Evaluation of efficacy of four laparoscopic needle drivers.

INTRODUCTION: To evaluate the impact of needle driver design on laparoscopic suturing skills by experts and novices. METHODS: Three experienced laparoscopic surgeons and 3 novice junior residents were asked to perform a fixed set of suturing tasks in a laparoscopic pelvic-trainer. The laparoscopic needle drivers compared were (1) the Ethicon driver (E 705R), (2) Karl Storz (KS) pistol grip (26173 KC), (3) KS finger grip (26167 SK), and (4) KS palm grip (26173 ML). Times were recorded for each operator to grasp and position a needle for suturing in a particular angle, as well as to throw a horizontal and a vertical stitch and tie a single square knot using 2-0 Vicryl suture with a taper CT-1 needle. Subsequently, participants were asked to complete a subjective questionnaire rating the drivers. RESULTS: The average suturing time provided the most discriminatory power in comparing the needle drivers. For experienced operators, the KS pistol grip allowed faster suturing times than did the KS finger grip and the KS palm grip but not the Ethicon driver. For novice users, the Ethicon driver allowed faster suturing times than did the KS finger grip but not the KS pistol grip or the KS palm grip. In the subjective questionnaire, the KS pistol grip received the highest scores, and the KS finger grip received the lowest scores. CONCLUSION: Novice laparoscopists performed best with the KS pistol grip as well as the Ethicon laparoscopic needle drivers while experienced laparoscopists performed best with the pistol grip KS needle driver.

Sacral nerve stimulation for voiding dysfunction: One institution's 11-year experience.

AIM: The purpose of this study was to review our institution's 11-year experience with SNS for the treatment of refractory voiding dysfunction. Dating back to 1993, it covers a span of time which describes the evolution of SNS as it includes PNE trials, non-tined (bone-anchored or fascial-anchored) leads, percutaneous tined leads with two-staged procedures, and even percutaneous pudendal trials. METHODS: A retrospective review was performed on SNS patients who received an implantable pulse generator (IPG) in our practice from 12/1993 to 12/2004. After Institutional Review Board approval, consents for chart review were obtained from 104 patients, representing 44% of this neuromodulatory patient population. RESULTS: Of our population, 87% were female and 13% were male. Average age at implant was 50 years +/- 13.4 years. Duration of symptoms before implantation was 116 months (range 9-600 months). Eighty percent were implanted for a predominant complaint of urinary urgency and frequency (U/F). Overall, 22% had U/F only, 38% had concomitant urge incontinence (UI), and 20% had concomitant mixed incontinence (MI). Twenty percent were treated for non-obstructive urinary retention (UR), with half of these associated with a neurogenic etiology. Additionally, 46.2% had pelvic pain, 58.6% had bowel complaints, and 51% reported sexual dysfunction. In patients with U/F, mean voiding parameters as described by pre-implant voiding diaries revealed the following: 12.4 (+/-5.1) voids per 24 hr; 2.3 (+/-1.8) voids per night; 5.0 (+/-4.7) leaks per 24 hr; and 2.3 (+/-2.6) pads per 24 hr. Statistically significant improvements post-implantation were noted with mean decreases in the following: 4.3 voids per 24 hr; 1.0 void per night; 4.4 leaks per 24 hr; and 2.3 pads per 24 hr (all P < 0.05). In the UR group a statistically significant improvement post-implantation was noted only in voids per night, with a mean decrease of 0.8 (P < 0.05). With a mean follow up of 22 months (range 3-162 months), sustained subjective improvement was >50%, >80%, and >90% in 69%, 50%, and 35% of patients, respectively. By quality of life survey, 60.5% of patients were satisfied and 16.1% were dissatisfied with current urinary symptoms. Only 13% (14 patients) abandoned therapy, making up a significant portion of those dissatisfied with current urinary symptoms. Good overall lead durability was seen (mean 22 months, range 1-121 months), with the first successful lead proving to be the most durable (mean 28 months, range 1.4-120 months). Lead durability decreased progressively with subsequent trials. Overall, 53% of patients experienced at least one reportable event (RE) attributable to either lead or IPG. A total of 126 REs were noted, with 97% mild-to-moderate in severity. REs included lack of efficacy, loss of efficacy, infection, hematoma/seroma, migration, pain, undesirable change in sensation, and device malfunction. In this population, 47.1% of leads were tined while 52.9% were non-tined. Tined leads had an overall lower RE rate as compared to non-tined leads: 28% and 73%, respectively. CONCLUSIONS: SNS is an effective method for treating certain types of voiding dysfunction. Although 53% of patients experienced at least one RE, 97% were mild-to-moderate and did not appear to affect the continued use of this therapy. With improved technology, such as percutaneous tined leads, the RE rate is decreasing. Further analyses of subsets of this population are currently underway.

