Syndromes and anomalies associated with cleft

Orofacial clefts are one of the commonest birth defects, and may be associated with other congenital anomalies. The majority of these orofacial clefts are nonsyndromic . A significant percentage of these clefts both syndromic and non-syndromic may have associated anomalies. Apart from reviewing other studies, this article also analyses a study of associated anomalies from a tertiary cleft centre in India.

A novel and non-destructive method to examine meniscus architecture using 9.4 Tesla MRI

OBJECTIVE

To investigate the ability of high-field (9.4 T) magnetic resonance (MR) imaging to delineate porcine knee meniscal tissue structure and meniscal tears.

MATERIALS AND METHODS

Porcine knees were obtained from a local abattoir, and eight medial menisci with no visible defects were dissected. Lesions simulating longitudinal tears were created on two of the menisci. MR images of the menisci were obtained at 9.4 T using a three-dimensional (3D)-FLASH sequence. A detailed 3D internal architecture of the intact and injured menisci was demonstrated on high-resolution MR images.

RESULTS

High-resolution 3D MR imaging allowed visualisation of internal architecture of the meniscus and disruption to the internal structural network in damage models. The architecture of the porcine knee meniscus revealed by the MR scans appeared similar to the structures visualised by histology in previously reported studies.

CONCLUSION

High-field MRI is a non-destructive technique to examine the internal structural components and damage/wear of meniscal tissue. It has tremendous potential in the field of functional cartilage/meniscus biomechanics and biotribology.

Syndromes and anomalies associated with cleft

Orofacial clefts are one of the commonest birth defects, and may be associated with other congenital anomalies. The majority of these orofacial clefts are nonsyndromic. A significant percentage of these clefts both syndromic and non-syndromic may have associated anomalies. Apart from reviewing other studies, this article also analyses a study of associated anomalies from a tertiary cleft centre in India.

Economic cost of cataract surgery procedures in an established eye care centre in Southern India

PURPOSE

To estimate the direct and indirect costs of three cataract surgery procedures: extracapsular cataract extraction with intra-ocular lens implantation (ECCE-IOL), phacoemulsification (PHACO) and manual small incision cataract surgery (MSICS) using economic costing principles in a well-established eye care programme (Aravind Eye Hospital) in Tamil Nadu, South India during 2000-01. Previous literature suggests that PHACO and MSICS have similar effectiveness.

METHODS

The average unit cost for each surgical procedure was calculated from the societal perspective using economic costing methods. Total annual provider's direct costs for each input to surgery were calculated and apportioned appropriately to different cataract surgery techniques using a 'micro-costing approach'. The patient's direct and indirect costs for each procedure were calculated by interviewing staff and patients and by using assumptions about prices for relevant cost items such as transportation, food, medicine, spectacles and economic productivity loss.

RESULTS

Average provider's direct costs were highest for PHACO procedures (25.55 US dollars) compared to MSICS (17.03 US dollars) and ECCE-IOL (16.25 US dollars). The difference can be attributed to the cost of equipment and materials. Average direct and indirect patient costs were highest for ECCE-IOL (19.85 US dollars), while the costs for PHACO and MSICS were identical (12.37 US dollars). ECCE-IOL had the highest total costs and MSICS had the lowest total costs from the societal perspective.

CONCLUSIONS

Our results suggest that MSICS may have a lower societal cost than other options. Government and NGO hospitals providing cataract surgeries should invest in regular cost analyses, reviews of the literature on effectiveness, and formal cost-effectiveness analyses in order to plan economically efficient interventions. Considering the small incremental cost for providers (less than 1 US dollar), improved outcomes, and lower patient costs, we also believe that MSICS is an important technique to use in efforts to eliminate cataract blindness in India and this result may be generalised to other developing countries.

