Peter E. Andersen, MD

• Professor, Department of Otolaryngology/Head and Neck Surgery
• Professor, Department of Neurosurgery
• Director of Head and Neck Surgery
• Oregon Health and Science University
• Portland, Oregon

Fontan Circulation the Fontan procedure is a palliative surgical procedure that redirects the systemic venous return directly to the pulmonary arteries without passing through a subpulmonary ventricle arthritis self help diet order line voltaren. The total cavopulmonary anastomosis or lateral tunnel Fontan consists of a direct arthritis diet to help buy voltaren 100 mg otc, end-to-side superior cavopulmonary anas- tomosis (bidirectional Glenn operation) along with an intra- atrial baffle connecting the inferior vena cava to the underside of the pulmonary artery dealing with arthritis in feet cheap 50 mg voltaren overnight delivery. The long-term complications include protein losing enteropathy as a result of elevated venous pres- sure and intestinal lymphangiectasia arthritis pain sleeping cheap voltaren 100 mg free shipping, arrhythmias arthritis pain relief gel order voltaren 50mg overnight delivery, throm- boembolic complications arthritis relief ankle order generic voltaren from india, obstruction of the conduit, and progressive ventricular dysfunction and cyanosis. What is a simple clinical test that will help you to differenti- ate between the two possible diagnoses Pulse oximetry between feeds his saturation drops to the 60s especially when he cries. Congenital Heart Defects: Decision Making for Cardiac Surgery: Volume 1 Common Defects. Two important determinants of blood pressure are cardiac output and total peripheral resistance which will be discussed in detail later in the chapter. Hypertension is one of the most common conditions, especially in the aging popula- tion. It is commonly referred to as the silent killer because it remains asymptomatic until it manifests as one of the life- threatening complications, for example, stroke, myocardial infarction, kidney dysfunction, and so on. In order to better comprehend the mechanism of increased blood pressure, it is imperative to have a better understanding of the individual factors that determine hypertension. The incidence of hypertension has been increasing in industrial countries, which can be attributed to a large extent to dietary habits and an increase in obesity. Furthermore, hypertension is an important worldwide public health challenge- in a pooled data review (Kearney et al. The number of adults with hypertension is expected to increase by 60% to a total of 1. Although control of hypertension has improved significantly over the last 2 decades, it is still not adequate. Factors that increase the heart rate or stroke volume result in changes in blood pressure. The stroke volume is dependent on cardiac contractility and blood volume, which equates with sodium homeostasis. The autonomic nervous system affects both cardiac contractility and stroke volume. Another factor impacting cardiac output is the heart rate that is also controlled mainly by the autonomic nervous system. Both environmental and genetic factors play an important role in blood pressure control. Intracellular calcium has been associ- ated with increased muscle tone of the vascular smooth mus- cle and increased blood pressure. A calcium-rich diet has also been associated with a reduction in the lipogenesis in the fat cells, thus providing an additional beneficial effect on blood pressure. Other environmental factors include low levels of physical activity, increased stress, increased levels of alcohol intake, dyslipidemia, personality traits (eg, a hostile attitude or time urgency, impatience) can negatively impact the blood pressure. Several genes have been implicated in the development of hypertension and thus it is called a polygenic disorder. An important genetic mutation involved in the pathogenesis of hypertension is the Adducin family of genes (genes for cytoskeleton protein Adducin), which can lead to increased sodium reabsorption from the kidneys. The Connexin 40 gene mutation (a gap junction protein gene in the juxtaglomerular apparatus) has also been impli- cated in the pathogenesis of hypertension. Another important mutation is the angiotensinogen gene, which leads to increased levels of angiotensinogen, a precursor for angiotensin. Alto- gether, the interplay of both environmental and genetic factors determines the increased levels of blood pressure. Stretch-sensitive sen- sory nerve root endings are located in the carotid sinuses and the aortic arch. As the arterial pressure rises, the rate of firing of these neurons increases, causing a decrease of sympathetic outflow, which in turn causes a decrease in the heart rate and arterial pressure. This is the primary mechanism for the regu- lation of blood pressure in an acute setting, and acts as the buffer in changes of posture and acute changes in the blood volume. However, if the blood pressure remains elevated, a downregulation of the baroreceptor reflex occurs, and is set to a higher pressure point. Long-term blood pressure main- tenance is dependent mainly on intravascular blood volume through the renin-angiotensin-aldosterone mechanism. As the intravascular volume increases, the stroke volume and cardiac output increases, and this causes the blood pressure to rise. However, if blood pressure remains elevated for a long period of time, the total peripheral resistance will decrease and the cardiac output will become normal. Primary versus Secondary Hypertension Primary hypertension, or hypertension without an identifiable cause (formerly called essential hypertension), accounts for approximately 95% of all cases of hypertension. Although it is idiopathic in nature, there are many genetic and environmen- tal factors that interact with one another to cause and develop primary hypertension. Important factors that can contribute to this condition include increased sympathetic activity and responsiveness of the adrenergic system. Increased angioten- sin 11 activity and mineralocorticoid excess are other impor- tant considerations. Primary hypertension is 4 times more common in African Americans and progresses more rapidly, and is associ- ated with more complications as compared to rates of primary hypertension in Caucasians. The pathophysiology behind age relates the increase in blood pressure to the loss of elasticity, stiffening of the arteries, and a decrease in the renal ability to hypertension and requires further workup (ie, diagnostic tests). Other important clues to the presence of secondary hyperten- sion include severe or resistant hypertension (resistant hyper- tension is defined as hypertension that is not being controlled by 3 antihypertensive agents, one of them being a diuretic), and malignant or accelerated hypertension (Table 13. Renovascular Hypertension Renovascular hypertension is the most common cause of sec- ondary hypertension and is potentially correctable. The former is common in older patients who generally have other manifestations of atherosclerotic disease. Generally, athero- sclerotic plaque involves the proximal renal arteries at their origin in patients with atherosclerotic disease. Fibromuscular dysplasia is more frequently associated with young Cauca- sian females (8 