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Cost-effective management of pelvic fracture urethral injuries.
Johnsen NV, Penson DF, Reynolds WS, Milam DF, Dmochowski RR, Kaufman MR
(2017) World J Urol 35: 1617-1623
MeSH Terms: Adult, Cost-Benefit Analysis, Fractures, Bone, Humans, Lower Urinary Tract Symptoms, Male, Models, Economic, Patient Care Management, Pelvic Bones, Reconstructive Surgical Procedures, United States, Urethra, Urethral Stricture, Urologic Surgical Procedures, Wounds, Nonpenetrating
Show Abstract · Added September 16, 2019
PURPOSE - To compare the cost-effectiveness of various treatment strategies in the management of pelvic fracture urethral injuries using decision analysis.
METHODS - Five strategies were modeled from the time of injury to resolution of obstructed voiding or progression to urethroplasty. Management consisted of immediate suprapubic tube (SPT) placement and delayed urethroplasty; primary endoscopic realignment (PER) followed by urethroplasty in failed patients; or PER followed by 1-3 direct vision internal urethrotomies (DVIU), followed by urethroplasty. Success rates were obtained from the literature. Total medical costs were estimated and incremental cost-effectiveness ratios (ICERs) were generated over a 2-year follow-up period.
RESULTS - PER was preferred over SPT placement in all iterations of the model. PER followed by a single DVIU and urethroplasty in cases of failure was least costly and used as the referent approach with an average cost-effectiveness of $17,493 per unobstructed voider. The ICER of a second DVIU prior to urethroplasty was $86,280 per unobstructed voider, while the ICER of a third DVIU was $172,205. The model was sensitive to changes in the success rate of the first DVIU, where when the probability of DVIU success is expected to be less than 32% immediate urethroplasty after failed PER is favored.
CONCLUSIONS - Management of pelvic fracture urethral injuries with PER is the preferred management strategy according to the current model. For those who fail PER, a single DVIU may be attempted if the presumed success rate is >32%. In all other cases, urethroplasty following PER is the preferred approach.
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MeSH Terms
Tracheocutaneous fistula repair with autologous auricular cartilage cap graft.
Yawn RJ, Yawn JR, Gelbard A, Wootten CT
(2016) Laryngoscope 126: 2085-8
MeSH Terms: Adult, Aged, Cutaneous Fistula, Ear Cartilage, Female, Humans, Male, Middle Aged, Postoperative Complications, Reconstructive Surgical Procedures, Tracheal Diseases, Tracheotomy, Transplantation, Autologous, Treatment Outcome
Added January 25, 2017
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14 MeSH Terms
Characteristics and intraoperative treatments associated with head and neck free tissue transfer complications and failures.
Hand WR, McSwain JR, McEvoy MD, Wolf B, Algendy AA, Parks MD, Murray JL, Reeves ST
(2015) Otolaryngol Head Neck Surg 152: 480-7
MeSH Terms: Female, Follow-Up Studies, Free Tissue Flaps, Head and Neck Neoplasms, Humans, Incidence, Intraoperative Care, Male, Middle Aged, Odds Ratio, Postoperative Complications, Reconstructive Surgical Procedures, Retrospective Studies, Risk Factors, South Carolina, Treatment Failure, Treatment Outcome
Show Abstract · Added October 17, 2015
OBJECTIVE - To investigate the association between perioperative patient characteristics and treatment modalities (eg, vasopressor use and volume of fluid administration) with complications and failure rates in patients undergoing head and neck free tissue transfer (FTT).
STUDY DESIGN - A retrospective review of medical records.
SETTING - Perioperative hospitalization for head and neck FTT at 1 tertiary care medical center between January 1, 2009, and October 31, 2011.
