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PubMed1999

Approaches to the sellar and parasellar region: anatomic comparison of the microscope versus endoscope.

OBJECTIVE: Traditionally, surgical approaches to the sellar region require the use of the operating microscope. Over the past decade endoscopic surgery has gained much popularity because of advances in optics and illumination. Endoscopic surgery of the sellar region has been performed successfully. The goal of the present study was to quantify the amount of exposure to the sellar and suprasellar region that the endoscope provides versus the microscope, with three different anterior approaches to the sellar region. METHODS: The transethmoidal, endonasal-transsphenoidal, and sublabial-transsphenoidal approaches were performed on 14 formalin-fixed cadaver heads with a 0 degrees endoscope and repeated with the operative microscope. The distances of relevant surgical landmarks and the amount of exposure superior and anterior to the dorsum sella, as well as the lateral exposure, were measured. The mean distances were then used to calculate the volume of exposure for each of the approaches. RESULTS: It was found that the endoscope provided greater view than the operating microscope in all three approaches. The difference was statistically significant using a paired Student t test and a signed-rank test (P<.001). CONCLUSION: The authors believe that endoscopic surgery of the sellar region can be performed safely and effectively, while providing the surgeon with a view that is superior to that afforded by the operating microscope.

Cadaver↗
PubMed1999

Endoscopic surgical management of sphenoid sinus disease.

OBJECTIVES: To assess the outcome of functional endoscopic sphenoid sinus surgery, and to determine the predictors of outcome. STUDY DESIGN: Retrospective chart review of 651 consecutive endoscopic sinus procedures performed between 1992 and 1997. SETTING: USC University Hospital, University of Southern California, Los Angeles. MATERIALS AND METHODS: Seventy-four patients (11.4% of all endoscopic procedures) with sphenoid sinus disease were selected. All 74 patients were mailed a sinusitis-specific questionnaire, and 46 of them (62.2%) responded. Outcome measures derived from clinician ratings were applied to all 74 patients, and those derived from self-report were applied to 46. Outcome measures were determined from patient questionnaires at a minimum of 6-month postoperative follow-up, operative complications, and clinician perceptual ratings. Patient questionnaires addressed general patient satisfaction, symptom score, and medication usage. A statistical analysis was performed using chi2 test, linear regression, and one-way nonparametric ANOVA. RESULTS: Favorable surgical outcomes based on general patient satisfaction (84.8%, n = 39) and clinician perceptual rating (78.4%, n = 58) were noted. Minor postoperative complications were noted in 10 patients (13.5%) and 8 patients (10.8%) needed revision endoscopic procedures during follow-up. Of the complications, eight (80%) occurred in revision endoscopic procedures. The use of an expanded, sinus-specific symptom score revealed far fewer favorable outcomes (56.5%, n = 26). Seven outcome predictors were established, although none of the predictors held for more than one of the six outcome measures used. CONCLUSION: Endoscopic sphenoid sinus surgery is safe and effective. An expanded symptom score is recommended to assess the outcome of this procedure.

Adult↗
PubMed2000

Saccharin test of maxillary sinus mucociliary function after endoscopic sinus surgery.

OBJECTIVES: To determine the usefulness of the saccharin time (ST) test for evaluating the mucociliary function of the maxillary sinus after endoscopic sinus surgery (ESS) for chronic sinusitis. STUDY DESIGN METHODS: This study was conducted on 88 maxillary sinuses of 74 patients after ESS. The maxillary sinus fontanel was broadly opened via the middle meatus using an endoscope, and a saccharin granule was adhered to the bottom of the maxillary sinus mucosa The time until the patient recognized the sweet taste was recorded. Before the ST test, the bilateral maxillary sinuses were classified into the following four groups on the basis of the post-ESS severity of mucosal edema and swelling as revealed by endoscopic observation: normal (45 sinuses), mild mucosal edema and swelling (24), moderate mucosal finding (14), and severe mucosal finding or filling of the sinus with a polyp(s) (5). RESULTS: The mean ST values in the normal group and the groups with mild, moderate, and severe mucosal edema and swelling were 35.7, 38.1, 63.6, and 88.0 minutes, respectively. Thus the ST increased with the post-ESS severity of the mucosal lesion. However, for the group with mild mucosal edema and swelling, scanning electron microscopic observation of three maxillary sinuses in which the ST exceeded 120 minutes and four sinuses in which the ST was 40 minutes revealed extensive cilia loss in the former sinuses, but not in the latter. A second post-ESS endoscopic observation was performed in 17 patients, revealing improvement in 11 sinuses, no change in 5 sinuses, and aggravation in 1 sinus (compared with the initial test). The ST test was also repeated, revealing that the ST became shorter in most of the endoscopically improved sinus group. However, a few sinuses showed a discrepancy between the change in the endoscopic findings and the ciliary function (ST). CONCLUSION: Measurement of the maxillary sinus ST is a simple, accurate, and useful technique for assessing the post-ESS mucociliary function in conjunction with endoscopy, and the information gained can help in deciding subsequent therapy.

