关于马来西亚医院白内障手术并发症的研究:相关因素、类型及预后

目的：研究白内障手术并发症的发生率及其相关影响因素,包括手术经验、手术类型、麻醉方式和术后视力。

方法：回顾性分析在马来西亚地区医院行白内障手术逾2a的患者。查看病人基本信息、手术类型、麻醉方式和医生手术经验,记录术中和术后的并发症以及术后最佳矫正视力。

结果：在1 007名行白内障手术的患者中,并发症发生率为11.1%,其中以后囊破裂最为常见(3.6%)。术中医生的手术经验及麻醉方式对并发症的发生不存在影响。白内障囊内摘除术(ICCE)、白内障超声乳化吸除术失败后转为白内障囊外摘除术(ECCE),均是与白内障并发症发生密切相关的两种手术方式(P<0.001),并且发生并发症的患者术后视力均不理想(P<0.001)。

结论：术中并发症的发生可显著影响术后视力,并与手术方式密切相关,但与医生手术经验和麻醉方式无关。建议今后行白内障囊内摘除术、白内障超声乳化吸除术失败后转为白内障囊外摘除术时,需格外注意并发症的发生,以期减少术后不良视力发生的可能性。     

马来西亚综合医院后囊破裂的诱发因素与相关性及结果分析

目的：：观察后囊破裂的诱发因素、相关性及结果。方法：回顾性研究。研究对象为2007~2014年我院出现后囊破裂患者。研究后囊破裂与眼部合并症、晶状体相关并发症、手术水平、手术类型、独立手术或联合手术的相关性,及患者最终视力情况。结果：在12846名患者中,后囊破裂是最常见的术中并发症(n=623,4.8%)。眼部合并症和晶状体状态不会引起后囊破裂。手术者的经验和资历与后囊破裂发生的相关性显著。基层医务人员手术时出现后囊破裂比知名专家多(P=0.0000),而知名专家手术时出现后囊破裂情况反而比一般专家多(P=0.000)。白内障手术中出现后囊破裂与下列手术方式显著相关：超声乳化术、超乳转囊外摘除术及囊内摘除术(P=0.000),晶状体吸出术(P=0.020)和白内障囊外摘除术( P=0.003)。术中发生( P=0.013)与未发生(P=0.001)后囊破裂时,专家均比学员的手术结果好。尽管如此,在复杂病例中,专家与学员术中出现后囊破裂无显著差异。后囊破裂致视力损害的主要原因是散光。视力丧失(P=0.000)和低视力(P=0.000)出现较多。相对于其它并发症,后囊破裂更易致低视力。结论：后囊破裂会发生在所有类型的白内障手术中,且是引起术后低视力的主要术中并发症。专家在处理后囊破裂的手术结果优于学员。因而初级外科医生应加强手术练习。     

Impact of Time Since Last Childbirth on Survival of Women with Premenopausal and Postmenopausal Breast Cancers

Background

Reproductive factors are associated with risk of breast cancer, but the association with breast cancer survival is less well known. Previous studies have reported conflicting results on the association between time since last childbirth and breast cancer survival. We determined the association between time since last childbirth (LCB) and survival of women with premenopausal and postmenopausal breast cancers in Malaysia.

Method

A historical cohort of 986 premenopausal, and 1123 postmenopausal, parous breast cancer patients diagnosed from 2001 to 2012 in University Malaya Medical Centre were included in the analyses. Time since LCB was categorized into quintiles. Multivariable Cox regression was used to determine whether time since LCB was associated with survival following breast cancer, adjusting for demographic, tumor, and treatment characteristics.

Results

Premenopausal breast cancer patients with the most recent childbirth (LCB quintile 1) were younger, more likely to present with unfavorable prognostic profiles and had the lowest 5-year overall survival (OS) (66.9; 95% CI 60.2–73.6%), compared to women with longer duration since LCB (quintile 2 thru 5). In univariable analysis, time since LCB was inversely associated with risk of mortality and the hazard ratio for LCB quintile 2, 3, 4, and 5 versus quintile 1 were 0.53 (95% CI 0.36–0.77), 0.49 (95% CI 0.33–0.75), 0.61 (95% CI 0.43–0.85), and 0.64 (95% CI 0.44–0.93), respectively; P _trend = 0.016. However, this association was attenuated substantially following adjustment for age at diagnosis and other prognostic factors. Similarly, postmenopausal breast cancer patients with the most recent childbirth were also more likely to present with unfavorable disease profiles. Compared to postmenopausal breast cancer patients in LCB quintile 1, patients in quintile 5 had a higher risk of mortality. This association was not significant following multivariable adjustment.

Conclusion

Time since LCB is not independently associated with survival in premenopausal or postmenopausal breast cancers. The apparent increase in risks of mortality in premenopausal breast cancer patients with a recent childbirth, and postmenopausal patients with longer duration since LCB, appear to be largely explained by their age at diagnosis.

     

A novel method of bladder neck imbrication to improve early urinary continence following robotic-assisted radical prostatectomy

Early return of continence forms an important component of quality of life for patients after robotic-assisted radical prostatectomy (RALP). Here we describe the steps of bladder neck imbrication and vesico-urethral anastomosis improving early continence after RALP. Between April 2008 and July 2009, 202 consecutive patients underwent RALP for clinically localised prostate cancer in a tertiary referral centre by a single surgeon. One hundred and thirty-two (65 %) of these patients agreed to participate in the study. Prior to November 2008, 51 patients underwent standard RALP as described by Patel et al. From November 2008, 81 patients underwent a novel method of bladder neck imbrication. The robotic urethro-vesical anastomosis commences on the posterior wall of the urethra and proceeds anteriorly. In our technique the anastomosis is halted with the suture arms fixed to the anterior abdominal wall. A new suture is used to perform a two-layer repair, anchoring proximally then continuing anteriorly to the level of the urethral stump, where it returns upon itself. The aim is to narrow the urethra to 16 Fr and tighten the second layer to create an imbrication effect. Posterior reconstruction was performed in all patients. Outcome measures were recorded prospectively using the Expanded Prostate Cancer Index Composite tool. Our technique shows significant improvement at all stages of follow-up in urinary summary and incontinence scores. Absolute continence rates increased from 8.2 to 20.5 %, 26.7 to 44.3 %, and 47.7 to 62.3 % at 1.5, 3 and 6 months, respectively. These results support the use of our technique in patients undergoing RALP.     

Prostate‐specific antigen velocity (PSAV): a practical role for PSA?

Background: Prostate cancer is a leading cause of morbidity and mortality in Australian men. Early detection and treatment are critical to patient outcome, but detection is often difficult because of the limited accuracy of available tests. This paper assesses whether the use of prostate specific antigen kinetics has a practical use in the contemporary urological setting. Methods: A Medline literature review was performed examining related articles on the commonly available tests for prostate cancer, what they mean, their limited accuracy in cancer detection, and how this accuracy can be improved. Discussion: Detection of significant organ‐confined prostate cancer should be the goal of general practitioners and urologists alike. Prostate‐specific antigen and digital rectal examination are commonly used but lack specificity and sensitivity, especially for small organ‐confined cancers. The additional use of prostate‐specific antigen velocity may enhance the specificity and sensitivity of detection.