SUBJECTS AND METHODS - Consecutive patients (N=235) who underwent head and neck FTT. Demographic, patient characteristic, and intraoperative data were extracted from medical records. Complication and failure rates within the first 30 days were collected
RESULTS - In a multivariate analysis controlling for age, sex, ethnicity, reason for receiving flap, and type and volume of fluid given, perioperative complication was significantly associated with surgical blood loss (P=.019; 95% confidence interval [CI], 1.01-1.16), while the rate of intraoperative fluid administration did not reach statistical significance (P=.06; 95% CI, 0.99-1.28). In a univariate analysis, FTT failure was significantly associated with reason for surgery (odds ratio, 5.40; P=.03; 95% CI, 1.69-17.3) and preoperative diagnosis of coronary artery disease (odds ratio, 3.60; P=.03; 95% CI, 1.16-11.2). Intraoperative vasopressor administration was not associated with either FTT complication or failure rate.
CONCLUSIONS - FTT complications were associated with surgical blood loss but not the use of vasoactive drugs. For patients undergoing FTT, judicious monitoring of blood loss may help stratify the risk of complication and failure.
© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2014.
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17 MeSH Terms
Urinary functional outcomes in female neobladder patients.
Bartsch G, Daneshmand S, Skinner EC, Syan S, Skinner DG, Penson DF
(2014) World J Urol 32: 221-8
MeSH Terms: Adult, Aged, Aged, 80 and over, Cohort Studies, Cystectomy, Female, Follow-Up Studies, Humans, Intestines, Middle Aged, Predictive Value of Tests, Quality of Life, Reconstructive Surgical Procedures, Regression Analysis, Retrospective Studies, Surveys and Questionnaires, Treatment Outcome, Urinary Bladder, Urinary Bladder Neoplasms, Urinary Catheterization, Urination, Urodynamics
Show Abstract · Added March 11, 2014
PURPOSE - The ratio between orthotopic and non-orthotopic diversions in women is far lower than in male patients. Data on urinary function in female patients with neobladders are therefore sparse.
METHODS - We investigated the urinary function of female neobladder patients utilizing the Bladder Cancer Index, a validated and reliable health-related quality-of-life (HRQOL) questionnaire. Furthermore, we tried to identify preoperative factors that may influence functional results. All living female patients with an orthotopic neobladder (N = 82) from the University of Southern California Bladder Cancer Database were sent a questionnaire including the University of Michigan Bladder Cancer Index. Univariate analyses were performed using the Kruskal-Wallis test followed by a multivariate stepwise regression model.
RESULTS - Fifty-six patients (68.3%) responded and were included in the analysis. Thirty-five (62.5%) of these patients had to catheterize their neobladder to a certain amount, while 25 patients (44.6%) depend on catheterization to empty their neobladder. Univariate analyses showed that patient age (>65 years) was the only variable associated with a statistically significant lower rate of neobladder catheterization. Better urinary bother scores were associated with organ-confined disease (p = 0.038) and education level (p = 0.01). However, these variables were not significant in a multivariate stepwise linear regression model.
CONCLUSION - Considerably more women require urinary catheterization to void than previously reported. In this study, representing the largest investigated cohort in this topic, we were unable to identify any predictors of this outcome or any other urinary HRQOL in this cohort.
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22 MeSH Terms
The usefulness of a yearly head and neck surgery trip to rural Kenya.
Pearce EC, Mainthia R, Freeman KL, Mueller JL, Rohde SL, Netterville JL
(2013) Otolaryngol Head Neck Surg 149: 727-32
MeSH Terms: Adolescent, Adult, Aged, 80 and over, Child, Child, Preschool, Cleft Lip, Cleft Palate, Developing Countries, Female, Follow-Up Studies, Health Services Needs and Demand, Humans, Incidence, Infant, International Cooperation, Kenya, Male, Middle Aged, Neck, Prospective Studies, Reconstructive Surgical Procedures, Rural Population, Time Factors, Travel, Young Adult
Show Abstract · Added March 7, 2014
OBJECTIVE - Surgical specialty trips to third world countries have been praised and criticized. Our objective was to learn the usefulness of a yearly head and neck surgery trip through initial analysis of 2 years of patient data.
