Mutations in HOGA1 do Not Confer a Dominant Phenotype Manifesting as Kidney Stone Disease.

PURPOSE: The etiology of calcium-oxalate kidney stone formation remains elusive. Biallelic mutations in HOGA1 are responsible for primary hyperoxaluria type 3 and result in oxalate overproduction and kidney stone disease. Our previous study showed that carriers of HOGA1 mutations have elevated urinary levels of oxalate precursors. In this study we explored the possibility that mutations in HOGA1 confer a dominant phenotype in the form of kidney stone disease or hyperoxaluria. MATERIALS AND METHODS: An observational analytic case control study was designed to determine the prevalence of pathogenic HOGA1 mutations among adults with calcium-oxalate kidney stone disease. Given the high prevalence of HOGA1 mutations among Ashkenazi Jews, this group was evaluated separately. Carrier frequency of any of the 52 reported pathogenic mutations was compared to data derived from gnomAD for the corresponding ethnic group. Sanger sequencing of HOGA1 gene was performed on DNA samples from the following groups: 60 Ashkenazi Jews and 86 nonAshkenazi calcium-oxalate stone formers, 150 subjects with low and 150 with high urinary oxalate levels. RESULTS: The carrier prevalence of pathogenic mutations among the Ashkenazi Jews was 1.7% compared to 2.8% in the corresponding control group (p=0.9 OR=0.6 95% CI 0.01-3.51). We did not detect any mutation among the nonAshkenazi study group. No correlation was detected between hyperoxaluria and HOGA1 variants. CONCLUSIONS: This study shows that mutations in HOGA1 do not confer a dominant phenotype in the form of calcium-oxalate kidney stone disease or hyperoxaluria.

Holmium laser enucleation of the prostate using Moses 2.0 vs non-Moses: a randomised controlled trial.

OBJECTIVES: To compare the enucleation efficiency of Moses 2.0 with non-Moses technology in patients undergoing holmium laser enucleation of the prostate (HoLEP). PATIENTS AND METHODS: A double-blinded, randomised study of patients undergoing HoLEP at the Mayo Clinic in Arizona, using the Lumenis Pulse™ 120H laser system. Patients were randomised to either right lobe enucleation using Moses 2.0 and left lobe enucleation using non-Moses, or the opposite. The primary outcome was individual lobe enucleation efficiency. Secondary outcomes included individual lobe laser time, laser energy, individual enucleation and haemostasis laser energies, and fibre burn back. Two independent reviewers watched videos of the procedures and provided a subjective evaluation of the technologies. RESULTS: A total of 27 patients were included in the study. For the entire cohort, Moses 2.0 had less fibre degradation (3.5 vs 16.8 mm, P < 0.01) compared to non-Moses. When HoLEP procedures were performed by an expert, Moses 2.0 resulted in shorter enucleation time (21 vs 36.7 min, P = 0.016) and higher enucleation efficiency (1.75 vs 1.05 g/min, P = 0.05) compared to non-Moses. When HoLEP was performed by trainees, the Moses 2.0 cohort had a shorter haemostasis laser time (4.1 vs 9 min, P = 0.035) compared to the non-Moses. Fibre degradation was lower with Moses 2.0 compared to non-Moses for both experts and trainees. Moses 2.0 received a higher score than the standard technology for the incision sharpness, fibre control, tissue separation, tissue damage, haemostasis, visibility, and charring. The overall inter-observer correlation coefficient was 0.63. CONCLUSION: Moses 2.0 has higher enucleation efficiency compared to non-Moses when used by experts. The subjective evaluation favoured Moses 2.0.

Inter-imaging accuracy of computed tomography, magnetic resonance imaging, and transrectal ultrasound in measuring prostate volume compared to the anatomic prostatic weight.

