Francis M. Mondimore, M.D.

• Director, Mood Disorders Clinic, Johns Hopkins Bayview Medical Center.
• Associate Professor of Psychiatry and Behavioral Sciences

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0003881/francis-mondimore

Five patients with recurrence of the rectocele did not have prolapse in other compartments (Lim et al knee pain treatment bangalore buy on line rizact, 2005) pain treatment for osteoporosis buy rizact 10 mg otc. When deciding on treatment options for the posterior compartment pain treatment center albany ky buy genuine rizact line, both the surgeon and the patient should be aware that graft extrusion rates of 1 myofascial pain syndrome treatment guidelines cheap rizact 10 mg fast delivery. The proposed advantages of kits are a "less invasive" procedure pain treatment bone metastases purchase rizact mastercard, standardization of technique pain treatment center st louis 5 mg rizact free shipping, standardization of mesh, and the ability to repair multiple compartments through a vaginal approach. The presence of the mesh at the level of the vaginal apex with fixation is in contrast to the traditional colporrhaphy and may provide correction to multiple compartments, thus making comparisons with traditional prolapse repairs challenging. Implanting surgeons must realize that these procedures are using a significantly higher volume of mesh than conventional mid-urethral slings, and some procedures involve placing trocars into the deep pelvic musculature. Thus, pelvic surgeons must make an informed decision with the patient, which weighs the apparent advantage in anatomic efficacy, decreased invasiveness, and potential durability against the potential morbidity associated with mesh erosion and the possibility of more significant complications unique to these procedures. The anterior prolapse repair follows many of the same basic steps for all of the kit procedures. The full-thickness dissection is important to minimize the occurrence of vaginal exposure of mesh. The dissection progresses laterally to the level of the endopelvic fascia, which is entered by sharp or blunt dissection. The distal incisions are placed in the anteromedial edge of the obturator foramen at the level of the clitoris, and the proximal incisions are placed 2 cm below and 1 cm lateral to the distal incision. It should be noted that the proximal trocars in the Perigee system are different from the distal needles, which facilitates a deep passage of the proximal devices to the ischial spine. Sutures are used to fix the mesh both proximally at the level of the vaginal cuff (preferably delayed absorbable or permanent sutures) and distally proximal to the bladder neck with absorbable sutures. Before mesh placement, anterior colporrhaphy may be performed to correct a central defect if present. Care is taken to confirm the absence of excessive tension on each of the mesh arms (or points of attachment). The vagina is then closed without trimming the vaginal wall to minimize the occurrence of vaginal mesh extrusion. A loosely interrupted vertical mattress closure may be used to create a virtual two-layer closure of the vaginal epithelium. For all procedures, the dissection begins with a posterior vaginal incision, which is full thickness. The dissection proceeds laterally and proximally to expose the ischial spine (Apogee). With a hand in the vagina retracting the rectum, the trocars are advanced through the ischiorectal fossa. The mesh is trimmed so that it does not extend to within 1 cm of the perineal body. The mesh is fixed with permanent or delayed absorbable suture proximally to the vaginal apex or posterior lip of the cervix. As with the anterior compartment, no trimming of the epithelium is recommended, and closure is completed with absorbable suture. There is a special tool that facilitates adjustment of mesh tension after the tacking mechanism has been deployed proximally. An advantage of these devices is that there are no trocar passes required through the deep pelvic musculature. As with all prolapse procedures, there is a paucity of peerreview data to guide the most appropriate usage of transvaginal kits. Much of the literature regarding kits is from the experience with the Prolift device, not currently available in the United States. GauruderBurmaster and colleagues reported on a retrospective analysis of 121 women undergoing procedures with Apogee or Perigee mesh. Five mesh exposures occurred, and there were no other significant complications (Moore and Miklos, 2009). Rane and colleagues reported on a 5-year prospective experience with the Perigee system for anterior repair. Five required repeat prolapse surgery, 2 having hysterectomy for stage 3 uterine prolapse. Two patients had hematoma- one requiring evacuation and another a transfusion (Rane et al, 2012). With a minimum of 1-year follow-up in all patients, the authors concluded that the anatomic outcomes were significantly better after the Perigee procedure for the anterior defect. A prospective multicenter trial evaluated Elevate anterior and apical compartment repair. Three of the mesh excision patients required in-office revision, and 3 required revision under anesthesia (Stanford et al, 2013). Rapp and colleagues evaluated the Elevate procedure prospectively in 40 patients for a minimum of 2 years (mean 34 months). These authors also noted that 36 patients experienced anatomic success, with only 4 having recurrent prolapse, of whom 2 were symptomatic. There were significant improvements in the QoL questionnaire assessments, leading these authors to conclude that the Elevate is a safe and effective system for prolapse correction (Rapp et al, 2014). Feiner and colleagues performed a meta-analysis of the peer-reviewed literature and select peer-reviewed gynecologic abstracts to evaluate outcomes and complications following transvaginal synthetic apical suspension procedures. After the Apogee procedure, 525 women had a mean follow-up of 26 weeks (range 10 to 56 weeks). In the same meta-analysis, posterior or total Prolift was performed in 1295 women with mean follow-up time of 30 weeks (range 12 to 52 weeks), and the mean objective success rate was 87% (range 75% to 94%) (Feiner et al, 2009). Although these early data demonstrate successful outcomes, it is important to note that serious complications, some unique to these procedures, are being reported. These concerns have prompted comments regarding new procedures and materials for the treatment of incontinence and prolapse, warning that there are insufficient data supporting the routine use of these devices (Ostergard, 2007). Local complications such as pelvic pain, defecatory pain, and dyspareunia have been reported after kit procedures (Altman and Falconer, 2007; de Tayrac et al, 2007). When examining these patients, one must carefully look for areas of impaired healing, banding or tenting of the mesh, "trigger points" that elicit pain, and signs of focal inflammation. If these abnormal areas are identified, release of the arms or the site of mesh tension may alleviate these areas of discomfort. When performing the mesh release, one should excise as much offending mesh material as possible before vaginal closure. In cases of infection, granulomas, or persistent draining sinuses, all mesh involved in the infected areas must be removed. If no local incriminating factors are found, a period of conservative therapy consisting of physical therapy, trigger point injections, and other adjunctive techniques should be attempted first. In light of this, it is incumbent on physicians to openly discuss these issues with patients. The exposures seem to occur more frequently on the anterior wall, and a concomitant hysterectomy significantly increases the risk (de Tayrac et al, 2007; Gauruder-Burmester et al, 2007). Measures to minimize the occurrence of vaginal mesh exposure are minimizing excessive vaginal wall trimming and closing without tension. Some advocate closing with a vertical mattress technique to separate the graft from the wound (de Tayrac et al, 2006a). Examination by palpation as well as visualization is important to detect this complication. Although some patients can be managed with either observation or local treatment, most will require excision with primary vaginal closure (de Tayrac et al, 2006a). Infected vaginal mesh can lead to sinus formation, abscess, and enterovaginal fistula formation. One case of necrotizing fasciitis with Staphylococcus aureus requiring extensive perineal debridement and colostomy has been reported after a kit procedure (Abdel-Fattah et al, 2008). Unfortunately, significant lower urinary tract erosion into the bladder or urethra has also been reported, with significant consequences (Yamada et al, 2006). Including transvaginal kits systems, the incidences of visceral (including urethra) injuries have been reported from 2. Bladder perforation after retropubic mid-urethral sling procedures is not uncommon and appears to be a benign event in the presence of adequate bladder drainage (Kuuva and Nilsson, 2002). The fate of bladder injury at the time of mesh prolapse repairs is much less certain. If the bladder is injured, it is our opinion that the procedure should be completed without a mesh interposition of the anterior compartment, as placing mesh in the setting of a bladder laceration would prohibitively increase the risk of erosion. Extensive erosions into the bladder necessitating partial cystectomy have been reported (Abdel-Fattah et al, 2008). With urethral injury, the defect should be repaired primarily, and again, mesh or graft placement should not be performed. If rectal injury is recognized intraoperatively, synthetic mesh should not be placed (Mercer-Jones et al, 2004; de Tayrac et al, 2006b). Rectal erosion of synthetic mesh may necessitate both rectal and vaginal excision (Hurtado et al, 2007). From these outcomes, it is clear that if the rectum is perforated, a multilayer closure should be performed; povidone-iodine