One hand is better than two: conversion from pure laparoscopic to the hand-assisted approach during difficult nephrectomy

INTRODUCTION

The incidence of conversion from a laparoscopic to an open approach during nephrectomy is reported at 6-8%.¹ Conversion to an open procedure may be necessary to control haemorrhage or allow progress in dissection but the well established benefits of minimally invasive surgery (MIS) are obviously lost. Hand-assisted laparoscopy (HAL) also offers the benefits to the patient of MIS. We have used HAL to convert from the pure laparoscopic approach during difficult nephrectomies, rather than converting to traditional open surgery.

MATERIALS AND METHODS

A review of our prospective database was carried out to identify any conversions from the pure laparoscopic approach during nephrectomy or nephroureterectomy for benign or malignant disease.

RESULTS

A total of 87 laparoscopic nephrectomies (LNs) were identified over a 3-year period. There were five conversions to the HAL approach (5.7%) and no conversions to open surgery. The reason for conversion was failure to progress in all five cases. Operative times averaged 190 minutes with blood loss of 180ml. Histology revealed xanthogranulomatous pyelonephritis in four cases and renal cell carcinoma in one case. The median postoperative stay was 4 days.

CONCLUSIONS

Conversion to HAL during LN maintains the benefits of MIS in difficult nephrectomy and should be considered prior to converting to open surgery.     

A case of intravascular lymphomatosis (IVL) presenting as polyneuropathy

Intravascular lymphomatosis (IVL) is a rare, yet important, cause of a variety of unexplained neurological syndromes. In this clinical context, the only clue to the diagnosis may be a significantly raised plasma lactate dehydrogenase (LDH) on a background of clinical features of a systemic illness.     

Geriatric syndromes as predictors of adverse outcomes of hospitalization

Aims: The aim of this study was to determine the association between the common geriatric syndromes and predefined adverse outcomes of hospitalization and to identify the most important independent predictors of adverse outcomes using information gained within 24 h of admission in older general medical patients. Methods: A prospective longitudinal cohort study of patients aged ≥75 years admitted to the rapid assessment medical unit in a teaching hospital was carried out. The role of geriatric syndromes in predicting outcomes was examined in univariate and multivariate models. The outcome measures were (i) length of hospital stay (LOS) of 28 days or more, (ii) institutionalization or change in residential care status to a more dependent category at discharge or during 3 months post‐discharge, (iii) unplanned readmissions during 3 months and (iv) mortality in hospital or 3 months post‐discharge. Results: The presence of geriatric syndromes was significantly associated with increased LOS and institutionalization or change in residential care status to a more dependent category. The factors most predictive of these outcomes were impaired pre‐admission functional status in activities of daily living, recurrent falls, urinary incontinence and supported living arrangements. The geriatric syndromes appeared less important in predicting unplanned readmission and death. Conclusion: The presence of geriatric syndromes in older general medical patients is an important determinant of adverse outcomes of hospitalization, particularly of LOS and admission to residential care. The predictors most useful for screening patients for these outcomes, within 24 h of admission, appear to be the presence of certain pre‐existing geriatric syndromes before admission.     

Osteoporotic fractures and vitamin D deficiency

Case study: A caucasian woman aged 79 years, with a history of hypertension, hyperlipidaemia, and osteoarthritis, was referred for assessment of osteoporosis and generalised musculoskeletal pain after surgery for a right midshaft femoral fracture. Further history revealed she had suffered nonspecific musculoskeletal pain, particularly of the pelvic girdle, and unsteady gait for many weeks, but denied suffering any falls. She had limited mobility due to osteoarthritis of both knees. She had been mostly housebound and was on an animal product restricted diet in view of her history of hypercholesterolaemia. Initial X-rays confirmed an incomplete fracture of the midshaft of the right femur. She had an orthopaedic review, and subsequent bone scan and X-rays (Figure 1) revealed incomplete fractures of the midshaft of both femurs and the seventh rib. She was managed conservatively (alendronate 70 mg per week) and progress was closely monitored. Three weeks later, she presented to the emergency department with worsening right thigh pain and difficulty in weightbearing. X-rays revealed an extension of the right femoral fracture traversing the entire cortex that required surgery. Physical examination revealed a mild thoracic kyphosis. There was no muscle or bone tenderness, proximal muscle weakness, or other significant abnormality. The plasma biochemistry revealed: mild hypocalcaemia (1.98 mmol/L), hypophoshataemia (0.7 mmol/L), raised alkaline phosphatase (ALP) (216 iu/L), low 25-hydroxyvitamin D (250HD) (22 nmol/L), and a mildly raised parathyroid hormone (PTH) level (8 pmol/L). Thyroid, renal, and liver functions were normal. The patient was treated with nine capsules of Ostelin 1000 per day, which was tapered over 8 weeks to one capsule. The repeat plasma 25OHD after 6 weeks was 56 nmol/L, and her musculoskeletal symptoms were completely resolved. There was normalisation of biochemical abnormalities and X-rays demonstrated healing of both femoral fractures. A bone biopsy taken at the time of surgery revealed an increased amount of osteoid. However, undecalcified bone sections were not examined, nor was quantitative histomorphometry performed. Dual energy X-ray absortiometry (DEXA) scan revealed a T-score of -3.32 at the hip and -1.38 at the lumbar spine. Corresponding Z-scores were -1.05 and -0.7.     

Clinical outcomes following ICSI cycles using surgically recovered sperm and the impact of maternal age: 2004–2015 SART CORS registry

Purpose

The aims of this study were (1) to evaluate clinical outcomes after ICSI cycles using surgically recovered sperm and (2) to assess the influence of maternal age on those outcomes.

Methods

A retrospective cohort study of 24,763 IVF cycles of fresh autologous oocytes and ICSI using surgically recovered sperm reported to the SART CORS database from 2004 to 2015.

Results and conclusions

Older women had significantly longer stimulation (p?<?0.001), a lower number of oocytes retrieved (p?<?0.001), a lower number of 2PN zygotes (p?<?0.001), a lower chance of having a blastocyst transferred (p?<?0.001), and a higher number of fresh embryos transferred (p?<?0.001). There was no significant association between the number of 2PNs per oocyte retrieved and maternal age (p?=?0.214). Both clinical pregnancy rates and live birth rates (LBR) decreased with advanced maternal age (p?<?0.001). LBR ranged from 50.4% in women <?30 to 7.2% in women >?42 years, and for cleavage-stage transfers, the LBR ranged from 47.3% in women<?30 to 6.3% in women >?42 years. There were no differences in gestational age at delivery, proportion of term deliveries, preterm deliveries, neonatal birth weight <?2500 g, neonatal birth weight >?4000 g and average birthweight of neonates for singleton pregnancies according to age. For twin pregnancies, women <?30 years had significantly higher number of live births, term deliveries, and lower preterm deliveries than older women. There was a similar number of female (6051) and male neonates (5858; p?=?0.2). Overall, pregnancy outcomes with ICSI using surgically recovered sperm are reassuring and comparable to those of ICSI with ejaculated sperm.