Estimation of Mound Height in Endoscopic Treatment of VUR

Estimation of Mound Height in Endoscopic Treatment of VUR A Numerical Study to Precise the Estimation of the Good Mound Height in Endoscopic Treatment of VUR Author(s):  Mehdi Shirazi1, Zahra Jahanabadi2, Zeinab Hooshyar5, Zahra Mortazavinia4, Alireza Mehdizadeh3, Mojtaba Taherisadr6 Abstract Purpose: it seems that there is no definite and standard index to ascertain the technique and volume of injection in order to increase the success rate of endoscopic VUR treatment. In this study, we introduced a novel method to numerically define the relationship between some indexes in order to determine optimum mound height promise to standardize the injection technique in this kind of treatment. Material and method: The main purpose of this study is to construct a finite element simulation of intramural ureter and injected mound which aims to numerically define the relationship between indexes which have influence in VUR endoscopic treatment. Using linearization software and numerically simulation data the relationship between effective indexes has been derived. Result: By linearization of the effective parameters of different finite element models, the relationship between effective parameters in filling phase is derived as: H=0.7456D+ 0.02174L +0.01846. This equation depicts adequate injected mound height as a function of internal diameter and intramural length, H=f(L,D). Conclusion: Using numerical simulation, we introduced the novel formula to predict the height of injected mound in endoscopic VUR treatment. As a result of this study, in order to increasing the success rate of this treatment, the ratio of mound height to intramural ureter diameter should be approximately 74% (~3/4). Keywords: Mound height, Endoscopic treatment, Vesico ureteral reflux, Finite element model Introduction Vesico ureteral reflux (VUR) is a major disorder of childhood declared by retrograde urine flow from the bladder toward the kidney, predisposing patients to UTI and renal scarring and in long term leading to renal insufficiency and hypertension[1]. Current treatment options include close observation with urinary chemoprophylaxis, minimally invasive endoscopic subureteral injection of bulking agents and open or laparoscopic reimplantation[2]. The prophylactic antibiotic approach is proper for uncomplicated reflux (grade I-III without significant renal scarring or breakthrough infection)[3]. This type of treatment doesn’t cure VUR and has some problems such as patient noncompliance and increased antibiotic resistance[4]. Surgical reimplantation of the ureter is an invasive method[5] and already used for patients with high grade reflux, children with breakthrough UTI and children with reflux and developed renal scarring[6]. Endoscopic subureteral injection of bulking agents was introduced by Matouscheck as an evolution in treatment of reflux with a high success rate and minimal invasion[6], [7]. The substance used as a bulking material should be biocompatible, nonantigenic, nonmigratory and non-toxic with minimal local inflammation[8]. Multiple techniques on injection have been described. These methods include subureteral needle placement[8], intraureteral needle placement[9], [10] or some combinations of these. During recent years, several studies have been done to determine success or failure of endoscopic treatment, and various injection techniques have been introduced. Puri et al., described â€Å"volcano† appearance as the main sign of success of injection[11]. The proper shape was demonst rated by adequate coaptation of the ureteral orifice and by its location in the bladder below the ureteral orifice and/or along the waldeyer’s sheat[12], [13]. Despite all the studies carried out to determine the success or failure of endoscopic treatment, such as description of volcano appearance, injection technique in combination with hydrodistention, increasing injected volume, use of intraoperative cystogram with a simulated voiding phase, there is no definite and standard index to ascertain the technique and volume of injection in order to increase the success rate. In this study, we introduced a novel method to numerically define the relationship between some indexes in order to determine optimum mound height promise to standardize the injection technique. Materials Method In this study, a computational simulation was proposed to simulate the intramural ureter and injected mound which aims to numerically define the relationship between indexes which have influence in retrograde urine flow from intramural ureter. Geometry of the numerical model Fig. 1 illustrates diagrammatic representation of the functional anatomy of the ureterovesical junction and urinary anti reflux mechanism as the accumulation of urine within the bladder will lead to the tight closure of the portion of the ureter in between, thus preventing the backward return of urine to the kidneys, urinary anti reflux mechanism. In Fig. 1, P, D, H and L are intravesical pressure, intramural ureter diameter, injected mound height, and intramural ureter length, respectively. Section â€Å"A† in Figure 1 depicts the cross section of the intramural ureter with injected mound. The geometrical data of intramural