Acute effect of vasectomy on the function of the rat epididymal epithelium and vas deferens.

Persistent infertility after apparently successful vasectomy reversal is common. One possible etiology is epididymal epithelial dysfunction resulting in improper sperm maturation after vasectomy reversal. The epididymal epithelium secretes a number of proteins that are thought to be required for the maturation of sperm. Ligation of the vas deferens during vasectomy may affect the synthesis of some of these proteins. In the present study, the function of the epididymal epithelium was assessed at early times after vasectomy (1, 4, and 7 days) by measuring the level of mRNA of 4 secreted proteins: Crisp-1, clusterin, osteopontin, and transferrin. In addition, the site of synthesis of these proteins was determined by immunocytochemistry. The results demonstrated that the expression of Crisp-1 and clusterin, representative epididymal secretory proteins, was largely unaffected by vasectomy. However, osteopontin mRNA increased in the vas deferens in response to vasectomy. Immunocytochemical localization of osteopontin suggested that both infiltrating immune cells and deferential luminal epithelium were responsible for this up-regulation. Transferrin expression was viewed as a marker for immune cells at the site of injury. However, both the caput epididymis and deferential epithelia were found to express transferrin, in addition to immune cells. In conclusion, there appear to be only minor changes in expression of genes encoding epididymal secretory proteins acutely after vasectomy, but, not surprisingly, there was evidence of an inflammatory response after vasectomy.

Irrigation and drainage properties of three-way urethral catheters.

OBJECTIVES: To evaluate in an in vitro study the irrigation and drainage capabilities of a variety of available catheters. Three-way Foley catheters are used when irrigation of the bladder is anticipated to prevent or manage blood clots in the bladder. METHODS: Six operators applied maximal one-handed pressure irrigation with a catheter-tip syringe through the irrigation and drainage ports of the Bardex and Dover three-way catheters (16F to 26F). Maximal manual irrigation flow was recorded using a flowmeter. Continuous gravity irrigation and drainage flows were measured by suspending a 2-L irrigation bag 80 cm above the catheters and fastening an artificial bladder to the drainage tip of each Foley catheter with the catheter balloon inflated to 30 mL. RESULTS: The Bardex 22F and 24F catheters had superior manual irrigation using the irrigation port (maximal urinary flow rate 8.9 +/- 1.3 mL/s and 9.5 +/- 1.5 mL/s, respectively, P < 0.000001) compared with the Dover 22F and 24F catheters. The Bardex and Dover 22F catheters (maximal urinary flow rate 29.0 +/- 1.9 mL/s and 29.3 +/- 1.9 mL/s, respectively, P = 0.66) and 24F catheters (maximal urinary flow rate 30.5 +/- 2.0 mL/s and 30.6 +/- 1.2 mL/s, respectively, P = 0.83) performed equally in manual irrigation using the drainage port. The Bardex 22F (average flow rate 1.6 +/- 0.1 mL/s, P < 0.00001) and 24F (average flow rate 1.7 +/- 0.0 mL/s, P < 0.000001) catheters exhibited better continuous irrigation and flow than the Dover 22F and 24F catheters. CONCLUSIONS: Three-way catheters are placed in situations in which efficient bladder irrigation is essential for patient safety. The Bardex 22F to 26F catheters optimized continuous bladder irrigation of the catheters tested.