The Efficacy and Safety of a Conservative Management Approach to Radiation-Induced Male Urethral Strictures in Elderly Patients With Comorbidities

2022 ◽  
Vol 3 (1) ◽  
Author(s):  
Alexander T. Rozanski ◽  
Matthew J. Moynihan ◽  
Lawrence T. Zhang ◽  
Alexandra C. Muise ◽  
Daniel D. Holst ◽  
...  
Keyword(s):  
Elderly Patients ◽  
Reconstructive Surgery ◽  
Conservative Management ◽  
Median Number ◽  
Management Approach ◽  
Urethral Reconstruction ◽  
Clean Intermittent Catheterization ◽  
Urethral Strictures ◽  
Radiation Induced

Objectives To assess the outcomes of a conservative management approach to radiation-induced urethral stricture disease (R-USD) in an elderly population with comorbidities. Methods Patients with R-USD managed with endoscopic procedures and/or clean intermittent catheterization (CIC) between 2007 and 2019 were included. Patients were excluded if they had an obliterative stricture, prior urethral reconstruction/urinary diversion surgery, or < 3 months follow-up. Primary outcome measures were urinary tract infection (UTI), acute urinary retention (AUR), serum creatinine, uroflowmetry/post-void residual, and urinary incontinence (UI). Failure was defined as progression to reconstructive surgery or permanent indwelling catheterization. Results Ninety-one men were analyzed with a median follow-up of 15.0 months (IQR 8.9 to 37.9). Median age was 75.4 years (IQR 70.0 to 80.0), body mass index was 26.5 kg/m2 (IQR 24.8 to 30.3), and Charlson comorbidity index was 6 (IQR 5 to 8). Median stricture length was 2.0 cm (IQR 2.0 to 3.0). Stricture location was bulbar (12%), bulbomembranous (75%), and prostatic (13%). A total of 90% underwent dilation, and 44% underwent direct visual internal urethrotomy (DVIU). For those that underwent these procedures, median number of dilations and DVIUs per patient was 2 (IQR 1 to 5) and 1 (IQR 1 to 3), respectively. Forty percent used CIC. Thirty-four percent developed a UTI, and 15% had an AUR episode requiring urgent treatment. Creatinine values, uroflowmetry measurements, and UI rates remained stable. Eighty percent avoided reconstructive surgery or indwelling catheterization. Conclusion Most elderly patients with comorbidities with R-USD appear to be effectively managed in the short-term with conservative strategies. Close observation is warranted because of the risk of UTIs and AUR. The potential long-term consequences of repetitive conservative interventions must be considered.

P0797VERY LOW PROTEIN DIET (VLPD) WITH KETOANALOGUE SUPPLEMENTS AS CONSERVATIVE MANAGEMENT OF UREMIA IN ELDERLY PATIENTS: A SINGLE-CENTER EXPERIENCE

2020 ◽  
Vol 35 (Supplement_3) ◽  
Author(s):  
Battista Fabio Viola ◽  
Alessandra Pola ◽  
Roberto Zubani ◽  
Bernardo Lucca ◽  
Francesco Scolari
Keyword(s):  
Elderly Patients ◽  
Conservative Management ◽  
Chronic Dialysis ◽  
Protein Diet ◽  
Low Protein Diet ◽  
Electrolyte Balance ◽  
Low Protein ◽  
Epidemiologic Data ◽  
Very Low Protein Diet

