Is Our Limited Understanding of the Effects of Nerve Stimulation Resulting in Poor Outcomes and the Need for Better "Rescue Programming" in SNM and PTNS, and Lost Opportunities for New Sites of Stimulation? ICI-RS 2024.

AIMS: Sacral neuromodulation (SNM) and percutaneous tibial nerve stimulation (PTNS) are strongly recommended by international guidelines bodies for complex lower urinary tract dysfunctions. However, treatment failure and the need for rescue programming still represent a significant need for long-term follow-up. This review aimed to describe current strategies and future directions in patients undergoing such therapies. MATERIALS AND METHODS: This is a consensus report of a Think Tank discussed at the Annual Meeting of the International Consultation on Incontinence - Research Society (ICI-RS), June 6-8, 2024 (Bristol, UK): "Is our limited understanding of the effects of nerve stimulation resulting in poor outcomes and the need for better 'rescue programming' in SNM and PTNS, and lost opportunities for new sites of stimulation?" RESULTS: Rescue programming is important from two different perspectives: to improve patient outcomes and to enhance device longevity (for implantable devices). Standard SNM parameters have remained unchanged since its inception for the treatment of OAB, nonobstructive urinary retention, and voiding dysfunction. SNM rescue programming includes intermittent stimulation (cycling on), increased frequency and changes in pulse width (PW). The effect of PW setting on SNM outcomes remains unclear. Monopolar configurations stimulate more motor nerve fibers at lower stimulation voltage; hence, this could be an option in patients who failed bipolar stimulation in the long term. Unfortunately, there is little evidence for rescue programming for PTNS. However, the development of implantable devices for intermittent stimulation of the tibial nerve may increase long-term adherence to therapy and increase interest in alternative programming. There has been recent promising neurostimulation targeting the pudendal nerve (PNS), especially in BPS/IC. More recently, preliminary data addressed the benefits of high-frequency bilateral pudendal nerve block for DESD and adaptive PNS on both urgency and stress UI in women. CONCLUSION: The exploration of rescue programming and new stimulation sites remains underutilized, and there are opportunities that could potentially expand the therapeutic applications of nerve stimulation. By broadening the range of target sites, clinicians may be able to tailor treatments according to individual patient needs and underlying conditions, thereby improving overall outcomes. However, further studies are still needed to increase the level of evidence, potentially allowing for an individualized treatment both in patients who are candidates for electrostimulation and in those who have already received surgical implants but seek a better outcome.

Delphi Consensus on Diagnostic Criteria for LUMBAR Syndrome.

OBJECTIVE: To develop consensus on diagnostic criteria for LUMBAR syndrome, the association of segmental infantile hemangiomas that affect the Lower body with Urogenital anomalies, Ulceration, spinal cord Malformations, Bony defects, Anorectal malformations, Arterial anomalies and/or Renal anomalies. STUDY DESIGN: These diagnostic criteria were developed by an expert multidisciplinary and multi-institutional team based on analysis of peer-reviewed data, followed by electronic-Delphi consensus of a panel of 61 international pediatric specialists. RESULTS: After 2 Delphi rounds, a 92% or higher level of agreement was reached for each Delphi statement. 98% of panelists agreed with the diagnostic criteria, and 100% agreed the criteria would be useful in clinical practice. The diagnosis of LUMBAR requires the presence of a segmental, or patterned, infantile hemangioma of the lumbosacral, sacrococcygeal, or pelvic cutaneous regions plus one additional criterion of the urogenital, spinal, bony, anorectal, arterial, or renal organ systems. CONCLUSIONS: These diagnostic criteria will enhance clinical care by improving screening, detection, and overall awareness of this poorly understood neurocutaneous disorder. The criteria can be utilized by a wide variety of pediatric subspecialists. In addition, formal criteria will improve phenotypic uniformity among LUMBAR syndrome cohorts and a patient registry, allowing investigators to assess clinical features, long-term outcomes, and results of genetic sequencing in a standardized manner. Finally, these criteria will serve as a starting point for prospective studies to establish formal screening and management guidelines.