OBJECTIVE: To evaluate the accuracy of transrectal ultrasound (TRUS), computed tomography (CT), and magnetic resonance imaging (MRI) compared to the reference standard of the post-surgical anatomic prostatic weight (APW). MATERIAL AND METHODS: A total of 349 patients from two institutions were included. The CT and MRI dimensions, and TRUS-reported prostate volumes (PV) were obtained. The prolate ellipsoid formula was used to calculate PV. Cross-sectional measurements were evaluated and compared to the reported post-surgical pathology measurements and calculated pathology volume (path PV). A basic statistical analysis was performed using the Pearson correlation, Bland-Altman analysis, and Passing-Bablok regression. RESULTS: A total of 198 patients were included in the MRI group, 118 in the CT group, 295 in the TRUS group, and 51 in the all-inclusive common cohort. The MRI PV demonstrated a good to excellent correlation with the APW (r=0.79). The CT PV demonstrated a good correlation with APW (r=0.78). The TRUS PV showed a correlation with APW (r=0.67). The correlations identified in each individual group held true in the common cohort as well. The path PV showed an excellent correlation with APW (r=0.87), followed by MRI PV (r=0.81), then CT PV (r=0.73), and lastly TRUS PV (r=0.71). CONCLUSION: MRI and CT are equally effective in assessing the PV, and they can be readily utilized to guide the benign prostatic hyperplasia (BPH) management without repeating in-office TRUS. This is not only cost-effective, but also eliminates patient anxiety and discomfort.

Kidney volume loss following percutaneous nephrolithotomy utilizing 3D planimetry.

Parenchymal damage and renal function impairment following percutaneous nephrolithotomy (PCNL) are of great concern. This study aims to evaluate post-operative changes in renal volume after PCNL. We retrospectively analyzed baseline and post-PCNL CT images from 25 eligible patients from a single tertiary care center. All CT imaging was reviewed using 3D planimetry software (3D Splicer®, Version 4.0). Segmentation was utilized to obtain total kidney volume (TKV), total kidney surface area, total stone surface area, and total stone volume. Wilcoxon signed-rank test was used for pair analysis, and univariate and multivariable analyses were performed to examine the relationships between clinical and planimetry data and renal volume loss. The median age of the cohort was 62 years, with the majority of the patients having undergone a previous PCNL (52.0%). The median TKV (cm3) pre- and post-PCNL were 225.25 and 178.09, respectively (p = 0.001), with average volume decline of 21%. While there was a statistically significant kidney volume loss in our cohort, there was no difference between pre- and post-operative serum creatinine (mg/dL): 0.93 and 0.94 (p = 0.696), respectively. Multivariable analysis showed a higher TKV loss with a larger kidney stone surface area (OR 1.002, CI 1-1.003, p = 0.035), while younger age was found to be protective (OR 0.791, CI 0.587-0.925 p = 0.028). Patients with previous history of PCNL experiences a more pronounced TKV loss (53.77 cm3, p = 0.031), as compared to PCNL naïve patients (13.05 cm3, p = 0.224). Our study consistently revealed a decrease in TKV following PCNL. Furthermore, among patients with larger stone surface areas, and history of previous PCNL there was an increase in the loss of TKV after the procedure.

Testicular Torsion Postorchiopexy: A Case of Twisted Hammock.

We herein report an unusual case of testicular torsion a decade after orchiopexy. An occurrence of postorchiopexy testicular torsion is an exceedingly rare event, infrequently reported in literature. Previously placed anchoring sutures in the inferior pole resulted in a "hammock" testicular torsion, resulting in twisting of cord with involvement of the sutures themselves.

Variability in Prices for Erectile Dysfunction Medications-Are All Pharmacies the Same?