times more common than in other population groups). The specific choice of the test depends on the condition of the patient and the available expertise. Once a diagnosis is established, treatment options depend upon patient characteristics and the goals of treatment. There is a strong pathogenic association of insulin resis- tance with hypertension. When 3 of these 5 manifestations are present in a patient, metabolic syndrome is diagnosed. Metabolic syn- drome increases the risk of heart disease, stroke, and diabetes mellitus. The exact mechanism by which insulin resistance induces hypertension is still unknown; however, insulin is known to increase both sympathetic activity and sodium and water retention. This seems to be the most plausible hypoth- esis for the correlation of insulin and hypertension. Salt sensi- tivity, another common mechanism for primary hypertension, also increases in insulin-resistance states. J Insulin resistance is a condition in which the body normally secretes insulin from B-cells ofthe pancreas, but does not use it effectively. Thus, the blood glucose level increases, which leads to an increase in the secretion of insulin as it attempts to compensate for the high glucose level. Secondary Hypertension Secondary hypertension is a hypertension with an identifi- able cause. The age of onset of hypertension before 30 or after 55 years of age raises the possibility of the presence of secondary Cushing Syndrome Cortisol increases blood pressure by acting on mineralo- corticoid receptors. Characteristic signs and symptoms raise the suspicion of the presence of Cushing syndrome. These include supraclaVicular fat pads, purplish skin striae, moon face, obesity, hyperten- sion, menstrual irregularity, and glucose intolerance. Before starting the workup for other causes of Cushing syndrome it is necessary to rule out the use of glucocorticoids, which can be the underlying cause. Primary Aldosteronism Nonsuppressible (primary) hypersecretion of aldosterone is an important and less commonly documented cause of. For patients with bilateral hyperplasia, medical therapy is the treatment of choice. Aldosterone antagonists, ie, spironolactone and eplerenone are the first-line agents used in this condition. Serum potassium, creatinine, and blood pressure should be monitored frequently during the first 4-6 weeks of medical therapy. Muscle weakness can occur but generally it is rare ifthe potassium level is more than 2. Confirmation by aldosterone suppression test, which is either unilateral abnormality but patient is more hyperaldosteronism have greater left ventricular mass and thus it is one ofthe risk factors for the development of cardiovascular disease. Common causes of primary aldosteronism include aldosterone-producing adenoma (the most common) and bilateral idiopathic hyperaldosteronism. The effects of hyperaldosteronism can be linked to the mechanism of action of aldosterone. It increases sodium reabsorption in the renal tubules and at the same time is responsible for the secretion of potassium and hydrogen ions. The osmotic gradient that is formed with sodium being reab- sorbed causes the fluid to follow, which is the basic underly- of aldosteronism. Thus, a relatively lower potassium level is found in hyperaldosteronism, but severe hypokalemia does not occur unless there is a precipitating factor, such as diuretic therapy. Pheochromocytoma Catecholamine-secreting tumors that arise from the chromaf- fin cells of the adrenal medulla and the sympathetic ganglia are referred to as pheochromocytoma and catecholamine- secreting paragangliomas, respectively. The only reliable clue to the presence of a malignant pheochromocytoma is local invasion into surrounding tissues and organs (eg, the kidneys, liver) or distant metastasis (Table 13. The aldosterone escape phenomenon prevents fluid accumulation and edema formation. Hypokalemia also does not reach profound levels, as hypokalemia itself counteracts the potassium-wasting effects Clinical features Episodic headaches, sweating, and tachycardia. Fifty percent of patients have paroxysmal hypertension while the rest have primary hypertension or normal blood pressure. Lab workup Initial test to identify catecholaminesecreting tumor is to measure fractionated metanephrine and catecholamine in 24-hour urine collection. Plasma fractionated metanephrine is not specific enough to be recommended as a first-line test. B-adrenergic blockage should never be initiated first as it can cause fatal hypertensive crisis. The likelihood of developing these complications starts to increase once the blood pressure exceeds 115/75 in all age groups. In addition, the presence of other risk factors also increases the chances of developing these complications. These complications will be discussed based on the pri- mary organs that are affected by hypertension. Heart: Hypertension is the single most important risk factor for the development of premature heart disease. Left ventricular hypertrophy is commonly seen in hypertensive patients and it can in turn lead to diastolic heart failure, cardiac arrhythmia, myocardial infarction, and sudden death. In order to identify patients with left ventricular hypertrophy and diastolic dysfunction, an echocardiogram is the most accurate noninvasive test. Cardiac catheterization still remains the gold standard for diagnostic purposes but is not performed routinely because of its invasive nature and risk of complications. Diastolic heart failure is commonly associated with hypertension and the systolic function is preserved. Optimal treatment of hypertension leads to the normalization of the blood pressure and nonprogression or even regression of left ventricular hypertrophy. Brain: Hypertension is the most common and important risk factor for stroke, both ischemic and hemorrhagic. Optimal blood pressure control is the best strategy to prevent strokes in a high-risk population. Hypertension has also been found to have a strong association with impaired cognition in the elderly. The mechanism of cognitive decline needs further research; however, currently suggested mechanisms include either a large vessel infarct or multiple small lacunar infarcts. Hypertensive encephalopathy is another important hypertension-related brain complication. It is characterized by signs of cerebral edema caused by breakthrough hyper-perfusion, which is a result of sudden and severe rises in blood pressure. Such severe rises in blood pressure cause a failure in the autoregulation mechanism of cerebral perfusion and a disruption of the vascular endothelial function. Signs and symptoms of hypertensive encephalopathy include nausea, vomiting, headaches, neurological signs such as restlessness and confusion, with a possible progression to coma and death if left untreated. This condition is initially treated with parenteral agents with the goal of lowering the blood pressure by not more than 25% in 4 to 6 hours. Kidneys: Hypertension is a risk factor for chronic kidney disease and end-stage renal disease. Systolic hypertension is more strongly associated with the development of renal disease as compared to diastolic hypertension. African Americans are also more likely to develop renal complications as compared to Caucasians, even at with same level of blood pressure.