Adolescent↗
PubMed2000

Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea: a meta-analysis.

OBJECTIVES/HYPOTHESIS: Trauma and surgery are the most common causes of cerebrospinal fluid (CSF) rhinorrhea. Surgical repair is recommended for patients with CSF leaks that do not respond to conservative measures, traumatic CSF leaks that require transcranial surgery for associated brain injuries, and iatrogenic defects that are discovered intraoperatively. The purpose of our study was to ascertain the outcome after transnasal endoscopic repair of CSF leaks and to identify factors regarding the patient, CSF fistula, and treatment that may influence the results of the repair. METHODS: We performed a meta-analysis of all studies published in English between 1990 and 1999 that reported a minimum of five patients with CSF fistulae that were repaired using an endoscopic approach. We analyzed data that included type of graft and technique used during the repair, surgical complications, the use of packing, and the use of lumbar drains and antibiotics. The success rate was monitored and correlated with the other variables. The meta-analysis database was compared with and added to a database comprising our own patients. RESULTS: Fourteen studies comprising 289 CSF fistulae met the inclusion criteria. Endoscopic repair of CSF leaks was successful in 90% (259/289) of the cases after a first attempt. Seventeen of 30 persistent leaks (52%) were closed after a second attempt. Thus ultimately 97% (276/289) of the leaks were repaired using an endoscopic approach. The success rate of repairs using any of the reported techniques and materials was high and not statistically different. The incidence of major complications such a meningitis, subdural hematoma, and intracranial abscess was less than 1% for each complication. CONCLUSION: The endoscopic approach is highly effective and is associated with low morbidity. The literature supports the endoscopic approach using a variety of techniques and materials for the repair of CSF leaks.

Adolescent↗
PubMed2000

New guidelines for endoscopic localization of the anterior ethmoidal artery: a cadaveric study.

OBJECTIVES: To determine objective data to improve the methods of identification of the anterior ethmoidal artery during endoscopic dissection. STUDY DESIGN: Cadaveric dissection of adult human heads. METHODS: A 0 degrees, 4-mm rigid endoscope was used to guide uncinectomy and frontoethmoidectomy. The location of the anterior ethmoidal artery was first determined visually and then confirmed by passing a needle through the anterior ethmoidal foramen from the orbit into the nose in all cases. The distances were endoscopically measured using a simple ruler between two nasal landmarks and the anterior ethmoidal artery. RESULTS: Fifty-six nasal fossae in 28 cadavers were dissected endoscopically. The median distance between the artery and the "axilla" formed by the anterior attachment of the middle turbinate to the lateral nasal wall was 20 mm (range, 17-25 mm), irrespective of the side. The measurement differed by less than 2 mm between the sides in the same individual. The median distance between the artery and the "axilla" formed by the medial and lateral crura of the lower lateral cartilage (superomedial edge of the nostril) was 62 mm (range, 55-75 mm) for both sides. The artery was found to be in direct alignment with the two "axillae" formed by the middle turbinate and the nostril edge. CONCLUSIONS: The distance between the ethmoidal artery and the axilla of the middle turbinate showed the least intraindividual and interindividual variations. The tip of the endoscope (or the ruler) points directly at the anterior ethmoidal artery in the fovea ethmoidalis when its edge is aligned with the two nasal landmarks. These simple guidelines can aid the identification of the artery in endoscopic frontoethmoidectomy.

Adult↗
PubMed2001

Combined external and endoscopic frontal sinusotomy with stent placement: a retrospective review.