BACKGROUND: Variability in prices of medications is a well-known phenomenon; however, this variability has not been quantified in the realm of erectile dysfunction (ED) medications. ED medications are ideal for this quantification, because they are often not covered by insurances; therefore, the cost is the most direct reflection of price variability among pharmacies as they affect the patients. AIM: To evaluate the variability in cash prices for phosphodiesterase type 5 inhibitors (PDEIs) for ED. We also evaluated whether certain types of pharmacies consistently offer better pricing than others, and whether there was any correlation with demographic factors. METHODS: 331 pharmacies were contacted within a 25-mile radius of our institution to obtain the cash price for 4 commonly used ED medications with prespecified doses. After exclusion, 323 pharmacies were categorized as chain, independent, wholesale, or hospital-associated. Cash prices for the specified medications were evaluated. In addition, we identified demographic and socioeconomic factors to determine if these had an impact on median drug pricing within each zip code. MAIN OUTCOME MEASURE: The main outcome was the cost for patients to fill each prescription. RESULTS: Independent pharmacies provided the lowest cost for 3 of 4 of the PDEIs. The largest price difference for 10 tablets of 100 mg sildenafil between all pharmacies was 38,000%. The median cost difference between independent pharmacies and chain pharmacies for sildenafil was >900%, and >1,100% for independent pharmacies vs hospital-associated pharmacies. Demographic and socioeconomic factors had no impact on the cost. CLINICAL IMPLICATIONS: Our goal is to promote patient counseling among practitioners and to empower patients to shop for the best prices for their medications. STRENGTH AND LIMITATIONS: A strength of the study is the large cohort that was surveyed; however, a weakness is that the large majority of the cohort was comprised of chain pharmacies. Mail pharmacies could not be evaluated as they required a valid prescription before offering prices. CONCLUSION: The drastic differences in cash prices for the PDEIs give us an insight into the variability and cost-inflation of medications in the United States. These patterns hold true for other essential medications as well, and improved transparency will allow patients to make informed decisions when choosing where to purchase their medications. It may also encourage certain pharmacies to provide medications at more affordable prices. Mishra K, Bukavina L, Mahran A, et al. Variability in prices for erectile dysfunction medications-Are all pharmacies the same? J Sex Med 2018;15:1785-1791.

Preoperative Bladder Urine Culture as a Predictor of Intraoperative Stone Culture Results: Clinical Implications and Relationship to Stone Composition.

PURPOSE: We examine the relationship between urine and stone cultures in a large cohort of patients undergoing percutaneous stone removal and compare the findings in infectious vs metabolic calculi. MATERIALS AND METHODS: A total of 776 patients treated with percutaneous nephrolithotomy who had preoperative urine cultures and intraoperative stone cultures were included in the study. Statistical analysis used chi-square or logistic fit analysis as appropriate. RESULTS: Preoperative urine culture was positive in 352 patients (45.4%) and stone cultures were positive in 300 patients (38.7%). There were 75 patients (9.7%) with negative preoperative cultures who had positive stone cultures, and in patients with both cultures positive the organisms differed in 103 (13.3%). Gram-positive organisms predominated in preoperative urine and stone cultures. CONCLUSIONS: Preoperative urine cultures in patients undergoing percutaneous nephrolithotomy are unreliable as there is a discordance with intraoperative stone cultures in almost a quarter of cases. There has been a notable shift toward gram-positive organisms in this cohort of patients.

Shock wave lithotripsy targeting of the kidney and pancreas does not increase the severity of metabolic syndrome in a porcine model.

PURPOSE: We determined whether shock wave lithotripsy of the kidney of pigs with metabolic syndrome would worsen glucose tolerance or increase the risk of diabetes mellitus. MATERIALS AND METHODS: Nine-month-old female Ossabaw miniature pigs were fed a hypercaloric atherogenic diet to induce metabolic syndrome. At age 15 months the pigs were treated with 2,000 or 4,000 shock waves (24 kV at 120 shock waves per minute) using an unmodified HM3 lithotripter (Dornier MedTech, Kennesaw, Georgia). Shock waves were targeted to the left kidney upper pole calyx to model treatment that would also expose the pancreatic tail to shock waves. The intravenous glucose tolerance test was done in conscious fasting pigs before lithotripsy, and 1 and 2 months after lithotripsy with blood samples taken for glucose and insulin measurement. RESULTS: Pigs fed the hypercaloric atherogenic diet were obese, dyslipidemic, insulin resistant and glucose intolerant, consistent with metabolic syndrome. Assessments of insulin resistance, glucose tolerance and pancreatic ß cell function from fasting plasma glucose and insulin levels, and the glucose and insulin response profile to the intravenous glucose tolerance test were similar before and after lithotripsy. CONCLUSIONS: The metabolic syndrome status of pigs treated with shock wave lithotripsy was unchanged 2 months after kidney treatment with 2,000 high amplitude shock waves or overtreatment with 4,000 high amplitude shock waves. These findings do not support a single shock wave lithotripsy treatment of the kidney as a risk factor for the onset of diabetes mellitus.