distention of the rectum should follow to ensure the integrity of the repair, and the procedure should be abandoned. The trocars are passed through the pelvic muscular complex for both anterior and posterior kit repairs. The trocars pass near the ischial spine, and significant intraoperative bleeding may occur. This would usually emanate from the pudendal neurovascular bundle, and embolization of the source of bleeding has been reported (Mokrzycki and Hampton, 2007). Multiple authors have reported pelvic hematomas following transvaginal kit procedures (Ignjatovic and Stosic, 2007; LaSala and Schimpf, 2007; AbdelFattah et al, 2008). Abdel-Fattah described concerning vascular complications after Prolift and Apogee or Perigee procedures, including arterial injury. Commonly, patients will report unusually more pelvic pain than typically encountered. Biologic materials have been used, but unfortunately have had inconsistent results owing to variability of graft function. To accomplish this, considerably more vaginal dissection through wider incisions is required. Fluid accumulation or bleeding from deep dissection as well as tension or buckling of the mesh sheets may adversely affect graft incorporation, leading to an exposure, erosion, or pain. Tacking or tunneling of larger volumes of mesh into the deep pelvic musculature may lead to neuromuscular dysfunction of the levator ani complex and subsequent pelvic floor dysfunction. Lastly, some surgeons who were not performing transvaginal tissue-based prolapse repairs may have started performing these procedures as an "extension" of the transobturator technique. There is no doubt that a number of high-volume accomplished vaginal surgeons are performing meshbased prolapse repairs safely on their patients (Murphy et al, 2012). With the first-generation mid-urethral sling, the efficacy and safety have been demonstrated worldwide through multiple studies with little dispute (U. Most would agree that anatomic outcomes appear better in the anterior compartment (Maher et al, 2013a). When subjective outcomes and reoperation rates are included, the data regarding mesh for prolapse are less clear- distinctly opposite from the first-generation mid-urethral sling (U. This message describes a risk associated with the use of a medical device and provides recommendations to avoid or reduce the risk. As a result, a number of recommendations were made to physicians, which included obtaining specialized training for each mesh placement technique and informing patients that implantation of surgical mesh is permanent. It was also recommended to inform patients about the potential for serious complications and their adverse effect on QoL. Longer follow-up data is available in the literature, but there are fewer of these long-term studies compared to studies with one-year follow-up. During this period, any prolapse kits using mesh currently available will still be able to be used by surgeons. No premarket data or postmarket 522 data will be required for the first-generation mid-urethral sling procedures (retropubic and obturator) (U. Millions of dollars have already been awarded, and this figure will likely rise exponentially. Some of these advertisements contend that the mesh is "defective" and has been "recalled. What can we do to appropriately counsel and guide our patients regarding surgical procedures that are best for them It is clear that these answers do not exist, and comparative trials as well as registries are desperately needed to guide us through this process. They should be informed that they are getting mesh (and why it is best for them), that there are nonmesh alternatives, and that there are complications that do occur that are unique to mesh. They should be informed that these complications may be permanent and may require more than one operation, which may or may not correct the problem. Patients should also be informed that the most common complication unique to mesh is mesh exposure, which may be asymptomatic or may require a surgical revision, which may address the problem. They should be encouraged to learn more about their procedure in advance of the surgery. Mesh techniques are an adjunct to perform pelvic floor procedures in properly selected patients. Obtaining proficiency in these surgical skills should precede any introduction of apical mesh kit procedures. Surgeons should directly address these concerns and offer assistance in second-opinion referrals in the absence of an explanation. With the current uncertainty and negative perceptions of mesh, patients need reassurance that their concerns are adequately addressed and that reasonable attempts are being made to address them.

Imprecise verbiage on the pathology report can lead the urologist to misinterpret invasion of muscularis mucosae to be muscle invasive pain treatment center hartford ct buy 5 mg rizact free shipping, risking an overstaging error pain treatment guidelines buy rizact overnight. Direct communication between urologist and pathologist is essential when this occurs pain management for dogs with bone cancer buy 5 mg rizact visa. These evaluations can show that low-grade papillary tumors tend to exhibit relatively few chromosomal abnormalities pain management treatment purchase rizact 5 mg line, primarily involving loss of all or part of chromosome 9 (particularly the q arm comprehensive pain headache treatment center derby ct generic 5 mg rizact otc, which holds tumor-suppressing loci) pain treatment video cheap rizact 5 mg without a prescription. In contrast, high-grade tumors tend to have numerous and greatly variable chromosomal gains and losses. In addition to their relatively predictable aneuploidy, high-grade tumors can also lose all or part of chromosome 9 (Richter et al, 1997). Although almost any chromosome can be affected, aneuploidy of chromosomes 7, 9, and 17 is associated with especially aggressive tumors (Olumi et al, 1990; Waldman et al, 1991; Degtyar et al, 2004). Because of these differing genetic imprints, it has been suggested that papillary pTa tumors could almost be considered benign and might be a completely separate disease entity in contrast to high-grade tumors (Sauter and Mihatsch, 1998; Harnden, 2007). However, the value of substaging has not been validated in other studies (Platz et al, 1996), so the 1998 Bladder Cancer Consensus Conference Committee rejected the concept (Epstein et al, 1998). Although recurrence is common, especially in the setting of multiplicity, progression is rare. Microscopically, the slide will demonstrate disorderly histology with nuclear atypia characteristic of high-grade malignancy; denudement of some or all of the mucosa as a result of loss of cellular cohesion sometimes complicates interpretation. Again, unambiguous communication between pathologist and urologist can minimize the risk for misinterpretation. The presence of irritative voiding symptoms has been associated with diffuse disease, invasion, and a compromised prognosis, but there is no consensus on this finding in the literature (Smith et al, 1999; Sylvester et al, 2005). TumorBiology Low-grade tumors rarely invade the lamina propria or detrusor, so invasive tumors may be almost equated with high-grade histology. However, tumors of all grades and degrees of potential aggressiveness can be identified before invasion, so no such grading assumption can be made about these lesions. Low-grade Ta lesions recur at a rate of 50% to 70% and progress in approximately 5% of cases. In contrast, high-grade T1 lesions recur in more than 80% of cases and progress in 50% of patients within 3 years. This behavior is primarily grade, rather than stage, dependent, because high-grade tumors progressed with similar frequency regardless of whether they were invasive (T1) or noninvasive (Ta) (Herr, 2000b). Prognosis also correlates with tumor size, multiplicity, papillary versus sessile configuration, presence or absence of lymphovascular invasion, and status of the remaining urothelium (Althausen et al, 1976; Lutzeyer et al, 1982; Heney et al, 1983a, 1983b; Kunju et al, 2008). The variance in biologic behavior for low-grade versus highgrade lesions correlates with the known dual molecular lines of genetic development for these two pathways and supports the concept that high-grade and low-grade cancers may be considered as essentially different diseases (Hasui et al, 1994; Droller, 2005). These usually follow an indolent course unless they convert to or are associated with a tumor of the second pathway (Kiemeney et al, 1993). Urinary cytology is obtained as a baseline and to establish the likelihood of high-grade disease. Retrograde pyelography or ureteroscopy can be planned for any upper tract abnormalities identified. Expert consensus is that patients with solitary or limited low-grade Ta lesions do not need imaging unless they have concomitant hematuria, owing to the very low risk of extravesical disease (Goessl et al, 1997; Davis et al, 2012). Bimanual examination of the bladder is often performed with the patient under anesthesia before preparation and draping unless the tumor is clearly small and noninvasive, and is repeated after resection. Fixation or persistence of a palpable mass after resection suggests locally advanced disease, although the additional value of this maneuver in the era of modern imaging appears limited and may even be misleading (Ploeg et al, 2012). An increase in abdominal girth or fullness after resection suggests intraperitoneal perforation. Complete visualization to plan the resection is facilitated by either the flexible cystoscope or preferably the 70-degree rigid rod lens, which allows maintenance of the anatomic relationships. Resection is performed using a 12- or 30-degree lens placed through a resectoscope sheath because this deflection allows visualization of the loop placed at this location. Continuous irrigation with the bladder filled only enough to visualize its contents minimizes bladder wall movement and