Sacral neuromodulation therapy for urinary and defecatory disorders: experience in a Latin American public hospital.

Objective: To show the experience of a Latin American public hospital, with SNM in the management of either OAB, NOUR or FI, reporting feasibility, short to medium-term success rates, and complications. Methods: A retrospective cohort was conducted using data collected prospectively from patients with urogynecological conditions and referred from colorectal surgery and urology services between 2015 and 2022. Results: Advanced or basic trial phases were performed on 35 patients, 33 (94%) of which were successful and opted to move on Implantable Pulse Generator (GG) implantation. The average follow-up time after definitive implantation was 82 months (SD 59). Of the 33 patients undergoing, 27 (81%)reported an improvement of 50% or more in their symptoms at last follow-up. Moreover, 30 patients (90%) with a definitive implant reported subjective improvement, with an average PGI-I "much better" and 9 of them reporting to be "excellent" on PGI-I. Conclusion: SNM is a feasible and effective treatment for pelvic floor dysfunction. Its implementation requires highly trained groups and innovative leadership. At a nation-wide level, greater diffusion of this therapy among professionals is needed to achieve timely referral of patients who require it.

Sacral neuromodulation therapy for urinary and defecatory disorders: experience in a Latin American public hospital

Abstract Objective: To show the experience of a Latin American public hospital, with SNM in the management of either OAB, NOUR or FI, reporting feasibility, short to medium-term success rates, and complications. Methods: A retrospective cohort was conducted using data collected prospectively from patients with urogynecological conditions and referred from colorectal surgery and urology services between 2015 and 2022. Results: Advanced or basic trial phases were performed on 35 patients, 33 (94%) of which were successful and opted to move on Implantable Pulse Generator (GG) implantation. The average follow-up time after definitive implantation was 82 months (SD 59). Of the 33 patients undergoing, 27 (81%)reported an improvement of 50% or more in their symptoms at last follow-up. Moreover, 30 patients (90%) with a definitive implant reported subjective improvement, with an average PGI-I "much better" and 9 of them reporting to be "excellent" on PGI-I. Conclusion: SNM is a feasible and effective treatment for pelvic floor dysfunction. Its implementation requires highly trained groups and innovative leadership. At a nation-wide level, greater diffusion of this therapy among professionals is needed to achieve timely referral of patients who require it.

Surgical treatment of sacral pressure wounds in patients with COVID-19: A case series.

INTRODUCTION: The COVID 19 pandemic has resulted in an increased number of patients requiring intubation and intensive care. This has led to an increased incidence of sacral pressure ulcers requiring surgical management. We report our experience of COVID 19 related sacral pressure ulcers requiring surgical reconstruction. METHODS: A case series study was performed with 12 patients who presented grade IV sacral pressure ulcers after hospitalization for COVID-19 in a single institution. The mean age was 49.8 years and the most frequent comorbidities were arterial hypertension, diabetes and obesity, each present in 6 patients. All of them were submitted to surgical reconstruction with fasciocutaneous flaps after improvement of their clinical status. Follow up time was of at least 30 days after reconstruction. Preoperative laboratory tests and surgical outcomes were compared to data available in the literature. RESULTS: No major dehiscence was observed and minor dehiscence happened in 2 cases (16.7%). Out of the 12 patients, 8 (66.7%) had hemoglobin levels less than 10.0 and 5 (41.7%) had albumin levels less than 3.0, though this did not lead to a higher rate of complications. CONCLUSION: This study showed that ambulating patients with grade IV pressure ulcer after COVID- 19 infection may undergo debridement, negative-pressure wound therapy and closure with local flaps with adequate results and minimal complication rate.