Even when researchers use outcomes that are not dependent on the presence of a partner rheumatoid arthritis urinary problems buy voltaren 50mg with amex, subjects may be reluctant to honestly report their function for fear of embarrassment arthritis pain all over purchase generic voltaren online. Importantly what does arthritis in back feel like order 100mg voltaren overnight delivery, sexual function is multidimensional and encompasses libido arthritis in both feet order voltaren 50mg amex, arousal arthritis in fingers remedies quality 50 mg voltaren, erection (men) arthritis diet stories purchase voltaren 100mg without prescription, and ejaculation/ orgasm. A problem in any of these areas can be perceived as sexual dysfunction and can cause bother for patients. The instrument was reduced to 12 items and also contains an additional 7 items, 2 of which deal with sexual function and 5 of which deal with quality of life. Includes an 8-item symptoms bother scale and 25 health-related quality-of-life items. Consists of 3 scored items that assess how often the subject experiences urinary leakage, how much leakage the patient thinks she experiences, and how much it interferes with everyday life. The fourth item is descriptive and attempts to determine what activities cause leakage. Unfortunately, these objective studies can also be problematic, as they are usually performed in "clinical" environments, which may not reflect what the patient is experiencing at home on a daily basis. In addition, they may not accurately assess the degree of dysfunction in subjects with psychogenic etiologies (Blander et al. To this end, patient-reported outcomes are crucial when assessing sexual function. Although this also has its problems, when done properly, patient survey instruments for use in sexual dysfunction can be expected to obtain valid and reliable outcomes. There are more than 20 validated instruments for male sexual dysfunction in addition to a number of additional questionnaires for which there are no published psychometric data available, most of which focus on sexual dysfunction as it relates to both the patient and his partner (Arrington et al. This may affect the utility of many of these tools when patients do not have a partner. There are few tools that assess sexual function outcomes independent of the role of the partner. In summary, there is no perfect tool of outcomes assessment in male sexual dysfunction, and clinicians and researchers should choose instruments based on the particular clinical setting of interest and the question they wish to answer. To comprehensively capture outcomes in male sexual dysfunction, instruments should assess results in various domains, including libido, erection, and orgasm/ejaculation. The International Index of Erectile Dysfunction assesses outcomes in all of these domains and has become the gold standard instrument for assessing outcomes in male erectile dysfunction. This questionnaire includes 15 items, has been shown to be psychometrically sound, and has been used in numerous clinical trials (Rosen et al. This shortened instrument has also been used in numerous studies, as have some of the individual items from the questionnaire (Barqawi et al. An overview of commonly used instruments for assessment of outcomes in male sexual dysfunction is presented in Table 6. The three domains assessed are sexual interest/desire, sexual activity, and sexual satisfaction. The Female Sexual Function Inventory is a 19-item questionnaire that generates scores in the six domains of lubrication, arousal, desire, pain, orgasm, and satisfaction (Meston, 2003; Rosen et al. A total of 25 questions in the two parts assess the five domains of sexual cognition and fantasy, sexual arousal, sexual behavior and experiences, orgasm, and sexual drive and relationship. Because of the interview component, this tool has not been widely used and probably is not of value in the clinical urology setting. A summary of the available patient-reported measures for use in female sexual function is presented in Table 6. To this end, researchers need to be able to assess this outcome objectively and accurately. Many elements of human experience affect well-being and quality of life, including access to adequate food and shelter, personal responses to illness, and activities associated with professional responsibilities (Patrick and Erickson, 1993). General patient satisfaction with health care has been used as an outcome in various studies of urologic disease (Kaye et al. The survey also includes four items to direct patients to relevant questions, three items to adjust for the mix of patients across hospitals, and two items that support Congressionally-mandated reports (Centers for Medicare and Medicaid Services, n. There are a number of general patient-satisfaction surveys available for research use, although few if any are focused specifically on urologic disease (Ware and Hays, 1988; Wiggers et al. Accurate cost data have proven difficult to collect because of differences in prices across countries and within regions of the same country, the proprietary nature of economic data, and the fact that different elements of health care costs are borne by different entities. Acknowledging this, it is possible to divide the cost of a health care intervention into three components: direct costs, indirect costs, and intangible costs. These include inpatient and outpatient services (which includes professional fees, staffing costs, equipment costs, and so on), pharmaceuticals, and other expenses directly related to the delivery of health care. Traditionally, these costs have been gleaned from administrative databases and/or hospital chargemasters, which may not be accurate (Brill, 2013). Although this technique may seem difficult (and perhaps it is), it has already been successfully employed in urology to identify the cost of delivering prostate cancer care (Laviana et al. Indirect costs include lost wages to the patient and his or her caregivers and other potential opportunity costs. This is obviously dependent on the age of the patient and his or her social support status, in addition to the severity and length of the condition the patient is suffering from (Finkelstein and Corso, 2003; Gold et al. Finally, intangible costs consist of the monetary value of pain and suffering, anxiety, and