ureter and ureterovesical junction were utilized as per Table 1. Materials Properties and Boundary Conditions Material properties for the intramural ureter wall were assumed to be linear elastic, isotropic, incompressible, and homogeneous with Young’s modulus of 10 Kpa [18]. The injected mound was modeled as a rigid volume as shown in Fig. 3. The boundary conditions for the wall were (1) the bottom surface of intramural wall was fixed at the connection to the internal bladder wall. (2) The upper wall was assumed to be free such that the deformation would occur due to the intravesical pressure and contribute to the tight closure of the portion of the ureter in between. Solution Method The ANSYS 11 software was employed to simulate the intramural ureter with injected mound in voiding phase. The intravesical pressure was applied on the upper portion of the intramural wall. The upper bound of intravesical pressure was considered to be 160 CmH2 O to encompass both male and female intravesical voiding pressures[15], see Table 1. The 8-Node structural solid mesh has been utilized in finite element model to have adequate adoption with this geometry and material behavior. 3 Results Fig. 2 illustrates the total deformation of the intramural ureter with injected mound in voiding phase. As shown, the intramural ureter has been closed due to the intravesical pressure. Fig. 3 shows the deformed and undeformed intramural wall in resting and voiding phase. As shown, in voiding position the injected mound height is high enough for the intramural ureter to be closed due to the intravesical pressure and prevents retrograde urine flow. In the first attempt, keeping the intramural ureter length constant, by changing intravesical pressure and internal diameter, the adequate injected mound height leading to tight closure of intramural ureter was obtained. By linearization of the effective parameters of about 30 different finite element models, the primary relationship between injected mound height, intravesical pressure and internal diameter of intramural ureter was defined as bellow, H=f(D,P) H=-0.0000003219P+0.7864D+0.000233(4) According to this relationship, it has been inferred that intravesical pressure coefficient is minute in comparison with coefficient of other effective parameters and it shows that changing the intravesical pressure plays an insignificant role in adequate injected mound height. In order to investigate the more effective indexes on injected mound height, the intramural length has been considered as one of variable parameters in finite element modeling. Varying internal diameter, intramural length and linearization of obtained data, the relationship between parameters was derived as: H=0.7456D+ 0.02174L +0.01846(5) This equation depicts optimum mound height as a function of internal diameter and intramural length, H=f(L,D). 4Discussion Endoscopic treatment of VUR was introduced more than 25 years ago and since then many different substances and injection techniques have been used with different results[13]. Choosing endoscopic treatment is reasonable, as it has many advantages, such as technical simplicity, greater acceptance of patients and parents and significant decrease in post- operation complications[7]. By improving the injection techniques the rate of endoscopic treatment has significantly increased as compared with open ureteral reimplantation[2]. During the recent years, many studies have been done to increase the ability to identify factors predicting success with the endoscopic subureteral injection[19]. At 2003, Puri et al.[11] described â€Å"volcano† appearance as the main sign of success of injection. The proper shape was demonstrated by adequate coaptation of the ureteral orifice and by its location in the bladder below the ureteral orifice and/or along the waldeyer’s sheat[12]. In different studies conducted by Lavelle et al.[12] and Yucel et al. [20], it was found that a subjectively proper mound appearance was highly predictive of injection success, but it should be noted that the morphology and location of the mound are not perfectly predictive of injection success or failure, as the mound seems perfectly adequate in some injections but the injection is not successful; also, the imperfect mound morphology does not necessarily imply injection failure[12]. Moreover, Ellworth PI et al. showed no correlation between the presence of a mound on post-injection ultrasound and the success of injection[19]. Some research agrees that an intraureteral injection technique in combination with hydrodistention results in higher success rates but this is controversial[9],[10],[20],[21]. The effect of injected volume on increasing the success rate is also controversial. Mathew D et al. showed that increasing the injection material volume will improve the success of subure teric injection[22] but other centers have shown that higher injection material volume doesn’t necessarily increase the treatment success rate[21]. So the effect of the injected volume in association with improved success rate remain unclear[12]. To determine the treatment success or failure, Tarry WF et al. described the utility of an intraoperative cystogram with a simulated voiding phase, but they demonstrated that an