Surgery in the elderly is not a challenge anymore. Yet, malnutrition stays one of the principal adverse factors in surgery, particularly in the aged. In ten months, 250 patients aged 65 years or older (mean: 75) have been operated in our general surgery department, with 25% of major complications and a mortality 3.6%. Nutritional state was evaluated on a clinical basis and by measurement of the serum albumin level. In case of malnutrition, morbidity was multiplied by 2, mortality by 3. These results emphasize the necessity for identification of this high risk population and the need to correct their nutritional state preoperatively by hyperalimentation.
Since the bladder is well protected by the bony pelvis, it is seldom injured. However, the initial trauma may be a major one, and associated lesions are frequent, especially in case of extraperitoneal ruptures. Retrograde cystography still remains an essential examination, for which the technique must be straightforward. This work is a review of our cases of pure bladder rupture from 1981 to 1992. Investigations, treatment, and our results are discussed, and the literature is reviewed. In the last few years, we have been favoring a conservative approach of extraperitoneal lesions.
250 patients aged 65 and more were operated in a general surgical unit and were studied prospectively on admission. 16 parameters have been studied, trying to determine the factors which might induce a risk of post-operative complications. These complications, minor or major, were found in 25% of the cases (62) of whom 11 (4%) died. As expected, this study shows that with the increase in the importance or the number of unfavorable factors, the complication rate rises. The statistical analysis shows that some factors are of low significance, such as the degree of emergency of the surgical operation or hyperglycemia. Other factors are highly significant for predicting complications: increased dependence, bad mental score, anemia, increased prothrombin time, hyponatremia or the presence of other pathological states than those studied. The importance and the type of the surgical operation, particularly bone traumatology, vascular surgery, thoracic and visceral surgery involve a high rate of post-operative complications. The same is true when malnutrition or hypoalbuminemia are present. Advancing age represents per se an augmentation of these risks, because the elderly patients are not able to meet the increased metabolic demand. This loss of reserve capacity is the most important factor that decreases the elderly patient's ability to tolerate operations. The risk factors mentioned above are particularly important because some pathological states can be corrected, and some other preventive measures can be taken before surgery, as far as one is not dealing with emergency.
In regard to the risk of stent obstruction, there are persistent controversies concerning the use of the Wallstent® self-expandable metal stents in the ureter. Only a few clinical trials have been published to date, and, from a technical point of view, no success predictors have been identified. In an experimental study using a pig model, we have shown that neither the length of the stent (5 or 10 cm) nor an initial 1-month intubation had any influence on the outcome of the stents. Among the eight implantations studied (four 5-cm and four 10-cm stents), only one 5-cm stent was perfectly patent at 35 days. In all the remaining stents, after 35 or 90 days, constant failure was related to distal narrowing at the edge of the stent, with no difference between the 5- and 10-cm stents or between the intubated and the nonintubated stents. This distal narrowing, probably attributable to a functional discrepancy between an adynamic stented ureter and a normal underlying ureter, demands extreme caution in human applications when the ureter is normally peristaltic.
Radical prostatectomy remains the gold standard for treatment of localised prostate cancer. Standardisation of the open retro-pubic anatomic prostatectomy by P Walsh allows skilled but not expert surgeons to achieve a high standard of performance. Learning curve is short with this technic, with minor morbidity. Rates of incontinence are low and impotency is now rather uncommon in the younger patient while oncological control is optimal for histologicaly organ confined cancer. "Mini invasive technics", laparoscopy and robot-assisted laparoscopy, have a longer learning curve, including a higher rate of complications that are unusual with open surgery. Operating time remains longer, costs are superior to the open technic and oncological control is not yet clearly validated while rates of classical late complications are not lower. Consequently, most urologist still prefer the open approach
A case of laparoscopic management of intraperitoneal traumatic bladder rupture is presented. The indication for laparoscopic revision of intraperitoneal bladder rupture is discussed. The advantages of an automatic suturing device are emphasized.