Functional outcomes and satisfaction rates of sacral nerve stimulation in the treatment of one and multiples pelvic floor dysfunctions

Objective: Few studies have addressed the use of sacral nerve stimulation (SNS) in the treatment of patients with multiple pelvic floor dysfunctions (PFD). So, we evaluated the functional outcomes and level of satisfaction with SNS in selected patients with one or multiples PFD. Methods: A prospective database was used to collect information on eligible patients treated for PFD with SNS, and severity of symptoms was assessed with scores and satisfaction rates by visual analogue scale (VAS) at baseline and by the end of follow-up. Results: We recruited 70 patients, 98.6% of whom responded positively during the evaluation period (Global Response Assessment ≥ 50% for at least one type of PFD), resulting in the implantation of a permanent SNS device. Additionally, 49 of the patients (71%) had a single PFD (fecal incontinence [FI] = 38; constipation/obstructed defecation syndrome [C/ODS] = 11), while 20 (29%) had more than one PFD (double incontinence/n = 12; double incontinence + C/ODS/n = 8). All scores improved significantly between baseline (pre-SNS) and the end of follow-up (post-SNS), as did VAS in all groups (single and multiple PFD). The pre-SNS scores were higher in patients with a single PFD, including FI (Cleveland clinic Florida incontinence score [CCF-FI]) and C/ODS (Cleveland clinic constipation score [C-CCF] and the Renzi ODS score). The pre-SNS impact of VAS scores was similar in all groups (single and multiple PFD), but the VAS (post-SNS) was significantly lower (better response) for FI alone compared with multiple PFD. Conclusion: The SNS technique is an effective and safe option for patients with one or more PFD refractory to conservative measures. Response was positive for at least two PFD, based on reduced correspondent scores and satisfaction rate. (AU)

Giant anterior sacral meningocele associated with hydroureteronephrosis and renal injury: illustrative case.

BACKGROUND: Anterior sacral meningocele (ASM) is a defect in the closure of the neural tube. Patients can be asymptomatic or present with genitourinary, neurological, reproductive, or colorectal dysfunction. Magnetic resonance imaging (MRI) is the gold standard test because it can assess communication between the spinal subarachnoid space and the lesion and identify other abnormalities. Surgical correction is the definitive treatment because untreated cases have a mortality rate of more than 30%. OBSERVATIONS: A 24-year-old woman with Marfan syndrome presented with polyuria, recurrent urinary tract infections, and renal injury for 3 months along with a globose abdomen, with a palpable mass in the middle and lower third of the abdomen that was massive on percussion. MRI showed an ASM consisting of two cystic lesions measuring 15.4 × 14.3 × 15.8 and 6.7 × 6.1 × 5.9 cm, respectively, compressing the distal third of the right ureter and causing a hydroureteronephrosis. Drainage and ligature of the cystic lesion were performed. The urinary outcome was excellent, with full recovery after surgery. LESSONS: ASM should be suspected in all abdominal masses with progressive symptoms in the setting of Marfan syndrome. Computed tomography and MRI are important to investigate genitourinary anomalies or other types of dysraphism to guide the best surgical approach.

Cross-cultural Adaptation of Self-report S4-5 Sensory and Motor Function Questionnaire (S4-5Q) in People with Spinal Cord Injury to Portuguese.

Objective The "Self-report S4-5 sensory and motor function questionnaire (S4-5Q)" is a short questionnaire that aims to assess the function of the sacral segments, S4 and S5, after a spinal cord injury (SCI), with the purpose of replacing the rectal exam test. The aim of the present study was to carry out a cross-cultural adaptation of the S4-5Q to the Brazilian Portuguese language and to investigate the test-retest reliability of this version. Method The translation and cross-cultural adaptation was performed using the methodology of translation and backtranslation. Initially, translations were done by three independent translators. Their synthesis was then submitted to an expert committee for analysis (SCI health professionals); then, the backtranslation to the original language was sent to the original author and, after all the adjustments, the final version was completed. For test-retest reliability, 24 individuals with chronic SCI were recruited (2 evaluations with an interval of 7 to 14 days between them). Statistical analysis was performed using IBM-SPSS (Version 20, SPSS Inc, Chicago, IL, USA) with data pretabulated in Microsoft Excel (Microsoft Corporation, Redmond, WA, USA). Reliability was tested with Cohen Kappa, and internal consistency with Cronbach α, both adopting p < 0.05 as significant. Results In the reliability analysis, the results of all questions showed almost perfect agreement (Kappa > 0.81) and good internal consistency (Cronbach α: 0.65-0.77) between the questions and final classification. Conclusion The cross-culturally adapted S4-5Q is reliable to be applied to the Brazilian population with chronic SCI to determine their S4-5 sensory and motor function.