introperative cystogram can only detect de novo contralateral reflux but is not a proper method to predict the final success of injection[6]. Despite all the mentioned studies, still there is no definite and standard index to ascertain the technique and volume of injection, and also there is no quantitative index for determining the proper mound size and shape. So, we have conducted a study aiming to define an optimum injection mound by finite element modeling. In this study, we introduced a novel method to numerically define the relationship between some indexes in order to determine optimum mound height promise to standardize the injection technique in VUR treatment. It should be noted that due to every patient individual properties of intramural, it is not logical to consider similar injected mound height for all VUR treatment cases. Thus, it is needed to state the adequate injected mound height based on individual indexes of each case. The Intravesical pressure, intramural ureter diameter and length are some of these effective indexes. By specifying the relationship between all of these effective factors, the adequate and optimum injected mound height can be determined which can contribute to more success in treatment of VUR. In addition, it can help to save the needed injected mound height and make this injection method more economical. The results of this study show that the intravesical pressure has an insignificant effect on the required injected mound height. However, intramural length plays an important role on it in comparison with Intravesical Pressure. Moreover, the ratio of mound height to intramural ureter diameter is approximately 0.74 (~3/4), which is drawn that in order to have successful VUR treatment, it is needed that about 74% of intramural ureter diameter be filled with the injected mound. It should be mentioned that in Department of Urology of Shiraz University for the first time, an innovative method, introduced by Taheri et al.[23], is used to measure the injected mound height to assure the adequate injected mound height. In this method by adjusting camera, laparoscopy lens and imaging screen, it would be possible to measure the injected mound height as a ratio of projected picture on the screen. This study has served some limitation. The realistic cross section of intramural ureter has star shape. However, because of some limitation in finite element modeling, the circular one considered. Furthermore, we considered computational simulation only in voiding phase, although VUR may occur in resting phase. Conclusion In this study using numerical simulation, we introduced the novel formula to predict the height of injected mound in endoscopic VUR treatment. As a result of this study, in order to increase the success rate of this tevhnique, the ratio of mound height to intramural ureter diameter should be approximately 74% (~3/4). Moreover, clinical study has been conducted to ascertain the accuracy of this obtained height. Fig. 1Diagrammatic representation of the functional anatomy of the ureterovesical junction Fig. 2Intramural ureter displacement in voiding phase Fig. 3Deformed and undeformed intramural urine wall References Lenaghan, D., et al., The natural history of reflux and longterm effects of reflux on the kidney. J Urol, 1976. 115(6): p. 728-30. Cerwinka, W.H., et al., Radiologic features of implants after endoscopic treatment of vesicoureteral reflux in children. AJR Am J Roentgenol, 2010. 195(1): p. 234-40. Harper, L., et al., Postoperative cystography and endoscopic treatment of lowgrade vesicoureteral reflux. J Laparoendosc Adv Surg Tech A, 2008. 18(3): p. 461-463. Hsieh, M.H., et al., Treatment of Pediatric Vesicoureteral Reflux Using Endoscopic Injection of Hyaluronic Acid/Dextranomer Gel: Intermediate-term Experience by a Single Surgeon.j urology, 2010. 76(1): p. 199-203. Elder, J.S., et al., Pediatric Vesicoureteral Reflux Guidelines Panel Summary Report on the Management of Primary Vesicoureteral Reflux in Children. j urology, 1997. 157(5): p. 1846-1851. Perlmutter, A.E., et al., Utility of an intraoperative cystogram with a simulated voiding phase after endoscopic treatment of vesicoureteral reflux. W V Med J, 2008. 104(4): p. 22-4. Rivilla, F., Endoscopic treatment of vesicoureteral reflux in a paediatric surgery ambulatory unit. Vol. 7. 2011. 132-5. Bae, Y.D., et al., Endoscopic Subureteral Injection for the Treatment of Vesicoureteral Reflux in Children: Polydimethylsiloxane (Macroplastique ®) versus Dextranomer/Hyaluronic Acid Copolymer (Deflux ®). Korean J Urol, 2010. 51(2): p. 128-131. Gupta, A. and W. Snodgrass, Intra-Orifice Versus Hydrodistention Implantation Technique in Dextranomer/Hyaluronic Acid Injection for Vesicoureteral Reflux. J urology, 2008. 180(4): p. 1589-1593. Kirsch, A.J., et al., The modified sting procedure to correct vesicoureteral reflux: improved results with submucosal implantation within the intramural ureter. J urology, 2004. 171(6 Pt 1): p. 2413-2416. Puri, P., et al., Treatment of Vesicoureteral Reflux by Endoscopic Injection of Dextranomer/Hyaluronic Acid Copolymer: Preliminary Results. J urology, 2003. 170(4): p. 1541-1544. Routh, J.C. and Y. Reinberg, Predicting Success in the Endoscopic Management of Pediatric Vesicoureteral Reflux. Uro, 2010. 76(1): p. 195-198. Lavelle, M.T., M.J. Conlin, and S.J. Skoog, Subureteral injection of Deflux for correction of reflux: Analysis of factors predicting success. Uro, 2005. 65(3): p. 564-567. Yeung CK, G.M., Duffy PG, Ransley PG., Nat<

