Use of venous-thrombotic-embolic (vte) prophylaxis in patients undergoing surgery for renal tumors in Nordic countries (the Norenca-II study)
Objective: This study evaluated whether more effective perioperative analgesia can be part of a multimodal approach to minimizing morbidity and improving postoperative management after the open surgical approaches frequently used in the treatment of renal cell carcinoma (RCC). The aim of the study was to determine whether spinal anesthesia with clonidine can enhance postoperative analgesia, speed up mobilization and reduce the length of hospital stay (LOS). Materials and methods: Between 2012 and 2015, 135 patients with RCC were randomized, in addition to general anesthesia, to receive either spinal analgesia with clonidine or epidural analgesia, stratified to surgical technique. Inclusion criteria were American Society of Anesthesiologists (ASA) score of III or less, age over 18years and no chronic pain medication or cognitive disorders. Results: The median LOS was 4days for patients in the spinal group and 6days in the epidural group (p=0.001). There were no differences regarding duration of surgery, blood loss, RENAL score, tumor size or complications between the given analgesia methods. A limitation was that different anesthesiologists were responsible for administering spinal or epidural anesthesia, as in a real-world clinical situation. Conclusions: In this randomized controlled study, spinal analgesia with clonidine was superior to continuous epidural analgesia in patients operated on with open nephrectomy, based on shorter LOS. A shorter LOS in the study group indicates faster mobilization and improved analgesia. Spinal analgesia did not carry more complications than epidural analgesia.
Objective. Ureteropelvic junction obstruction (UPJO) is a common cause of symptomatic ureteral obstruction. The aim of this study is to assess the outcome of laparoscopic pyeloplasty in patients with UPJO. Patients and Methods. Medical reports of 47 UPJO patients treated with laparoscopic pyeloplasty were retrospectively analysed. All patients were recruited from our center in the period 2004–2011. Results. We evaluated 47 patients. Mean age was 36 years and mean hospital stay 3.6 days. 42 (79%) of the patients had pain and 46 (98%) were diagnosed with hydronephrosis. 19 patients (40%) had a renal function below 40% of the affected kidney and 49% had impaired renal scan drainage. Postoperative significant improvement in pain score and renal scan drainage was found in 92% and 47% of the patients, respectively. Improvement of renal function > 10% was found in 11 patients (23%); the function remained stable in 31 patients (66%) and deteriorated > 10% in 5 patients (11%). We found no correlation between sex or age and the outcome. Conclusion. Laparoscopic pyeloplasty for UPJO leads to relief of pain and preserved or improved renal function in the majority of the patients. Overall laparoscopic pyeloplasty is an efficient treatment for UPJO.
Objective. The objective of this study was to determine the effect of laminarin on the expression of kidney endoplasmic reticulum molecular chaperones (GRP78 and GRP94) in rats with renal interstitial fibrosis. Material and methods. A renal interstitial fibrosis model in rats was developed by unilateral ureteral obstruction (UUO). Rats were randomly divided into control group, model group, enalapril group, laminarin high-dosage group, laminarin median-dosage group and laminarin low-dosage group. The rats were killed 7 days after surgery and blood samples were collected. Serum creatinine (SCr) and blood urea nitrogen (BUN) levels were determined. Renal tubular damage index was determined by hematoxylin and eosin staining. The percentage of areas with renal interstitial fibrosis collagen was determined by the Masson staining method. Expression of kidney tissue endoplasmic reticulum stress (ERS) protein GRP78 and molecular chaperone GRP94 was determined by Western blotting. Results. Tubulointerstitial injury index, renal interstitial fibrosis, SCr level, BUN level and expressions of GRP78 and GRP94 were significantly different between the model group and treatment groups (p < 0.01). Expressions of GRP78 and GRP94 in rat nephridial tissue was increased (p < 0. 05), tubulointerstitial injury and renal interstitial fibrosis degree were decreased (p < 0.05) and renal function, SCr and BUN were decreased (p < 0.05) compared to those in the laminarin medium-dosage group. Conclusions. The results demonstrate that UUO activated the reaction of ERS and increased the expression of GRP78 and GRP94 in the early period after laminarin was applied, which helped the refolding, assembling and membrane transportation of denatured proteins. Consequently, the ERS signal transduction pathway was blocked, apoptosis was prevented and the development of renal interstitial fibrosis was reduced.