METHODS - We reviewed data from a prospectively maintained repository of surgical patients treated during head and neck surgical trips to Malindi, Kenya, in 2010 and 2011. Basic demographics, distance traveled for care, access to physicians, preoperative diagnosis, surgical procedure(s), and pathology were recorded when available.
RESULTS - In 2 years, 226 surgeries were performed. Patient age ranged between 3 months and 85 years, and gender was evenly split. Half of patients came from outside the town of Malindi, and a third traveled over 100 kilometers for care. The majority reported access to a local physician, yet very few patients were offered prior surgical treatment. The most common operations performed were adenotonsillectomy and hemithyroidectomy. A wide variety of cases were performed, including parotidectomies, maxillectomies, mandibulectomies, cleft lip and palate repair, and free flap reconstructions. Local and national visiting otolaryngologist-head and neck surgeons participated or observed throughout our visits with teaching emphasis based on their skills and specific learning goals.
CONCLUSIONS - Annual surgical specialty trips to rural, resource-limited regions are useful and worthwhile and offer procedures not otherwise available. On such trips, it is important to collect patient, surgical, and pathology data to help visiting surgeons determine the best procedures to teach local physicians and provide needed resources.
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25 MeSH Terms
Outcomes of incontinent ileovesicostomy in the pediatric patient.
Ching CB, Stephany HA, Juliano TM, Clayton DB, Tanaka ST, Thomas JC, Adams MC, Brock JW, Pope JC
(2014) J Urol 191: 445-50
MeSH Terms: Adolescent, Child, Child, Preschool, Comorbidity, Cystostomy, Female, Humans, Ileostomy, Infant, Intermittent Urethral Catheterization, Male, Meningomyelocele, Postoperative Complications, Reconstructive Surgical Procedures, Retrospective Studies, Treatment Outcome, Urinary Bladder, Neurogenic, Urinary Diversion, Urinary Incontinence, Urodynamics
Show Abstract · Added February 19, 2015
PURPOSE - Ileovesicostomy is a reconstructive option in complex urological cases but pediatric specific outcomes are lacking. We report our results with pediatric ileovesicostomy.
MATERIALS AND METHODS - We retrospectively evaluated patients younger than 18 years undergoing incontinent ileovesicostomy at Vanderbilt University. History, urinary tract management and operative course were reviewed in the electronic medical record. Particular attention was given to immediate and long-term postoperative complications.
RESULTS - Nine patients underwent incontinent ileovesicostomy between 2000 and 2013 at a mean age of 10.3 years (range 1.4 to 15.5). Surgical indication was sequelae of neurogenic or nonneurogenic neurogenic bladder (such as infection or worsening hydronephrosis) in 5 patients, reversal of vesicostomy in 3 and closure of cloacal exstrophy in 1. All 9 patients were thought incapable of reliable clean intermittent catheterization due to family unwillingness, poor social support or patient refusal. Median followup was 11.5 months (mean 48.2, range 1.3 to 144.8). Immediate postoperative complications included ileus requiring total parenteral nutrition and a wound infection in 1 patient. Long-term complications included urinary tract infection in 2 patients (febrile in 1 and positive culture for foul smelling urine in 1), stomal issues in 2 and temporary urethral leakage in 1. Constipation affected 3 children in long-term followup (all with neurogenic bowel preoperatively). Postoperative creatinine was stable or improved in all patients.
CONCLUSIONS - Ileovesicostomy is a viable approach in children left with few other options, particularly those who are noncompliant or physically/socially unable to handle catheterization. This operation can help keep such patients out of diapers.
Copyright © 2014 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
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20 MeSH Terms
Vaginal approaches to pelvic organ prolapse repair.
