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By Q. Brenton. National-Louis University.

Rarely strictures may result from estrogen deficiency purchase on line tadapox erectile dysfunction operations, usually at the meatus (meatal stenosis) discount 80mg tadapox with visa drinking causes erectile dysfunction. Urethral destruction/ablation may result from urethral trauma, chronic indwelling urethral catheterization (usually in a patient with decreased or absent sensation) or as a complication of urethral surgery. Typically, urethral strictures result in a reduced maximum flow rate with a flattened appearance to the flow curve, rather than the typical bell shape. Physical exam may show inflammation or atrophy around the urethral meatus and/or the surrounding vulva. In cases when there is a high suspicion of urethral stricture, one can attempt catheterization (or calibration), and this can be done as part of the physical exam. Some authors have defined failure to admit a 14 French catheter as an inclusion criterion for urethral stricture [10–12]. If there is any resistance, the process is stopped, and further, more definitive testings are recommended. In a patient with a true urethral stricture, a 10 French catheter often will not pass [13], but its passage does not rule out a stricture. Radiographic evaluation of urethral stricture is best accomplished with voiding cystourethrogram; however, in order to perform this test, a catheter must be passed into the bladder. For this, a small 6–8 French catheter can be used if a larger catheter will not pass. Typically, one will see distal urethral narrowing with proximal urethral ballooning [1]. For example, if the bladder neck is closed with Valsalva, that is usually the level of continence. However, if with straining the bladder neck opens and the level of continence is at or near the stricture, there may be concern for posturethroplasty incontinence. Finally, endoscopic evaluation can be helpful to evaluate the extent of the stricture. Gentle dilatation of the stricture can be performed to facilitate endoscopy, especially if a biopsy is desired. Perhaps, this discrepancy is attributable to the relative rarity of stricture disease in women, combined with the more varied causes of strictures in women. In men, urethral strictures are commonly caused by blunt trauma; however, due to the female urethra’s short length, its anatomic position behind the pubic arch, and its relative mobility, the incidence of stricture following trauma in females is low (range of 0%–6%). More commonly, stricture disease in women is seen following endoscopic or open urethral surgery, urethral dilatation, and pelvic radiation therapy for gynecological malignancies. Salvage procedures (bladder neck closure and/or urinary diversion) The driving factors for treatment of female urethral stricture will often be based on the patient’s degree of obstruction, bothersome symptoms, and emptying patterns. In cases in which a patient is adequately emptying and not encumbered with bothersome symptoms, they may be offered the option to be conservatively monitored with routine follow-up. In cases in which treatment is warranted, the course of treatment should be based on the degree of urethral stenosis and/or retention, the functionality of the bladder, and the risk for any upper tract dysfunction. Additionally, if the underlying mechanism of stricture formation can be ascertained, such as radiation, this should be kept in consideration. Ultimately, if there is suspicion for urethral stricture in a woman, it is imperative to fully assess them in order to make an accurate diagnosis for which a proper treatment course may be offered. For example, in cases of pelvic floor dysfunction or dysfunctional voiding, it may present and appear as a urethral stricture, but the treatments are profoundly different. Counseling the patient is very important throughout the process, as symptoms of frequency and urgency may persist even after treatment of a stricture [13]. Selfcatheterization involves teaching the patient how to perform intermittent catheterization at various intervals based on the degree and timing of scarring. If a stricture is diagnosed early, self-catheterization can likely be initiated without requiring urethral dilations or surgical therapies. The patient should be followed at regular intervals to ensure no problems with or worsening symptoms between catheterizations. If a patient fails intermittent self-catheterizations or elects to have more definitive therapy, a discussion regarding other conservative and surgical options should be initiated with the patient. Urethral dilation gained rapid popularity in the 1960s when it was proposed to dilate a “contraction ring” noted in the urethras of young girls up to 32–45 French [14]. This notion as a treatment for “urethral syndrome” in those with recurrent urinary tract infections and chronic urethritis subsequently expanded. Since then, studies have demonstrated that in the absence of a true stricture, urethral dilation does little in the way of helping with urinary symptoms of frequency and