difference in stone free rate, but UMP 100 mmHg group showed 37.1% of post operative febrile urinary tract infection rate and 11.4 % in UMP 40 mmHg group and they are significantly different (p = 0.039). CONCLUSIONS: Strict irrigation pressure control below 40 mm during UMP can reduce post operative febrile UTI without affecting SFR.

Ultra-Mini Percutaneous Nephrolithotomy (UMP) with Strict Lower Irrigation Pressure Control: Correlation with Post Operative Febrile Urinary Tract Infection Rate

Background: Ultra-mini PCNL (UMP) is a device that removes stones by using 7.5 Fr. nephroscope and 11/12 Fr. working sheath. The stone free rate (SFR) does not lag behind the convetional PCNL, but due to the diameter of the small device, UMP has many disadvantages; Irrigation pressure increases easily during surgery and post operative febrile urinary tract infection (UTI) is relative common. The purpose of this study is to present the surgical results of UMP with strict irrigation pressure control using a pressure control irrigator. Methods: 70 consecutive patients who underwent UMP surgery for kidney stones were enrolled retrospectively. All surgeries proceeded with the shoulder rotated supine position. Of these, initial 35 patients underwent surgery using 100 mmHg irrigation power previously and later 35 patients underwent surgery below 40 mmHg irrigation power. Results: The stone size of the UMP 100 mmHg group was 2.52 ± 1.05 and that of the UMP 40 mmHg group was 2.79 ± 1.32 respectively. Operative time was also slightly shorter in the UMP 40 mmHg group, but there was no statistical difference between the two groups. There was no statistical difference in stone free rate, but UMP 100 mmHg group showed 37.1% of post operative febrile urinary tract infection rate and 11.4 % in UMP 40 mmHg group and they are significantly different (p = 0.039). Conclusions: Strict irrigation pressure control below 40 mm during UMP can reduce post operative febrile UTI without affecting SFR (AU)

Role of Intrarenal Pressure in Modern Day Endourology (Mini-PCNL and Flexible URS): a Systematic Review of Literature.

PURPOSE OF REVIEW: To review the latest evidence about intrarenal pressures (IRPs) generated during flexible ureteroscopy (fURS) and mini percutaneous nephrolithotomy (mPCNL) and present tools and techniques to maintain decreased values. RECENT FINDING: fURS and PCNL constitute the primary means of stone treatment. New flexible ureterorenoscopes with small diameter and miniaturized PCNL instruments achieve optimal stone-free rates (SFRs) while decreasing invasiveness and morbidity. Nevertheless, endourologists must remain cognizant regarding the dangers of increased IRPs to avoid complications. Current research presents essential information for urologists regarding this topic. During fURS, using a ureteral access sheath (UAS), we avoid extremely high IRPs with all irrigation types. During mPCNL, pressure remains low, mainly using the purging effect or a vacuum-assisted sheath. Devices of intraoperative IRP measurement and intelligent pressure control have proven their feasibility, accuracy and efficacy. These will have an increasing role to play in the future management of stone disease.

Pressure matters 2: intrarenal pressure ranges during upper-tract endourological procedures.

PURPOSE: To perform a review on the latest evidence related to intrarenal pressures (IRPs) generated during upper-tract endourology, and present different tools to maintain decreased values, to decrease complication rates. METHODS: A literature search was performed using PubMed, restricted to original English-written articles, including animal, artificial model and human studies. Different keywords were: percutaneous nephrolithotomy, PCNL, ureteroscopy, URS, RIRS, irrigation flow, irrigation pressure, intrarenal pressure, intrapelvic pressure and renal-pelvic pressure. RESULTS: IRPs reported during retrograde intrarenal surgery (RIRS), PCNL, miniPCNL, and microPCNL range 40.8-199.35, 3-40.8, 10-45 and 15.37-41.21 cm H2O, respectively. By utilizing ureteral access sheaths (UASs) IRPs usually remain lower than 30 cm H2O at an irrigation pressure (IP) of ≤ 100 cm H2O but could increase to > 40 cm H2O at an IP of 200 cm H2O. By utilizing the minimally invasive PCNL system, IRPs remain low at 20 cm H2O even at high IPs. Utilizing endoluminal isoproterenol during RIRS, could reduce IRP increases with a rate of 27-107%, and maintain low IRPs values, usually below 50 cm H2O. CONCLUSIONS: Increased IRP values have been reported during RIRS and UASs constitute the most efficient tool for decreasing them. IRPs during mini-PCNL can be decreased utilizing the vacuum-cleaner and purging effects but might remain uncontrolled during micro- and ultra-mini PCNL. Intraluminal pharmacological treatment could play a role in IRP decrease, with isoproterenol being the most studied agent.

Pressure matters: intrarenal pressures during normal and pathological conditions, and impact of increased values to renal physiology.