OBJECTIVES: To examine the long-term results of combined external and endoscopic frontal sinusotomy using frontal sinus stents and to compare our results with those reported for the endoscopic Lothrop procedure. STUDY DESIGN: We performed a retrospective review of 40 patients with chronic frontal sinusitis refractory to medical management who underwent a total of 62 combined external and endoscopic frontal sinusotomies with stent placement. All procedures were performed by the senior author at Vanderbilt University Medical Center. MAIN OUTCOME MEASURES: Postoperative nasofrontal duct patency and subjective patient improvement based on the last clinical examination. RESULTS: The overall patency rate of the nasofrontal duct was 79% (95% confidence interval [CI] of +/-10%.) The overall subjective patient improvement rate was 78% (95% CI of +/-14%.). The average length of stent placement was 5 weeks. The mean patient follow-up time was 12 months. There were no surgical complications. The nasofrontal duct patency rate and patient improvement rate from our study did not differ statistically from results reported by other authors using the endoscopic Lothrop procedure. CONCLUSION: We have found endoscopic frontal sinusotomy, in conjunction with external frontal sinusotomy and placement of frontal sinus stents, to be as effective in obtaining frontal sinus patency rates and overall patient improvement rates as the endoscopic Lothrop procedure.

Chronic Disease↗
PubMed2002

Reduction of diplopia following endoscopic orbital decompression: the orbital sling technique.

OBJECTIVE: Although endoscopic orbital decompression has become the surgical treatment of choice for patients with proptosis from Graves disease, postoperative diplopia requiring corrective eye muscle surgery can occur in up to 63% of patients. The purpose of the study was to evaluate a new technique intended to reduce the incidence of diplopia following endoscopic orbital decompression. STUDY DESIGN: Case-control. METHODS: Endoscopic orbital decompression was performed on 58 orbits in 37 patients with proptosis from Graves disease. The orbital sling technique, which makes use of a horizontal strip of periorbital fascia to prevent prolapse of the medial rectus muscle, was used on 20 orbits in 13 patients. Conventional endoscopic decompression was performed in 24 control subjects. The mean duration of follow-up was 3.3 +/- 1.3 years (range, 1.7-5.1 y). RESULTS: The incidence of new-onset or worsened diplopia following endoscopic decompression was significantly lower for the orbital sling group compared with control subjects (0% vs. 29.2%, respectively [ =.038]). No patients in the orbital sling group developed new-onset diplopia following surgery. Of the eight patients with pre-existing diplopia from the orbitopathy, double vision improved in four patients (50%) and was unchanged in the remaining four patients (50%). The mean reduction in proptosis was comparable for the orbital sling and control groups (5.1 +/- 1.1 mm vs. 5.0 +/- 1.9 mm, respectively [ P=.98]). CONCLUSIONS The preservation of a fascial sling overlying the medial rectus muscle during endoscopic orbital decompression appears to reduce the incidence of postoperative diplopia, while still allowing for a satisfactory reduction in proptosis. This modification of the standard decompression technique should be considered for the treatment of patients with proptosis.

Adult↗
PubMed2004

Outpatient endoscopic Zenker diverticulotomy.

OBJECTIVES/HYPOTHESIS: Staple-assisted, endoscopic Zenker diverticulotomy has been shown to decrease both cost of treatment and length of convalescence when compared with the standard open approach. Although the endoscopic technique is generally considered to be safe, the feasibility of outpatient endoscopic Zenker diverticulotomy has never been reported. STUDY DESIGN: Retrospective cohort study. METHODS: All endoscopic Zenker diverticulotomy procedures performed at Oregon Health and Science University (Portland, OR) between 1998 and 2002 were reviewed. The study group was limited to patients whose surgeries were planned on an outpatient basis. Medical charts were reviewed for indications, demographics, operative findings, complications, and resolution of symptoms. RESULTS: Of the 51 patients who underwent endoscopic, staple-assisted Zenker diverticulotomy, 40 were treated with the intent of outpatient management. Thirty-two cases were primary surgeries, and eight cases were revision treatments. The average patient age was 68 years (age range, 35-91 y), and the mean follow-up period was 5.9 months (range, 1-37 mo). Eight (20%) complications were noted in the study group. Intraoperative complications included 3 patients (7.5%) with mucosal disruptions. These patients underwent uneventful suture repair of small hypopharyngeal mucosal tears encountered intraoperatively and were temporarily observed in the hospital. One patient was admitted for postoperative urinary retention and another for fever and tachycardia 48 hours after surgery. One patient sustained a myocardial infarction. The remainder of patients were fed immediately and discharged home on the day of surgery. Two patients (5%) had iatrogenic tooth fracture. CONCLUSION: Appropriately selected patients undergoing endoscopic, staple-assisted Zenker diverticulotomy can be managed safely on an outpatient basis. Intraoperative complications, such as a mucosal disruption, warrant conversion to inpatient monitoring.