Current management of paediatric urolithiasis.

We aimed to review a current management of paediatric nephrolithiasis. The current literature, including our own experience on the treatment of paediatric nephrolithiasis was reviewed by MEDLINE/PubMed search. We have used in our search following keywords: urolithiasis, nephrolithiasis, paediatrics, surgical treatment, conservative management, ESWL, ureteroscopy, and open renal surgery. The search was limited to the English language literature during the period of time from 1990 to 2011. All papers were reviewed independently by all co-authors and only the manuscripts directly related to the reviewed subjects were included into the current review. Due to the high incidence of predisposing factors for urolithiasis in children and high stone recurrence rates, every child with urinary stone should be given a complete metabolic evaluation. Most stones in children can be managed by ESWL and endoscopic techniques. Paediatric stone disease is an important clinical problem in paediatric urology practice. Because of its recurrent nature, every effort should be made to discover the underlying metabolic abnormality so that it can be treated appropriately. Obtaining a stone-free state with interventional management and close follow-up are of utmost importance.

The utility of noncontrast computed tomography in the prompt diagnosis of postoperative complications after percutaneous nephrolithotomy.

INTRODUCTION: Noncontrast computed tomography (CT) is commonly utilized after percutaneous nephrolithotomy (PNL) to assess stone-free (SF) status. In addition to assessing SF status, CT is useful in the recognition of complications after PNL. We characterized complications demonstrated by postoperative CT scan and compared hospital re-admission rates based on whether or not CT was performed. METHODS: We retrospectively reviewed records of 1032 consecutive patients from April 1999 to June 2010. Patients were divided into two cohorts based on whether they had a CT within 24 hours of PNL. Demographic data, CT findings, and need for re-admission for complication management were assessed. RESULTS: Nine hundred fifty-seven patients (92.7%) underwent post-PNL CT. CT-diagnosed complications were perinephric hematoma in 41 (4.3%; 2 requiring embolization and 9 necessitating transfusion), pleural effusion in 25 (2.6%; 10 requiring intervention), colon perforation in 2 (0.2%), and splenic injury in 2 (0.2%). Of patients with postoperative complications, 33% required intervention. Among patients with a CT, 6 (0.6%) were readmitted despite negative postoperative CT (four perinephric hematomas, one calyceal-pleural fistula, and one pseudoaneurysm). The sensitivity of CT for diagnosing complications was 92.7%. Seventy-five patients (7.3%) did not undergo CT post-PNL. Of these, four (5.33%) were readmitted: three for perinephric hematomas and one for ureteral clot obstruction. Patients undergoing post-PNL CT were less likely to be readmitted because of missed complications (p=0.02). CONCLUSIONS: Serious post-PNL complications are uncommon, but their prompt diagnosis and treatment is imperative. In addition to identifying residual stones, CT is useful in diagnosing postoperative complications. Postoperative CT could potentially be considered for all patients undergoing PNL, particularly in complex cases such as patients with anatomical abnormalities (renal anatomic abnormality or retrorenal colon), patients requiring upper pole access (risk of thoracic, hepatic, and splenic complications), and patients requiring multisite access (higher risk of perinephric hematoma or need for transfusion).

Management of urogenital trauma: state of the art.

