[The role of nonoperative management of penetrating renal trauma].

INTRODUCTION: Penetrating renal trauma has been treated traditionally by renal exploration. In view of the successful outcome of nonoperative treatment of major blunt renal trauma, there has been a gradual shift in the approach to penetrating renal injuries, in selected cases. This study reviews the local experience with the conservative approach to penetrating renal injuries. PATIENTS AND METHODS: The researchers retrospectively reviewed the medical records of patients with penetrating renal injuries during a period of 10 years at two medical centers (Meir in Kfar Saba and Hillel Yaffe in Hadera). The data included mechanisms of injury, grading of the injury, homodynamic stability presence of hematuria, associated injuries, management conservative versus operative, complications and outcome. RESULTS: The study group consisted of 18 patients, with mean age of 22.5 years (15-40 years). The mechanisms of injury were stab wounds (10 patients) and gunshot injuries (8 patients). Nine patients (50%) required surgical intervention for associated injuries. Nonoperative treatment of the urological injury was selected in 10 patients (55.5%), 4 of them required surgery for associated abdominal injuries but did not undergo renal or retroperitoneal exploration, 8 patients (44.5%), were managed primarily by renal exploration. Grade I-II renal injuries were treated conservatively while all grade V injuries were explored. Of grade III injuries, 3 were treated conservatively and renal exploration was performed in 2. Half of grade IV injuries (4 patients) were treated conservatively. Follow-up of conservatively treated patients, demonstrated a viable kidney in all cases. Nephrectomy was performed in 3/8 patients who were treated primarily by renal exploration. These patients had grade IV or V injuries. Renorrhaphy was performed in the remaining 5 patients of whom one required delayed nephrectomy. Overall, the injured renal unit was lost in half of the operated patients. CONCLUSIONS: The present study presents a successful conservative approach to penetrating renal injuries in 10 out of 18 cases. All renal units in the nonoperated patients were preserved in comparison to only half in the surgically treated patients. Hence, nonoperative treatment is a reasonable option for the majority of minor penetrating renal injuries as well as in many selected high-grade injuries. This approach provides maximal preservation of the injured kidney with manageable complications.

Positive effect of counseling and dose adjustment in patients with erectile dysfunction who failed treatment with sildenafil.

OBJECTIVE: Many patients with erectile dysfunction (ED) stop using sildenafil due to subjective failure. This study examined whether counseling and maximal dosing (100 mg) could achieve better treatment compliance and could possibly improve treatment outcome. MATERIAL AND METHODS: Patients were recruited by newspaper advertisements and referred to 5 ED centers throughout the country. Details about their previous experiences with sildenafil were recorded and following an explicit explanation about the nature and action of the drug, were offered to enter the study. Instructions on drug use were provided during each visit in which four 100 mg Sildenafil tablets were provided. Treatment outcomes were assessed by the international index of erectile function (IIEF) questionnaire after taking 4 and 8 tablets. In 2 ED centers a short video with sexual counseling content was added in between visits. RESULTS: The study cohort was comprised of 220 patients aged 27-88 years. The majority reported having received limited or no instructions on drug use when sildenafil was first prescribed. A significant increase in IIEF erectile function domain scores (EFDS) between visits 1, 2 and 3 was observed (10.96+/-0.40, 16.73+/-0.51 and 17.82+/-0.55 mean+/-SE, respectively), with 23.6% of the study patients achieving normal erectile function at the end of the study. The parameters of age and initial severity of ED most influenced treatment success. CONCLUSIONS: Counseling and dose adjustment were directly influential in achieving an excellent response to a second trial of sildenafil in patients with ED who had previously failed treatment with the drug, and obviated their needing to seek more invasive measures.

Combined cystolithotomy and transurethral resection of prostate: best management of infravesical obstruction and massive or multiple bladder stones.

OBJECTIVES: To investigate the results of combined suprapubic cystolithotomy followed by transurethral resection (TUR) of the prostate (TURP) or TUR of the bladder neck in patients with infravesical obstruction and massive or numerous bladder stones. We also reviewed the medical literature and compared the success, morbidity, and mortality rates of the treatment modality presented here and the nonsurgical modality of transurethral lithotripsy and resection of the prostate or bladder neck. METHODS: Through a 10-year period, 20 men with benign prostatic hyperplasia or bladder neck obstruction and massive or numerous bladder stones underwent cystolithotomy for stone clearance followed by TURP or TUR of the bladder neck. A second group of 20 randomly selected men who underwent TURP alone was studied retrospectively for time of surgery, number of days of postoperative indwelling catheter use, and hospital stay. RESULTS: No deaths occurred. All stones were successfully evacuated (100% stone-free rate). The operative time and number of days of postoperative indwelling catheter use and hospital stay were notoriously shorter in the present series compared with the transurethral lithotripsy and TURP modality. A single case of fever (5% complication rate) occurred in each group. When comparing the data of the present series with a group of 20 men who underwent TURP only, no differences were found in the times of postoperative indwelling catheter use and hospital stay. Cystolithotomy performed before TURP prolonged the total time of surgery an average of 18.4 minutes. CONCLUSIONS: In the era of endoscopic and minimally invasive surgery, a small suprapubic cystostomy followed by TURP is still the treatment of choice in cases of infravesical obstruction and very large or numerous bladder stones. The procedure is quick and easy to perform and bears a low morbidity rate compared with transurethral lithotripsy and TURP. A small cystotomy does not prolong the time of indwelling catheter use and hospital stay.

Fast-track eligibility of geriatric patients undergoing short urologic surgery procedures.

UNLABELLED: Our primary objective was to assess the feasibility of geriatric patients (>65 yr) bypassing the postanesthesia care unit (PACU) after ambulatory surgery. A secondary objective was to compare recovery profiles when using three different maintenance anesthetics. Ninety ASA physical status I--III consenting outpatients (>65 yr) undergoing short urologic procedures were randomly assigned to one of three anesthetic treatment groups. After a standardized induction with fentanyl and propofol, anesthesia was maintained with propofol (75-150 microg center dot kg(-1) center dot min(-1) IV), isoflurane (0.7%-1.2% end tidal), or desflurane (3%-6% end tidal), in combination with nitrous oxide 70% in oxygen. In all three groups, the primary anesthetic was titrated to maintain an electroencephalographic-bispectral index value of 60-65. Recovery times, postanesthesia recovery scores, and therapeutic interventions in the PACU were recorded. Although emergence times were similar in the three groups, the time to achieve a fast-track discharge score of 14 was significantly shorter in patients receiving desflurane compared with propofol and isoflurane (22 +/- 23 vs 33 +/- 25 and 44 +/- 36 min, respectively). On arrival in the PACU, a significantly larger percentage of patients receiving desflurane were judged to be fast-track eligible compared with those receiving either isoflurane and propofol (73% vs 43% and 44%, respectively). The number of therapeutic interventions in the PACU was also significantly larger in the Isoflurane group when compared with the Propofol and Desflurane groups (21 vs 11 and 7, respectively). In conclusion, use of desflurane for maintenance of anesthesia should facilitate PACU bypass ("fast-tracking") of geriatric patients undergoing short urologic procedures. IMPLICATIONS: Geriatric outpatients undergoing brief urologic procedures more rapidly achieve fast-tracking discharge criteria after desflurane (versus isoflurane and propofol) anesthesia. Use of isoflurane was also associated with an increased need for nursing interventions in the early recovery period compared with desflurane and propofol.