Adult↗
PubMed2004

Endoscopic neck surgery: resection of the submandibular gland in a cadaver model.

OBJECTIVES/HYPOTHESIS: The objective was to evaluate the feasibility of performing a totally endoscopic resection of the submandibular gland in a cadaver model. STUDY DESIGN: Prospective, nonrandomized experimental investigation in a cadaver model. METHODS: A modified endoscopic surgical approach (representing a hybrid of balloon dissection and low-pressure carbon dioxide insufflation) previously developed in a porcine model was implemented in fresh cadavers. Once a reliable protocol was achieved, eight procedures were performed in six cadavers. Data collected prospectively included the operative time, inadvertent neurovascular injury, and size of the glands. RESULTS: All eight endoscopic submandibular gland resections were successfully performed in six consecutive cadavers (no conversions to open resection were necessary). The duration of the procedures ranged from 50 to 150 minutes, with a median duration of 65.5 minutes and a steady trend toward a shorter duration. Histological examination confirmed the presence of normal glandular architecture without evidence of excessive trauma or thermal injury. The optimal spacing of the instrument ports was 4 cm from the camera port. There were no cases of neurovascular injury. In two cadavers, a minimal amount of subcutaneous emphysema could be appreciated, which was limited to the skin overlying the dissection. CONCLUSION: Totally endoscopic resection of the submandibular gland is possible by combining balloon dissection with low-pressure carbon dioxide insufflation. The excellent visualization afforded by the endoscope provided a safe operative approach. Ultimately, a number of endoscopic neck procedures may be possible, and clinical trials are under way.

Cadaver↗
PubMed2004

Bacterial infection after endoscopic sinus surgery: a controlled prospective study.

OBJECTIVES/HYPOTHESIS: The objective was to determine whether infections occurring after endoscopic sinus surgery represent overgrowth of sinonasal flora versus de novo bacterial infection. STUDY DESIGN: Prospective controlled cohort study. METHODS: A cohort of adult patients was prospectively followed after endoscopic sinus surgery. Baseline postoperative control cultures of the ethmoid sinus were obtained. Patients with acute infectious exacerbations of chronic rhinosinusitis had endoscopic culture, and these results were compared with baseline culture data. RESULTS: One hundred thirteen patients were followed for a mean period of 14.5 months after endoscopic sinus surgery. Baseline postoperative culture data revealed that the ethmoid labyrinth was sterile in 23% of cases, carried oral flora in 18% of cases, and was colonized in 60% of cases. Gram-positive cocci, particularly staphylococcal species, were the most common colonizing organisms (41% of cases). Twenty acute exacerbations were cultured in 17 patients during the follow-up period. All infectious cultures recovered bacteria; one culture recovered only oral flora. Gram-positive cocci predominated (56% of isolates) with Staphylococcus aureus being the most common isolate (28%). Of the 36 isolates, only 9 isolates (25%) corresponded to bacteria identified at the time of baseline culture. CONCLUSION: Although the postoperative sinonasal cavity may be colonized by bacteria after endoscopic sinus surgery, infections arising postoperatively most commonly represent de novo infections by bacteria other than colonizing bacteria. Empirical therapy based on baseline data may be misleading; acute exacerbations of chronic rhinosinusitis after endoscopic sinus surgery should be cultured to guide optimal antibiotic therapy.

Chronic Disease↗
PubMed2004

Endoscopic management of limited attic cholesteatoma.

