Arthur Mourtzinos

Incomplete Renal Tumor Destruction Using Radio Frequency Interstitial Ablation

PURPOSE We evaluate the efficacy of temperature based radio frequency ablation as a potential treatment modality for small (less than 3.5 cm.) renal tumors. MATERIALS AND METHODS We treated 15 patients with a total of 20 tumors with radio frequency ablation through an open surgical approach immediately before partial nephrectomy. All tumors were biopsied before radio frequency ablation treatment. Tumors were heated to 90 to 110C for 6 to 16 minutes (mean 9.1). Tumor ablation was monitored by direct vision and ultrasound. Partial nephrectomy was performed in standard fashion. All specimens were stained with hematoxylin and eosin, and 5 specimens were stained for nicotinamide adenine dinucleotide (NADH) diaphorase activity. RESULTS Tumors ranged from 1.5 to 3.5 cm. (mean 2.4) in greatest dimension. All 20 specimens had evidence of morphologically unchanged tumor and normal renal parenchyma on standard hematoxylin and eosin staining. Of the 5 specimens 4 stained positively for NADH in areas confirmed to be tumor in hematoxylin and eosin stained neighboring sections. There was 1 intraoperative renal pelvic thermal injury requiring pyeloplasty and 2 postoperative caliceal leaks requiring stent placement. CONCLUSIONS In our series radio frequency therapy did not result in total tumor destruction when specimens were examined with hematoxylin and eosin or NADH staining. We believe that radio frequency interstitial tumor ablation of renal cell carcinoma without subsequent tissue resection should continue to be an investigational treatment modality for those who would otherwise undergo partial or radical nephrectomy.

Management of renal cell carcinoma with vena cava and atrial thrombus: minimal access vs median sternotomy with circulatory arrest

The topics covered in this section include renal, prostate, bladder and testicular cancer. As can be seen, these contributions come from all over the world and are of interest for several reasons. For example, the first paper, from the USA, describes the management of RCC with vena caval and atrial extension, using minimal access as against median sternotomy with circulatory arrest. Other more unusual subjects include RCC of native kidneys in renal‐transplant recipients and radical prostatectomy in patients with HIV.

The advance transobturator male sling for post-prostatectomy incontinence: subjective and objective outcomes with 3 years follow up.

To determine patient‐perceived and clinical outcomes of the AdVance sling at 3 years follow‐up in men with post‐prostatectomy incontinence (PPI).

Management Goals for the Spina Bifida Neurogenic Bladder: A Review from Infancy to Adulthood

Patients with spina bifida require longitudinal urological care as they transition from childhood to adolescence and then to adulthood. Issues important to urological health, such as protection of the upper tracts and prevention of incontinence, need vigilant follow-up throughout the patients life. As the child ages, additional issues such as sexual functioning also become increasingly important for social integration. Despite this need for regular assessment, many adult patients with spina bifida lose coordinated urological care after leaving specialized pediatric spina bifida clinics. Consequently, urologists frequently encounter an adult patient with spina bifida in practice and they need to understand the basic urological treatment goals and potential complications for this population.

Spiral Sling Salvage Anti-Incontinence Surgery for Women With Refractory Stress Urinary Incontinence: Surgical Outcome and Satisfaction Determined by Patient-Driven Questionnaires

PURPOSE Female patients with refractory stress urinary incontinence (SUI) are a unique surgical challenge. They undergo multiple surgical procedures and eventually are left with urethral closure and continent diversion as their final option. We previously presented our initial experience of a technique that provides circumferential coaptation of the urethra in patients with severe urethral incompetence due to neurologic injuries or congenital anomalies. This study expands on that experience and reports on the clinical and quality of life of patients after spiral sling placement in a defined population of patients with refractory SUI. METHODS We prospectively evaluated 46 patients with refractory SUI who had undergone spiral sling placement. The surgical outcome was determined by clinical history and physical examination and, primarily, by patient self-assessment and included validated symptom, bother, and quality-of-life questionnaires. RESULTS Their mean age was 62 years. The mean follow-up was 15 months. At presentation, the patients had undergone a mean of 2.8 incontinence procedures and wore a mean of 5.5 pads daily. The mean pad use decreased to 1.3 pads daily (P <.05). Preoperatively, the mean severity and bother score from the SUI symptoms was 3.0 and 2.9, respectively (0, none; 3, severe). Postoperatively, these numbers decreased to 1.0 and 0.8 (P <.05). The mean overall improvement in symptoms was 82%. No perioperative complications developed. The procedure failed in 1 patient, who underwent urethral closure with urinary diversion. Two patients underwent repeat proximal spiral sling procedure. CONCLUSIONS The spiral sling is an effective salvage transvaginal procedure that can be considered for female patients with refractory SUI.