urgency [15,16]. In general, emerging literature advocates against the use of urethral dilation in the absence of a true urethral stricture. This change in management trends is reflected in surveys given to practicing urologists, with those trained within the 10 years prior to 1999 considering dilation to be as largely unsuccessful, contrasted by 21% of those trained more than 10 years before 1999 considering it to be very successful [17]. Another recent British survey found that 69% of urologists still regularly perform urethral dilation despite data to suggest its lack of efficacy [18]. It is unclear why this practice continues, and it has been suggested that generous reimbursements by Medicare may play a role. Analysis of public datasets estimate an annual cost of $61 million for treatment of stricture disease in women, of which the majority (67%) were for ambulatory surgery visits [19]. Diagnosis of urethral stricture in a woman averages a cost of $8444 in health-care costs compared to $4658 in those with similar complaints without that diagnosis. Long-term data on outcomes of dilation are scarce, and many studies are performed in the absence of the diagnosis of a true urethral stricture. They were dilated to 30 French, left with a catheter for 1 week, and then asked to intermittent catheterized once a day for 6 months. All women had at least one prior dilation prior to presentation, and of those that underwent another dilation, nearly all had a recurrence (16 of 17 patients) subsequently requiring another dilation or urethroplasty. Success rate at a mean follow-up of 2 years was a meager 6%, thereby prompting the authors to conclude that urethral dilation is very rarely effective. At a mean follow-up of 43 months, the urethral dilation success rate was 47% with higher rates of success in those that had not had a prior dilation (58%) than if they had a prior dilation (27%). The authors concluded that in cases of repeat dilation, it often serves primarily a palliative purpose rather than as a cure likely due to extension of the scarring. The group concluded that on-demand dilations are superior because they provide similar outcomes with less urethral manipulation. Finally, adjunctive therapy with vaginal estrogen in order to improve atrophy and improve tissue either pre- or posttreatment can be considered [13,24]. Very scant literature exists on endoscopic management of urethral strictures in women. Most of the existing literature for lasers is for the treatment of male urethral strictures and as with literature in female strictures is sparse [27,28]. These range from meatoplasty to vaginal inlay flaps for distal strictures, more extensive vaginal flap urethroplasty for midurethral strictures, and onlay grafts for mid and proximal urethral strictures.

Making an Observation First purchase tadapox 80 mg fast delivery erectile dysfunction uk, an observation is made of a phenomenon or a group of phenomena order 80 mg tadapox with mastercard erectile dysfunction vitamin. This observation leads to the formulation of questions or uncer- tainties that can be answered in a scientifically rigorous way. For example, it is readily observable that regular exercise reduces body weight in many people. In this case there are two observable phenomena, regular exercise and diet change, that have the same endpoint. Formulating a Hypothesis In the second step of the scientific method a hypothesis is formulated to explain the observation and to make quantitative predictions of new observations. Often hypotheses are generated as a result of extensive background research and literature reviews. Explicit definitions of these terms are given in Chapter 7, which discusses the science of testing hypotheses. Suffice it to say for now that a research hypothesis from the weight-loss example would be a statement such as, “Exercise appears to reduce body weight. A statistical hypothesis may be stated using quantitative terminology as follows: “The average (mean) loss of body weight of people who exercise is greater than the average (mean) loss of body weight of people who do not exercise. The role of the statistician in this step of the scientific method is to state the hypothesis in a way that valid conclusions may be drawn and to interpret correctly the results of such conclusions. Designing an Experiment The third step of the scientific method involves designing an experiment that will yield the data necessary to validly test an appropriate statistical hypothesis. This step of the scientific method, like that of data analysis, requires the expertise of a statistician. Improperly designed experiments are the leading cause of invalid results and unjustified conclusions. Further, most studies that are challenged by experts are challenged on the basis of the appropriateness or inappropriateness of the study’s research design. Those who properly design research experiments make every effort to ensure that the measurement of the phenomenon of interest is both accurate and precise. It should be noted that in the social sciences, the term validity is sometimes used to mean