ACC 290 Financial Statements Essay

Financial statements are a means of communicating numbers within a business. Without proper numbers your business could be a success or a big failure. â€Å"You will rely on them to make decisions, and managers will use them to evaluate your performance. That is true whether your job involves marketing, production, management, or information systems† (Kimmel, 2009). The financial statements shows the business financial standpoint at a given time period, and it also helps the business to understand what they need to do to improve. A company’s livelihood depends greatly on their financial statement because it determines if the business is successful, can it hire new employees, or can it receive any more additional loans. A financial standpoint of the company is monitored by its financial statements. The four basic financial statements are retained earnings statement, balance sheet, income statement, and statement of cash flow. During a certain time period presenting a snapshot of what your business owns (its assets) and what it owes (its liabilities), you prepare a balance sheet. â€Å"To show how successfully your business performed during a period of time, you report its revenues and expenses in an income statement† (Kimmel, 2009). Specifying how much of prior income was dispersed to you and the other owners of your business in the form of dividends and how much was reserved in the business to allow for future growth a retained earnings statement is presented. Showing where your business obtained cash during period of time you would prompt a statement of cash flow. The purpose of balance sheet it to show the amount of assets a company has obtained by evaluating the claims of creditors and the claims of owners. This type of relationship can be shown in an equation assets equal liabilities plus stockholders equity. A company success or failure is monitored by its income statement because it shows a company’s revenue monitored by its expenses. The net income is obtained through the income statement by deducting its expenses from its revenues. The retained earnings statements are different because retained earnings are the net income retained in the corporation. Dividend payment practices are assessed because the amount of the retained earnings statements is deducted or added by the company’s dividends. The statement of cash flow shows the company operating, investing, and financing doings. It shows the company cash position and what is happening to its most important source. Managers use financial statements for several purposes. If a company needs to meet labor demands and need to hire new employees the financial statements helps in knowing how many employees they can afford to hire. On the income statement, management compares sales and expenses of a period of time with recent events to notice if there is a big change. They can identify likely problems and investigate the cause; however, they can regulate if they can afford new equipment, merchandise, and other operating expenses. Using the balance sheet managers can determine if a change applied helped the company or delayed it. Employees look at financial statements to know if the company is managing their money well and can meet payroll obligations. Employees also can gain knowledge of potential bonuses or layoffs based of the net income that is reported on the income statement. Financial statements are useful to investors and creditors because it shows the company’s financial position and allows them to make better decisions concerning the company. For the investors and creditors financial statements helps to evaluate the risks related to the possible investment or loans issued as well as estimate returns from the money invested. Investors and creditors analyzes company’s financial position, operational results, cash generated by different activities before making investment decisions. If the company owes more than it owns than creditors may not allow that company to receive additional loans. To investors it shows if the company is operating profitably. Financial statements are vital to the success of a business. They can be used as a roadmap to direct you in the correct direction and help you avoid costly failures. Maintaining financial statements for a company can only help a company. Improper financial statements put a company in jeopardy. The different statements show if a company can afford to hire new employees or if they need to do some lay-offs. To determine if a company can be approved for additional loans or if it is expected to fail you must rely on the financial statements. In general financial shows the financial standpoint of a company and decisions a company has to make cannot be made if there are no financial statements.

Religion Of Christianity, Judaism, And The Existence Of...

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A Reflection in Learning - 1871 Words

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