lessens thinning of the detrusor through overdistention, which should reduce the risk of perforation (Koch and Smith, 1996). Resection is performed piecemeal, delaying transection of any stalk until most tumor has been resected, to maintain countertraction. Friable, low-grade tumors can often be removed without the use of electrical energy because the nonpowered cutting loop will break off many low-grade tumors. This minimizes the chance of bladder perforation and unnecessary cautery damage or loss of specimens. Higher-grade, more solid tumors and the base of all tumors require the use of cutting current; cautery yields hemostasis once the entire tumor has been resected. Lifting the tumor edge away from detrusor lessens the chance of perforation (Holzbeierlein and Smith, 2000). Repeated slow fulguration may complicate the ability of the pathologist to determine grade or invasion status. In patients with multiple tumors who had adjuvant treatment, recurrence rates varied from 7. After all visible tumor has been resected, an additional pass of the cutting loop or a cold-cup biopsy can be obtained to send to pathology separately to determine the presence of muscle invasion of the tumor base. Final confirmation of hemostasis in the presence of minimal irrigation after all chips have been removed through vigorous irrigation is helpful. Deep penetration into the lamina propria, especially if involving muscularis mucosae, increases the risk of recurrence and progression in some reports. Lymphovascular invasion (Lotan et al, 2005), pyuria (Azuma et al, 2013), and bladder neck involvement (Kobayashi et al, 2014) also increase this risk. His subsequent review noted that understaging errors from 34% to 62% have been reported (Stein et al, 2001), and a study from the Mayo Clinic before widespread use of intravesical therapy showed that 78% of patients with clinical T1 disease who underwent cystectomy had muscle invasion, with 62% having extravesical disease. Although it is likely that the patients who underwent cystectomy had more serious risk factors than those who did not, these data offer compelling evidence that the term superficial to describe all such lesions is misleading and would ideally be eliminated from urologic practice and the literature. Glycine is more expensive, and there is no evidence of its benefit in this setting compared with water (Holzbeierlein and Smith, 2000). The use of general anesthesia with muscle-paralyzing agents also prevents obturator reflex, although I find this rarely necessary. This can also be accomplished by direct injection of 20 to 30 mL of local anesthetic (lidocaine) into the obturator nerve and its canal, but few centers have experience with this (Khorrami et al, 2010). Resection of diverticular tumors presents significant risk of bladder wall perforation, and accurate staging is difficult to achieve in this circumstance because the underlying detrusor is absent. Invasion beyond the diverticular lamina propria immediately involves perivesical fat (stage T3a by definition). Low-grade diverticular tumors are best treated with a combination of resection and fulguration of the base. Conservative resection can be followed with subsequent repeat resection if the final pathologic interpretation is high grade. High-grade tumors require adequate sampling of the tumor base, often including perivesical fat, despite the near certainty of bladder perforation. Partial or radical cystectomy should be strongly considered for high-grade diverticular lesions. Anterior wall tumors and tumors at the dome in patients with large bladders can be difficult to reach. Minimal bladder filling combined with manual compression of the lower abdominal wall to bring the tumor toward the resectoscope facilitates removal. Modern resectoscopes are long enough to reach the entirety of most bladders; creation of a temporary perineal urethrostomy offers deeper access but is rarely necessary except in the obese patient with an inaccessible tumor. Digital manipulation through the rectum or vagina can occasionally facilitate resection. Care must be taken during resection near the ureteral orifice to prevent obstruction from scarring after fulguration. Pure cutting current causes minimal scarring and may be safely performed, including resection of the orifice if necessary. Resection of the intramural ureter can sometimes lead to complete eradication of the tumor but risks reflux of malignant cells. Alternatively, small tumors may be resected using the cold-cup biopsy forceps alone. This is especially helpful in elderly women, who are predisposed to perforation owing to their thin-walled bladders. A successful cauterization method involves placing the Bugbee electrode inside the biopsy site with the bladder under minimal distention. When the electrode touches the cut surface of the biopsy crater, the electrical energy will cause the mucosa to contract around the electrode unless the bladder is full. Light irrigation clears the area of blood and vaporization bubbles created during fulguration. Visualizing a small (1 to 2 mm) ring of white coagulation confirms hemostasis and yields less damage to the bladder than that occurring when the biopsy area is "painted" with cautery. Removing the electrode from the site before discontinuing the energy current lessens the chance of pulling the fresh clot off as the Bugbee electrode separates from the urothelium. If a tumor appears to be muscle invasive, biopsies of the borders and base to establish invasion may be performed in lieu of complete resection, because cystectomy will likely follow based on confirmatory biopsies. Failure to demonstrate invasion necessitates repeat resection unless the decision is made to proceed to cystectomy based on factors other than muscle invasion. The necessity of obtaining detrusor muscle in the surgical specimen is widely taught but not established in benefit. For example, the potential for muscle invasion for low-grade disease is essentially nonexistent, so a transmural biopsy offers little potential benefit compared with the risk of bladder perforation incurred. The major complications of uncontrolled hematuria and clinical bladder perforation occur in fewer than 5% of cases, although a majority of patients will exhibit contrast agent extravasation indicative of minor perforation if cystography is performed. The incidence of perforation can be reduced by attention to technical details, avoiding overdistention of the bladder, and using anesthetic paralysis during the resection of significant lateral wall lesions to lessen an obturator reflex response. Moreover, large, bulky tumors and those that appear to be muscle invasive are often best resected in a staged manner because it is believed that repeat resection can more safely remove residual tumor if indicated. The vast majority of perforations are extraperitoneal, but intraperitoneal rupture is possible when tumors are resected at the dome (Collado et al, 2000). The risk of tumor seeding from perforation appears to be low (Balbay et al, 2005). Anecdotal reports have identified extravesical recurrences after perforation, theoretically caused by seeding (Mydlo et al, 1999). It has been suggested that the risk of tumor seeding is higher in patients who undergo surgical repair, but this may be related to patient selection because only serious intraperitoneal perforations are likely to be managed in this manner (Mydlo et al, 1999; Skolarikos et al, 2005). Management of extraperitoneal perforation by prolonged urethral catheter drainage is usually possible. Intraperitoneal perforation is less likely to close spontaneously and usually requires open or laparoscopic surgical repair. Decisions for surgical correction should be made on the basis of the extent of the perforation and the clinical status of the patient. As long as resection of the ureteral orifice is performed with pure cutting current, scarring is minimal and obstruction unlikely. Cystoscopy to visualize efflux, which is occasionally aided by intravenous administration of indigo carmine or methylene blue or retrograde ureteropyelography, can determine presence or absence of obstruction. If fluorescence cystoscopy is in use as described later, the urine jet will fluoresce brightly as well. If the orifice is resected or cautery is used nearby, renal ultrasonography in the postoperative period can identify asymptomatic obstruction. Balloon dilation of the orifice or endoscopic incision can relieve obstruction, but failure to respond will rarely necessitate reimplantation (Chang et al, 1989). The potential for understaging high-risk disease ranged from 18% to 37% (Amling et al, 1994). The Vanderbilt University group reported a 64% risk of understaging T1 lesions when muscle was absent, compared with 30% when muscle was present in the specimen (Dutta et al, 2001). Herr (1999) reported that a second resection changed treatment in one third of patients. Repeat resection is helpful in the setting of a second opinion unless clear evidence of muscle invasion is identified on the initial resection, especially if the outside pathology slides are not available for review. Alternatively, subspecialty pathologic reinterpretation at the time of second opinion can yield information potentially leading to a change in management in almost one third of patients (Lee et al, 2010). The consensus is that patients with pT1 and many high-grade Ta tumors merit repeat resection. There is no consensus on timing, but most authors recommend 1 to 6 weeks after the initial resection (Nieder et al, 2005). LaserTherapy Laser coagulation allows minimally invasive ablation of tumors up to 2. Lesions can be coagulated until nonviable through protein denaturation using a straight or 90-degree noncontact "free beam" laser using power output of up to 60 W. The most significant complication of laser therapy is forward scatter of laser energy to adjacent structures, resulting in perforation of a hollow, viscous organ such as overlying bowel.