Abstract Objective. The objective of this study was to investigate the relationship between the ankle brachial index (ABI) and the severity of atherosclerotic renal artery stenosis (ARAS). Material and methods. In total, 138 patients with a complete clinical record were enrolled in this study. The severity of ARAS was judged by renal artery angiography and the ABI was measured according to the method recommended by the American Heart Association. Results. Hypertension, coronary artery disease, chronic renal dysfunction and hyperlipidaemia were significantly increased in the ARAS group (p < 0.05 or 0.01), and the ARAS patients were significantly older than the non-ARAS patients (p < 0.05). There were 31 cases of mild renal artery stenosis, 26 of midrange stenosis, 14 of severe stenosis and 16 of bilateral stenosis. In total, 104 cases had a normal ABI, while 34 cases had an abnormal ABI (≤0.9). Abnormal ABI values were not significantly correlated with mild ARAS, but the abnormal ABI value in patients with midrange and severe ARAS was approximately four times the normal ABI in these patients. Conclusion. ABI is a valuable predictive index of midrange to severe ARAS.
OBJECTIVE:This study aimed to evaluate the results of the Danish experience with the ProACT urinary continence device inserted in men with stress urinary incontinence. MATERIAL AND METHODS:The ProACT was inserted in 114 patients. Data were registered prospectively. The main endpoints were complications, pad use per day and 24 h urinary leakage. A questionnaire evaluating symptoms and satisfaction was sent to the patients. RESULTS:Data including preoperative and postoperative pad use and urinary leakage were available for 92 and 90 patients, respectively. A decrease in the median 24 h urinary leakage (352.5 vs 11 ml, p < 0.001) and in the median number of pads used per day (4.75 vs 2.25, p = 0.001) was demonstrated. Forty-six patients had a pad use of 0-1 pads per day and/or a daily urinary leakage less than 8 g, corresponding to an overall dry rate of 50%. A decrease in urinary leakage > 50% was seen in 72 patients (80%). Complications were seen in 23 patients. All of these were treated successfully by removal of the device in the outpatient setting followed by replacement of the device. Another eight patients had a third balloon inserted to improve continence further. Fourteen patients (12%) ended up with an artificial sphincter or a urethral sling. Sixty patients (63%) experienced no discomfort and 58 (61%) reported being dry or markedly improved. Overall, 50 patients (53%) reported being very or predominantly satisfied. CONCLUSIONS:Adjustable continence balloons seem to be a good alternative in the treatment of male urinary incontinence. Complications are mild and easily treated.
A 53-year-old man presented with a 6-month history of intermittent right flank pain. Radiological imaging confirmed the diagnosis of retrocaval ureter (RCU) and ureteral calculus. Retroperitoneal laparoendoscopic single-site surgery (LESS) ureterolithotomy and ureteroureterostomy was successfully performed. The operative time was 185 min and the blood loss was approximately 20 ml. The patient's postoperative course was uneventful. Postoperative analgesia was not needed. The patient was discharged on the third postoperative day. The drain and double-J stent were respectively removed at 1 and 8 weeks postoperatively. At the 3-month follow-up, nuclear scan showed no evidence of obstruction of the right kidney and the patient also remained symptom free. It may be concluded that retroperitoneal LESS repair for RCU is a feasible and safe procedure, which can be considered as a option for the management of RCU even if it is complicated by the presence of a ureteral calculus.