PURPOSE: To perform a review on the latest evidence related to normal and pathological intrarenal pressures (IRPs), complications of incremented values, and IRP ranges during endourology. METHODS: A literature search was performed using PubMed, restricted to original English-written articles, including animal, artificial model, and human studies. Different keywords were: percutaneous nephrolithotomy, PCNL, ureteroscopy, URS, RIRS, irrigation flow, irrigation pressure, intrarenal pressure, intrapelvic pressure and renal pelvic pressure. RESULTS: Normal IRPs range from zero to a few cm H2O. Pyelovenous backflow may occur at pressure range of 13.6-27.2 cm H2O. During upper tract endourology, complications such as pyelorenal backflow, sepsis, and renal damage are directly related to increased IRPs. Duration of increased IRPs and concomitant obstruction are independent predictors of complication development. CONCLUSIONS: IRP increase remains a neglected predictor of upper tract endourology complications and its intraoperative monitoring should be taken into consideration. Further research is necessary, to quantify pressures generated during upper tract endourology, and introduce means of controlling them.

Wound irrigation does not affect health-related quality of life after open fractures: results of a randomized controlled trial.

AIMS: The Fluid Lavage in Open Fracture Wounds (FLOW) trial was a multicentre, blinded, randomized controlled trial that used a 2 × 3 factorial design to evaluate the effect of irrigation solution (soap versus normal saline) and irrigation pressure (very low versus low versus high) on health-related quality of life (HRQL) in patients with open fractures. In this study, we used this dataset to ascertain whether these factors affect whether HRQL returns to pre-injury levels at 12-months post-injury. PATIENTS AND METHODS: Participants completed the Short Form-12 (SF-12) and the EuroQol-5 Dimensions (EQ-5D) at baseline (pre-injury recall), at two and six weeks, and at three, six, nine and 12-months post-fracture. We calculated the Physical Component Score (PCS) and the Mental Component Score (MCS) of the SF-12 and the EQ-5D utility score, conducted an analysis using a multi-level generalized linear model, and compared differences between the baseline and 12-month scores. RESULTS: We found no clinically important differences between irrigating solutions or pressures for the SF-12 PCS, SF-12 MCS and EQ-5D. Irrespective of treatment, participants had not returned to their pre-injury function at 12-months for any of the three outcomes (p < 0.001). CONCLUSION: Neither the composition of the irrigation solution nor irrigation pressure applied had an effect on HRQL. Irrespective of treatment, patients had not returned to their pre-injury HRQL at 12 months post-fracture. Cite this article: Bone Joint J 2018;100-B:88-94.

Irrigation dynamic pressure-assisted hydrodissection during cataract surgery.

The irrigation dynamic pressure-assisted hydrodissection technique (irrigation-hydro [iH]) does not require performing manual hydrodissection using a syringe and cannula to achieve cortical-capsular cleavage during cataract surgery. Since the iH technique uses the phaco tip to intentionally vacuum the intraocular fluid in order to induce the irrigation dynamic pressure for cortical-capsular cleavage, there is a reduction in the intraocular pressure (IOP) from the bottle-height-dependent hydrostatic pressure. Thus, since the peak irrigation pressure derived from the phaco tip sleeve will be limited by the height of the irrigation fluid bottle, this is advantageous in helping to avoid excessively high IOP during cortical-capsular hydrodissection. Using this technique, we were able to effectively perform phacoemulsification without complications in 607 of 609 cataract eyes. Our findings show that utilization of the iH technique would be of benefit to patients, as it prevents high-pressure hydrodissection-related complications, such as capsular block syndrome and tears in the anterior hyaloid membrane during cataract surgery.

Suction assisted pulse lavage: randomised controlled studies comparing its efficacy with conventional dressings in healing of chronic wounds.

Chronic, open, non-healing wounds pose a continual challenge in medicine as the treatment is variable and there are no documented consistent responses. Although wound aetiologies vary and there are a number of factors that affect chronic wound pathogenesis, wound ischaemia and bacterial colonisation of wounds are the chief concerns among them. Conventionally, pulse lavage has been used primarily as a wound debriding device. To address both the critical factors of wound ischaemia and bacterial burden, a couple of technical points were proposed and applied in this study. The objective of our study was to evaluate pulse lavage therapy's ability to improve the healing rate of chronic wounds compared to that of the traditional saline-wet-to-moist dressings. The study period was from 1 August 2010 to 31 January 2012 and was conducted in our institution. Thirty patients with 31 chronic, non-healing wounds were enrolled in the study after obtaining proper consent. Subjects were randomised (15 patients each) to the pulse lavage group and the control group. Patients in the test group were subjected to irrigation of their wounds with pulsed lavage at 10 to 15 psi pressure. In the control group, wound was closed by applying moist betadine saline gauze dressings after cleaning with saline. Wounds treated with pulse lavage system significantly reduced in size, had better control of bacterial contamination and had overall faster healing rates. Efficacy of pulse lavage can be increased by correct method of administration of the irrigant.