The posterior wall of the bladder can be sutured to the psoas tendon (psoas hitch) with 2-0 Prolene sutures to take any tension off of the ureteral reimplantation regional pain treatment center generic rizact 5 mg otc. Minimally invasive management of longer ureteral defects is discussed in the next section on psoas hitch and bladder advancement flaps pain treatment herniated disc purchase discount rizact line. Complications were minimal and included three ureteral injuries tennova comprehensive pain treatment center generic 10 mg rizact, two of which required open reimplantation back pain treatment lower order 5 mg rizact with amex. Yeung and colleagues (2005) performed 30 laparoscopic transvesical cross-trigonal reimplantations in 16 patients pain treatment for shingles order rizact with mastercard. The mean operative time was 112 minutes for unilateral cases and 178 minutes for bilateral cases unifour pain treatment center statesville buy genuine rizact on line. In the largest reported series in adult patients, Seideman and colleagues (2009) reported on 45 patients undergoing laparoscopic ureteral reimplantation for benign and malignant pathology. Minimal complications were experienced, including urinary extravasation at the anastomotic site in three patients, which was conservatively managed. Rassweiler and colleagues (2007) compared 10 patients undergoing laparoscopic ureteral reimplantation with 10 patients treated by open techniques. In this small series, the laparoscopic approach was associated with less blood loss, lower analgesic requirements, less time to oral intake, shorter hospital stay, and shorter convalescence time. Similarly, Simmons and colleagues (2007) retrospectively compared 12 laparoscopic versus 34 open ureteral reimplantation procedures, demonstrating a reduced blood loss and shorter hospitalization associated with laparoscopy. Complication rates and ureteral patency rates were equivalent at a mean follow-up of nearly 2 years. Several authors have documented the feasibility of robotic-assisted ureteral reimplantation (Yohannes et al, 2003; Uberoi et al, 2007; Patil et al, 2008). The robotic technique recapitulates the laparoscopic technique and may facilitate the learning curve for reconstructive procedures requiring intracorporeal suturing. With a median follow-up of 29 months, none of the three patients required revision or had recurrent stricture disease. OutcomesandComplications Clinical experience with laparoscopic and robotic ureteroneocystostomy continues to evolve. Small feasibility studies prevail; however, Conclusions Laparoscopic and robotic ureteroneocystostomy are viable alternatives to open surgery. Blunt dissection allows the bladder to "drop" posteriorly, and the space of Retzius is entered. If this maneuver does not suffice, a Boari flap or bladder advancement flap is performed. Using electrosurgical scissors or a 10-mm LigaSure device, an anterior bladder flap is created beginning approximately 2 cm from the bladder neck and extending to the ipsilateral bladder dome; the apex of the flap is approximately 2 cm, and the base of the flap is approximately 4 cm. Care should be taken to confirm that the base of the flap is wide enough to ensure adequate vascularity. The spatulated ureter is anastomosed to the apex of the flap with interrupted 4-0 absorbable suture. After placement of a 7-Fr double-pigtail catheter over a guidewire, the flap is closed in a running fashion in two layers with 4-0 and 2-0 absorbable suture or with the assistance of an EndoStitch device. The bladder is filled to 300 mL to identify any sites of anastomotic leakage, and a Jackson-Pratt drain is placed through the 5-mm trocar site. The Jackson-Pratt drain is typically removed in 48 hours, and the Foley catheter is removed in 1 week after cystography confirms no urinary leakage. The Boari bladder flap was introduced for bridging larger gaps between the ureter and bladder in 1894 in a canine model and in humans in 1947 (Fugita and Kavoussi, 2001). Laparoscopic Boari flap was first performed in a porcine model and in humans in 2001 (Fergany et al, 2001; Fugita and Kavoussi, 2001). This procedure can be performed with or without a psoas hitch to anchor the bladder to gain additional length and avoid anastomotic tension. The robotic approach can ease the technical burdens of extensive intracorporeal suturing required for Boari flap creation (Schimpf and Wagner, 2008; Allaparthi et al, 2010). More recent literature has documented the feasibility of laparoscopic Boari flap to reach the proximal ureter and/or renal pelvis in select cases. When this approach is insufficient, ureteroureterostomy, transureteroureterostomy, autotransplantation, or ileal ureteral substitution can be considered. Laparoscopic or Robotic Bladder Advancement Flap Laparoscopic bladder advancement flap was first described by Lima and colleagues (2005) as a simplified alternative to a Boari flap. The bladder is opened with a transverse incision, placed one third of the distance from the dome to the bladder neck. The spatulated ureter is anastomosed to the bladder flap in a fashion similar to a Boari flap, described previously. Laparoscopic "Mega-Boari" Flap Proximal ureteral strictures generally have required ureteral substitution or autotransplantation. We have had success with "megaBoari" flap formation, successfully mobilizing a bladder flap to the level of the proximal ureter or renal pelvis, in six patients (Richstone and Kavoussi, unpublished data, 2007). The kidney is mobilized completely, and, when necessary, descensus and nephropexy is performed to gain length. The ureter or renal pelvis is divided at the proximal aspect of the diseased segment. The bladder is mobilized by incising the peritoneum bilaterally, medial to the obliterated umbilical ligaments. The bladder flap is created with a transverse cystotomy incision along the lateral and posterior bladder wall above the trigone. To gain length for the flap, several stepwise 1-cm incisions are made along both of the edges of the bladder flap. In this fashion, the "mega-Boari" flap can reach the level of the spatulated renal pelvis without tension. Preoperative evaluation of ureteral obstruction includes antegrade and/or retrograde urography to estimate the extent of disease and aid in planning for the surgical approach. Ultimately, intraoperative findings dictate the need for Boari flap and/or psoas hitch. Technique Laparoscopic or Robotic Boari Flap Laparoscopic Boari flap was first described in humans by Fugita and Kavoussi (2001) in a series of three patients with distal ureteral obstruction. The robotic-assisted laparoscopic approach was first reported several years later (Schimpf and Wagner, 2008). With either approach, the procedure begins by incising the ipsilateral white line of Toldt and identifying the ureter as it crosses the iliac vessels. The ureter is mobilized distally, and the diseased segment is excised, ensuring that the distal margin is well vascularized and healthy. If indicated, a distal margin is sent for frozen section, and the ureter is spatulated. Alternatively, multiple standard trocars can be introduced through a single site, typically the umbilicus. B, the spatulated ureter is anastomosed to the apex of the flap with interrupted 4-0 absorbablesuture. After access is obtained, the procedure is performed identically to laparoscopic and robotic flap creation (Khoder et al, 2011). OutcomesandComplications the first clinical series of laparoscopic ureteral reimplantation with Boari flap was reported in 2001 and involved three patients (Fugita and Kavoussi, 2001). The approach was demonstrated to be feasible with a mean operative time of 220 minutes and estimated blood loss ranging from 400 to 600 mL. With a mean follow-up period of 11 months, all patients had resolution of obstruction. Castillo and colleagues (2005) reported a slightly larger series of laparoscopic Boari flap in eight patients. Operative times (mean 157 minutes), blood loss (mean 124 mL), and hospital stay (mean 3 days) further validated the feasibility of the technique. Two complications occurred, including one pulmonary embolism and one episode of urinary leakage at the anastomosis requiring laparoscopic repair. Seideman and colleagues (2009) reported the largest single-center series of laparoscopic Boari flap in 21 of 45 patients undergoing laparoscopic ureteral reimplantation with significant follow-up (mean 24 months). In a multi-institutional series of 30 patients undergoing laparoscopic Boari flap, excellent outcomes were achieved (Castillo et al, 2013). In that series, mean operating room time was 161 minutes, and mean estimated blood loss was 123 mL with no intraoperative complications or conversion to open surgery. Postoperative complications occurred in 17% of patients, with a success rate of 97% at a mean follow-up of 32 months. Similarly, excellent results have been reported with a robotic approach, albeit with smaller series to date (Allaparthi et al, 2010; Musch et al, 2013). Viewedanteriorly,theflapismobilized; dashed lines and translucency indicate incision and flap on the outer posterior aspect ofthebladder(B). Docimo and colleagues (1995) were the first to perform a purely laparoscopic gastrocystoplasty in a single patient. Although the procedure took almost 11 hours and involved a 13-day hospital course, the feasibility of the technique was demonstrated. Subsequently, Gill and associates (2000) described laparoscopic ileocystoplasty, sigmoidocystoplasty, and cecocoloplasty with bowel anastomosis done extracorporeally. Over the past decade, ileocystoplasty has emerged as the most widely employed technique. Most commonly, these patients have a neurogenic bladder secondary to spinal dysraphism or other anatomic abnormalities. An ultrasound scan should be obtained to rule out hydronephrosis, which should be evaluated before surgery. All patients must be physically and psychologically competent and willing to perform self-catheterization. Contraindications to either open or minimally invasive augmentation include renal insufficiency, renal tubular acidosis, and gastrointestinal disease including short gut syndrome, inflammatory bowel disease, and liver failure (Elliott et al, 2002). Technique the