PURPOSE OF REVIEW: The field of urogenital trauma is undergoing constant improvement mainly due to better diagnostic tools, a shift toward standardized treatments and better trauma care. The purpose of this review is to summarize the most relevant studies published within the last 3 years on the subject. RECENT FINDINGS: Computerized tomography grading of renal trauma is an excellent predictor of the need for surgery and the final renal outcome in these patients, as most patients can be treated conservatively. Computerized tomography cystography has become the standard for the diagnosis of bladder rupture in which the indications for surgical intervention may be changing. The most common urethral trauma is posterior urethral injury due to pelvic fracture. The best results in adults and children are achieved by urethroplasty. SUMMARY: The diagnosis and treatment of genitourinary trauma is still evolving. The long-term sequels of these injuries may best be treated by urologists expert in urogenital reconstruction. In the future, tissue engineering may have an important place in the treatment of these patients.

Changing composition of renal calculi in patients with musculoskeletal anomalies.

BACKGROUND AND PURPOSE: Calculi from patients with musculoskeletal (MS) anomalies who are largely immobile and prone to urinary infections have been traditionally composed primarily of struvite and carbonate apatite. Because of substantial improvements in the care of these patients in recent decades, stone etiology may have shifted from infectious to metabolic. We assessed the composition of renal calculi and metabolic characteristics in a contemporary cohort of patients with MS anomalies who underwent percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: Retrospective analysis of patients who underwent PCNL between April 1999 and June 2009 and had follow-up 24-hour urine studies was performed. Patients with MS anomalies included spinal cord injury, myelomeningocele, muscular dystrophy, multiple sclerosis, cerebral palsy, or other clinical syndromes causing kyphoscoliosis and contractures. RESULTS: Our cohort included 33 patients with MS anomalies and 334 consecutive patients as a control group who underwent PCNL and had metabolic workup. Stones were infectious in etiology in 18.4% and 6.2% in MS and control groups, respectively. Thus, most patients harbored stones of metabolic origin. Metabolic stones in the MS group were composed of 52.7% hydroxyapatite, 10.5% calcium oxalate, 7.9% brushite, 2.6% uric acid, 0% cystine, and 7.9% other. Metabolic stones in the control group were 50.5% calcium oxalate, 16.4% hydroxyapatite, 11.5% brushite, 10.8% uric acid, 4.3% cystine, and 0.3% other. Mean 24-hour urine values for patients with metabolic stones in MS/control groups were volume 2.18/1.87 L/d, pH 6.78/6.05, calcium to creatinine ratio 220/151 mg/g, and oxalate 44.8/39.5 mg/d. CONCLUSIONS: Although patients with MS anomalies are traditionally thought to harbor infection-related calculi, most will be found to have calculi of metabolic etiology. The incidence of calcium phosphate stones is high in this group of patients, perhaps reflecting their high urinary pH.

Imaging evaluation in the patient with renal stone disease.

Numerous imaging modalities are available for the evaluation of patients with renal stone disease. The study of choice is dependent on the clinical scenario and the indication for imaging. Additional factors such as patient age and pregnancy status will influence the radiographic study that is chosen. Currently available technologies for the evaluation of urolithiasis include plain abdominal radiography, ultrasound, intravenous pyelogram, computed tomography, and magnetic resonance imaging. This article reviews the indications, advantages, and disadvantages of each study in the evaluation of patients with known or suspected stone disease.

New advances in benign prostatic hyperplasia: laser therapy.

Throughout the past decade, numerous techniques for the treatment of benign prostatic hyperplasia have emerged. Laser therapy, in particular, has gained widespread popularity among urologists. Since its inception in 1996, holmium laser enucleation of the prostate (HoLEP) has been evaluated rigorously in the treatment of glands of all sizes. HoLEP has produced superior relief of bladder outlet obstruction as compared to transurethral resection of the prostate based on urodynamics, and has proved equally as effective as open prostatectomy, for the management of very large glands (>100 cc), with lower morbidity. In addition to HoLEP, several newer but less well-studied laser techniques currently are available. These include photoselective laser vaporization utilizing the potassium-titanyl-phosphate (KTP or "green light") laser, thulium laser enucleation, and high-power diode laser vaporization. This report reviews the most current literature on laser therapies utilized in the treatment of benign prostatic hyperplasia with regards to safety, outcome, efficiency, and long-term durability.