Osborn DJ, Reynolds WS, Dmochowski R
(2013) Curr Opin Urol 23: 299-305
MeSH Terms: Female, Humans, Pelvic Organ Prolapse, Reconstructive Surgical Procedures, Risk Assessment, Risk Factors, Surgical Mesh, Treatment Outcome, Urologic Surgical Procedures, Vagina
Show Abstract · Added March 6, 2014
PURPOSE OF REVIEW - Changes in perception regarding the safety of mesh require a review of vaginal approaches for pelvic organ prolapse surgery with and without mesh. The purpose of this article is to examine the implications of the negative stigma toward mesh and review the outcomes of different vaginal approaches to pelvic organ prolapse repair.
RECENT FINDINGS - Defining a successful outcome of pelvic organ prolapse surgery from a symptomatic perspective instead of an anatomic perspective reveals that native tissue repairs and graft repairs are equivalent. In the posterior and apical compartments, a review of multiple studies shows that native tissue and graft transvaginal repairs have similar anatomic results except that native tissue repairs do not carry the risk of mesh extrusion. After failure of a native tissue repair, the majority of surgeons will use a graft-augmented repair.
SUMMARY - Controversy exists about how to define a successful outcome after pelvic organ prolapse surgery. Native tissue repairs require a more individualized approach than mesh-augmented repairs because native tissue requires the surgeon to closely examine the patient to determine the exact compartment and location that is affected before deciding on a surgical approach.
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10 MeSH Terms
Massive flap donor sites and the role of negative pressure wound therapy.
Schmedes GW, Banks CA, Malin BT, Srinivas PB, Skoner JM
(2012) Otolaryngol Head Neck Surg 147: 1049-53
MeSH Terms: Female, Head, Humans, Male, Middle Aged, Neck, Negative-Pressure Wound Therapy, Reconstructive Surgical Procedures, Retrospective Studies, Surgical Flaps, Transplant Donor Site, Wound Healing
Show Abstract · Added March 28, 2013
OBJECTIVE - Report our experience with negative pressure wound therapy (NPWT) applied to massive scapular and latissimus free flap donor sites, in the setting of microvascular reconstruction for extensive head and neck defects.
STUDY DESIGN - Retrospective case series with chart review.
SETTING - Tertiary academic referral center.
SUBJECTS AND METHODS - Retrospective review was conducted of all patients who underwent scapular or latissimus free tissue transfer by the senior author for head and neck reconstruction, over a 5-year period (2006-2011). In addition to NPWT details, comprehensive patient data were abstracted and compiled, including demographics, operative details, hospital stay, postoperative follow-up, and donor site complications.
RESULTS - Ninety-four patients underwent reconstruction of extensive postablative head and neck defects using either a scapular or latissimus free flap. Mean harvested flap skin paddle size was 140 cm(2). All donor sites were closed primarily. Fifty-two patients (55%) had NPWT applied over closed donor site incisions postoperatively. The other 42 patients (45%) received only conventional incision care. Major donor site complications occurred in 12% (n = 5) of the patients who did not undergo NPWT, as compared with a 6% (n = 3) complication rate among patients in the NPWT-treated group.
CONCLUSION - This is the first study to examine NPWT in the postoperative treatment of closed high-tension wounds following scapular or latissimus dorsi harvest for reconstruction of extensive head and neck defects. Our results suggest that NPWT is a safe technique in the management of massive scapular and latissimus free flap harvest sites that may decrease associated major donor wound complications.
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12 MeSH Terms
Approach to management of iatrogenic foreign bodies of the lower urinary tract following reconstructive pelvic surgery.