Abstract Background and Aims EDTA published data gathered between 2012 and 2016 showed greatly reduced survival in elderly prevalent dialysis patients as compared to similar aged individuals in the general population: a 70 year-old dialysis patient had a life expectancy of 5 years (instead of 16), an 80 year-old patient could expect to survive 3 years (instead of 9). This was due to the multiple comorbidities often present in elderly patients with advanced Chronic Kidney Disease (CKD). This burden of disease is further increased by dialysis itself, in particular by hemodynamic instability during treatment and by vascular access problems which often determine the need for central venous catheter insertion and for hospitalization. In 2007 the DODE study (a randomized, controlled, multicentric study in which our center took part) validated a conservative treatment of uremia based upon a Very Low Protein Diet supplemented with ketoanalogues (sVLPD): survival in patients on conservative management was similar to that of patients on chronic dialysis; also, no negative effect on nutritional status was observed. Our aim was to analyse clinical and epidemiologic data and outcomes of patients treated at our center with a sVLPD. Method We analized 222 selected from a group of approximately 300 patients with stage 5 CKD managed conservatively with a sVLPD (0.3 g/kg/day proteins). The inclusion criterion was active follow-up for at least six months; patients unable to maintain fluid and electrolyte balance with medical therapy were excluded. Except for one patient, all subjects were aged 75 years and older. Clinical and epidemiologic data were recorded at the beginning, during and at the end of follow-up. Results Mean age at the beginning of observation was 80 ± 7 years (51-96); 48% of patients were male (107), 52% were female (115). Median initial Renal Residual Function (RRF, ml/min) was 6,3 ± 2,1 ml/min, at the end of follow-up it was 5,3 ± 2,9 ml/min. The most common significant comorbidities were hypertension (84,5%), heart (61,4%) and vascular disease (48,6%); these and other significant comorbidities are illustrated in Fig. 1. Conservative management allowed to delay the initiation of dialysis by an average of one year; 24% of patients continued on the sVLPD for two year and some patients reached a duration of treatment of 7 years. Median duration of sVLPD is shown in Fig. 2. At the end of follow-up 40% of patients had begun chronic hemodialysis and 9% peritoneal dialysis, 8% were still on conservative management, 27% were deceased (Fig. 3). Conclusion The supplemented Very Low Protein Diet is an effective treatment which can delay the beginning of chronic dialysis in elderly stage 5 CKD patients with multiple comorbidities. It is a safe treatment and does not increase morbility and mortality. Current epidemiologic data (incident patients in dialysis: 170 pmp/year, 50% aged over 70 years old) support the use of this conservative strategy which can represent a valid alternative to dialysis in selected patients.

scholarly journals Revisiting One-Stage Urethroplasties for Distal Urethral Strictures

2021 ◽  
Vol 10 (24) ◽  
pp. 5905
Author(s):  
Matthias D. Hofer ◽  
Lauren Folgosa Cooley ◽  
Ayman Elmasri ◽  
Francisco E. Martins
Keyword(s):  
Surgical Technique ◽  
Operative Time ◽  
Scar Tissue ◽  
Urethral Reconstruction ◽  
One Stage ◽  
Urethral Strictures ◽  
Average Operative Time ◽  
The Mean ◽  
Flap Repairs

Background: Reconstructive approaches for distal urethral strictures range from simple meatotomy to utilizing grafts or flaps depending on the etiology, length and location. We describe a contemporary cohort of distal urethral strictures and report a surgical technique termed distal one-stage urethroplasty developed to address the majority of distal urethral strictures encountered. Methods: Thirty-four patients were included. The mean age was 56.7 years (range 15.7–84.9 years), the mean stricture length was 1.1 cm (0.5–1.5) and the mean follow-up was 42.5 months (28–61.3). Results: The vast majority of distal strictures (27/34 (79.4%)) were treated with our hybrid one-stage approach combining a distal urethral reconstruction with excision of the scar tissue without the need to use grafts or flaps. The average stricture length was 0.68 cm and average operative time was 24.43 min. Post-operative spraying was reported in a minority of patients (4/27 (14.8%)). The length of stricture and surgery were significantly longer in those 7/34 (20.6%) patients in whom grafts or flaps were used (2.88 cm and 154.8 min, respectively, p < 0.001 for both when compared to the hybrid one-stage approach). We noted 6/34 (17.6%) recurrences of distal urethral strictures, all of which were treated successfully with graft and flap repairs. Conclusions: The vast majority of distal urethral strictures are amenable to a distal one-stage urethroplasty, avoiding the use of grafts and/or flaps while achieving reasonable outcomes. This limited approach, at least initially, is associated with shorter operative time and time of catheter placement and avoids morbidity associated with graft or flap harvesting. Spraying of urine is seldomly encountered and comparable to other approaches addressing distal urethral strictures.

scholarly journals VeSpAR trial: a randomized controlled trial comparing vessel-sparing anastomotic repair and transecting anastomotic repair in isolated short bulbar urethral strictures

Trials ◽  
2020 ◽  
Vol 21 (1) ◽  
Author(s):  
Wesley Verla ◽  
Marjan Waterloos ◽  
Mieke Waterschoot ◽  
Benjamin Van Parys ◽  
Anne-Françoise Spinoit ◽  
...  
Keyword(s):  
Sample Size ◽  
Functional Outcome ◽  
Phase Ii ◽  
Functional Outcomes ◽  
Phase Ii Trial ◽  
Phase Iii ◽  
Urethral Reconstruction ◽  
Randomized Controlled ◽  
Urethral Strictures

