Ultrasound guided placement of foramen needle during Stage I sacral neuromodulation results in reduction of radiation exposure to the patient, surgeon, and operating room staff. Further studies are necessary to determine the learning curve and efficacy of this technique.
Upper tract urothelial carcinoma (UTUC) represents only 5% of all urothelial cancers. The 5-year cancer-specific survival in the United States is roughly 75%, with grade and stage being the most powerful predictors of survival. Nephroureterectomy with excision of the ipsilateral ureteral orifice and bladder cuff en bloc remains the gold standard treatment of the upper urinary tract urothelial cancers. However, endoscopic and laparoscopic approaches are rapidly evolving as reasonable alternatives of care depending on grade and stage of disease. A critical review of the current literature and various guidelines regarding tumor management in UTUC was undertaken, with a focus on surgical options. Topics reviewed include percutaneous and endoscopic approaches, laparoscopic nephroureterectomy (LNU), options regarding the management of the distal ureter, the role of lymphadenectomy, and the emerging role of chemotherapy in the treatment of UTUC. Both National Comprehensive Cancer Network (NCCN) and European Association of Urology (EAU) current guidelines are reviewed. Limited recommendations are provided by the American Urological Association (AUA). Scant level 1 or grade A evidence was noted in the establishment of the various guidelines. There is debate regarding how to best manage UTUC. With the current trend towards minimally invasive, localized, and precise surgical treatments for all solid malignancies, we must evaluate this movement as it applies to UTUC. Nephron sparing surgery is the preferred option, when feasible, in the management of other renal malignancies. This, too, must be considered when managing UTUC. Higher quality research is needed to better establish evidence-based guidelines. However, this is a challenging prospect given the low incidence of UTUC and the difficulties encountered in creating appropriate protocols.
Percutaneous nephrolithotomy (PCNL) is a standard treatment for patients with large or complex kidney stones. The procedure has traditionally included postoperative placement of a nephrostomy tube to allow for drainage and possible reentry. This practice was first implemented after complications incurred after tubeless PCNL in a small patient population. Recently, tubeless PCNL has reemerged as a viable option for selected patients, resulting in decreased pain and analgesic use, shorter hospitalization, quicker return to normal activity, and decreased urine extravasation. Gelatin matrix sealants are occasionally used in nephrostomy tract closure. Techniques for delivery of these agents have been ill described, and placement may be performed with varying results. We present a literature review comparing tubeless PCNL to its traditional variant with indications for use of each, as well as a comparison of agents used in closure. Finally, we outline a novel, reproducible technique for closure of the dilated percutaneous renal access tract.
Introduction:We evaluated the necessity of obtaining routine postoperative laboratory studies, such as complete blood count and basic metabolic panel, after robotic assisted radical prostatectomy.Methods: This study is a retrospective review of 200 robotic assisted radical prostatectomy cases performed over a year and a half at our institution. The incidences of laboratory abnormalities were examined along with any clinical intervention. Patient demographics, tumor stage, Gleason score, operative time, estimated blood loss, length of hospital stay, presence of comorbidities and postoperative laboratory studies were extracted from the electronic medical record. The costs of laboratory studies were tabulated to further analyze potential savings to patients.Results: Only 15 (7.5%) patients demonstrated laboratory abnormalities that required medical intervention. Of these 15 patients, all demonstrated hypokalemia that was treated with potassium supplementation. Patients with longer lengths of stay demonstrated higher percentages of medical intervention. The costs of these laboratory studies were calculated at $8,840.Conclusions: Lower blood loss and transfusion rates with the advent of robotic assisted radical prostatectomy along with the results described in this study provide greater evidence that postoperative laboratory studies may be futile. By eliminating these laboratory studies, substantial cost savings are realized if extrapolated across the United States. This study is limited in its evaluation of complications from different types of medical centers, higher risk patients, postoperative laboratory studies impact on symptomatic patients, and absence of emergency room visits or hospital readmissions.
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