costs to society. These are very difficult to measure and are not usually included as endpoints in clinical research studies. Structure and process measures are easier to assess, but outcomes tend to be most meaningful to clinicians and patients. Specifically, studies using overall mortality can still be subject to lead- and length-time bias, and studies using disease-specific mortality may be subject to attribution bias. Despite this, urologists routinely use proxy endpoints in research and clinical practice. Although urologists should use these reporting systems whenever possible, they should also remember that use of these systems does not completely eliminate the potential for bias in research because of study design and other factors. Physicians and researchers should always use validated and reliable patient-centered tools when possible. Agency for Healthcare Research and Quality: Outcomes research fact sheet, Rockville, 2000, Agency for Healthcare Research and Quality. Mansson A, Davidsson T, Hunt S, et al: the quality of life in men after radical cystectomy with a continent cutaneous diversion or orthotopic bladder substitution: is there a difference Clinical assessment of indications and outcomes Assessment of Urologic and Surgical Outcomes 114. Morgan M, Smith N, Thomas K, et al: Is Clavien the new standard for reporting urological complications Verger E, Salamero M, Conill C: Can Karnofsky performance status be transformed to the Eastern Cooperative Oncology Group scoring scale and vice versa The purpose of this chapter is to provide a brief history of the origins of medical ethics and legal principles of informed consent, to define key ethical principles and their application to clinical decision making, and to consider the ethical and legal requirements for informed consent in both the clinical and surgical settings. The oath establishes the moral framework governing the physician-patient relationship and introduces the ethical principles of beneficence, nonmaleficence, confidentiality, and accountability to the medical profession (Antoniou et al. However, in the 20th century, the traditional values embodied by the oath were challenged by prominent ethicists such as Robert Veatch. As a result, the oath undermines the growing respect for patient autonomy that emerged during the late 20th century (Veatch, 1991; Veatch, 2009). Additionally, the oath has been criticized for not addressing issues surrounding justice in the allocation of medical resources, instead focusing on the individual outside of the social context of his care (Veatch, 1991). As criticism of the Hippocratic oath grew, the interdisciplinary field of bioethics emerged. During the 1960s, physicians first began to discuss the impact of technology, such as antibiotics and genetic testing, on medical care (Jonsen, 2001). In 1970 Van Rensselaer Potter first coined the term bioethics to describe "the study of the moral relationship between humans and their social and physical world (Jonsen, 2001; Potter, 1970). This focus on respect for patient autonomy and informed consent was reinforced in the research realm as information about the Tuskegee syphilis studies became public in the early 1970s (Jonsen, 2001). In 1979 the "Four Principles" framework for addressing ethical issues in medicine was first described by Beauchamp and Childress. This approach remains the cornerstone of modern medical ethics (Beauchamp and Childress, 1979). The Four-Principles Framework the four principles delineated by Beauchamp and Childress were developed to help provide a common set of moral commitments and language with which to address ethical issues (Gillon, 1994). These principles are considered equal in weight and should be considered prima facie binding unless in conflict, leading to ethical dilemmas in circumstances in which the physician and patient must prioritize among conflicting principles (Gillon, 1994). This principle is grounded in the Kantian "categorical imperative" that people be considered ends in themselves rather than a means to an end. Although some have postulated that autonomy should be prioritized when in conflict with other principles, it is also considered bound by justice or the consideration of autonomy of others in addition to the individual patient (Gillon, 1994). Respect for autonomy provides the foundation for several physician obligations, including informed consent, confidentiality, and avoidance of deceit. Importantly, communication is essential to providing the physician with the information about patient preferences and attitudes needed to guide discussions of options and to frame medical decision making in a way that is respectful of the patient (Gillon, 1994). Nonmaleficence is grounded in the Hippocratic dictum primum non nocere (first do no harm) and refers to the obligation to avoid or minimize harm to the patient. As a result, the complementary principles of beneficence and nonmaleficence can be seen as an obligation not only to provide training to the individual clinician but also to conduct research to ensure that the information we offer is as accurate as possible. Finally, the weighing of risks and benefits should be considered both at the individual and at the population level (justice) to ensure that risks and benefits are equally shared among patients. Justice refers to the obligation to seek and achieve fairness in the distribution of resources, benefits, and risks across patients. Although equality and justice share many traits, they are not equivalent; "people may be treated unjustly even if they are treated equally" (Gillon, 1994). Additionally, the physician should try to minimize waste of resources when possible. Competing values in justice may lead to different outcomes: does just distribution require equal access to care, provision to those who need it most, advocacy by physicians to maximize the benefit for their patients, limitation of societal costs (via taxes or insurance deductibles), or respect for patient choice Although all of these values have merit, how do we as physicians and as a society determine which should have priority (Gillon, 1994) Medical Ethics in Clinical Practice Despite the focus on these four principles in medical society codes of ethics and in training, the translation of these principles to specific medical care may not always be clear (Page, 2012).