accuracy and that reliability is sometimes used to mean precision. In the context of the weight-loss example given earlier, the scale used to measure the weight of study participants would be accurate if the measurement is validated using a scale that is properly calibrated. If, however, the scale is off by þ3 pounds, then each participant’s weight would be 3 pounds heavier; the measurements would be precise in that each would be wrong by þ3 pounds, but the measurements would not be accurate. For much scientific research, however, the standard for data collection is experimentation. A true experimental design is one in which study subjects are randomly assigned to an experimental group (or treatment group) and a control group that is not directly exposed to a treatment. Continuing the weight-loss example, a sample of 100 participants could be randomly assigned to two conditions using the methods of Section 1. A sample of 50 of the participants would be assigned to a specific exercise program and the remaining 50 would be monitored, but asked not to exercise for a specific period of time. At the end of this experiment the average (mean) weight losses of the two groups could be compared. The reason that experimental designs are desirable is that if all other potential factors are controlled, a cause–effect relationship may be tested; that is, all else being equal, we would be able to conclude or fail to conclude that the experimental group lost weight as a result of exercising. The potential complexity of research designs requires statistical expertise, and Chapter 8 highlights some commonly used experimental designs. For a more in-depth discussion of research designs, the interested reader may wish to refer to texts by Kuehl (5), Keppel and Wickens (6), and Tabachnick and Fidell (7). Conclusion In the execution of a research study or experiment, one would hope to have collected the data necessary to draw conclusions, with some degree of confidence, about the hypotheses that were posed as part of the design. It is often the case that hypotheses need to be modified and retested with new data and a different design. Whatever the conclusions of the scientific process, however, results are rarely considered to be conclusive. That is, results need to be replicated, often a large number of times, before scientific credence is granted them. Include all of the steps, including the hypothesis to be tested and the design of your experiment. Include all of the steps, paying particular attention to how you might design the experiment and which hypotheses would be testable given your design. Computers can perform more calculations faster and far more accurately than can human technicians. The use of computers makes it possible for investigators to devote more time to the improvement of the quality of raw data and the interpretation of the results. The current prevalence of microcomputers and the abundance of available statistical software programs have further revolutionized statistical computing. The reader in search of a statistical software package may wish to consult The American Statistician, a quarterly publication of the American Statistical Association. Statistical software packages are regularly reviewed and advertised in the periodical. Computers currently on the market are equipped with random number generating capabilities. As an alternative to using printed tables of random numbers, investigators may use computers to generate the random numbers they need. Actually, the “random” numbers generated by most computers are in reality pseudorandom numbers because they are the result of a deterministic formula. However, as Fishman (8) points out, the numbers appear to serve satisfactorily for many practical purposes. The usefulness of the computer in the health sciences is not limited to statistical analysis. The reader interested in learning more about the use of computers in the health sciences will find the books by Hersh (4), Johns (5), Miller et al. Those who wish to derive maximum benefit from the Internet may wish to consult the books Physicians’ Guide to the Internet (13) and Computers in Nursing’s Nurses’ Guide to the Internet (14). Current developments in the use of computers in biology, medicine, and related fields are reported in several periodicals devoted to the subject. A few such periodicals are Computers in Biology and Medicine, Computers and Biomedical Research, International Journal of Bio-Medical Computing, Computer Methods and Programs in Biomedicine, Computer Applications in the Biosciences, and Computers in Nursing. Computer printouts are used throughout this book to illustrate the use of computers in ® biostatistical analysis. We defined statistics as an area of study concerned with collecting and describing data and with making statistical inferences. We defined statistical inference as the procedure by which we reach a conclusion about a population on the basis of information contained in a sample drawn from that population. We learned that a basic type of sample that will allow us to make valid inferences is the simple random sample.