OBJECTIVES: Microscopic postauricular tympanomastoidectomy provides a limited exposure to the attic, especially anteriorly. In contrast, the endoscope offers wide transcanal access to the attic, allowing for complete removal of limited attic disease, possibly without interrupting the ossicular chain. This report evaluates 8 years of experience with transcanal endoscopic management of limited attic cholesteatoma. STUDY DESIGN: Case series. METHODS: Seventy-three ears with limited attic cholesteatoma underwent endoscopic transcanal tympanotomy and extended atticotomy to access and completely remove the sac. Disease was dissected off the tegmen, the medial and lateral attic walls, and the ossicles. Appropriate ossicular reconstruction was performed. The defect was reconstructed with a composite tragal graft. RESULTS: A transcanal endoscopic approach was adequate for removal of disease in all cases. There were no iatrogenic facial nerve injuries. Bone thresholds were stable. Disease was dissected off the head of the malleus and the body of incus with preservation of both in 24 ears. Mean follow-up was 43 months. Five ears required revision for recurrent disease, and eight were revised for failed ossicular reconstruction or persistent perforation. Moderate to severe retraction in other areas of the tympanic membrane was evident in 28 cases; none of these required further intervention. CONCLUSION: An endoscopic technique allows transcanal, minimally invasive, eradication of limited attic cholesteatoma. Preservation of the ossicles coupled with complete removal of disease is more likely with the endoscope.

Adolescent↗
PubMed1998

Rectus muscle diastasis in males: primary indication for endoscopically assisted abdominoplasty.

Endoscopic techniques through umbilical and mons pubis ports have provided a method to plicate rectus muscle diastasis without skin resection. Limited or no skin excision is performed. Major series have included only women. The criteria for patient selection for endoscopic abdominoplasty include a protuberant abdomen caused by rectus muscle diastasis with minimal actual or potential skin laxity. There should not be significant intra-abdominal obesity. Extra-abdominal familial fat deposits may be part of the abdominal aesthetic deformity. In most women, rectus muscle diastasis because of pregnancy, obesity, or aging is associated with actual or potential skin laxity of the abdomen and lateral trunk. Endoscopic abdominoplasty in these women would produce mediocre early results and poor aging potential for the future. There are a limited number of women who are reasonable candidates for the endoscopic approach. In contrast, rectus muscle diastasis without skin laxity is a common finding in men older than 30 to 40 years of age. There may be a history of weight fluctuations, weightlifting, or full-excursion sit-up exercises, which may lead to progressive separation of the rectus muscles over time. Other etiologic factors include chronic or intermittent abdominal distension, advancing age, or familial weakness of the abdominal musculofascial tissues. Endoscopically assisted abdominoplasty was performed in four male patients with good to excellent results at 4 to 18 months. Minor complications occurred in half the patients but were successfully treated without re-operation. Men with prominent abdominal contours who are diet- and exercise-resistant should be examined both for familial fat deposits and for significant rectus muscle diastasis. Contouring of the male abdomen may be the primary indication for endoscopically assisted abdominoplasty.

Abdominal Muscles↗
PubMed2001

Image-guided endoscopic spine surgery: Part I. A feasibility study.

STUDY DESIGN: A feasibility study was performed to determine the efficacy of computer assistance in endoscopic spine surgery. OBJECTIVES: To assess a new method for computer assistance based on image guidance during thoracoscopic or any endoscopic spine procedure. To evaluate the reproducibility, the sensitivity and the reliability of the technique first in vitro and second in clinical use. SUMMARY OF BACKGROUND DATA: The computer-based, image-guided surgery is now a routine tool used in open spine surgery. Exposure of the anatomy of the vertebra is needed for registration. This methodology is inapplicable in endoscopic approach. Fluoroscopic-based navigation combines the technology of image-guided surgery and C-arm fluoroscopy. The navigation is based on the fluoroscopic images acquired before surgery. This technology is applicable to endoscopic surgery but the navigation is based on fluoroscopic image. The computed tomography images are not exploited. There are no published data on a technique that allows image-guided surgery based on computed tomography and magnetic resonance imaging. METHOD: A laboratory study was performed on a thoracic human spine. One vertebra was marked on the right lateral side of the body with five titanium marks. A percutaneous reference frame was specifically designed to be placed in the pedicle of the same marked vertebrae. The reference frame acted as a 3D localizer and a registration tool. The spine model was scanned including the reference frame. A standard Stealth station treatment guidance platform (Medtronic, Sofamor Danek, Memphis, TN) was used for simulation. The registration was obtained using the reference frame. Twenty navigation procedure trials were done and the error was recorded based on the distance between the anatomical point and the corresponding virtual one. RESULTS: Registration was always possible using the stealth station and a standard spine navigational software (spine 3, Medtronic Sofamor Danek, Memphis, TN). The mean error after registration given by the computer was 0.96 mm. The mean error recorded during the navigation simulation was 1.6 mm. CONCLUSIONS: This technique allows the possibility of computed tomography and magnetic resonance imaging-based, image-guided endoscopic surgery. It is probable that in the near future, as image fusion technology improves, the fluoronavigation based on fluoroscopic images would enable to navigate on multimodal images. Otherwise the technique described in this article is the only reproducible one that allows computed-tomography-based computer assistance during endoscopic procedures.