Abstract Background Vessel-sparing anastomotic repair (vsAR) has been developed as a less traumatic alternative to transecting anastomotic repair (tAR) to treat isolated short bulbar urethral strictures. This vessel-sparing technique could result in improved functional outcomes without jeopardizing the excellent surgical outcome after (transecting) anastomotic repair. The purpose of this study is to directly compare vsAR and tAR for both surgical and functional outcomes. Methods This trial is a prospective, interventional, multi-center, single-blinded, 1:1 randomized, controlled, non-inferiority, phase II trial. Sample size calculation resulted in a required sample size of 100 patients (50 patients per arm). Trial participants will be randomized by an independent third party using a computer-based random sequence generator with permuted blocks of variable size. The primary objective of this trial is to show that vsAR is non-inferior to tAR in terms of failure-free survival after 24 months of follow-up, considering a non-inferiority limit of 10%. Failure is defined as the inability to pass a 16-Fr flexible cystoscope through the reconstructed area without damaging the urethral mucosa. Secondary end-points mainly include differences in postoperative complications and changes in functional outcome parameters, which will be assessed with validated questionnaires. All participants are scheduled for follow-up at 3, 12, and 24 months postoperatively. Discussion This trial will provide level Ib evidence about the differences in both surgical and functional outcome between vsAR and tAR, which may importantly scape the future of bulbar urethral reconstruction. Depending on the trial results, this phase II trial may generate a larger phase III trial with more statistical power and a lower alpha value. Trial registration This trial is registered at clinicaltrials.gov (NCT03572348) and in the Belgian Clinical Trial Registry (B670201837335). The trial was registered prospectively. Registered on 28 June 2018.

scholarly journals Conservative Management of Complicated Colonic Diverticulitis in Early and Late Elderly

Medicina ◽  
2021 ◽  
Vol 58 (1) ◽  
pp. 29
Author(s):  
Gennaro Perrone ◽  
Mario Giuffrida ◽  
Elena Bonati ◽  
Gabriele Luciano Petracca ◽  
Antonio Tarasconi ◽  
...  
Keyword(s):  
Conservative Treatment ◽  
Elderly Patients ◽  
Conservative Management ◽  
Acute Diverticulitis ◽  
The Elderly ◽  
Complicated Diverticulitis ◽  
First Episode ◽  
Colonic Diverticulitis ◽  
Acute Colonic Diverticulitis

Background and Objectives: The management of complicated diverticulitis in the elderly can be a challenge and initial non-operative treatment remains controversial. In this study, we investigate the effectiveness of conservative treatment in elderly people after the first episode of complicated diverticulitis. Materials and Methods: This retrospective single-centre study describes 71 cases of elderly patients with complicated acute colonic diverticulitis treated with conservative management at Parma University Hospital from 1 January 2012 to 31 December 2019. Diverticulitis severity was staged according to WSES CT driven classification for acute diverticulitis. Patients was divided into two groups: early (65–74 yo) and late elderly (>75 yo). Results: We enrolled 71 elderly patients conservatively treated for complicated acute colonic diverticulitis, 25 males and 46 females. The mean age was 74.78 ± 6.8 years (range 65–92). Localized abdominal pain and fever were the most common symptoms reported in 34 cases (47.88%). Average white cells count was 10.04 ± 5.05 × 109/L in the early elderly group and 11.24 ± 7.89 in the late elderly group. CRP was elevated in 29 (78.3%) cases in early elderly and in 23 late elderly patients (67.6%). A CT scan of the abdomen was performed in every case (100%). Almost all patients were treated with bowel rest and antibiotics (95.7%). Average length of stay was 7.74 ± 7.1 days (range 1–48). Thirty-day hospital readmission and mortality were not reported. Average follow-up was 52.32 ± 31.8 months. During follow-up, home therapy was prescribed in 48 cases (67.6%). New episodes of acute diverticulitis were reported in 20 patients (28.1%), elevated WBC and chronic NSAID therapy were related to a higher risk of recurrence in early elderly patients (p < 0.05). Stage IIb-III with elevated WBC during first episode, had a higher recurrence rate compared to the other CT-stage (p = 0.006). Conclusions: The management of ACD in the elderly can be a challenge. Conservative treatment is safe and effective in older patients, avoiding unnecessary surgery that can lead to unexpected complications due to co-morbidities.