Padmanabhan P, Hutchinson RC, Reynolds WS, Kaufman M, Scarpero HM, Dmochowski RR
(2012) J Urol 187: 1685-90
MeSH Terms: Adult, Aged, Aged, 80 and over, Device Removal, Dyspareunia, Female, Foreign Bodies, Humans, Iatrogenic Disease, Middle Aged, Pain, Postoperative, Pelvic Organ Prolapse, Polypropylenes, Postoperative Complications, Reconstructive Surgical Procedures, Retrospective Studies, Suburethral Slings, Sutures, Urinary Incontinence, Stress
Show Abstract · Added March 6, 2014
PURPOSE - Evolving techniques and materials for pelvic reconstruction have resulted in corresponding increases in the risk of iatrogenic foreign bodies in the lower urinary tract and vagina. We review the presentation, management and outcomes of iatrogenic foreign bodies in the female lower urinary tract and vagina.
MATERIALS AND METHODS - We performed a retrospective review of the records of all women undergoing removal of lower urinary tract foreign bodies during a 9-year period. All patients underwent a structured evaluation including history, physical examination, ancillary testing as indicated and subjective symptom appraisal.
RESULTS - A total of 85 women were identified, of whom 48 had vaginal, 40 had lower urinary tract, and 3 had concomitant vaginal and lower urinary tract excision of foreign material. Of the lower urinary tract cases the foreign body was located in the urethra in 12, bladder neck in 10, bladder wall in 18 and trigone in 3, while the remainder of the cases was vaginal in location. Aggressive surgical management aimed at removal or debulking of the exposed foreign body necessitated cystorrhaphy/partial cystectomy (20), urethroplasty (18) and fistula repair (3). Of the patients with vaginal excision 36 (75%) reported cure (of presenting symptoms), 10 (20.8%) reported improvement and 2 were unavailable for followup. Of the patients with lower urinary tract excision 21 (52.5%) reported cure, 14 (35%) indicated improvement and 5 were unavailable for followup.
CONCLUSIONS - In a complex group of women with vaginal or lower urinary tract foreign body extrusion, aggressive operative management resulted in high rates of subjective patient cure. Adequate assessment of newer reconstructive technologies is critical to assess the full impact of these complications.
Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
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19 MeSH Terms
Complications of alloderm and dermamatrix for parotidectomy reconstruction.
Athavale SM, Phillips S, Mangus B, Datta J, Sinard RJ, Netterville JL, Burkey BB, Yarbrough WG
(2012) Head Neck 34: 88-93
MeSH Terms: Collagen, Female, Humans, Male, Parotid Gland, Parotid Neoplasms, Postoperative Complications, Prostheses and Implants, Reconstructive Surgical Procedures, Retrospective Studies, Skin, Artificial
Show Abstract · Added March 7, 2014
BACKGROUND - AlloDerm and DermaMatrix are 2 acellular dermal implants currently used by reconstructive surgeons at our institution for reconstruction of parotidectomy defects. We looked at the postoperative complication rates following subcutaneous implantation of these acellular dermal implants for parotid bed reconstruction.
METHODS - A retrospective analysis was conducted following approval by the Institutional Review Board at Vanderbilt University Medical Center. All parotid and reconstructive operations were performed between 2001 and 2009 by 1 of 4 surgeons in the Department of Otolaryngology-Head and Neck Surgery. Data were collected to determine operative variables and postoperative course. Operative variables assessed were tumor type, type of implant used, type of parotidectomy (total or subtotal), and duration of Jackson Pratt (JP) drain placement.
RESULTS - One hundred patients were analyzed. Sixty-nine AlloDerm implants were associated with 5 complications (7%), whereas 31 DermaMatrix implants were associated with 8 complications (26%) (p = .0107). When comparing total parotidectomies, the complication rate was 1 of 20 for AlloDerm (5%) and 1 of 12 for DermaMatrix (8%) (p = .7061). When looking at subtotal parotidectomies, the incidence of complications was found to be 4 of 49 for AlloDerm (8%) and 7 of 19 for DermaMatrix (37%) (p = .004).
CONCLUSIONS - Our study suggests that DermaMatrix was associated with increased postoperative complications compared to AlloDerm, especially in the subset of patients undergoing subtotal parotidectomy.
Copyright © 2010 Wiley Periodicals, Inc.
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11 MeSH Terms