Vaginal distention rodent model for fecal incontinence: a pilot study on the effect on defecation behavior

Objectives: Vaginal balloon inflation simulates the compressive forces on the pelvic floor during the second phase of natural delivery. The foremost use of this animal model of vaginal distention (VD) is to study the mechanisms underlying urinary incontinence. As damage to the pelvic floor during natural birth is a common cause of fecal incontinence, the present paper aimed to investigate the effect of VD on defecation behavior in adult rats. Methods: Vaginal distention was performed in 8 rats for 2 hours, and in 3 rats for 4 hours, and sham inflation was performed in 4 rats. With the use of a latrine box in the rat home-cage and 24/7 video tracking, the defecation behavior was examined. The time spent in and outside the latrine was monitored for two weeks preoperatively and three weeks postoperatively, and a defecation behavior index (DBI; range: 0 [continent] to 1 [incontinent]) was defined. Pelvic floor tissue was collected postmortem and stained with hematoxylin and eosin. Results: Vaginal balloon inflation for 2 hours resulted in fecal incontinence in 29% of the animals (responders) whereas the DBI scores of non-responders (71%) and control animals did not change in the postoperative phase compared with the baseline score. A 4-hour balloon inflation resulted in fecal incontinence in 1 animal and caused a humane endpoint in 2 animals with markedly more tissue damage in the 4-hour responder compared with the 2-hour responders. Conclusions: Vaginal balloon inflation, with an optimum duration between 2 and 4 hours, can be used as a model to study changes in defecation behavior in rats induced by pelvic floor damage. (AU)

Cross-cultural Adaptation of Self-report S4-5 Sensory and Motor Function Questionnaire (S4-5Q) in People with Spinal Cord Injury to Portuguese / Adaptação transcultural para o Português do questionário de autorrelato da função sensorial e motora de S4-5 (S4-5Q) em pessoas com lesão medular espinhal

Abstract Objective The "Self-report S4-5 sensory and motor function questionnaire (S4-5Q)" is a short questionnaire that aims to assess the function of the sacral segments, S4 and S5, after a spinal cord injury (SCI), with the purpose of replacing the rectal exam test. The aim of the present study was to carry out a cross-cultural adaptation of the S4-5Q to the Brazilian Portuguese language and to investigate the test-retest reliability of this version. Method The translation and cross-cultural adaptation was performed using the methodology of translation and backtranslation. Initially, translations were done by three independent translators. Their synthesis was then submitted to an expert committee for analysis (SCI health professionals); then, the backtranslation to the original language was sent to the original author and, after all the adjustments, the final version was completed. For test-retest reliability, 24 individuals with chronic SCI were recruited (2 evaluations with an interval of 7 to 14 days between them). Statistical analysis was performed using IBM-SPSS (Version 20, SPSS Inc, Chicago, IL, USA) with data pretabulated in Microsoft Excel (Microsoft Corporation, Redmond, WA, USA). Reliability was tested with Cohen Kappa, and internal consistency with Cronbach α, both adopting p < 0.05 as significant. Results In the reliability analysis, the results of all questions showed almost perfect agreement (Kappa > 0.81) and good internal consistency (Cronbach α: 0.65-0.77) between the questions and final classification. Conclusion The cross-culturally adapted S4-5Q is reliable to be applied to the Brazilian population with chronic SCI to determine their S4-5 sensory and motor function.

