Search

Perioperative management of antithrombotic therapy in patients treated with coronary stents undergoing surgery remains poorly defined. Importantly, surgery represents a common reason for premature treatment discontinuation, which is associated with an increased risk in mortality and major adverse cardiac events. However, maintaining antithrombotic therapy to minimize the incidence of perioperative ischemic complications may increase the risk of bleeding complications. Although guidelines provide some recommendations with respect to the perioperative management of antithrombotic therapy, these have been largely developed according to the thrombotic risk of the patient and a definition of the hemorrhagic risk specific to each surgical procedure, key to defining the trade-off between ischemia and bleeding, is not provided. These observations underscore the need for a multidisciplinary collaboration among cardiologists, anesthesiologists, hematologists and surgeons to reach this goal. The present document is an update on practical recommendations for standardizing management of antithrombotic therapy management in patients treated with coronary stents (Surgery After Stenting 2) in various types of surgery according to the predicted individual risk of thrombotic complications against the anticipated risk of surgical bleeding complications. Cardiologists defined the thrombotic risk using a "combined ischemic risk" approach, while surgeons classified surgeries according to their inherent hemorrhagic risk. Finally, a multidisciplinary agreement on the most appropriate antithrombotic treatment regimen in the perioperative phase was reached for each surgical procedure. (C) 2018 by the American College of Cardiology Foundation.

Introduction Artificial urinary sphincter (AUS) is an option for the treatment of neurogenic stress urinary incontinence (nSUI), but complications and re-operation rates are high, and there is no clear indication from guidelines ( 1 ). The aim of our study is to evaluate the effectiveness of a less invasive continence device in neurogenic population: Adjustable Continence Therapy ProACT/ACT®. Methods We retrospectively includedpatients with spinal cord injuries in this study, complaining of nSUI and treated at our Institution with Pro-ACT/ACT® implantation. Diagnosis of nSUI was achieved with clinical history data collection and video-urodynamic testing. Results We treated 13 males and 3 females by proACT/ACT device, mean age 47.5 years (range 27-71). Fifteen implantations were performed bilaterally under spinal anesthesia and under fluoroscopic control; in one male patient, only the right balloon was implanted. Mean refilling number was 2.8 (range 0-6), and mean final volume was 3.6 ml. No patient reported any perioperative complications according to Clavien-Dindo. Follow-up was 37 months (range 7-156). Five patients (31%) underwent device explantation for deflate in one case, erosion or migration in three cases (18%), and infection in one case. About 43.75% of patients were dry and 18.75% improved more than 50% their urine loss, 37.5% of patients improved less than 50%, and no one reported worsening of incontinence. Conclusions Implantation of proACT/ACT® device is safe and a minimally invasive procedure also in neurological patients, with a relative low rate of intra and postoperative complications. Efficacy is good, although slightly lower than the results in non-neurological patients.

Introduction Primary female bladder neck obstruction is a rare clinical condition characterized by the absence/incomplete bladder neck opening during the voiding phase of micturition. Methods We present the cases of two women complaining dysuria, abdominal straining and sensation of incomplete bladder emptying. Videourodynamic evaluation was fundamental for a correct diagnosis. Results Videourodynamic evaluation showed a high detrusor pressure during emptying phase, partial use of abdominal strain, very low urine flow rate and significant postvoid residual; imaging showed a defect in the physiological funneling of the bladder neck, absent or incomplete. The first step therapy is represented by oral alpha-blockers and clean intermittent self-catheterization in case of high postvoid residual. Surgical operations, such as bladder neck incision and resection, represent the last option. Conclusions In our experience, bladder neck obstruction is a rare condition in women and only a complete clinical evaluation associated with videourodynamic study can lead to an appropriate diagnosis and treatment.

Purpose: ProACT™ is an adjustable continence therapy implant for post-prostatectomy incontinence. We evaluated the exact device location in clinical success and failed implant cases using spiral multidetector computerized tomography. Materials and Methods: We evaluated 18 consecutive patients postoperatively using pelvic spiral multidetector computerized tomography. Of the patients 11 (61%) were dry or improved and 7 (39%) had not improved despite multiple balloon adjustments. Thin pelvic collimated scans with bone algorithm were obtained, completed by multiplanar reformatting and a volume rendering technique. The computerized tomography technique is described. Results: Multidetector computerized tomography showed device sites compared to local anatomical structures. In 64% of dry or improved patients the devices were above the urogenital diaphragm and adjacent to the urethral wall (the correct position) while in the remaining 36% of cured patients only 1 device was positioned correctly. Of nonimproved patients 86% had balloons that were not adjacent to the urethra. The scout view did not show malpositioning in any of these cases. Only multiplanar reformatting with the volume rendering technique revealed misplacement. Conclusions: Multidetector computerized tomography data shows that a poor outcome in most failed cases results from poor device positioning. In a few failed cases an unsuccessful result is probably caused by excessive tissue sclerosis. To our knowledge we report for the first time how continence can be determined by the action of only 1 device.

