Alexander Kastin

The Value of Quantitative 99MTechnetium Dimercaptosuccinic Acid Renal Scintigraphy For Predicting Postoperative Renal Insufficiency In Patients Undergoing Nephrectomy

PURPOSE Radical nephrectomy is a routine urological practice. However, little is known about the use of dimercapto-succinic acid (DMSA) scan to evaluate compensatory changes after surgery and its ability to identify patient at risk for postoperative chronic renal failure or insufficiency. We predicted remaining kidney function using DMSA scan and serum creatinine. MATERIALS AND METHODS A total of 42 patients were enrolled in the study. All underwent DMSA scan before surgery and in 38 DMSA scan was done after unilateral nephrectomy. Serum creatinine was determined before and 1 year after surgery. The Student t test was used to determine statistical significance. Spearman rank core analysis was used to evaluate the association of calculated creatinine clearance time after surgery and renal absolute uptake before surgery. We performed 1-way ANOVA comparison of the means to determine the influence of age distribution on kidney hypertrophy and the increase in kidney uptake. RESULTS Average patient age was 61.5 years. Baseline mean creatinine clearance time was 71.5 ml. per minute, which decreased to 58.6 ml. per minute after nephrectomy (p <0.0001). Before surgery DMSA scan of the remaining kidney demonstrated an absolute uptake of 4.2% higher than that in the resected kidney (13.5% versus 9.35%, p = 0.0008). After nephrectomy the remaining kidney had an average increase of 3.9% of mean absolute uptake (17.7% versus 13.8%, p = 0.0001). Spearman rank core analysis demonstrated an association of higher preoperative absolute uptake in the remaining kidney with postoperatively high creatinine clearance time (r = 0.458, p = 0.003). Furthermore, 75% of patients with postoperative creatinine clearance time less than 40 ml. per minute presented with a preoperative absolute uptake of lower than 11% in the remaining kidney. In contrast, 75% of those with a postoperative creatinine clearance time of higher than 40 ml. per minute had a preoperative absolute uptake of higher than 11%. CONCLUSIONS A preoperative absolute uptake of lower than 11% in the remaining kidney was a significant risk factor for postoperative chronic renal insufficiency.

Bladder neck suspension using bone anchors for the treatment of female stress incontinence

A new technique and related devices for the treatment of urinary incontinence in women was developed and tested. The technique involves soft tissue to bone fixation by means of miniature bone anchors and a bone anchor inserter. The novel bone anchors are made of a shape-memory nickel titanium alloy (Nitinol) attached to Polypropylene or Gortex suture. A spring-loaded bone anchor inserter drives the anchors through the vaginal wall to a predetermined depth into the pubic bone medulla regardless of the bones hardness, with no incision or drilling required. The device allows for the performance of a minimally invasive transvaginal bladder neck suspension. The procedure has minimal morbidity and a short learning curve. This technique was evaluated clinically in 15 women with incontinence, with a mean follow-up of 6 months. Good urinary continence was achieved in all patients, with no mechanical failures.

A new intraurethral sphincter prosthesis with a self contained urinary pump

An intraurethral sphincter prosthesis with a self contained urinary pump for the management of atonic bladder in women was developed and tested. The prosthesis is comprised of a short, self retaining silicone catheter in which there is a valve and pump. Available in a range of lengths and diameters according to urethral size, its insertion is similar to that of a urethral catheter. The prosthesis is secured by a novel fixation method that has soft expandable silicone fins at the bladder neck and a flexible flange at the external meatus. It is activated by a small hand-held control device. To urinate, the activator is placed on the lower abdomen area and the “on” button is pressed, providing energy to the pump by a magnetic coupling method. Once activated, the valve opens and the pump rotates at a high speed, drawing urine from the bladder and pushing it forward, allowing the patient to “void” with a urine flow of 10 to 12 cc/sec. When the bladder is completely evacuated, the pumping ceases and the valve closes, restoring continence. The device was evaluated clinically in 17 women. Fifteen of the patients had a range of use of 2 weeks to 16 months during which they were dry and had complete bladder emptying. Two patients did not tolerate the device because of uninhibited detrusor contractions and, in both cases, it was removed without complication after 5 days.