It is also a good idea to leave the nasogastric tube in the jejunal loop to calibrate the loop and avoid any bites in the posterior wall while suturing the gastrotomies and enterotomies purchase 80mg tadapox mastercard erectile dysfunction venous leak treatment. It is created in the same fashion described in the technique of Roux-en-Y gastric bypass in the bariatric surgery chapter tadapox 80 mg free shipping erectile dysfunction 42, and the gastrojejunal anastomosis is performed as described above. It is more straightforward and requires no greater muscle incision than that for removal of the specimen. The rationale is to exteriorize the stomach and jejunum through a 3 cm muscle splitting incision in the left rectus muscle by enlarging the 10 mm trocar port used for the introduction of the instruments. To inspect the bowel and pick up the jejunal loop, the surgeon moves to the right side of the patient, who is put in the Trendelenburg position. This will expose the small bowel, while the assistant retracts upward on the transverse colon. The jejunal loop that will be exteriorized is marked with endoclips for identifcation: this can be one small mark proximally and two marks distally (Fig. First, until the surgeon gains experience with this operation, the stomach should be checked for leaks by flling it with methylene blue and infating. Second, placing the patient in a Trendelenburg position ensures that all fuids are collected above the mesocolon and aspirated, as some enteral fuid may remain and promote abscess creation in the postoperative period. The surgeon (S) moves to the right side of the patient and the scope is oriented down towards the pelvis Perforated If the patient’s condition is stable, and peritonitis is diagnosed within 12 h of onset, it is Duodenal Ulcer possible to perform an operation laparoscopically (after 12 h, chemical peritonitis will give way to bacterial peritonitis presenting with severe sepsis, and laparoscopy may not be recommended in this situation). Care should be taken not to use a high insuffation pressure which could push intra-abdominal bacteria into the blood stream leading to bacteremia and septic shock. Four ports are then inserted using the triangulation concept, to form a diamond-shape. The surgeon stands between the legs of the patient, with the frst assistant to the right and a second assistant to the left. The lead surgeon thus works comfortably with two hands, triangulated between the cameras (Fig. A umbilicus; B surgeon’s right hand; C surgeon’s left hand, D irrigation and suction and/or fan retractor for liver retraction. The gallbladder is passed to the assistant using the subxyphoid port, which is placed to the right of the falciform ligament. The exposed area is checked and the perforation is usually clearly identifed as a pinpoint hole on the ante- rior aspect of the duodenum, which has been covered by the fundus of the gallbladder. If the perforation is larger than the tip of the irrigation suction device (7–8 mm) and the crater is infamed and friable, it is recommended to convert to an open procedure to safely close the perforation following a Kocher maneuver. Abdominal Washout The next step is careful and thorough irrigation and suction of all the intra-abdominal fuid. This should be done before the closure of the perforation to avoid any inadvertent disruption of the sutures during the washout. To irrigate and aspirate the whole abdomen requires about 10 L of saline mixed with local antibiotics. Each quadrant is cleaned methodically, starting at the right upper quadrant, going to the left, moving down to the left lower quadrant, and then fnally over to the right. Fibrous membranes are removed as much as possible, since they may contain bacteria. However, if taking out fbrin attachments means injuring the intra-abdominal viscus, it should be done conservatively. Management of the upper