scholarly journals Reconstruction of the long urethral strictures with the buccal mucosal free graft

2014 ◽  
Vol 61 (1) ◽  
pp. 41-44
Author(s):  
Ivan Ignjatovic ◽  
Dragoslav Basic ◽  
Jablan Stankovic ◽  
Milan Potic ◽  
Ljubomir Dinic
Keyword(s):  
Urethral Reconstruction ◽  
Graft Material ◽  
Free Graft ◽  
Residual Symptoms ◽  
Urethral Strictures ◽  
Buccal Mucosal Graft ◽  
Exact Evaluation ◽  
Primary Graft Failure ◽  
One Year

Introduction: Reconstruction of the long urethral strictures is a difficult task in urology. The most frequently used method is augmentation with the free buccal mucosal graft. Material and methods: Restrospective analysis of 57 patients with the long urethral stricture was performed. All patients were evaluated endoscopically and radiologically before the surgery. Buccal mucosal graft harvested from the inner side of the cheek (unilateral or bilateral) was used for the urethral reconstruction in all patients. Follow-up was one year. Results: Complete follow up is achieved in 44/57 (77.2%)patients. The most important etiology of the strictures was previous iatrogenic trauma (instrumentation). The strictures were the most frequently located in the bulbar urethra. Preoperative exact evaluation of the stricture length was possible in only 35/57 patients (61.4%). Overall success rate of the surgery was 38/44 (86.3%). Complications occurred in 6/44 (13.7%) of patients-primary graft failure and urinary fistula. Mean preoperative IPSS was 19,2?5,2, and postoperative 10.3?3,2 (p<0.0001). IPSSQOL was 4.9?3.7 before the surgery, 2.9?1,1 after the surgery(p<0.001). Persistent urinary infection was present in 12/44(27.2%) patients. Conclusion: Buccal mucosal free graft could be successfully used in the reconstruction of long urethral strictures. However, complications are not uncommon, and residual symptoms still exist after the surgery, and could not be neglected.

A National Evaluation of the Conservative Management of Uncomplicated Acute Appendicitis: How Common Is This and What Are the Issues?

2015 ◽  
Vol 32 (5) ◽  
pp. 325-330 ◽  
Author(s):  
Michael E. Kelly ◽  
Asif Khan ◽  
Jameel ur Rehman ◽  
Ronan M. Waldron ◽  
Waqar Khan ◽  
...  
Keyword(s):  
Acute Appendicitis ◽  
Conservative Management ◽  
Management Practice ◽  
Pediatric Population ◽  
Management Approach ◽  
Complication Rates ◽  
Delayed Presentation ◽  
Interval Appendicectomy ◽  
Uncomplicated Acute Appendicitis

Introduction: The management approach for acute appendicitis has been challenged in recent years, with numerous randomized controlled trials demonstrating that antibiotics/conservative management is an efficacious treatment, with lower complication rates. Methods: A national survey of all consultant general surgeons evaluating their practices was performed. Reasons for changed practices, choice of antibiotics and follow-up investigations were evaluated. In addition, the role of interval appendicectomy and conservative management in the pediatric population was also assessed. Results: The response rate for this survey was 74.7% (n = 74/99). Over one-fifth (n = 17, 22.9%) routinely treat acute appendicitis conservatively, while another 14.8% (n = 11) consider this approach in selected cases. Main reasons for modified practices included the presence of inflammatory phlegmon (75%), delayed presentation (64%), and recent evidence-based medicine developments (46%). Co-amoxiclav/clavulanic acid was the most popular antibiotic for conservative management (53%). Alternatively, combinations of antibiotics were also utilized. One-third felt interval appendicectomy was warranted, while one-fifth supported conservative management in the paediatric setting. The overwhelming majority (>95%) advocate follow-up colonoscopy ± computed tomography in any patient aged >40 years managed conservatively. Conclusion: Considerable variation in management of uncomplicated appendicitis remains in Ireland despite growing evidence suggesting that the non-operative approach is safe. Reasons for adopting a conservative management practice have been identified and reflect the expanding literature on this subject.