Measurements of renal volume may be appropriate in cases of severe renal impairment arthritis in the knee and running buy discount voltaren 50mg line. Renal measurements should be obtained in the midsagittal plane and midtransverse plane medication to ease arthritis discount 100 mg voltaren. Measurements taken in other than the midsagittal plane and midtransverse may be spuriously low arthritis in feet exercises order voltaren amex. The thickness of the parenchyma is the average distance between the renal capsule and the central band of echoes rheumatoid arthritis nsaids buy cheap voltaren 100 mg online. Although there is no universal standard arthritis injections in fingers purchase cheapest voltaren, the renal cortical thickness should be greater than 7 mm (Roger et al arthritis pain and inflammation buy voltaren 50mg with amex. Doppler ultrasound may be helpful in evaluating the renal artery and renal vein and assessing the vascular resistance in the kidney. Doppler modes may also be useful in evaluating neovascularity associated with renal tumors and in correctly characterizing hypoechoic structures in the renal pelvis such as a parapelvic cyst, the renal vein, or the dilated collecting system. Procedural Applications Percutaneous renal biopsy as an office procedure has been used by several groups for the past two decades and found to be a safe and effective procedure (Christensen et al. In their series, increasing the number of biopsy passes did not increase the complication rate, but severe hypertension did. Fraser and Fairley (1995) compared 118 outpatient ultrasound-guided biopsies with 232 inpatient procedures and found no difference in complication rate. They had only one case requiring interventional radiology for persistent blood loss, 2. Although the prostate cannot be imaged with the same resolution achieved during transrectal scanning, the size and morphology of the prostate can be demonstrated. Although transabdominal scanning is the most common means of evaluating the bladder, the bladder may also be assessed via a transvaginal and transrectal approach. These approaches are useful in patients who are obese or who are not suitable candidates for transabdominal scanning. Measurement of bladder volume or postvoid residual urine Assessment of prostate size and morphology Demonstration of secondary signs of bladder outlet obstruction Evaluation of bladder wall configuration and thickness Evaluation of hematuria of lower urinary tract origin Detection of ureteroceles Assessment for ureteral obstruction Detection of perivesical fluid collections Evaluation of clot retention Confirmation of catheter position Removal of retained catheter Guidance of suprapubic tube placement Establishment of bladder volume before and after flow rate determination Limitations Some patients are not favorable candidates for renal ultrasonography. Obesity, intestinal gas, and physical deformity may be impediments to complete renal evaluation. Renal ultrasonography has poor sensitivity for renal masses less than 2 cm (Warshauer, McCarthy, and Street, 1988). Angiomyolipoma has characteristics that are distinctive on ultrasonography (highly echoic), but some small renal cell carcinomas have been shown to be indistinguishable from angiomyolipoma by ultrasound criteria (Forman, Middleton, and Melson, 1993; Yamashita, Takahashi, and Watanabe, 1992). Transabdominal Pelvic Ultrasound Transabdominal pelvic ultrasonography is a tremendously versatile tool for the urologist. It is a noninvasive method for evaluating the lower urinary tract and prostate in men and the bladder in women. For determining only a residual urine or bladder volume, an automated bladder scanner is often employed. Normal Findings Transabdominal pelvic ultrasonography should include evaluation of the lumen of the bladder, as well as bladder wall configuration and thickness. The emergence of urine from the ureteral orifices (ureteral jets) can be demonstrated. Numerous studies have shown that for bladder volumes between 100 and 500 mL, such calculated volumes are within 10% to 20% of the actual bladder volume (Ghani et al. The scan should be performed in a warm room and the patient draped to provide for comfort and privacy. Scanning technique depends on the circumstances and the reason for the examination but in general should be performed with a moderately full bladder. In this transverse view of the bladder, ureteral "jets" emerging from the left (arrow) and right (arrowhead) ureteral orifices are demonstrated by power Doppler. In this sagittal view, bladder wall thickness is measured posteriorly (arrow) near the midline. In the sagittal plane, the dome (D) of the bladder is to the left and the prostate (P) to the right. Transabdominal ultrasonography of the prostate is useful in characterizing prostatic urethral length, the size and configuration of the middle lobe of the prostate, and some secondary information about the physiology of bladder outlet obstruction. This information is valuable in treatment planning for bladder outlet obstruction. Procedural Applications Transabdominal ultrasound-guided percutaneous bladder aspiration with or without catheter placement has been successfully used in neonates, children, and adults (Gochman et al. Ultrasound-guided aspiration has also been used for peritoneal drainage after bladder perforation (Manikandan et al. It has been shown that measuring bladder wall thickness may predict bladder outlet obstruction with greater accuracy than free uroflowmetry, postvoid residual urine, and prostate volume (Oelke et al. Transabdominal prostatic ultrasonography requires angling the probe beneath the pubic bone. In the transverse plane the transducer is fanned inferiorly until the largest transverse diameter of the prostate is identified. The transducer is then rotated 90 degrees clockwise to produce a true sagittal image of the prostate. Depending on the degree of prostatic hypertrophy and the presence or absence of a middle lobe, this "V" may be more or less apparent and more or less anterior or posterior in its position. The apex of the prostate may be identified by using the hypoechoic urethra as a guide. The degree of protrusion of the prostate into the bladder may have some predictive value for bladder outlet obstruction. It has been shown that intravesical prostatic protrusion correlates relatively well with formal urodynamic evaluation of bladder outlet obstruction (Chia et al. The measurement is obtained by drawing a line corresponding to the bladder base on sagittal scan Limitations Transabdominal pelvic ultrasonography yields limited information in patients with an empty bladder. The ability to identify distal ureteral obstruction, bladder stones, and bladder tumors requires a full bladder. Although prostatic morphology and volume can be assessed with an empty bladder, it is much easier when the bladder is full. Pelvic structures may be difficult to evaluate in patients with a protuberant abdomen or panniculus. Automated measurement of bladder volume or residual urine, although using ultrasonography, is not an imaging study. Lack of imaging confirmation can lead to inaccurate residual urine