procedure begins with cystoscopic evaluation and placement of bilateral open-ended or single-J ureteral catheters, which are secured to a urethral catheter. The bladder is fully mobilized by incising the peritoneum medial to the obliterated umbilical ligament bilaterally, and the urachus is divided to "drop" the bladder posteriorly and enter the space of Retzius. An appropriate 15- to 20-cm segment of bowel is chosen taking care to ensure an adequate vascular pedicle and that the segment will reach to the bladder neck. The bowel work can be completed via a purely laparoscopic approach (Meng et al, 2002) or extracorporeally by extending the length of the umbilical incision (Gill et al, 2000) as described subsequently. The bowel segment is irrigated copiously, the staple lines are excised on each end, and the segment is then opened along the antimesenteric border. During ileal augmentation, the sides of the bowel segment are approximated to form a U-shaped segment with running 2-0 polyglactin 910 suture. At this time, the bladder is filled with saline and bivalved at the midsagittal line. The segment is brought down to the pelvis without tension or torsion of the mesenteric pedicle. With the bowel segment oriented so that the apex of the U is positioned anteriorly at the bladder neck, the patch is sutured to the bladder in a running continuous fashion with 2-0 polyglactin 910 suture, beginning posteriorly and ending anteriorly (Gill et al, 2000; Elliott et al, 2002; Meng et al, 2002). The integrity of the completed augmentation is confirmed by irrigating the bladder via the Foley catheter, and finally a pelvic drain is positioned. B, the selected bowel segment (15cm) is exteriorized through an extension of the umbilical port incision. For patients with concomitant refractory constipation, the Malone antegrade continence enema procedure can be performed concurrently (Shadpour et al, 2005). As an alternative to vesicoplasty for select patients, appendicovesicostomy has been performed laparoscopically (Hsu and Shortliffe, 2004; Lorenzo et al, 2007) and with a roboticassisted laparoscopic approach (Lendvay et al, 2008). OutcomesandComplications Complications of laparoscopic and robotic bladder augmentation are similar to complications encountered during open surgery and include infection, metabolic derangements, stones, perforation, mucus production, and malignancy. Intracorporeal bowel segment irrigation and detubularization may increase the risk of infectious complications. Docimo and colleagues (1995) performed the first pure laparoscopic gastrocystoplasty in a patient with a five-port technique. The procedure involved almost 11 hours of operating time and a 13-day hospitalization. A laparoscopic-assisted approach, in which the laparoscopic work was largely limited to bowel mobilization, followed (Hedican et al, 1999; Chung et al, 2004). Gill and colleagues (2000) reported the first laparoscopic ileocystoplasty, sigmoidocystoplasty, and cecocoloplasty. Bowel harvest and anastomotic work was done extracorporeally with a four-port approach. In this small series of three patients, operative times of 5 to 8 hours and blood loss of 50 to 200 mL were reported. The first purely laparoscopic ileocystoplasty in a human was reported in 2002 (Elliott et al, 2002; Meng et al, 2002). The patient underwent a 9-hour procedure and required a 13-day hospitalization secondary to prolonged ileus. The largest published series of minimally invasive cystoplasty comprises six patients who underwent pure laparoscopic ileocystoplasty and an antegrade continence enema procedure (Shadpour et al, 2005). Complications included one ileal anastomotic leak that resolved conservatively and one appendiceal stomal stenosis requiring revision. With intermediate-term follow-up (13 to 16 months), all patients were continent of urine between catheterizations, and nearly all had perfect fecal continence. Purely intracorporeal robotic augmentation ileocystoplasty with and without Mitrofanoff appendicovesicostomy also has been described (Al-Othman et al, 2008; Gundeti et al, 2008). The technique is essentially identical to the laparoscopic approach, but it may facilitate the learning curve for intracorporeal suturing. Famakinwa and associates (2013) updated this series and reported their experience of 18 children who underwent robotic-assisted laparoscopic Mitrofanoff appendicovesicostomy. The appendix was anastomosed to the posterior wall of the bladder intravesically when concomitant enterocystoplasty was performed.

Further mobilization and separation of the posterior wall of the bladder from the anterior vaginal wall allows a tension-free closure pain management for osteosarcoma in dogs trusted rizact 5 mg. Because the trigone and ureteric orifices invariably lie in close proximity to the fistulous edges heel pain treatment yahoo buy rizact now, it is important to avoid uncontrolled blunt and wide excision leg pain treatment natural buy discount rizact on-line, which may hamper subsequent closure heel pain yoga treatment buy rizact 5 mg on-line. It is preferable to do a slow and careful sharp dissection of the fistulous edges pain treatment center natchez cheap rizact 10 mg without prescription, which must be freshened treatment pain right upper arm cheap rizact 5 mg without a prescription. Reconstruction of vagina in two layers (arrowhead); bladder wall repaired in two layers (arrow). The closure of vagina is performed using 3-0 barbed suture, which is placed transversely for tension-free closure as a running watertight suture. If the size and the orientation of the vaginal gap allow less tension on the closure line, a vertically placed suture line could be acceptable. The bladder is usually closed in a vertical manner to minimize the contact surface of suture lines. Bladder closure is initiated at the caudal part or close to the trigone area or at the most distal part of cystotomy near the ureteric orifices. If two-layer closure is contemplated, then the first layer includes mucosa and a portion of detrusor muscle layer using a 4-0 monofilament absorbable suture in a running continuous fashion. If the cystotomy is quite long, the bladder closure can be started from the proximal open bladder edge until the superoposterior part of the bladder is closed. Then, with new suture, the most distal segment of the cystotomy is closed until the two are securely knotted together approximately in the middle of the cystotomy line. In so doing, the proximal suture can be used as traction to provide better exposure and subsequently improved visualization for the critical part of the cystotomy closure near the ureteric orifices. In addition, using two separate sutures for cystotomy closure avoids possible laxity of the single suture line. Tissue interposition between the bladder and vaginal suture lines is performed, preferably using a well-vascularized pedicle of omentum. To reduce tension on the vascular pedicle of omentum and better mobilize this in the lower abdomen, the patient is placed in an almost horizontal position. In case the omentum is completely retracted in the upper abdomen, it can be mobilized in the beginning and can be tagged to pelvis. Whenever omentum is easily available, it is the best choice and should always be used for interposition between the suture lines. If omentum is unavailable or cannot be adequately mobilized, the epiploic appendices of the sigmoid colon or a peritoneal flap from the nearest anatomic location is used as tissue for interposition. At the anterior vaginal wall distal to the vaginal closure, a 3-0 barbed suture is placed, which is used as a fixation to anchor the interpositional tissue. To avoid any contact between both suture lines and provide stability on fixation, the interpositional tissue is anchored with a suture on the resilient vaginal wall and distally to the end of the vaginal closure line. To prevent laxity on fixation, the interpositional tissue is also fixed left and right on the peritoneal edges of the cystotomy. Thus the interpositional tissue completely covers the suture line of the vagina, forming a triangle; each point is fixed on elastic and well-vascularized tissue. A 15-Fr Jackson-Pratt is introduced into the pelvis through left robotic port and secured to the skin with a silk suture. Reducing the pressure of pneumoperitoneum under 10 mm Hg, the robotic and assistant trocar sites are removed under endoscopic guidance to make sure there is no bleeding from vessels of the abdominal wall. At the end, the fascia of the 12-mm camera port is closed with monofilament absorbable suture. The drain is typically removed within 24 hours postoperatively or when drainage fluid is less than 50 mL. Typically patients go home within 24 to 48 hours with an indwelling urethral catheter, which ensures continuous drainage of the bladder and proper healing. A retrograde cystogram may be performed before removal of the bladder catheter to confirm fistula closure but is not always mandatory. Patients are warned to avoid the use of tampons and refrain from sexual activity for at least 8 weeks postoperatively. Early mobilization and ambulation are encouraged using the principles of fast-track postoperative care: no nasogastric tube, with mobilization starting 6 hours after the end of the procedure. The patient is started on a liquid diet same evening and is progressed to a normal diet the next day. Robotic-assisted laparoscopic repair has led to higher success rates over pure laparoscopy, which is technically more difficult. Conversion to open surgery may be required based on nonprogression of surgery, severe inflammation, severe adhesions, or difficulty in suturing or if there is a requirement for simultaneous bladder augmentation. Major complications have been reported, including compartment syndrome in lower extremities, enterocutaneous fistula, and inferior epigastric artery injury, with the overall major complication rate being 2. Sotelo and colleagues reported an expeditious approach, intentionally opening first the bladder, leading accurately to the fistulous tract without the need for additional vaginal incisions or further dissection of the vesicovaginal space. A few studies reported that patients were discharged with a urethral catheter and