Pelvic Organ Prolapse Surgery in Academic Female Pelvic Medicine and Reconstructive Surgery Urology Practice in the Setting of the Food and Drug Administration Public Health Notifications

OBJECTIVE To understand the effect of the Food and Drug Administration (FDA) public health notifications regarding transvaginal placement of surgical mesh for pelvic organ prolapsed (POP) on surgeon practice patterns in tertiary care academic medical centers. MATERIALS AND METHODS Surgical volume for procedures performed primarily by fellowship trained Female Pelvic Medicine and Reconstructive Surgery at a sampling of 8 academic institutions across the US were collected using current procedural technology codes for POP repair and revision surgeries from 2007 to 2013. SAS statistical software was used to analyze data for trends and to assess differences in number of procedures across years by performing Spearman correlation analysis and Pearsons chi-squared test. Significance of trend was defined as P <.05 for both analysis methods. RESULTS There has been a substantial reduction in transvaginal mesh-augmented repair of POP since the FDA warning statements of 2008 and 2011. Mesh revision surgery has increased over this same period. However, the total number of interventions for POP has remained stable over the study period. Abdominal sacrocolpopexy has increased as a whole but represents only a small percentage of total cases. CONCLUSION Surgical correction of POP comprises a large portion of Female Pelvic Medicine and Reconstructive Surgery practice that continues to evolve in the aftermath of the FDA public health notifications. The utilization of transvaginal placement of surgical mesh augmented POP repair has decreased among practicing urologists at a sampling of academic institutions across the United States. Indications for surgery, complications, and outcomes were not evaluated during this retrospective study; however, such data may provide alternative insights into the reasons for the observed trends.

Stress urinary incontinence surgery trends in academic female pelvic medicine and reconstructive surgery urology practice in the setting of the food and drug administration public health notifications.

To investigate the possible effects of the Food and Drug Administration (FDA) Public Health Notifications in 2008 and 2011 regarding surgical trends in transvaginal mesh (TVM) placement for stress urinary incontinence (SUI) and related mesh revision surgery in Female Pelvic Medicine & Reconstructive Surgery (FPMRS) practice in tertiary care academic medical centers in the United States.

Repair of vaginal vault prolapse and pelvic floor relaxation using polypropylene mesh

Purpose of review Innumerable techniques have been described for vaginal vault prolapse and enterocele repair including abdominal (open, laparoscopic, and robotic) and vaginal techniques. Recently, the use of surgical mesh in pelvic floor surgery has become increasingly popular due to the high incidence of recurrence with primary repairs and no surrogate material. The increasing variety of available materials and techniques, combined with a lack of well conducted clinical trials, make the choice of repair to use difficult. Recent findings This article provides an update review on the different procedures available to the urogynecologist and female urologist for repair of vault prolapse. We will also discuss a new surgical technique for the repair of vault prolapse, which recreates the sacrouterine–cardinal ligament complex and reconstructs the pelvic floor with mesh. Summary The best approach to vaginal vault prolapse remains unknown. Surgeon comfort and preference as well as proper patient selection remain critical. The use of graft materials in pelvic floor reconstruction should have limited use in a carefully selected patient population. There is a need for well powered, controlled, long-term, randomized studies with patient generated quality-of-life questionnaires comparing the short and long-term outcomes of these techniques.

Are multichannel urodynamics required prior to surgery in a woman with stress urinary incontinence

The National Institute for Clinical Excellence recommends that cystometry need not be performed before conservative therapy for incontinence in women, nor is cystometry routinely recommended in the small group of women with a clearly defined diagnosis of pure stress incontinence. Nonetheless, it is frequently utilized in the assessment of women with stress urinary incontinence in the hope that results will shed light on preoperative risk factors for failure or postoperative voiding dysfunction. The ability of urodynamic studies to characterize these parameters reliably remains under investigation. Because urodynamic studies are invasive, costly, and not always available, it is imperative that its benefit be carefully explored. This review highlights the recent arguments for and against this recommendation.

Editorial comment: Advances in female stress urinary incontinence: mid-urethral slings

The advantages of the mid-urethral sling techniques as stated by Bullock et al. [1] are clear: minimally invasive, short operative duration and ‘learning curve’, ability to perform the procedure on an outpatient basis, and generally well tolerated by patients. However, Bullock et al. caution that, as these techniques have gained popularity, it has become clear that they are not without complications. Intraoperative complications are mainly caused by aberrant passage of the trocars. Injuries, including vascular complications, nerve entrapment, urethral perforation, and bowel injury, are being reported with increased frequency as shown in Table 2 of their report [1]. If these events are not recognized during surgery, they can create significant morbidity and, in some cases, mortality. Although the TOT procedure was developed to avoid the blind passage of introducers within the retropubic space, we have found that this technique also has the potential for complications. As stated by Bullock et al ., injuries of the lower urinary tract, including erosions, pelvic abscesses, groin haematomas, and obturator nerve entrapment, have been reported. Perhaps the most problematic complication is postoperative voiding dysfunction (see Table 4 of [1]). This can include de novo urgency symptoms, short-term urinary retention, and long-term urinary retention requiring transvaginal urethrolysis, urethral dilatation or clean intermittent catheterization. Despite success in treating SUI, postoperative voiding dysfunction might negatively affect a patient’s quality of life, as has been shown in patient derived self-assessment questionnaires.