An update on holmium laser enucleation of the prostate and why it has stood the test of time.

PURPOSE OF REVIEW: Holmium laser enucleation of the prostate is an endoscopic alternative for the treatment of symptomatic benign prostatic hyperplasia for men with prostates of any size. Holmium laser enucleation of the prostate is superior to other modalities for the treatment of benign prostatic hyperplasia. We present the most current literature on this procedure. RECENT FINDINGS: In the 18-month span of this review, there have been a number of articles published on holmium laser enucleation of the prostate. These studies assessed the safety, efficacy, and durability of this procedure. Among these is the largest study to date providing supporting evidence to the long-term efficacy and safety of holmium laser enucleation of the prostate. Other studies provide compelling evidence to suggest that holmium laser enucleation of the prostate can be used in prostates of any size and can provide long-term durable outcomes. SUMMARY: Holmium laser enucleation of the prostate represents an effective, well tolerated, and durable procedure to relieve bladder outlet obstruction due to benign prostatic hyperplasia. Holmium laser enucleation of the prostate is a minimally invasive approach which accomplishes complete adenoma removal and, as such, provides unique advantages over other surgical treatments for men with benign prostatic hyperplasia.

Holmium laser enucleation of the prostate: efficiency gained by experience and operative technique.

PURPOSE: Holmium laser enucleation of the prostate is highly effective for symptomatic benign prostatic hyperplasia. Despite its steep learning curve the procedure is an efficient treatment, especially for large prostate glands. We determined the change in enucleation efficiency with time with increased operative experience and improved technique. MATERIALS AND METHODS: We reviewed the records of all 949 consecutive men who underwent holmium laser enucleation of the prostate between 1999 and 2007. Patients were excluded from analysis when enucleated gm or time was not recorded and enucleated tissue was less than 5 gm. Efficiency was measured in gm enucleated prostate tissue per minute. Descriptive statistics on laser time, gland weight and efficiency were evaluated in an 8-year period. RESULTS: A total of 91 patients met study exclusion criteria, leaving 858 available for evaluation. Mean enucleation time was 94 minutes (range 12 to 485). Mean prostate specimen weight was 77 gm (range 5 to 376). Mean efficiency or enucleation rate was 0.55 vs 1.32 gm per minute in the first 4 vs the last 5 years. Further efficiency improvements were noted in the last 5 years with a mean of 1.57 gm per minute enucleated in the last 2 years. CONCLUSIONS: As experience with holmium laser enucleation of the prostate grows, advances in operative technique have been made. Prostatic enucleation efficiency continues to improve, further strengthening the role of holmium laser enucleation of the prostate for benign prostatic hyperplasia of small and large prostate glands.

Shock wave lithotripsy: advances in technology and technique.

Shock wave lithotripsy (SWL) is the only noninvasive method for stone removal. Once considered as a primary option for the treatment of virtually all stones, SWL is now recognized to have important limitations that restrict its use. In particular, the effectiveness of SWL is severely limited by stone burden, and treatment with shock waves carries the risk of acute injury with the potential for long-term adverse effects. Research aiming to characterize the renal response to shock waves and to determine the mechanisms of shock wave action in stone breakage and renal injury has begun to suggest new treatment strategies to improve success rates and safety. Urologists can achieve better outcomes by treating at slower shock wave rate using a step-wise protocol. The aim is to achieve stone comminution using as few shock waves and at as low a power level as possible. Important challenges remain, including the need to improve acoustic coupling, enhance stone targeting, better determine when stone breakage is complete, and minimize the occurrence of residual stone fragments. New technologies have begun to address many of these issues, and hold considerable promise for the future.

Holmium laser endoureterotomy for benign ureteral stricture: a single center experience.