drain on the first postoperative day, whereas other centers kept their patients in the hospital while the urethral catheter and drain were kept in place for up to 2 weeks. Laparoscopy allows fistula repair with a limited bladder incision, unlike in an open procedure, with all the advantages of minimally invasive procedures such as a magnified view of the operative field, hemostasis, decreased hospital stay, and shorter convalescence. This series included six patients with advantages of shorter hospital stay, faster recovery, and less morbidity. The success rate reported for robotic-assisted repair was close to 100% in most of these small series, with the potential advantage that the robotic device allows more surgeons to use this minimally invasive approach. Two retrospective studies described transition from open to laparoscopic repair and found that the latter was minimally invasive with similar success (Ou et al, 2004). The most significant difference between the two groups was shorter average hospitalization (3. Ureteral catheterization is an important step to prevent inadvertent ureteral injury during dissection as well as during reconstruction. It allows visualization of the ureteric orifices within the bladder, preventing the surgeon from taking a stitch too close to them during bladder reconstruction. It also keeps the operating field relatively dry, and ureteral catheters can be removed at the end of the procedure. Such adhesions could be parietal in nature, wherein adhesiolysis may be necessary to allow appropriate port placement, or could be visceral wherein bowel loops may obscure the area of interest in the pelvis. Gentle and sharp dissection to aid the bowel to fall away is imperative to prevent a bowel injury during fistula dissection and to allow tension-free closure of the vagina and bladder. The modified technique prevents bivalving of the bladder and extensive dissection. Posterior cystotomy or limited dissection to quickly access the fistulous site and subsequent meticulous dissection and freshening of edges or, if needed, excision of fibrous edge are necessary. It is important to mobilize well-vascularized flaps to allow tension-free closure. If available, omentum is preferred, especially when repairing recurrent fistula, because it helps in rapid absorption of the inflammatory exudates owing to abundant lymph supply, and it significantly decreases the chance of failure. The key points of surgery include vaginoscopy and cystoscopy to assess the fistula and placement of ureteral catheters through the fistula and normal ureters. This is achieved by placement of a ureteral catheter from the bladder, cystoscopically, cannulating the fistula and retrieving it from the vagina. Occasionally a reverse "railroading" is needed owing to the angulation of the fistulous tract, wherein the guidewire is placed transvaginally and retrieved from the bladder transurethrally. If the fistula is large, a Foley catheter can be directly placed transvaginally into the bladder. Tugging the catheter aids in locating the approximate site of the fistula as seen from within the abdominal cavity, allowing the placement of a minimal cystotomy near the area of interest, close to the midline. However, a Foley catheter placed transvaginally through the fistula into the bladder allows better appreciation of the movement and location in the transperitoneal endoscopic view. Transvaginal repair remains a minimally invasive approach with little morbidity and convalescence in the hands of a skilled and experienced surgeon. For patients requiring an open abdominal approach or flap interposition, laparoscopic or robotic-assisted approaches offer decreased morbidity and convalescence compared with traditional open techniques. If available, use of robotic assistance in laparoscopy is the preferred approach for minimally invasive surgeons. A hemostat is used to transfer the fibrofatty flap from the harvest site, through the tunnel, to the level of the fistula repair. The flap is placed over the fistula repair and secured with interrupted absorbable sutures in a tension-free manner. The vaginal wall flap is advanced over the Martius flap and closed as previously described. A small Jackson-Pratt or Penrose drain may be left in the labial incision in the operative bed. The labial incision is closed, and a pressure dressing may be applied to the labial skin incision. The borders of dissection include the labiocrural fold laterally, the labia minora and the bulbocavernosus muscle medially, and Colles fascia covering the urogenital diaphragm posteriorly. Dissecting down to the adductor muscles laterally before coming around the width of the Martius flap facilitates the harvest of a thick, fatty segment for flap placement. Before final division of the flap inferiorly or superiorly, mobilization may be facilitated by gentle downward traction using a Penrose drain, incorporating the entire thickness of the fibrofatty flap. For a posterior-based flap, the main vascular supply to the flap is located at the base of the labia majora. The blood supply of the greater omentum derives principally from the right and left gastroepiploic arteries, as well as the distal branches of the gastroduodenal and splenic arteries, respectively. The right and left gastroepiploic arteries join along the greater curvature of the stomach to form the gastroepiploic arch. The arterial anatomy within the greater omentum is variable but usually consists of a right and left omental artery, and occasionally a middle omental artery, all of which run perpendicular to their origin off the gastroepiploic arch. The caliber of the right gastroepiploic artery is usually larger than the left one, which generally favors a pedicle based on this artery; however, in practice, a pedicle based on either artery may be used (Kiricuta and Goldstein, 1972; Bissada and Bissada, 1992). In addition, anatomically, the origin of the right gastroepiploic artery is somewhat caudal compared with the left one, allowing a slight advantage in reaching into the deep pelvis. In some cases, the free distal end of the greater omentum is long enough to reach into the deep pelvis in a tension-free manner without any further mobilization. Securing the omental flap beyond and between the suture lines of the closed viscera prevents overlying or apposed suture lines. Obstetric fistulae associated with significant urethral loss may be repaired, in part, with the use of anterior or posterior bladder flaps (Hanash and Sieck, 1983; Elkins et al, 1992; Khanna, 1992). The gracilis muscle in the medial thigh is a convenient adjunct to repair large soft-tissue defects, especially those associated with radiation therapy (Obrink and Bunne, 1978; Heckler, 1980). The gracilis muscle is in close proximity to the vagina and has a reliable blood supply. The muscle is mobilized through a thigh incision from its distal attachment on the tibial condyle, with care taken to preserve its blood supply. It is tunneled cephalad into the vagina subcutaneously and secured over the fistula. The fistula tract is identified and denuded of mucosa circumferentially for approximately 1 cm. Some authors have suggested that urinary diversion should be strongly considered as primary therapy (Murray et al, 2002) for radiation-induced fistulae because the results with surgical repair in this group are less than optimal (Langkilde et al, 1999). Furthermore, the safety of using such materials in the setting of extensive reconstruction, such as that after repair of an obstetric fistula, is not established. This is probably most commonly associated with existing pelvic malignancy, severe radiation damage, and/or large soft-issue loss, especially in the setting of obstetric fistula. However, some patients may simply not be candidates for repair owing to coexistent medical morbidities, making them a prohibitive surgical risk. In the former group, urinary diversion in the form of either a urinary conduit (Kisner and Kesner, 1987) or a continent reservoir can be considered. Fistulae in patients who are not candidates for surgical intervention may be managed by percutaneous ureteral occlusion and permanent nephrostomy (Kinn et al, 1986; Stern et al, 1987; Hubner et al, 1992; Farrell et al, 1997; Amsellem-Ouazana et al, 2006; Natarajan et al, 2007; Shindel et al, 2007). In the developing world, where catheters and ostomy appliances are either too expensive or completely unavailable, continent urinary diversion or incontinent urostomies are often not practical, which presents ethical issues with the alternative treatments (Wall et al, 2008). In these situations, internal urinary diversion with ureterosigmoidostomy has some application in patients with unreconstructable lower urinary tracts (Attah and Ozumba, 1993). It should be recognized that this is clearly a last-resort operation owing to its significant metabolic and neoplastic potential. Voiding images should be obtained if the fistula was not demonstrated on the filling images of the cystogram. In the properly selected patient, transabdominal and transvaginal approaches to fistula repair have similar success rates. Adjuvant tissue flaps may be useful to prevent surgical failure in the setting of complex or recurrent fistula, radiation fistula, obstetric fistula, and fistulae with tenuous repairs. Risk factors for the development of ureterovaginal fistulae include endometriosis, obesity, pelvic inflammatory disease (Symmonds, 1976), and radiation therapy and pelvic malignancy. Nevertheless, Symmonds has noted that the patient with a ureteral injury after gynecologic surgery is typically one who had an uncomplicated, technically easy hysterectomy for minimal disease (Symmonds, 1976). Thus, except for those oncologic cases wherein a segment of ureter is deliberately excised, many ureteral injuries are likely the result of technical or iatrogenic factors. Etiology and Presentation the most common cause of ureterovaginal fistulae is surgical injury to the distal ureter, with gynecologic procedures being by far the most common (Symmonds, 1976; Dowling et al, 1986; Badenoch et al, 1987; Lee et al, 1988; Blandy et al, 1991) (Box 89-6). The incidence of iatrogenic ureteral injury during major gynecologic surgery is estimated to be about 0.