MP75-10 TAILORING ANTIBIOTIC PROPHYLAXIS FOR URETEROSCOPIC PROCEDURES BASED ON LOCAL RESISTANCE PROFILES MAY LEAD TO REDUCED RATES OF INFECTIONS AND UROSEPSIS

INTRODUCTION AND OBJECTIVES: The insertion of double J ureteral catheters is a common practice in modern urology. Unfortunately, different symptoms may occur with indwelling stents, such as dysuria, hematuria, flank and suprapubic pain. The objective of the present study was to evaluate the safety and efficacy of levobupivacaine as an intravesical instillation in the control of pain and urinary symptoms generated by the ureteral stent. METHODS: 77 patients with double J catheter (Percuflex 26/6 TM, Boston Scientific) after endoscopic treatment of an ureteral stone were randomized into 2 groups. Both groups received standard therapy for catheter discomfort management (paracetamol, ketorolac and tamsulosine). At the end of the procedure group 1 received instillation of 30 cc of saline and group 2 received a dose of 150 mg (30 cc) of intravesical levobupivacaine. Surgeon and patient were blinded for type of instillation received. Symptomatology was evaluate at 4 and 24 hours after the procedure and at the moment of catheter removal. The USSQ survey, in its Spanish-validated version, was used for this purpose. Plasma levels of levobupivacaine were measured at 5, 10, 15 and 20 minutes after instillation in both groups. RESULTS: Both groups were comparable in terms of age, location and size of stone treated , duration of procedure, stone free rate and days of catheter permanence. Statistical analysis showed significant reduction in group 2 regarding the intensity of pain at 4 hours postoperatively (p 1⁄4 0.02). In addition, during the catheter carrying period, those patients in whom the levobupivacaine solution was applied had less alteration in work activities (p 1⁄4 0.03), and less discomfort in the sexual sphere (p 1⁄4 0.01) Plasma levels of levobupivacaine in the 40 patients exposed to the drug were undetectable (<0.1 mg / dL). There were no side effects attributable to intravesical levobupivacaine. CONCLUSIONS: To our knowledge this is the first clinical trial using levobupivacaine in bladder instillation, which demonstrate better pain control in the immediate postoperative period. There is a significant effect on daily life parameters that could allow better tolerance to the catheter during the time it should remain installed. Also, the use of this substance does not imply a higher cost and its safe, without side effects.

664 FUNCTIONAL SIGNIFICANCE OF USING TISSUE ADHESIVE SUBSTANCE IN NEPHRON SPARING SURGERY: ASSESSMENT BY QUANTITATIVE SPECT OF 99M TC-DIMERCAPTOSUCCINIC ACID SCINTIGRAPHY

OBJECTIVES To compare changes in renal function following nephron-sparing surgery (NSS) using tissue adhesive only versus NSS using standard suturing technique, as measured by quantitative SPECT of 99m Tc-dimercaptosuccinic acid uptake by the kidney (QDMSA). MATERIALS AND METHODS QDMSA was done before and 3-6 mo after the operation in 32 patients who underwent standard suturing technique and in 24 patients in whom tissue adhesive sealant (19 with albumin glutaraldehyde tissue adhesive [BioGlue]; 5 with CoSeal) was used to close the parenchymal defect. Individual kidney uptake was measured and retrospectively compared between the two groups. RESULTS Average tumor diameter was 3.4cm (range: 2.2-6) in the suture group and 3.56 (range: 1.7-6) in the tissue sealant group. In the tissue sealant group following surgery, we observed an average individual renal function loss of 11.49% compared with the suture group in whom an average individual renal function loss of 20.36% (p = 0.02) was measured by 99m Tc-DMSA. CONCLUSIONS The use of tissue sealant to close the parenchymal defect during NSS demonstrated a statistically significant advantage in reducing functioning renal loss as measured by the absolute uptake of QDMSA. Further clinical studies are required to establish the role of tissue sealants in NSS.