Endoscopy↗
PubMed2004

Revision endoscopic frontal sinus surgery.

PURPOSE OF REVIEW: Recurrent or persistent frontal sinus disease after endoscopic sinus surgery poses formidable challenges owing to the frontal sinus outflow tract's complex variable anatomy, close proximity to vital structures, and predilection for scarring and stenosis. Frontal sinus obliteration used to be the preferred technique of most sinus surgeons for addressing difficult frontal sinus disease; however, several effective endoscopic techniques exist as excellent alternative procedures for addressing this difficult clinical problem. RECENT FINDINGS: Several endoscopic techniques have been described for addressing these problems including endoscopic frontal sinusotomy, the frontal sinus rescue procedure, endoscopic transseptal frontal sinusotomy, and the modified Lothrop procedure. Advances in treating recurrent frontal sinus disease have included recent articles reviewing the long-term outcomes of some of these techniques, the prevalence of frontal sinus cells, the optimization of medical management, and the spectrum of postoperative debridement regimens. SUMMARY: When used in the appropriate setting, these less invasive revision endoscopic techniques provide excellent results with low morbidity and several advantages. This article reviews recent developments in the treatment of recurrent or persistent frontal sinus disease including incorporation of these techniques.

Endoscopy↗
PubMed2004

Rupture of rectal varices treated with endoscopic variceal ligation.

We report here 3 cases of rectal varices treated with endoscopic variceal ligation and discuss the pathogenesis, treatment, and prognosis of rectal varices with referring to previous reports. Of the 3 patients, 2 had been diagnosed as liver cirrhosis and 1 as extrahepatic portal hypertension. All of the 3 patients had previously undergone treatment of esophagogastric varices. The rupture of rectal varices appeared to have some relationship with the treatment of esophageal varices. In previous reports, 73% of patients with ruptured rectal varices treated with endoscopic injection sclerotherapy or endoscopic variceal ligation had undergone treatments of esophageal varices. The endoscopic treatments resulted in a favorable prognosis in 2 patients. Although no fatality from endoscopic injection sclerotherapy or endoscopic variceal ligation has been reported, 1 of the present 3 cases died of liver failure.

Aged↗
PubMed2002

Influence of voiding dysfunction on the outcome of endoscopic treatment for vesicoureteral reflux.

PURPOSE: Some patients with vesicoureteral reflux also experience voiding dysfunction. Dextranomer/hyaluronic acid copolymer (Deflux, Q-MED AB, Uppsala, Sweden) is an effective endoscopic treatment for vesicoureteral reflux. In an open label study we investigated the effect of voiding dysfunction on the efficacy of endoscopic treatment with dextranomer/hyaluronic acid copolymer in patients with vesicoureteral reflux. MATERIALS AND METHODS: A total of 320 children 3 to 11 years old with grade II to IV vesicoureteral reflux confirmed by voiding cystourethrography underwent endoscopic treatment with dextranomer/hyaluronic acid copolymer. Of the patients 50 were re-treated with dextranomer/hyaluronic acid copolymer because of persistent reflux (grade II or greater). The first implantation technique was recorded on videotape. Voiding cystourethrography and micturition details were recorded at the 3 to 6-month followup visit and compared with baseline measurements. RESULTS: At baseline 13 patients had known voiding dysfunction and 18 were misdiagnosed as not having voiding dysfunction. Of the 50 patients who required re-treatment, the initial implant was correctly positioned in 45 according to the videotape. Endoscopic observation at the time of re-treatment revealed no evidence of the implant in 15 patients. The implant was displaced in 27 patients and remained correctly positioned in 3. A total of 27 patients had voiding dysfunction, the majority of whom had urgency and frequency incontinence, had not received any anticholinergic therapy and had a displaced implant. CONCLUSIONS: Uncontrolled voiding dysfunction contributed to endoscopic treatment failure with dextranomer/hyaluronic acid copolymer in our series. Therefore, we suggest that patients with voiding dysfunction be treated at least 6 months before endoscopic therapy with anticholinergics and/or micturition rehabilitation.