PURPOSE: Sacral nerve modulation appears to offer a valid treatment option for some patients with fecal incontinence and functional defects of the internal anal sphincter or of the striated muscle. METHODS: Sixteen patients with fecal incontinence (4 males; mean age, 51.4 (range, 27–79) years) with intact or surgically repaired (n=1) anal sphincter underwent permanent sacral nerve stimulation implant. Cause was traumatic in two patients, and associated disorders included scleroderma (2 patients) and spastic paraparesis (1 patient); eight (50 percent) of the patients also had urinary incontinence, and two (12.5 percent) had nonobstructive urinary retention. All patients were selected on the basis of positive findings from at least one peripheral nerve evaluation. The stimulating electrode was positioned in the S2 (1 patient), S3 (14 patients), or S4 (1 patient) sacral foramen. RESULTS: Mean follow-up was 15.5 (range, 3–45) months. Mean preimplant Williams score decreased from 4.1±0.9 (range, 2–5) to 1.25±0.5 (range, 1–2) (P=0.01, Wilcoxon test), and the number of incontinence accidents for liquid or solid stool in 14 days decreased from 11.5±4.8 (range, 2–20) before implant to 0.6±0.9 (range, 0–2) at the last follow-up. Important manometric data were an increase in mean maximal pressure at rest of 37.7±14.9 mmHg (implantable pulse generator 49.1±18.7,P=0.04) and in mean maximal pressure during squeeze (prestimulation 67.3±21.1 mmHg, implantable pulse generator 82.6±21.0,P=0.09). CONCLUSIONS: Neuromodulation can be considered an option for fecal incontinence. However, an accurate clinical and instrumental evaluation and careful patient selection are required to optimize outcome.

Urinary disorders are uncommon in the initial phases of multiple sclerosis, but increase in frequency as the disease progresses, with a negative impact on quality of life. The goal of this study was to propose a protocol for the diagnosis and treatment of urinary disorders in multiple sclerosis, based on data from the scientific literature and the experience of Italian clinical centres. In particular, the following clinical aspects were considered: what to do with patients with asymptomatic multiple sclerosis; what to do with symptomatic patients; how and when to perform a second-level diagnostic evaluation; and how to treat urinary disorders. A diagnostic-therapeutic algorithm is proposed, that can be applied in Italian clinical centres.

We investigated the impact of sacral neuromodulation on quality of life and assessed the importance of quality of life for determining the success of sacral neuromodulation in patients with detrusor hyperactivity, including instability and hyperreflexia. We also compared it with parameters documented in a voiding diary.From May 1998 to December 2000, 82 female and 31 male patients 17 to 79 years old (mean age 51.1) with urge incontinence (63), urgency/frequency (5), voiding disturbance (41) and pelvic pain (4) resistant to conservative treatment were enrolled in a national prospective registry after showing a positive response to percutaneous nerve evaluation testing. Of the patients 47 who were 32 to 79 years old (mean age 59.2) with urge incontinence due to detrusor instability and 16 who were 27 to 51 years old (mean age 51.5) with hyperreflexia were asked to complete a validated self-reporting incontinence domain specific quality of life questionnaire before, and 3, 6, 9, 12, 18, 24 and 36 months after implantation.Compared with baseline the quality of life index significantly improved at each followup, which strongly correlated with the decrease in the number of incontinence episodes.Evaluating quality of life may be an additional useful tool for assessing the results of sacral neuromodulation for urge incontinence. Our study confirms that sacral neuromodulation is effective therapy for urge incontinence that can have a positive effect on patient quality of life.

Results of sacral neurostimulation in urinary retention are reported in the literature without distinction between the 2 functional disorders causing this condition, detrusor acontractility and functional outlet obstruction. We have suggested a stimulation test to differentiate irreversible bladder myopathy (or complete neurogenic lesion) from potential bladder contractility eligible for sacral neurostimulation.Direct electrostimulation of the sacral nerves was performed with the patient under general anesthesia. Urodynamic monitoring of bladder (detrusor contractility test) and bowel pressures were used. If no bladder contraction (negative detrusor contractility test) was recorded with positive somatic and bowel responses a irreversible bladder myopathy was supposed and the patient discharged home. If no bladder and no bowel contraction were recorded a complete neurogenic lesion was supposed and the patient was also discharged.Of 96 patients tested with the detrusor contractility test 72 (65%) had no bladder contraction and were excluded from sacral neurostimulation therapy. In this series 15 patients had already been tested with percutaneous nerve evaluation on each S3 nerve with negative results. In 18 cases no bladder and no bowel contraction was evoked (neurogenic lesion). In the remaining 54 cases (bowel but no bladder contraction) a bladder myopathy was supposed. In 24 patients the detrusor contractility test was positive and 12 of these underwent implantation with a permanent device for sacral neurostimulation.The detrusor contractility test can be considered a reliable tool to rule out detrusor acontractility due to irreversible bladder myopathy or complete neurogenic lesion from sacral neurostimulation.