Comparison of laparoscopic and percutaneous cryoablation of renal tumors: a cost analysis

Cryoablation of renal masses is an evolving in situ ablative technique for the management of localized renal masses and can be performed in a laparoscopic or percutaneous manner. Its usefulness is increasing and correlates with the increasing frequency of incidentally diagnosed renal lesions. At present, this technique has been applied to patients deemed to be poor surgical candidates for extirpative therapy or those with a strong desire to avoid surgery, at least until long-term data become available to fully evaluate its cancer-control effectiveness. In addition, as costs become an ever more critical factor in healthcare, the costs of various management options for clinically localized kidney cancer will become as important as clinical outcomes in deciding appropriate treatment. We compare laparoscopic and percutaneous renal cryoablation from a cost perspective. Our findings indicate that percutaneous renal cryoablation may have distinct cost advantages over its laparoscopic counterpart. It remains to be seen whether these differences will translate into an overall increase in reliance on the percutaneous approach for renal cryoablation.

Prospective randomized comparison of a combined ultrasonic and pneumatic lithotrite with a standard ultrasonic lithotrite for percutaneous nephrolithotomy

PURPOSE

To compare the efficiency and cost effectiveness of a combined pneumatic and ultrasonic lithotrite (Lithoclast Ultra) and a standard ultrasonic lithotrite, (LUS-1) during percutaneous nephrolithotomy.

MATERIALS AND METHODS

In a prospective randomized trial, 30 patients undergoing percutaneous nephrolithotomy (PCNL) were randomized to PCNL with either the combined pneumatic and ultrasonic lithotrite (PUL) or a standard ultrasonic lithotrite (SUL). Patient demographics, stone composition, location, pre- and post-operative stone burden, fragmentation rates, and device failures were compared.

RESULTS

There were 13 patients in the PUL group and 17 patients in the SUL group. Stone burden and location were equal. Overall, 64% of the PUL group had hard stones (defined as stones that were either pure or a mixture of cystine [3], calcium oxalate monohydrate [CaOxMono; 2], and calcium phosphate [CaPO4; 2]), and four had soft stones (3 struvite and 1 uric acid [UA]). In the SUL group, there were eight hard stones (5 CaOxMono and 3 CaPO4), and six soft stones (4 calcium oxalate dihydrate [CaOxDi] and 2 UA) (P = 0.51). Stone composition data were unavailable for five patients. Fragmentation time for the PAL was 37 minutes versus 31.5 minutes for the SUL (P = 0.22). Stone retrieval and mean operative times were similar for both groups. There were a total of three (23.1%) device-related problems in the PUL group, and eight (47%) in the SUL group. There was one (7.7%) device malfunction in the PUL group due to probe fracture. There were two (11.7%) device failures in the SUL group; one failure required the device to be reset every 30 minutes, and the second was an electrical failure. Suction tubing obstruction occurred twice (15.3%) in the PUL group and 35.3% in the SU group (P = 0.35). The stone-free rates for the PUL and SUL were 46% and 66.7%, respectively (P = 0.26).

CONCLUSION

Although the PUL was more costly, stone ablation and clearance rates were similar for both the combined pneumatic and ultrasonic device and the standard ultrasonic device. When stratified with respect to stone composition, the PUL was more efficient for harder stones, and the SUL was more efficient for softer stones.

Longterm changes in creatinine clearance after laparoscopic renal surgery

BACKGROUND

Controversy exists about the impact of ischemia on renal function. We evaluated the creatinine clearance of patients having undergone laparoscopic renal extirpative and ablative surgery.

STUDY DESIGN

The records of patients undergoing laparoscopic procedures for renal masses from February 2000 to March 2004 were examined. Creatinine clearance (CrCl) for each patient was determined using the Cockcroft-Gault equation and ideal body weight. We compared CrCl changes of patients undergoing laparoscopic partial nephrectomy (without renal ischemia [LPN-none], with warm ischemia [LPN-warm], and with cold ischemia [LPN-cold]) with patients undergoing laparoscopic radical nephrectomy (LRN) and laparoscopic cryoablation. Patients predisposed to medical renal disease were substratified and evaluated.