OBJECTIVE:This study aimed to assess the impact of preoperative body mass index (BMI) on postoperative complications, cancer-specific survival (CSS) and overall survival (OS) in patients operated for renal cell carcinoma (RCC).MATERIAL AND METHODS:The study included 397 patients with BMI values, who underwent surgery for RCC between 1 January 1997 and 31 December 2010. Obese patients (BMI > 30 kg/m(2)) were compared to non-obese patients (BMI < 30 kg/m(2)) in regard to CSS and OS. A Cox proportional hazard model was used for the multivariate survival analyses. The mean age of the patients was 62.1 years. There were 259 males (65%) and 325 patients (82%) were non-obese. Mean BMI was 26 kg/m(2).RESULTS:In the total material, CSS was 94.7% for obese patients and 74.8% for non-obese patients (p = 0.06). The obese group had significantly better CSS in univariate analysis for presumed radically treated disease (pT1-3N0M0). Obesity was a significant protective prognostic factor in multivariate analysis. An accelerating protective effect for CSS was found with increasing levels of BMI. In regard to OS, no difference was found between the two groups. Obese patients had a significantly lower age, and a higher rate of diabetes mellitus, hypertension and incidental detection. Obese patients had a significantly higher total incidence of postoperative complications, but not surgery-related complications.CONCLUSIONS:In this material, increasing BMI was associated with improved CSS for presumed radically treated patients. However, obese patients had a higher total rate of postoperative complications.
Objective. The aim of this investigation was to determine whether postoperative urine colour could be used as a predictor for the presence or absence of a urinary leakage at the vesicourethral anastomosis after open radical prostatectomy. Material and methods. In this prospective study, the urine colour of 223 patients who underwent open radical prostatectomy due to histologically proven localized prostate cancer was assessed macroscopically and microscopically on postoperative day (POD) 6, 7 and 8. All patients underwent evaluation of perianastomotic extravasation by retrograde cystography on POD 8. Baseline characteristics included age; prostate-specific antigen; prostate volume; tumour, node, metastasis classification; and Gleason score. Results. The urine colour was a highly significant predictor for perianastomotic extravasation in cystography when it was red on POD 6, 7 and 8. The sensitivity and specificity of urine colour as a predictor for extravasation were 71.4% and 83.2% on POD 6, 71.4% and 85.8% on POD 7, and 81.8% and 90.9% on POD 8, respectively, with a clear or slightly ensanguined urine colour. The negative and positive predictive values were 98.6% and 81.8%, respectively. Conclusion. A cystography can be omitted if the patient demonstrates a clear urine colour on POD 8, without an increased risk of missing a perianastomotic extravasation.
Objective. Chronic kidney disease, characterized by a decline in renal function, is a public health challenge, affecting around 10% of the population worldwide. The aim of this study was to investigate the prevalence of decline in renal function in patients admitted for acute first-ever stroke from a local centre in China, and its impact on mortality and neurological impairment during a short follow-up period. Material and methods. In total, 640 patients hospitalized due to acute stroke were enrolled in this prospective study. Clinical data were obtained and a 3-month follow-up was executed by a team of trained investigators. The data indicated that the prevalence of estimated glomerular filtration rate (eGFR) decline (≤60 ml/min/1.73 m2) was 18.5% in this specific population. Results. Hyperuricaemia, elevated homocysteine and smoking history were identified as three major risk factors associated with eGFR decline. An eGFR ≤60 ml/min/1.73 m2 was detected in 45.1% of haemorrhagic stroke patients, while 14.7% of ischaemic stroke patients had an accompanying eGFR decline. During the follow-up period, the mortality rate was 18.1% in patients with eGFR decline and 1.5% in patients with eGFR >60 ml/min/1.73 m2. Conclusions. This study clearly shows that the prevalence of renal impairment is high in acute stroke patients in China, and renal impairment may confer a significant risk for worse outcomes such as impaired neurological function and death, at least in the short term.
Although extracorporeal shockwave lithotripsy (ESWL) is one of the primary treatments for urolithiasis, very often residual fragments of the calculi are still present for a long time after the ESWL session. These fragments are usually asymptomatic and can be managed expectantly, but sometimes they can cause symptoms and require intervention. Secondary procedures are not routinely applied to all patients with residual fragments, but only to those with significant symptoms. Medical therapy may play an important role in the management of residual fragments, by correcting an underlying metabolic disorder and by preventing the growth of residual calculi and the formation of new ones.