Resumo Objetivo O "Self-report S4-5 Sensory and Motor Function Questionnaire (S4-5Q)" é um breve questionário de avaliação da função dos segmentos sacrais S4 e S5 após uma lesão medular (LM), cuja finalidade é substituir o exame de toque retal. O objetivo do presente estudo foi realizar uma adaptação transcultural do questionário S4-5Q para a língua portuguesa do Brasil e investigar a confiabilidade teste-reteste desta versão. Método A tradução e a adaptação transcultural foram realizadas utilizando a metodologia de tradução e retrotradução. Inicialmente, as traduções foram realizadas por três tradutores independentes. Sua síntese foi então submetida a um comitê de especialistas (profissionais de saúde com experiência em LM). Em seguida, a retrotradução para o idioma original foi enviada ao autor original, sendo que a versão final foi concluída após todas as adaptações. Para a confiabilidade teste-reteste, foram recrutados 24 indivíduos com lesão medular espinal (LME) em fase crônica (2 avaliações com intervalo de 7 a 14 dias entre elas). A análise estatística foi realizada no IBM-SPSS (Version 20, SPSS Inc, Chicago, IL, USA) com dados pré- tabulados no programa Microsoft Excel (Microsoft Corporation, Redmond, WA, EUA). A confiabilidade foi testada por meio do coeficiente Kappa de Cohen, e a consistência interna foi medida através do α de Cronbach, ambas adotando p < 0,05 como significante. Resultados Na análise de confiabilidade, os resultados de todas as perguntas apresentaram concordância quase perfeita (Kappa > 0,81) e boa consistência interna (α de Cronbach: 0,65-0,77) entre as perguntas e a classificação final. Conclusão O questionário S4-5Q adaptado culturalmente é confiável, podendo ser aplicado à população brasileira com LME crônica, com o objetivo de avaliar a função sensorial e motora nos segmentos sacrais S4-S5.

Conservative Management of Spondylodiscitis after Laparoscopic Sacral Colpopexy: A Case Report and Review of Literature / Manejo conservador da espondilodiscite após colpopexia sacral laparoscópica: Relato de caso e revisão da literatura

Abstract Sacral colpopexy is one of the standard procedures to treat apical pelvic organ prolapse. In most cases, a synthetic mesh is used to facilitate the colposuspension. Spondylodiscitis is a rare but potentially serious complication that must be promptly diagnosed and treated, despite the lack of consensus in the management of this complication.We report one case of spondylodiscitis after a laparoscopic supracervical hysterectomy and sacral colpopexy treated conservatively. We also present a literature review regarding this rare complication. A conservative approach without mesh removal may be possible in selected patients (stable, with no vaginal lesions, mesh exposure or severe neurologic compromise). Hemocultures and culture of imageguided biopsies should be performed to direct antibiotic therapy. Conservative versus surgical treatment should be regularly weighted depending on clinical and analytical progression. A multidisciplinary team is of paramount importance in the follow-up of these patients.

Resumo A colpopexia sacral é um dos procedimentos padrão para tratar o prolapso de órgãos pélvicos apical. Na maioria dos casos, uma tela sintética é usada para facilitar a colposuspensão. A espondilodiscite é uma complicação rara, mas potencialmente grave, que deve ser prontamente diagnosticada e tratada, apesar da falta de consenso no manejo dessa complicação. Relatamos um caso de espondilodiscite após histerectomia supracervical laparoscópica e colpopexia sacral tratada conservadoramente. Também apresentamos uma revisão da literatura sobre essa complicação rara. Uma abordagem conservadora sem remoção da tela pode ser possível em pacientes selecionadas (estáveis, sem lesões vaginais, exposição da tela ou comprometimento neurológico grave). Hemoculturas e cultura de biópsias guiadas por imagem devemser realizadas para direcionar a antibioticoterapia. O tratamento conservador versus o cirúrgico deve ser avaliado regularmente, dependendo da progressão clínica e analítica. Uma equipe multidisciplinar é de suma importância no acompanhamento desses pacientes.

Surgical resection of a presacral solitary fibrous tumor with extension to iliac vessels using Karakousis's abdominoinguinal approach: Report of a rare case.