determinations in patients with obesity, clot retention, ascites, bladder diverticulum, or perivesical fluid collection. Ultrasonography of the Scrotum No aspect of urologic care is better suited to the use of ultrasonography than evaluation of the scrotum. A B patient should be supine with the scrotum supported on a towel or on the anterior thighs. The patient should be draped in such a way as to hold the penis out of the way and to ensure patient privacy. Copious amounts of conducting gel should be used to provide a good interface between the transducer and the scrotal skin because air trapping by scrotal hair results in unwanted artifacts. Complete but gentle contact between skin and transducer is essential because excessive pressure results in movement of testis or compression of the testis. Some sonographers prefer the maneuverability of a 4-cm transducer, whereas others prefer the longer 7. Imaging should be done in a systematic fashion and should include sagittal and transverse views of the testis. The sagittal view should proceed from the midline medially and then laterally and from the midtransverse section of the testis to the upper pole and the lower pole of the testis. In addition to the testis, the epididymis and entire scrotal contents should be imaged. In this sagittal view of the prostate, the middle lobe extends into the bladder (A). Assessment of scrotal and testicular mass Assessment of scrotal and testicular pain Evaluation of scrotal trauma Evaluation of infertility Follow-up after scrotal surgery Evaluation of the empty or abnormal scrotum understanding of the anatomy and extensive experience with the diagnosis and treatment of disorders that affect the scrotum. Because the scrotum and its contents are superficial, high-frequency transducers may be employed to yield excellent and detailed anatomic and physiologic information. Imaging information can be correlated with findings on direct physical examination. Normal Findings It is important to document the size and, if appropriate, the volume of the testes. For example, lymphomatous or leukemic involvement of the testis may result in a diffusely hypoechoic and homogeneous appearance, which may be unilateral Technique Sound technique is critical to performing adequate ultrasonography of the scrotum. In general, the examination should be carried out in a quiet room that is adequately warm for patient comfort. In this longitudinal view the head of the epididymis (E) is seen to the left, and the lower pole of the testis is to the right. Normal testicular sonographic anatomy is characterized by a homogeneous finely granular appearance of the testis. Simultaneous bilateral views are important to rule out a diffuse infiltrative process such as lymphoma. A diffuse and homogenous change in echogenicity in one testis could otherwise be unappreciated. The presence of paratesticular fluid (F) permits the identification of the appendix epididymis (A) and the appendix testis (B). Intratesticular blood flow is primarily supplied by the testicular artery, which ultimately divides to supply the individual testicular septa. Procedural Applications the testis provides easy access for ultrasound localization of internal structures and therefore for percutaneous access. In particular, small nonpalpable lesions can be localized by ultrasound, guiding placement of a needle for percutaneous biopsy or injection of a dye for localization during open biopsy (Buckspan et al. Future ultrasound-guided applications may include spermatogonia stem cell transfer to testes devoid of germ cells after gonadotoxic therapies. The sagittal image of this testis demonstrates a common anatomic finding, the hyperechoic mediastinum testis (arrows). The mediastinum testis is a normal structure resulting from the coalescence of the fibrous septa of the testis. Sonoelastography Two recent studies have used real-time elastography to differentiate benign from malignant testicular lesions because it is postulated that malignant lesions have an increased stiffness resulting from a higher concentration of vessels and cells compared with surrounding tissues. Limitations Caution should be used when interpreting Doppler flow studies in the evaluation of suspected testicular torsion. Comparison with the contralateral testis should be performed to ensure that the technical attributes of the study are adequate to demonstrate intratesticular blood flow. Ultrasonography of the Penis and Male Urethra Ultrasonography of the penis and male urethra provides exquisite anatomic detail and may be used in many cases in lieu of studies requiring ionizing radiation. Perineal Ultrasound the more proximal aspects of the urethra and corpora cavernosa are best assessed through a perineal approach by placement of the transducer on the perineum (Video 4. The technique for penile and urethral ultrasonography includes imaging the phallus in the longitudinal and transverse plane. As for scrotal ultrasound, the examination is best carried out in a quiet room that is adequately warm for patient comfort. The examination is performed in a systematic fashion beginning at the base of the penis and proceeding distally to the glans. It is possible to get an image of the proximal urethra and corporal bodies by scanning through the scrotum or the perineum. It may be helpful when evaluating the penile urethra, especially for stricture disease, to inject a sterile gel into the urethra in a retrograde fashion. This distends the urethra and allows better identification of urethral anatomy and the anatomy of the corpus spongiosum. Transperineal Ultrasound Transperineal and translabial ultrasound have also been used for evaluation of the pelvic floor for diagnostic and postprocedural follow-up. Further, in contrast to a transvaginal approach, they are noninvasive and do not distort the pelvic anatomy (Baxter and Firoozi, 2013). Excellent visualization of the female bladder, urethra, and pelvic floor can also be obtained via translabial ultrasound. This minimally invasive technique is performed by placing a 5-mHz curved array probe between the labia majora. This allows direct visualization of the urethra, including presence of urethral diverticula, tumors, or foreign bodies. The relationship between the bladder, urethra, and pelvic musculature can be assessed in real-time in cases of stress urinary incontinence and pelvic organ prolapse. This technique is also useful in assessing complications of urethral slings and pelvic reconstruction. A transverse view of the phallus with the transducer placed either on the dorsal or ventral surface. Note the compression of the urethra and corporal spongiosum compression in the ventral projection with minimal pressure applied to the phallus. Penile cavernosal artery internal diameter less than 1 mm can often be the first indication of vascular disease. The finding of arteriogenic dysfunction can often provide a window of opportunity (Miner, 2011) to identify and potentially alter the progressive nature of systemic vascular disease (Gazzaruso et al. Assessment of penile curvature most often involves palpation and ultrasound interrogation of the pharmacostimulated phallus.