Sacral neuromodulation has been examined in this regard and has had favorable results on the basis of some of the criteria listed for improvement pain medication for dogs human discount rizact 10 mg online. Ganio and associates (2001) described 16 patients who underwent permanent implantation of sacral leads for constipation whereby they had a more than 50% decrease in difficulty emptying the rectum and more than 80% improvement in the Cleveland Clinic constipation score that persisted during the course of 1 year of follow-up back pain treatment nerve block purchase rizact 10 mg overnight delivery. Other series have shown similar improvements pain treatment devices buy 10 mg rizact free shipping, although in smaller numbers (Kenefick et al knee joint pain treatment purchase rizact 5 mg overnight delivery, 2002a pain treatment lung cancer order rizact amex, 2002b; Sharma et al pain treatment center bethesda md cheap rizact 10 mg line, 2011). Still, with the small series available, it is difficult to make any meaningful analyses. All of these results suggest, at least, that there is some benefit of sacral neuromodulation in refractory constipation cases. Further study is warranted to assess prognostic factors to better decide on future candidates for this therapy. Guys and coworkers (2004) prospectively examined 21 patients to 21 years of age with sacral neuromodulation in the setting of neurologic disease consisting predominantly of spina bifida. The neuromodulation implant group had improved compliance and bladder capacity at 6 and 9 months but not at 12 months. Of the 21 patients, 9 improved their intestinal transit times and 1 patient had complete disappearance of urinary incontinence. McGee and associates (2009) described the use of an incisionless first- and second-stage sacral neuromodulation procedure with fairly high success rates in pediatric patients with dysfunctional elimination syndromes and had minimal complications. Usually patch electrodes are placed on both sides of the S3 nerve foramen and connected to a pulse generator and amplifier. Patients had daily therapy with the patch electrodes placed at S3, and stimulation was delivered at 2 Hz. A 76% response rate was observed, due in part to increase in bladder capacity and reduction in urgency urinary incontinence and urgency symptoms. Of 41 patients, 21 (51%) were definitively cured; the remainder experienced relapse in the ensuing 1 year of follow-up. Bower and colleagues (1998) reported a similar fairly high success rate with 17 children treated with S3 transcutaneous stimulation and demonstrated dryness in 73. A more recent study by Malm-Buatsi and associates (2007) also showed continued benefit in patients when 8 of 12 (75%) received statistically significant benefits when therapy was completed. Although this technology seems to have fairly good success, there has been no trial in a randomized prospective controlled fashion that may increase its acceptance. No patients had significant problems from the therapy, and it was overall thought to be both safe and well tolerated. Of the 28 children with urgency before therapy, the urgency disappeared after therapy in 7 and improved in 10. Of the 23 children with daytime incontinence before treatment, 4 became dry after stimulation and in 12 patients the incontinence decreased. Of the 19 patients who reported abnormal voiding frequency of either less than 4 or more than 8 voids per day, 16 of 19 achieved a normal frequency of 4 to 6 voids daily. Barroso and associates (2013) compared parasacral cutaneous neuromodulation with percutaneous tibial nerve stimulation and noted improved results with parasacral stimulation in a prospective nonrandomized study; however, despite improvements, they were not found to be statistically significant changes. Sacral neuromodulation was investigated for bowel disorders on the basis of some of the early experience in patients with bladder conditions who exhibited treatment benefits with regard to the bowel symptoms (Pettit et al, 2002). The use of sacral neuromodulation in bowel disorders has recently been approved for use in the United States and was predated for approval in many other parts of the world beforehand. The two major areas of interest with regard to neuromodulation and bowel disorders are fecal incontinence and constipation. Several studies have been done to examine the utility of sacral neuromodulation in fecal incontinence (Kenefick et al, 2002a, 2002b; Uludag et al, 2002; Melenhorst et al, 2007). Bilateral stimulation has been suggested as an alternative, particularly in failed unilateral lead placements, for potential salvage or added benefit as the bladder receives bilateral innervation (van Kerrebroeck et al, 2005). The initial consideration of bilateral stimulation was based on animal studies demonstrating that bilateral stimulation yielded a more profound effect on bladder inhibition than did unilateral stimulation (Schultz-Lampel et al, 1998a, 1998b). An animal model of unilateral versus bilateral stimulation has suggested that bilateral stimulation may be more effective overall (based on reduction of detrusor overactive contractions) than unilateral stimulation (Kaufmann et al, 2008). There has been only one prospective clinical study to demonstrate the differences in unilateral versus bilateral stimulation (Scheepens et al, 2002). Both unilateral and bilateral test stimulation was continued for 72 hours, and the patients were randomly assigned to start with unilateral or bilateral stimulation. The retention group had better parameters of emptying (volume per void) in bilateral compared with unilateral stimulation. Still, the numbers were too small in the retention group for adequate conclusions to be made. It appears that the data as presented, at least from a clinical perspective, do not suggest a large role for routine bilateral stimulation for most patients. Still, if the overall success rates of patients undergoing sacral neuromodulation could be increased, more patients could ultimately be helped. Accordingly, Pham and colleagues (2008) examined 124 patients undergoing stage I sacral neuromodulation and stratified patients into unilateral and bilateral groups, retrospectively. Successful stage I trials were noted in 58% of unilateral patients and 76% of bilateral patients. An important component that still needs to be evaluated is whether it is cost-effective to "routinely" place bilateral leads in the setting of most unilateral lead success rates approaching 70% and 80%. Perhaps the challenge lies in the fact that many consider sacral neuromodulation near end of the line therapy and accordingly try to optimize results with bilateral leads. Clinical trials of the rechargeable Bion device were halted in the United States and Europe. External Periurethral Nerve A relatively new way to stimulate the bladder has been investigated and is now underway with clinical trials in the use of external periurethral neuromodulation (Nissenkorn et al, 2004, 2005). This device basically entailed placement of a lead and generator apparatus in the periurethral location while the generator was in the lower abdomen subcutaneous space. The lead then stimulated the sphincter apparatus and nerves associated with this structure, presumably. Whereas their early results are fairly impressive, the device may help both urgency and stress urinary incontinence (16 patients with stress urinary incontinence were treated; 9 were dry during electrostimulation, and the remainder had a 74% reduction in pad weights). The exact positioning of the electrodes seems to be in the area proximate to the external urethral sphincter, thereby allowing for direct access to afferent nerve fibers (Whiteside et al, 2009). How this therapy benefits patients will be interesting because it has many potential uses, including stress and urgency urinary incontinence, pain syndromes, and neuromuscular disorders of the pelvic outlet. SelectiveNerveStimulation Pudendal Nerve Because the bladder afferent reflex works through sacral interneurons that then activate storage through pudendal nerve efferent pathways directed toward the urethral sphincter, the pudendal nerve is a logical target for developing neuromodulation therapies. The earliest attempts to manipulate this reflex through electrical stimulation were based on direct pelvic floor muscle stimulation by Caldwell and associates (Caldwell, 1963; Caldwell et al, 1965) and others with the development of the first implantable and external pelvic floor stimulators, anal plug stimulator (Hopkinson and Lightwood, 1966, 1967), and intravaginal pessary stimulation (Alexander and