INTRODUCTION AND IMPORTANCE: The solitary fibrous tumor (SFT) is a rare tumor of mesenchymal origin, with a reported incidence of 2.8 cases per 100,000 tumors and with distinctive histopathological and immunohistochemical characteristics. It was initially described as a pleural lesion and subsequently, it was found in different organs and tissues. The abdominoinguinal incision described by Karakousis allows a safe and radical approach for lower quadrants abdominopelvic tumors. CASE PRESENTATION: A 47-year-old man was referred to us with a 5-months history of lower backache radiating to the left lower limb. MRI and CT revealed a retroperitoneal mass of 10 cm extending to left iliac vessels. The initial diagnosis corresponded to a sarcomatous retroperitoneal tumor. It was decided to perform an abdominal exploration using Karakousis's approach for surgical resection. The immunohistochemistry and histopathological study revealed neoplasia compatible with a SFT. It was categorized as low risk for developing metastasis and death from disease, according to the new malignancy criteria. Currently, the patient is asymptomatic and disease-free at 19 months after surgery. CLINICAL DISCUSSION: Most patients with SFTs present symptoms derived from the tumor growth and the compression on adjacent structures with clinical manifestations that are frequently insidious and precede the tumor discovery. The diagnosis is based on histopathological studies. Nonetheless, when they present an extrathoracic location, they represent a diagnostic challenge, due to their variable histological characteristics. CONCLUSION: Presacral SFT is a rare entity, with a scant incidence reported regarding this location and long-term treatment. Surgical resection is needed as the immediate treatment.

Sacral fractures: An updated and comprehensive review.

Sacral fractures are often underdiagnosed but are relatively frequent in the setting of pelvic ring injury. Causes include traumatic insults and osteoporosis. Sacral fractures have become more frequent owing to the growth of the elderly population worldwide as osteoporosis is an age-related disease. Misdiagnosed and neglected sacral fractures can result in chronic back pain, spine deformity, and instability. Unfortunately, the wide range of classification systems hinders adequate communication among clinicians. Therefore, a complete understanding of the pathology, and communication within the interdisciplinary team, are necessary to ensure adequate treatment and satisfactory clinical outcomes. The aim of this manuscript is to present the current knowledge available regarding classification systems, clinical assessment, decision-making factors, and current treatment options.

Technical nuances of a posterior-only L5 vertebrectomy with anterior column reconstruction.

BACKGROUND: Burst fractures involving the L5 vertebra are quite rare . They can be managed with anterior, posterior, or combined 360 approaches. Here, we report a 25-year-old female who presented with a traumatic cauda equina syndrome attributed to an L5 burst fracture following a motor vehicle accident, and who did well after a posterior-only decompression/fusion. CASE DESCRIPTION: A 25-year-old female presented with a traumatic cauda equina syndrome attributed to an L5 burst fracture following a motor vehicle accident. She was treated with a posterior-only vertebrectomy and followed for 5 postoperative months. During this time, she experienced complete resolution of her preoperative neurological deficit and demonstrated radiographically confirmed spinal stability. CONCLUSION: One of the major pros for the all-posterior L5 corpectomy as in this case, was that the patient underwent a successful single-stage, single-position operation. However, the posterior-only L5 corpectomy approach is technically demanding, and only allows for the placement of a lower profile interbody cage.

Agenesia caudal con disrafismo espinal cerrado, reporte de un caso / Caudal agenesis with closed spinal dysraphism, a case report / Caudal agenesis with closed spinal dysraphism, a case report

RESUMEN La agenesia caudal es una patología poco frecuente; es difícil su diagnóstico y evaluación fetal. La presencia de disrafismo espinal cerrado a nivel del sacro debe obligarnos a evaluar la anatomía del sacro. La visualización del cono medular es una forma muy útil en la evaluación y descarte de disrafismo espinal cerrado y agenesia caudal. Comunicamos un caso poco frecuente de agenesia caudal.

ABSTRACT Caudal agenesis is a rare pathology, its diagnosis and fetal evaluation are complex. The presence of closed spinal dysraphism at the level of the sacrum should compel us to evaluate the anatomy of the sacrum. The evaluation of the medullary cone is very useful to evaluate and exclude closed spinal dysraphism and caudal agenesis. We report a rare case of caudal agenesis.