Objective. This study investigated the correlation between the operation time and the stone size as determined by multiple modalities and the computed tomography (CT) densities of bladder calculi using holmium: yttrium garnet (Ho:YAG) laser lithotripsy. Material and methods. A total of 68 patients underwent cystolithotripsy from March 2010 to October 2011. Thirty-six of these patients underwent cystolithotripsy using a Ho:YAG laser for bladder calculi by a single surgeon. The stone size was assessed by six modalities: sum of the stones' diameters: stone burden; maximum stone's diameter; number of stones; sum of the area using axial CT; sum of area using kidney-ureter-bladder (KUB) films; and volume using CT. In addition, the stone's CT density was measured by: the mean CT density of the maximum stone's whole area; maximum CT density of the maximum stone's whole area; and mean CT density of the maximum stone's center area. Correlations between the operation time and the stone size and the stone CT density were assessed. Results. A total of 36 patients (30 male and six female) who underwent cystolithotripsy using a Ho:YAG laser for bladder calculi were enrolled in this study. Spearman correlation showed that the area and volume were strongly correlated with the operative time. The multipliers between the stone size and stone CT density showed no advantages based on the stone area or volume alone. Conclusion. The area and volume of the stones correlated more closely with the operation time than the stone burden for bladder calculi lithotripsy using a Ho:YAG laser.
OBJECTIVE:The aim of this study was to explore whether vascular density and tumour cell proliferation are related to the risk of prostate cancer death in patients managed by watchful waiting. MATERIAL AND METHODS:From a consecutive series of men diagnosed with prostate cancer at transurethral resection in 1975-1990, tissue microarrays (TMAs) were constructed. A majority of men had no metastases at diagnosis and were followed by watchful waiting (n = 295). The TMAs were stained for Ki67, endoglin and factor VIII-related antigen (vWf). RESULTS:In univariate Cox analyses, increased Ki67 index, endoglin vascular density and vWf vascular density were associated with shorter cancer-specific survival. Ki67 index and endoglin vascular density added independent prognostic information to clinical stage, estimated tumour size and Gleason score (GS) in multivariate Cox analysis. In GS 6 tumours, high Ki67 index and high endoglin vascular density identified patients with poor outcome. After 15 years of follow-up not a single man out of 34 men with low staining for both markers (35% of all GS 6 tumours) had died of prostate cancer, in contrast to 15 prostate cancer deaths among the remaining 63 men with GS 6 tumours (65% cumulative risk of prostate cancer death). vWf vascular density in benign areas was a prognostic marker in GS 6 and 7 tumours. CONCLUSIONS:Men with GS 6 tumours with both low Ki67 index and endoglin vascular density staining scores have a low risk of progression. Additional studies are needed to test whether these two markers can be applied to core biopsies to select patients suitable for surveillance.
OBJECTIVE:The role of major surgery in patients with bladder pain syndrome/interstitial cystitis (BPS/IC) is not fully established. This report presents a single-institution experience with major surgery in patients with disabling BPS/IC where conservative treatment had failed.MATERIAL AND METHODS:Forty-one patients (34 women, seven men) with BPS/IC refractory to conservative treatment underwent major surgery from 1983 to 2004. Surgical approach was determined on a case-by-case basis. Postoperative pain and satisfaction were assessed by a questionnaire.RESULTS:Cystectomy was the primary procedure in five patients. The remaining 36 patients were primarily operated on with subtotal cystectomy and bladder augmentation (n = 16) or supravesical urinary diversion with intact bladder (n = 20). Thirteen of these patients were later operated on with cystectomy due to persisting pain 12 (6-146) months after the primary procedure. The questionnaire was answered by 38 of 41 patients after a median follow-up of 66 (6-238) months. In total, 28 patients (74%) were free of pain, and 26 patients (68%) were satisfied with the end result. There was no difference in reported pain between cystectomized and non-cystectomized patients. When comparing patients who reported pain at follow-up with those who did not report pain, preoperative length of symptoms was significantly increased, with 12.1 compared to 5.4 years (p = 0.02).CONCLUSIONS:Major surgery is associated with good symptom relief in strictly selected patients with disabling BPS/IC, where conservative treatment has failed. Extended preoperative duration of symptoms may be a predictor for persisting pain after major surgery for BPS/IC.