PURPOSE: We assessed the long-term outcome of laser endoureterotomy for benign ureteral stricture. MATERIALS AND METHODS: From a database of 69 patients who underwent retrograde laser endoureterotomy from October 2001 to June 2007 we identified 35 with a benign ureteral stricture. Clinical characteristics, operative results and functional outcomes were investigated. Success was defined as symptomatic improvement and radiographic resolution of obstruction. RESULTS: Median followup was 27 months (range 10 to 72). All except 1 patient were followed at least 16 months. All patients completed clinical followup and 33 completed imaging. Of 35 patients 29 (82%) were symptom-free during followup and 26 of 33 (78.7%) were free of radiographic evidence of obstruction. All except 1 failure occurred within less than 9 months postoperatively. The success rate was higher for nonischemic strictures (100% vs 64.7%, p = 0.027) and tended to be higher for strictures 1 cm or less (89.4% vs 64.2%, p = 0.109). CONCLUSIONS: Holmium laser endoureterotomy is effective for benign ureteral stricture in well selected patients. Most failures occur within less than 9 months after surgery, which may indicate a need for closer followup during postoperative year 1. Factors that might may outcome are ischemia and stricture length.

Does a second-look operation improve survival in patients with peritonitis due to acute mesenteric ischemia? A five-year retrospective experience.

Second-look laparotomy is one of the mainstays of surgical treatment of acute mesenteric ischemia (AMI). The aim of this study was to analyze its role in the survival of patients with infarcted gangrenous bowel resulting from AMI. A retrospective chart review of all patients admitted over the study period was undertaken. The study population consisted of 41 patients with clinical evidence of peritonitis and gangrenous, perforated bowel on surgical exploration. Outcome was compared among patients who underwent second-look laparotomy and those who did not. Fifteen patients with an American Society of Anesthesiologists (ASA) score of less than 4 underwent second-look laparotomy. Six patients had residual necrotic bowel that required additional resection. Only one (17%) of them survived. Of the nine remaining patients, who had no evidence of necrosis, only two survived (22%). Overall survival in this group was 20%. Twenty-six patients were managed without second-look laparotomy. Nine of them, with an ASA score of 4-5, died soon after the operation. The decision not to operate on the remaining 17 patients with an ASA score < 4 was made by an experienced surgeon. Eleven of those patients (65%) survived. Overall survival in the non-second-look group was 42%. Excluding the early deaths, the survival in the non re-explored group was significantly higher than in the second-look group (65% vs. 20%, p = 0.011). A selective approach to the surgical treatment of acute mesenteric ischemia based on the sound clinical judgment of an experienced surgeon may be as appropriate as its universal application.

Continence and quality of life assessment after artificial urinary sphincter implantation.

BACKGROUND: Sphincter-related incontinence after radical prostatectomy, benign prostatectomy or due to neurogenic disease has a considerable negative impact on quality of life. Artificial urinary sphincter implantation is a mainstay therapeutic option for these patients. OBJECTIVES: To assess patient satisfaction, subjective long-term continence and complications after AMS 800 artificial urinary sphincter implantation. METHODS: The medical records of 34 patients who underwent artificial urinary sphincter implantation for radical prostatectomy (n = 23), simple prostatectomy (n = 9) or neurogenic disease (n = 2) between 1995 and 2003 were studied retrospectively. Median follow-up was 49 months (range 3-102 months). Records were analyzed for urinary sphincter survival and complications. Quality of life and continence assessment was done by mailing an impact questionnaire. RESULTS: In 4 of the 34 patients (11.7%) the device was removed due to infection. One of the four had surgical revision elsewhere, and the other three were not interested in re-implantation of the device. Two patients (5.9%) underwent revisions due to mechanical failure. One patient died and three patients were not located. Twenty-seven out of a possible 30 patients (88%) completed the questionnaire; 22 (85%) achieved social continence (0-2 pads daily), and one patient had subjective difficulty activating the device. Subjective improvement and patient satisfaction was rated as 4.22 and 4.11, respectively (scale 0 to 5). CONCLUSIONS: Artificial urinary sphincter implantation is an efficacious option for sphincter-related incontinence. This study documents the positive impact of artificial urinary sphincter implantation on quality of life with acceptable complications; these results are comparable to other published studies.