RESULTS

All patients who underwent LRN or LPN-warm sustained a significant drop in CrCl on the first postoperative day, compared with patients who had LPN without ischemia or cryoablation (p < 0.01). The CrCl decrease correlated directly with warm ischemia time. Six months postoperatively, CrCl changes were no longer significant. Patients with medical renal disease risk factors were more likely to sustain longterm (1 year postoperatively) renal damage if they had renal ischemia, trending toward statistical significance.

CONCLUSIONS

Ischemia causes acute renal damage, which is apparently reversible in patients without evidence of medical renal disease. Patients with known medical renal disease have substantial longterm changes in renal function associated with unilateral renal ischemia. Considering the insensitivity of creatinine-based renal function metrics, only eliminating ischemic time will realize the goal of maximal nephron preservation, particularly in patients with preexisting medical renal disease.

Prospective randomized comparison of laparoscopic and hand-assisted laparoscopic radical nephrectomy

OBJECTIVES

The majority of localized renal cancers are currently managed by laparoscopic radical nephrectomy, with or without the hand-assist device. In this prospective randomized study, we evaluated the patient outcomes with a standard laparoscopic radical nephrectomy (LRN) versus a hand-assisted laparoscopic radical nephrectomy (HALN).

METHODS

Over a 3-year period, we randomly assigned 21 patients with a localized renal mass of 10 cm or larger to a LRN group with intact specimen extraction or a HALN. The trocar size and sites, the position of the hand-assist device, and the specimen extraction sites were standardized. Patient characteristics, surgical complications, postoperative pain, and convalescence were evaluated.

RESULTS

Twelve patients underwent LRN and 9 patients underwent HALN. Both groups had similar body mass indices (BMI), mean tumor diameter (LRN, 5.8 cm; HALN, 5.6 cm), and American Society of Anesthesiologists (ASA) scores. The HALN cohort was significantly older (mean age = 68 years) than the LRN cohort (mean age = 54 years) (P = 0.019). Perioperatively, both groups had similar mean times to oral intake and discharge (LRN 2.6 days and HALN 3 days, P = 0.6). Although both groups reported similar postoperative pain scale scores on day 1, at 1 and 3 months. Two patients in each group had complications (LRN 16% and HALN 22%).

CONCLUSIONS

In comparing HALN and LRN, there was no difference in the majority of operative and postoperative parameters, including hospital stay and postoperative pain. However, LRN patients had a significantly shorter convalescence with quicker return to normal activities and work than the HALN group. Part of the delay in long-term convalescence parameters may be due to the older patients in the HALN cohort.

Laparoscopic urological surgery: a review

In this manuscript some of the more common laparoscopic procedures and their indications will be reviewed.

Pediatric nephrolithiasis: does treatment affect renal growth?

OBJECTIVES

The long-term effects of shock wave lithotripsy on the growth of pediatric kidneys are not well defined. Likewise, no long-term data regarding renal growth after ureteroscopy or percutaneous nephrolithotomy have been published. We studied the effect of urolithiasis on renal growth in our pediatric patient population.

METHODS

A total of 165 children were treated for urolithiasis at St. Louis Children's Hospital from March 1993 to December 2003. Of these 165 children, 74 were available for long-term follow-up. Four groups were evaluated: those who underwent shock wave lithotripsy, ureteroscopy, or percutaneous nephrolithotomy, and those who received no intervention. The expected renal length was calculated using Chen's nomogram, and the observed renal length was measured using renal ultrasonography. All measurements were performed by one pediatric radiologist. The expected and observed renal growth was determined by subtracting the renal length at baseline from the length at follow-up, divided by the number of months of follow-up. Statistical analysis used paired data for each treatment group, and comparisons were made on a nonparametric single-rank method.

RESULTS

Of the 74 children, 39 were boys and 35 were girls, with a mean age at treatment of 9 years (range 9 months to 14 years) and a mean follow-up of 6.2 years (range 1.3 to 13.1). In all groups, the comparison between the treated side and nontreated side for expected and actual kidney size and growth was calculated as described. None of the groups had statistically significant differences in the observed or predicted renal growth rates.

CONCLUSIONS

Shock wave lithotripsy, ureteroscopic stone extraction, and percutaneous nephrolithotomy do not appear to impair renal growth.