Is there a role for sacral neuromodulation in patients with neurogenic lower urinary tract dysfunction?

PURPOSE: To review current literature regarding sacral neuromodulation (SNM) for neurogenic lower urinary tract dysfunction (NLUTD) focused on indications, barriers and latest technological developments. MATERIAL AND METHODS: A PubMed database search was performed in April 2020, focusing on SNM and various neuro-urological conditions. RESULTS: SNM has been increasingly indicated for lower urinary tract dysfunction (LUTD) in neuro-urological patients. Most studies are cases series with several methodological limitations and limited follow-up, lacking standardized definition for SNM clinical success. Most series focused on neurogenic overactive bladder in spinal cord injured (incomplete lesions) and multiple sclerosis patients. Barriers for applying this therapy in neurogenic LUTD were mainly related to magnetic resonance imaging incompatibility, size of the implantable pulse generator (IPG), and battery depletion. Newer technological advances have been made to address these limitations and will be widely available in the near future. CONCLUSIONS: SNM seems a promising therapy for neurogenic LUTD in carefully selected patients with incomplete lesions. Further studies are still needed to define which subgroups of neurological patients benefit the most from this minimally invasive technique.

The use of denosumab in giant cell tumors in the sacrum / O uso de denosumab em tumores de células gigantes no sacro / El uso de denosumab en el tumor de celulas gigantes en el sacro

ABSTRACT Giant Cell Tumor (GCT), a benign tumor with local aggression, corresponds to 5% of primary tumors. Fifteen percent of these are located in the sacrum. En bloc resection is an effective treatment, but when it cannot be performed, Denosumab may be indicated as an alternative treatment. The objectives of this work are: to justify the indication; determine the best dose and time of use; and recognize the need for post-treatment surgery. Methods A systematic search of clinical trials. Twenty-five articles were selected, ten of which met the inclusion criteria. The use of Denosumab is justified in advanced stages, with a dose of 120 mg administered subcutaneously, every 7 days in the first month and then maintained every 4 weeks, for 2.5 to 13 months. Adverse events are mild and can be observed in 84% of patients. With Denosumab, surgery may be less aggressive or even unnecessary. The bibliography justifies the indication of Denosumab in advanced stages of GCT, with a dose of 120 mg administered subcutaneously; there is no consensus as to the maintenance dose, which is a weekly dose in the first month and then every four weeks for 2.5 to 13 months. Complications are frequent but mild. Level of evidence III; Systematic review.

RESUMO O tumor de células gigantes (TCG), um tumor benigno com agressão local, corresponde a 5% dos tumores primários. Quinze por cento desses estão localizados no sacro. A ressecção em bloco é um tratamento eficaz, mas quando não pode ser realizada, o Denosumabe pode ser indicado como tratamento alternativo. Os objetivos desse estudo consistem em justificar a indicação; determinar a melhor dose e tempo de uso e reconhecer a necessidade de cirurgia pós-tratamento. Métodos Foi realizada uma busca sistemática de ensaios clínicos, sendo que foram selecionados 25 artigos, dos quais dez atenderam aos critérios de inclusão. O uso do Denosumabe é justificado em estágios avançados, com uma dose de 120 mg administrada por via subcutânea, a cada 7 dias no primeiro mês e, depois, mantida a cada 4 semanas, durante 2,5 a 13 meses. Os eventos adversos são leves e podem ser observados em 84% dos pacientes. Com o Denosumabe, a cirurgia pode ser menos agressiva ou nem necessária. A bibliografia justifica a indicação de Denosumabe em estágios avançados do TCG, com dose de 120 mg administrada por via subcutânea; não há consenso quanto à dose de manutenção, a qual é uma dose semanal no primeiro mês e depois a cada quatro semanas durante 2,5 a 13 meses. As complicações são frequentes, porém leves. Nível de evidência III; Revisão sistemática.