Nonsteroidal antiinflammatory medication should be avoided because of the risk for premature closure of the ductus arteriosus rheumatoid arthritis khan academy effective 100 mg voltaren. Chronic use of narcotics during pregnancy may cause fetal dependency numbness in fingers rheumatoid arthritis purchase voltaren overnight delivery, and it is recommended that the pregnant postsurgical patient be weaned off narcotic use as soon as possible best mattress for arthritis in back 50 mg voltaren free shipping. Notably rheumatoid arthritis in feet symptoms generic 50mg voltaren amex, hypertension and dyspnea were the most frequently seen comorbid risk factors in patients older than 80 years of age arthritis in back at 25 order voltaren 100mg without prescription, and preoperative transfusion history arthritis pain relief aleve order voltaren overnight delivery, emergency operation, and weight loss best predicted postoperative morbidity. Additionally, each 30-minute increment of operative time increased the odds of mortality by 17% in octogenarians (Turrentine et al. A unique and important factor in the perioperative care of the elderly is in the identification and prevention of delirium. Often overlooked as "sundowning," delirium can be the first clinical sign of metabolic and infectious complications (Townsend et al. Morbid Obesity the careful selection of the morbidly obese patient for elective surgery is of paramount importance. With the rising incidence of obesity, one must carefully weigh and balance the risk associated with any surgical procedure with the natural history of the disease when deciding the optimal time of the surgery in the morbidly obese. Cardiac symptoms such as exertional dyspnea and lower extremity edema are nonspecific in morbidly obese patients, and many of these patients have poor functional capacity. The physical examination often underestimates cardiac dysfunction in the severely obese patient. Severely obese patients with more than three coronary heart disease risk factors may require noninvasive cardiac evaluation (Poirier et al. Morbidly obese patients often have atherosclerotic cardiovascular disease, heart failure, systemic hypertension, pulmonary hypertension related to sleep apnea and obesity, hypoventilation, cardiac arrhythmias, deep vein thrombosis, history of pulmonary embolism, and poor exercise capacity. There are also numerous pulmonary abnormalities that result in a ventilation perfusion mismatch and alveolar hypoventilation. Obesity is a risk factor for postoperative wound infections, and, when appropriate, laparoscopic surgery should be considered. Nutritional Status Malnutrition compromises host defenses and increases the risk for perioperative morbidity and mortality. Adequate nutritional status is essential for proper wound healing, mounting appropriate immune response to infections, return of bowel activity, and maintenance of vital organ function (Evans et al. A 20-pound weight loss in the preceding 3 months before surgery is considered to be a reflection of severe malnutrition. The lymphocyte count and serum albumin level reflect visceral protein status, with lower levels indicating malnutrition (Reinhardt et al. Several studies have shown that 7 to 10 days of preoperative parenteral nutrition improves postoperative outcome in undernourished patients (Von Meyenfeldt et al. However, its use in well-nourished or mildly undernourished patients either is of no benefit or increases the risk for sepsis (Veterans Affairs Total Parenteral Nutrition Cooperative Study Group, 1991). Enteral nutrition is accomplished via a feeding tube, gastrostomy, or feeding jejunostomy. Enteral nutrition has the added benefits of maintaining the gut-associated lymphoid tissue, enhancing mucosal blood flow, and maintaining the mucosal barrier. There are hundreds of enteral products on the market, and most have a caloric density of 1 to 2 kcal/mL. These formulas are also lactose free and provide the recommended daily allowances of vitamins and minerals in less than 2 L/day. The guidelines recommend postoperative parenteral nutrition in patients who are unable to meet their caloric requirements within 7 to 10 days. Just as in the perioperative state, enteral feedings are preferred over parenteral nutrition when feasible (Sigalet et al. Dislodgement of nasoenteral tubes and percutaneous enteral catheters can result in pulmonary and peritoneal complications. Adynamic ileus may also occur because of decreased splanchnic perfusion, sympathetic tone, or opiate use. These include pneumothorax or hemothorax secondary to poor line placement and chylothorax secondary to thoracic duct injury. Line sepsis is the most common complication of indwelling central catheters and necessitates catheter removal. Venous thrombosis with associated thrombophlebitis and extremity edema has been reported. Catheter thrombosis has also been reported and can be Pregnancy Urologic surgery in the pregnant woman is most commonly related to the management of renal colic and urinary tract stones. The stones can be discovered during the sonographic evaluation of the fetus in an asymptomatic pregnant woman or during the evaluation of the pregnant woman who is experiencing renal colic. In general, a surgical procedure in the pregnant woman should be delayed, if at all possible, until the baby is mature enough for delivery unless significant harm to the mother or fetus will result. The indications for operative intervention in the pregnant patient are discussed elsewhere in this book. During the first trimester, the fetus may be directly exposed to the teratogenic effects of certain anesthetic agents. Later in pregnancy, anesthesia places the mother at risk for preterm labor and the fetus at risk for hypoxemia secondary to changes in uterine blood flow and maternal acid-base imbalance. For semi-elective procedures, an attempt should be made to delay surgery until after the first trimester. However, one must consider the continued exposure of the underlying condition in relation to the operative risks to both the mother and fetus. The second trimester is the safest time to perform surgery because organ system differentiation has occurred and there is almost no risk for anestheticinduced malformation or spontaneous abortion. Just as adequate preoperative evaluation is important, optimization of comorbid illness is critical in improving surgical outcomes and in reducing perioperative morbidity and mortality. With regard to cardiac disease, many studies have evaluated the prophylactic use of nitrates, calcium-channel blockers, and -blockers for patients who are at risk for perioperative myocardial ischemia. Similarly, a retrospective, cooperative group study of more than one-half million patients showed that perioperative -blockade is associated with a reduced risk for death among high-risk patients undergoing major noncardiac surgery (Lindenauer et al. In addition to -blockade, the concept of goal-directed therapy, employing the judicious use of fluids, inotropes, and oxygen therapy to achieve therapeutic goals may further reduce perioperative risk (Pearse et al. This concept was validated by Shoemaker, who reported an impressive reduction in mortality from 28% to 4% (P <. Smoking must be discontinued at least 8 weeks before surgery to achieve a risk reduction. Patients who discontinue smoking less than 8 weeks before surgery may actually have a higher risk for complications because the acute absence of the noxious effect of cigarette smoke decreases postoperative coughing and pulmonary toilet (Pearce and Jones, 1984). However, patients who stop smoking at least 8 weeks preoperatively will significantly lower their complication rate, and patients who have ceased smoking for more than 6 months have a pulmonary morbidity comparable with that of nonsmokers (Warner et al. Aggressive treatment of preexisting pulmonary infections with antibiotics and the pretreatment of asthmatic patients with steroids are essential in optimizing pulmonary performance. Likewise, the