quadrants requires the surgeon to stand between the patient’s legs. For the lower quadrants the surgeon should move to the right side of the patient, who should be tilted in Trendelenburg to give access to the pelvis. Special care- should be taken to irrigate and aspirate between the loops of the small bowel. Once all this has been done, the patient is tilted back to the normal position for the surgeon to close the perforation. Closure of the Perforation with an Omental Patch The perforation is closed using an omental patch (Fig. It is advisable to insert the omental patch in the knot (true Graham patch), rather than use the tails of the knot to fx the patch as a result of which a small space remains between the knot itself and the omental patch, thereby diminishing the effcacy of the patch (Fig. The classic technique follows the same rules as with the original open Graham patch. The assistant holds the omental patch while the surgeon uses both hands to knot the ties. It is not necessary to place an abdominal drain if the procedure has been conducted appropriately. Endosc Surg Allied Technol 2(2):117–118 Eypasch E, Stuttmann R, Jahn M, Troidl H, Doehn M (1995) Anesthesia for laparoscopic closure of perforated peptic ulcer–any harm or beneft? Endosc Surg Allied Technol 3(4):171–173 Fujita T (2009) Open or laparoscopic resection of a large gastric gastrointestinal stromal tumor. Arch Surg 144(2):193–194 Gagner M, Pomp A (1994) Laparoscopic pylorus-preserving pancreatoduodenectomy. Arch Surg 144(6):559–564 Jagot P, Sauvanet A, Berthoux L, Beighiti J (1996) Laparoscopic mobilization of the stom- ach for oesophageal replacement. J Laparoendosc Surg 4(6):447–450 Johansson B, Hallerback B, Glise H, Johnsson B (1996) Laparoscopic suture closure of perforated peptic ulcer. Endosc Surg New Technol 2:7–9 Katkhouda N (1995) Laparoscopic treatment on gastroesophageal refux disease; defn- ing a gold standard. Surg Endosc 9:765–767 Katkhouda N, Mouiel J (1991) A new technique of surgical treatment of chronic duode- nal ulcer without laparotomy by videocoelioscopy. Am J Surg 161:361–369 Katkhouda N, Iovine L, Mouiel J (1993) Right vagotomy and anterior fundic seromyot- omy in the treatment of non complicated duodenal ulcer. J Coeliosurg 7:5–9 (in French) Katkhouda N, Heimbucher J, Mouiel J (1994a) Laparoscopic posterior vagotomy and anterior seromyotomy. Endosc Surg New Technol 2:95–99 Katkhouda N, Heimbucher J, Mouiel J (1994b) Laparoscopic posterior truncal vagotomy and anterior seromyotomy. Arch Surg 134:845–850 116 Chapter 6  Gastric Surgery Katkhouda N, Friedlander M, Grant S, Mavor E, Achanta K, Essani R, Mouiel J (2000) Laparoscopic repair of intrathoracic volvulus. Ann Surg 248(5):793–799 Kitano S, Iso Y, Moriyama M, Sugimachi K (1994) Laparoscopy-assisted Billroth I gas- trectomy. Surg Laparosc Endosc 4(2):146–148 Kojima K, Yamada H, Inokuchi M, Kawano T, Sugihara K (2008) A comparison of Roux- en-Y and Billroth-I reconstruction after laparoscopy-assisted distal gastrectomy. Ann Surg 250(2):349–350 Liorente J (1994) Laparoscopic gastric resection for gastric leiomyoma. Arch Surg 140(9):841–846 Matsuda M, Nishiyama M, Hanai T, Saeki S, Watanabe T (1995) Laparoscopic omental patch repair for perforated peptic ulcer. Ann Surg 222(6):761–762 Miserez M, Eypasch E, Spangenberger W, Lefering R, Troidl H (1996) Laparoscopic and conventional closure of perforated peptic ulcer. Surg Endosc 10(8):831–836 Mouiel J, Katkhouda N (1991) Laparoscopic vagotomy in the treatment of chronic duo- denal ulcer disease. Prob Gen Surg 83:358–365 Mouiel J, Katkhouda N (1993) Laparoscopic vagotomy for chronic duodenal ulcer. World J Surg 7:34–39 Mouiel J, Katkhouda N, Gugenheim J, Fabiani P, Goubaux B (1990) Treatment of duode- nal ulcer by posterior truncal vagotomy and anterior fundic seromyotomy by video- coeliocopy.

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