Child↗
PubMed2003

Predictive factors for applicability and success with endoscopic treatment of upper tract urothelial carcinoma.

PURPOSE: We report on endoscopic treatment outcomes for upper tract urothelial carcinoma and identify predictive factors for success. MATERIALS AND METHODS: A total of 61 renal units were referred for endoscopic treatment of an upper tract tumor, 69% of which did not have a traditional indication for nephron sparing approaches. Tumor pathology and operative findings were assessed retrospectively for treatment outcomes and influential factors. RESULTS: Initial ureteroscopic inspection was undertaken in 53 renal units with resection attempted in 18 (34%) resulting in an 89% success rate with 16 treated. A percutaneous approach in 19 renal units (11 after ureteroscopy) was 100% successful in achieving tumor-free status, for a total of 35 renal units successfully treated endoscopically. Surveillance then began on 27 renal units with a recurrence rate of 88% and mean time to recurrence of 5.8 months (range 2 to 20). Of patients undergoing surveillance (31% of whom had high grade disease), 54% remain or have died of unrelated disease, during a mean followup of 21.0 months (range 3 to 48). Higher tumor grade, larger size, renal pelvis location (all p <0.01) and multifocality (p = 0.05) significantly correlated with decreased recurrence-free survival, but did not predict failure of local control by endoscopic surveillance. CONCLUSIONS: Although endoscopic techniques can render most patients tumor-free, there is a high associated recurrence rate and many need repeat procedures. Recurrence-free survival is greater in patients with low grade, solitary or less bulky disease. However, rigorous surveillance after endoscopic resection can lead to success even in patients with high grade, multifocal or large volume disease, resulting in preservation of renal units.

Aged↗
PubMed2005

Does prenatal diagnosis influence the morbidity associated with left in situ nonfunctioning or poorly functioning renal moiety after endoscopic puncture of ureterocele?

PURPOSE: We compared long-term morbidity associated with left in situ nonfunctioning or poorly functioning renal moiety of a duplex system in children with prenatal vs postnatal diagnosis of ureterocele who underwent endoscopic puncture. MATERIALS AND METHODS: A total of 48 children underwent primary endoscopic puncture of duplex system ureterocele. Of the cases 35 (73%) were diagnosed prenatally (group 1) and 13 (27%) postnatally (group 2). Median age at time of puncture was 4 months in group 1 and 3.5 years in group 2. A total of 20 patients in group 1 (57%) and 8 in group 2 (62%) presented with intravesical ureterocele, while 15 in group 1 (43%) and 5 in group 2 (38%) had ectopic ureterocele. A total of 20 children in group 1 (57%) and 7 in group 2 (54%) had a nonfunctioning renal moiety, and 15 in group 1 (43%) and 6 in group 2 (46%) had a poorly functioning ureterocele moiety. Vesicoureteral reflux (VUR) was present in 23 children in group 1 (66%) comprising 30 renal refluxing units (RRUs), and in 12 in group 2 (92%) comprising 14 RRUs. Median followup was 9 years (range 1 to 15) for both groups. RESULTS: Preoperative urinary tract infection (UTI) was common in group 2 (92%) vs group 1 (20%). No patient in group 1 had development of UTI after puncture, while 23% of the children in group 2 presented with UTI. Four children (2 from each group) with ectopic ureterocele required secondary puncture resulting in satisfactory drainage. A total of 14 RRUs (47%) showed spontaneous resolution of VUR in group 1 compared to 3 (21%) in group 2. Four RRUs (13%) required endoscopic correction due to high grade VUR in group 1. Two RRUs (17%) were treated with endoscopic correction and 2 (17%) with ureteral reimplantation due to UTI in group 2. Only 1 patient in group 1 underwent nephrectomy due to nonfunctioning kidney, while 2 patients in group 2 required partial nephrectomy due to UTI. CONCLUSIONS: Our data reveal that prenatal diagnosis of duplex system ureterocele is associated with fewer UTIs, and early endoscopic management may decrease UTI and the need for additional surgery. Nonfunctioning or poorly functioning renal moieties left in situ following successful endoscopic decompression of ureterocele are not associated with additional morbidity and do not require partial nephrectomy in the majority of the cases.

Age Factors↗