RESUMEN El tumor de células gigantes (TCG), un tumor benigno con agresión local, corresponde a 5% de los tumores primarios. Quince por ciento de éstos están localizados en el sacro. La resección en bloque es un tratamiento eficaz, pero cuando no puede ser realizada, el Denosumab puede ser indicado como tratamiento alternativo. Los objetivos de este estudio consisten en justificar la indicación, determinar la mejor dosis y tiempo de uso, y reconocer la necesidad de cirugía postratamiento. Métodos Fue realizada una búsqueda sistemática de ensayos clínicos, siendo que fueron seleccionados veinticinco artículos, de los cuales diez atendieron los criterios de inclusión. El uso de Denosumab está justificado en etapas avanzadas, con una dosis de 120 mg administrada por vía subcutánea, a cada 7 días en el primer mes y, después, mantenida a cada 4 semanas, durante 2,5 a 13 meses. Los eventos adversos son leves y pueden observarse en 84% de los pacientes. Con el Denosumab, la cirugía puede ser menos agresiva o ni necesaria. La bibliografía justifica la indicación de Denosumab en etapas avanzados de TCG, con dosis de 120 mg administrada por vía subcutánea; no hay consenso cuanto a la dosis de mantenimiento, la cual es una dosis semanal en el primer mes y después a cada cuatro semanas durante 2,5 a 13 meses. Las complicaciones son frecuentes, aunque leves. Nivel de evidencia III; Revisión Sistemática.

Underactive Bladder and Bladder Outlet Procedures in Women.

PURPOSE OF REVIEW: This review outlines current options for women suffering from both stress urinary incontinence (SUI) and underactive bladder (UAB). This is often a challenging patient population; however, many treatment options are available including behavioral, pharmacologic, and surgical. Therapies can be divided into those specifically targeting either the bladder or the bladder outlet. RECENT FINDINGS: For patients with SUI and UAB, several clinical trials have helped to formulate current guidelines. Also, a number of novel techniques and therapeutic agents are currently under investigation. Current surgical treatments frequently employed for SUI include midurethral slings and urethral bulking agents. In contrast, the current treatments for UAB are limited to either sacral neuromodulation in women with Fowlers syndrome or in the majority, clean intermittent catheterization. Recent studies have investigated the use of adjustable urethral slings and novel modes of neuromodulation with varying degrees of success. SUMMARY: Choosing the best treatment plan for SUI combined with UAB involves a thorough understanding of a patient's preferences and goals. Fortunately, women have many options that can significantly benefit their quality of life.

Partial Sacrectomy for Resection of a Sacral Chordoma: 2-Dimensional Operative Video.

Sacral chordomas are infrequent tumors that arise from remnants of the notochord. They are most often found in the sacrum and skull-base.1,2 These lesions rarely metastasize and usually have an indolent and oligosymptomatic clinical course. Chordomas show low sensitivity to standard radiation therapy and chemotherapy. Operative resection with wide resection margins offers the best long-term prognosis, including longer survival and local control.1,3 However, achieving a complete resection with oncological margins may be difficult because of the anatomic complexity of the sacrococcygeal region.4 The main complications of sacral resection include infections, wound closure defects, and anorectal and urogenital dysfunction. The rate of these complications is significantly increased when the tumor involves the S2 level or above. We report the case of a 64-yr-old male who presented with progressive sacrococcygeal pain and a feeling of incomplete evacuation. A heterogeneous, osteolytic lesion was found at the sacrococcygeal region. Full body imaging tests were negative for other lesions. A computed tomography (CT) guided biopsy was made. We usually use the midline approach in case we have to include the needle path in the resection. The pathology confirmed a sacrococcygeal, low-grade chordoma. We decided to perform an en bloc resection. A posterior, partial sacrectomy was planned distal to the S4 level.

Bloqueos de extremidad inferior / Lower extremity blocks

Lower limb blocks are described with emphasis on distribution according to sensitive distribution and its sonoanatomy.

Se describen los bloqueos de la extremidad inferior haciendo énfasis en la distribución de acuerdo a distribución sensitiva y a su sonoanatomia.