Rowan, 1968; Erlandson et al, 1977; Fall et al, 1977; Fall, 1985). To deliver optimal stimulation to the nerve directly, selective pudendal nerve stimulation was introduced by Vodusek and coworkers (1986) and shown to have an inhibitory effect on the micturition reflex. Because many of the sensory afferent nerve fibers contained in the sacral spinal nerves originate in the pudendal nerve, the pudendal nerve afferents are important targets for neuromodulating the inhibitory reflex on the micturition reflex (Peng et al, 2008; Woock et al, 2008; Yoo et al, 2008). Furthermore, high-frequency electrical stimulation of this nerve may achieve blockade of external sphincter contractions leading to sphincter relaxation (Gaunt and Prochazka, 2009). Thus techniques for direct pudendal nerve stimulation at alternative locations to the sacral foramen are being developed. Spinelli and associates (2005) modified existing sacral neuromodulation technology and adapted it to pudendal nerve stimulation and realized the need for more sensitive neurophysiologic guidance to better guide stimulation to the pudendal nerve target. Trials using different techniques and devices Dorsal Genital Nerve the dorsal genital nerves (dorsal nerve of the penis in males, clitoral nerve in females) are the terminal and most superficial branches of the pudendal nerve found at the level of the symphysis pubis. The nerves are afferent nerves that carry sensory information from the glans of the penis or clitoris. Proximally, the dorsal genital nerves form a component of the pudendal nerve and then the sacral spinal roots. As a pure sensory afferent nerve branch of the pudendal nerve, the dorsal genital nerve contributes to the pudendal-pelvic nerve reflex that has been proposed as a mechanism of bladder inhibition. Whereas squeezing the glans penis or manipulation of the clitoris is clinically known to help suppress bladder contractions as observed in behaviors of voiding avoidance, direct electrical stimulation of these organs does not produce a significant effect on the micturition reflex as measured by urodynamics during the storage phase (Yalla et al, 1978; Kondo et al, 1982). However, direct dorsal genital nerve electrical stimulation in experimental and clinical studies appears promising in producing an inhibition of the micturition reflex. Conditioning stimulation of afferents in the dorsal clitoral nerves also has been shown to suppress reflex bladder contractions in anesthetized cats (Jiang and Lindstrom, 1999). Similarly, recent work in anesthetized cats has shown that low-amplitude electrical stimulation of the S1 dorsal root (which in the cat carries the dorsal genital afferents) inhibits or abolishes ongoing reflex bladder contractions (Jezernik et al, 2001), resulting in significantly shorter bladder contractions. The micturition reflex can be activated and inhibited by stimulation of these dorsal penile afferent fibers in animal models (Woock et al, 2008). Still, one of the major limitations of this therapy is the need for continued and repeated sessions. Feasibility trials with this approach have been completed and demonstrate in a small series that 81% of patients experienced a 50% or greater improvement in urgency and 47% reported a 50% or greater reduction in incontinence episodes (Goldman et al, 2008). This approach seems to have further advantages in being minimally invasive, office based, and without the need for fluoroscopy or prone positioning. The exact stimulation parameters are not agreed on because different frequencies have been used; 2 Hz may stimulate pudendal afferents, whereas 50 Hz may stimulate striated paraurethral musculature. Therefore this technology is easy to perform and apply, but it may be required for extended periods to gain treatment benefits. Positive results have been demonstrated on the basis of urodynamic data, with improved bladder capacity, delay in first urge to void, and reduced detrusor instability (Bower et al, 2001; Hoebeke et al, 2001). For adequate maintenance of the benefits of this therapy it must be continued for longer durations. McGuire and associates (1983) described 16 patients with involuntary bladder contractions of varying cause who were treated with common peroneal or posterior tibial nerve patch electrode stimulation: 12 patients initially were dry, 3 were improved, and 1 was "possibly improved. Noninvasive magnetic stimulation of the sacral roots will inhibit bladder contractions and cause effects that will persist for short times beyond the period of stimulation. This type of stimulation at present cannot be applied for prolonged periods and is currently unsuitable for long-term treatment, although it may be helpful for preliminary assessment of candidates for chronic sacral root neuromodulation. Posterior Tibial Nerve the posterior tibial nerve is a mixed sensory and motor nerve containing fibers originating from spinal roots L4 through S3 that modulate the somatic and autonomic nerves to the pelvic floor muscles, bladder, and urinary sphincter. Objective reduction in frequency, urge severity, and incontinence episodes was similar in both groups. The American Urological Association Guidelines (Gormley et al, 2012) listed both therapies in the refractory setting, but clearly one must be aware of some pros and cons of each therapy to assist the patient in deciding which treatment is best for each patient subtype. Although many patients may do fine with either therapy, some scenarios may tilt the decision making in favor of one therapy over another. Furthermore, these patients need to be aware of the re-treatment intervals approximately every 6 months and this may aid in decision making. When more comparative data are available, the clinician will have a better understanding of the optimal place for each respective treatment. It appears that the introduction of the tined lead concept has changed the frequency and profile of the complications that were once only technology related while keeping the patientrelated complications at the same frequency. The complications were pooled from the different studies on the basis of the fact that the protocols, devices, efficacy results, and safety profiles were identical. The studies recruited 581 patients, 219 of whom underwent implantation of the InterStim system. The complications were divided into those related to percutaneous test stimulation and those that are postimplant-related problems. Of the 914 test stimulation procedures done on the 581 patients, 181 adverse events occurred in 166 of these procedures (18. For the 219 patients who underwent implantation of the InterStim system (lead and generator), pain at the neurostimulator site was the most commonly observed adverse effect at 12 months (15. Surgical revision of the implanted neurostimulator or lead system was performed in 33. This included relocation of the neurostimulator because of pain at the subcutaneous pocket site and revision of the lead for suspected migration. One should consider the fact that, at the time, the generator was implanted in the lower abdomen. Device-related pain was the most frequent problem and occurred equally in all implantation sites (sacral, flank, and abdominal). This occurred in 18 of the 53 patients (34%) and was more frequent in patients with dysuria and retention or perineal pain. Pain responded to physiotherapy in 8 patients, and no explantation was done for pain reasons. Revisions for prosthesis-related pain (n = 3) and for late failures (n = 6) were not successful. Similar series have been published by White and associates (2009) and show relatively low rates (30%) of adverse events and may have been predicted by trauma, body mass index, enrollment into a pain clinic, and history of adverse events. The reasons for either fall under response related, mechanical, or infection related. The majority of lead explantations were performed for unsatisfactory or poor clinical response (46 of 50, 92%). Explantation for response reasons is not truly considered a complication as much as it is an integral part of the procedure. Revisions were done for marginal response (13 of 22), frayed subcutaneous extension wire (6 of 22), lead infection (3 of 22), and improper localization of stimulus (1 of 22). When the revision was done for a marginal response (13 of 22), the response was ultimately clinically satisfactory in 5 of 13 (38. Typically, when the patient reported a marginal or equivocal response during the test stimulation in the absence of infection or mechanical problems, a lead revision was offered with intraoperative sensory testing.

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