scholarly journals Surgical treatment of urethral stricture disease – the earlier, the better

Folia Medica ◽  
2021 ◽  
Vol 63 (4) ◽  
pp. 481-487
Author(s):  
Valeri Mariyanovski ◽  
Emil Dorosiev ◽  
Boris Mladenov
Keyword(s):  
Surgical Treatment ◽  
Sexual Function ◽  
Reconstructive Surgery ◽  
Open Surgery ◽  
Treatment Options ◽  
Functional Results ◽  
Surgical Reconstruction ◽  
Urethral Reconstruction ◽  
Complication Rates ◽  
Urethral Strictures

Introduction: Surgical treatment of urethral strictures is a constantly evolving process. There are various treatment options like internal urethrotomy (IUT) and open surgery. A variety of techniques for urethral reconstruction are available (grafts, flaps, and excision-reanastomosis). Functional results of urethral reconstructive surgery are very satisfying and with low rate of complications. Aim: We assessed the early open surgical reconstruction in comparison with the continuation with the endourological treatment &ndash; IUTs. Materials and methods: The study included 129 patients with urethral strictures referred to our center. At that time point, they had received two unsuccessful IUTs and were divided into two groups &ndash; consecutive IUT and surgical repair, which included excision and reanastomosis or augmented urethroplasty. These patients were evaluated at 12 months using urethrography and uroflowmetry. Sexual function was evaluated using the international index of erectile function questionnaire 5-IIEF. Chi-squared test for statistical analysis was used. Results: Successful outcomes (urethrography presented equal caliber and Qmax was >15 ml/sec 12 months after the procedure) were achieved in 59 (88%) of the patients using reconstructive surgery versus 26 (41.9%) of the patients with consecutive IUT (p<0.001). Mild sexual dysfunction was reported by 12 (17.9%) patients from the group with open surgery and 7 (11.3%) from the group with continuous IUT (p=0.289). Conclusions: Early open surgery seems a reasonable solution to the problem of urethral strictures as there are only a few complications from this surgery and the functional results are satisfactory. The success rate using open surgery was found to be significantly greater than that in the consecutive IUT group, whereas no differences in the complication rates regarding sexual function were observed.

Evaluation of R-CHOP and R-CVP in the treatment of elderly patient with non-Hodgkin lymphoma

MedPharmRes ◽  
2019 ◽  
Vol 3 (3) ◽  
pp. 1-6
Author(s):  
Truc Phan ◽  
Tram Huynh ◽  
Tuan Q. Tran ◽  
Dung Co ◽  
Khoi M. Tran
Keyword(s):  
Elderly Patients ◽  
Hodgkin Lymphoma ◽  
B Cell Lymphoma ◽  
Complete Response ◽  
The Elderly ◽  
Free Survival ◽  
Non Hodgkin Lymphoma ◽  
Common Sign ◽  
Related Mortality

Introduction: Little information is available on the outcomes of R-CHOP (rituximab with cyclophosphamide, doxorubicin, vincristine and prednisone) and R-CVP (rituximab with cyclophosphamide, vincristine and prednisone) in treatment of the elderly patients with non-Hodgkin lymphoma (NHL), especially in Vietnam. Material and methods: All patients were newly diagnosed with CD20-positive non-Hodgkin lymphoma (NHL) at Blood Transfusion and Hematology Hospital, Ho Chi Minh city (BTH) between 01/2013 and 01/2018 who were age 60 years or older at diagnosis. A retrospective analysis of these patients was perfomed. Results: Twenty-one Vietnamese patients (6 males and 15 females) were identified and the median age was 68.9 (range 60-80). Most of patients have comorbidities and intermediate-risk. The most common sign was lymphadenopathy (over 95%). The proportion of diffuse large B cell lymphoma (DLBCL) was highest (71%). The percentage of patients reaching complete response (CR) after six cycle of chemotherapy was 76.2%. The median follow-up was 26 months, event-free survival (EFS) was 60% and overall survival (OS) was 75%. Adverse effects of rituximab were unremarkable, treatment-related mortality accounted for less than 10%. There was no difference in drug toxicity between two regimens. Conclusions: R-CHOP, R-CVP yielded a good result and acceptable toxicity in treatment of elderly patients with non-Hodgkin lymphoma. In patients with known cardiac history, omission of anthracyclines is reasonable and R-CVP provides a competitive complete response rate.

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