use of epidural and regional anesthetics, vigorous pulmonary toilet, rehabilitation, and continued bronchodilation therapy is all beneficial (Arozullah et al. As with cardiopulmonary comorbidities, the preoperative management and optimization of diabetic patients are quite important. Perioperative hyperglycemia can lead to impaired wound healing and a higher incidence of infection (Golden et al. Hypoglycemia in an anesthetized or sedated diabetic patient may be unrecognized and carries its own significant risks. Shorter-acting agents or sliding-scale insulin regimens are preferable, in general. It is recommended that blood glucose levels be controlled between 80 and 250 mg/dL. Frequent fingerstick glucose checks and a sliding scale short-acting insulin regimen are used in the postoperative period. Patients who manage their diabetes with the use of insulin pumps should continue their basal insulin infusions on the day of surgery. Patients with either hyperthyroidism or hypothyroidism should be evaluated by an endocrinologist, and surgery should be deferred until a euthyroid state has been achieved. The greatest risk in the hypothyroid patient is thyrotoxicosis, or thyroid storm, which can manifest with fevers, tachycardia, confusion, and cardiovascular collapse. Atrial fibrillation may also be present in 20% of hyperthyroid patients (Klein and Ojamaa, 2001). With regard to hyperthyroidism, careful attention should be given to the airway because the trachea can be compressed or deviated by a large goiter. In general, antithyroid medications such as propylthiouracil or methimazole, as well as -blockers, are continued on the day of surgery. In the event of thyroid storm, iodine and steroids may be necessary (Schiff and Welsh, 2003). Hypothyroidism is usually associated with an increased sensitivity to medications such as anesthetic agents and narcotics. Symptoms include lethargy, cold intolerance, hoarseness, constipation, dry skin, and apathy. The decrease in metabolic rate produces periorbital edema, thinning of the eyebrows, brittle hair, dry skin, hypothermia, bradycardia, and a prolonged relaxation of the deep tendon reflexes (Murkin, 1982). Once the diagnosis has been confirmed by a low thyroxine level and an elevated thyroid stimulating hormone level, thyroid replacement with levothyroxine can be initiated (Schiff and Welsh, 2003). For patients who take 5 mg of prednisone or the equivalent each day, no supplemental steroids are necessary, and the usual daily glucocorticoid dose may be given in the perioperative period. Minor procedures under local anesthesia do not require stress-dose steroids (Schiff and Welsh, 2003). Antithrombotic Therapy Most urologic patients have medical comorbidities; urologists frequently encounter patients on chronic vitamin K antagonist therapy. Perioperative management including interruption of this antithrombotic therapy can be a challenging problem. Therefore, urologists must carefully consider and balance the risks and benefits of interruption of chronic anticoagulation to determine the best course of perioperative management of these medications. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Patients with mechanical heart valves can also be stratified into risk groups according to the location (mitral vs. An increasing number of patients are receiving chronic antiplatelet therapy in the prevention of cardiovascular events and, more important, in the prevention of coronary stent thrombosis. Although the former indication poses little controversy for the urologist, the latter indication presents a significant and complex clinical challenge in which the urologist must weigh the risk for bleeding with the potentially devastating risk for perioperative stent thrombosis. Aspirin and clopidogrel are the two most commonly used antiplatelet drugs and are frequently used together. Both are irreversible inhibitors of platelet function and therefore need to be stopped 7 to 10 days before surgery to minimize bleeding risk. Current recommendations require dual antiplatelet therapy for 6 weeks after bare metal coronary stents and 12 months for drug-eluting stents. In most patients, urologists should defer elective surgery until after antiplatelet therapy can be safely interrupted. Even then, because acute stent thrombosis has been described with drug-eluting stents after 12 months, urologists should strongly consider at least single-agent antiplatelet therapy in these patients. Given the current lack of clinically useful alternatives to antiplatelet therapy, when surgery cannot be delayed. Nevertheless, communication between the urologist and the cardiologist throughout the perioperative period is essential to minimize complications and maximize outcomes. The rationale for bowel preparation before intestinal surgery is to decrease intraluminal feces and decrease bacterial colony counts to decrease the rate of anastomotic leak, intra-abdominal abscesses, and wound infections. The preparation itself consists of two components: antibiotic preparation and mechanical preparation. Because there are only a few small series in the urologic literature, the rationale for each must be inferred from the general surgery literature-specifically, from colorectal surgery literature. Although preoperative parenteral antibiotic prophylaxis before intestinal surgery is well established and widely used, oral antibiotic preparation is still somewhat controversial. The most commonly used regimen, oral neomycin and erythromycin, first became established in 1977 with the landmark study by Clark et al. In a double-blind, placebo-controlled study, 167 patients undergoing elective colonic surgery were randomized to receive mechanical bowel preparation with or without oral neomycin and erythromycin. The overall rates of septic complications were 43% with mechanical-only preparation and 9% with antibiotic plus mechanical preparation (P =. However, with current standards of the use of preoperative parenteral antibiotics, Chapter 8 the benefit of oral antibiotic preparation was debated. The disadvantage of oral antibiotic preparation is primarily related to increased incidence of pseudomembranous colitis secondary to Clostridium difficile infection. Inferring from the colorectal literature, most current guidelines and a 2014 Cochrane review recommend that antibiotics covering aerobic and anaerobic bacteria delivered orally or intravenously (or both) before elective colorectal surgery reduce the risk for surgical wound infection by as much as 75% (Nelson et al. Despite the lack of level 1 evidence in the literature, a recent survey of colorectal surgeons revealed that up to 87% of surgeons continue to administer oral antibiotic bowel preparation before elective surgery (Zmora et al. In the 2014 Cochrane review, however, it was acknowledged that it is unknown whether oral antibiotics would have any beneficial effect in reducing surgical wound infection when the colon is not empty (Nelson et al. Mechanical bowel preparation predates the use of antibiotics in intestinal surgery and was thought to decrease the rate of anastomotic complications. Before the development of nonabsorbable liquids, patients underwent several days of oral laxatives, bowel irrigations via nasogastric tubes, and repeat enemas. These regimens were associated with significant patient discomfort and clinical morbidity caused by electrolyte imbalances. Both regimens are suitable for most patients; however, polyethylene glycol is preferred in the elderly and in patients with renal insufficiency, congestive heart failure, existing electrolyte disturbances, and cirrhosis because it is completely nonabsorbable. The benefit of mechanical bowel preparation has been assumed for decades as evidenced by 99% positive response by colorectal surgeons when asked if mechanical preparation is routinely used (Zmora et al. The analysis included 14 trials including two large trials from the Netherlands and Sweden (Contant et al.

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