Comparison of Laparoscopic and Microscopic Subinguinal Varicocelectomy in terms of Postoperative Scrotal Pain

Background and Objectives:

In this study, 2 different varicocelectomy methods were compared with regard to postoperative scrotal pain, length of operation, and complications.

Methods:

Forty varicocele patients, who visited our clinic because of infertility or scrotal pain between 2008 and 2009, were enrolled in this clinical study. Microscopic subinguinal varicocelectomy was performed on 20 patients in Group I, and laparoscopic varicocelectomy was performed on 20 patients in Group II. Following surgery, the patients were assessed for postoperative requirements for analgesia; return to normal activity; varicocele recurrence; hydrocele formation; scrotal pain at postoperative days 1, 3, and 7; and other complications.

Results:

Mean age was 24.2±3.4 years in Group I and 25.1±2.1 years in Group II. Mean pain scores at postoperative 1, 3, and 7 days in Group I were (5.20±1.14, 4.60±0.97, and 3.50±0.97, respectively) significantly higher than those of Group II (0.70±0.82, 0.60±0.84, and 0.10±0.32, respectively). Time to return to normal activity was significantly shorter in Group II (3.7±2.1 days) compared with Group I (6.8±3.4 days) (p=0.028). However, the number of recurrences and hydroceles, as a complication of varicocelectomy, was 2 times higher in Group II (10%) than in Group I (5%).

Conclusions:

We believe that laparoscopic varicocelectomy is a safe, effective, and minimally invasive procedure. Furthermore, reduced postoperative discomfort and earlier return to normal activity are additional advantages of this method.     

Postoperative analgesia via transversus abdominis plane (TAP) catheter for small weight children-our initial experience

Pain management in small infants and children is challenging. We report the use of unilateral transversus abdominis plane (TAP) catheters for analgesia following single-sided open lower abdominal surgery when epidural analgesia was undesirable in a series of six low-weight children. Data collection was done via a retrospective chart review. All catheters attempted were successfully placed with resultant low pain scores and the minimal use of rescue analgesic medications. No complications were reported related to these catheters. TAP catheters, although technically challenging, are feasible for the provision of analgesia for surgeries involving the lower abdominal wall in very small patients.     

Pediatric epidural analgesia (PEA)

The pediatric epidural is an accepted method of advanced analgesia in children. Newer techniques have now superseded pediatric epidural analgesia (PEA), being as effective and safer, especially with the advances in ultrasonography. PEA is, however, still an important technique to master and employ, and it may be that the indications for this mode of analgesia have now become more defined.     

Safety and efficacy of extended-release bupivacaine local anaesthetic in open hernia repair: a randomized controlled trial

Background: Pain relief remains a major problem in hernia surgery. SABER‐Bupivacaine is an investigational extended‐release formulation of bupivacaine in a resorbable matrix, which may provide up to 72 h of local pain relief. Methods: A double‐blinded, randomized controlled trial was undertaken to evaluate the safety and efficacy of SABER‐Bupivacaine. Consented patients (n= 124) undergoing open inguinal hernia repair at five sites in Australia and New Zealand were randomized to receive either 2.5 (330 mg) or 5.0 mL (660 mg) of SABER‐Bupivacaine or SABER‐Placebo administered to the surgical wound at the end of the procedure. Analgesic efficacy and safety was evaluated. Results: SABER‐Bupivacaine appeared safe with no difference in the incidence of side effects compared with SABER‐Placebo. The 5.0 mL dose of SABER‐Bupivacaine reduced the mean area under the curve of pain intensity on movement compared with SABER‐Placebo (2.47 versus 3.60; P= 0.0033) and decreased the number of patients requiring supplemental opioids by 26% (although not statistically significant; P= 0.0909). Normal wound healing was reported throughout the trial and at 3‐ and 6‐month follow‐up in every treatment group. Conclusion: After open inguinal hernia repair, SABER‐Bupivacaine administered at the surgical site was safe and provided pain relief, reduced the need for supplemental (oral and parenteral) analgesia and did not impair wound healing.     

Laparoscopic management of the median arcuate ligament syndrome

Background: The median arcuate ligament syndrome (MALS) is an infrequent cause of abdominal pain. This diagnosis is made after exclusion of other more common causes of upper abdominal symptoms. Mesenteric duplex and a computerized tomography mesenteric angiography demonstrate dynamic compression of the coeliac axis during expiration. Methods: Retrospective analysis of presenting symptoms, preoperative findings and postoperative outcomes. Results: Five consecutive patients who underwent laparoscopic division of the median arcuate ligament over a 4‐year period (2006–2010) are presented. This procedure was associated with low morbidity and complete relief of symptoms in all patients. Conclusion: A minimally invasive procedure is the treatment of choice in selected patients with MALS.     

Increased use of laparoscopy in acute right iliac fossa pain – is it good for patients?

Aim The use of laparoscopy, with or without appendicectomy, is becoming more common in the management of acute right iliac fossa (RIF) pain, but little is known of the ‘unintended’ consequences of this change. This study aimed to evaluate the impact of increased use of laparoscopy on the number and type of patients treated surgically and on the rate of negative appendicectomy. Method A prospective audit was carried out of admissions to a teaching hospital over two, 3‐month periods during 2007 and 2008. The management, investigations and outcome of patients presenting with RIF pain were studied. Results Admissions were stable over the two time‐periods. There was a significant increase in the number of laparoscopic operations performed, from 22.5% (14/62) in 2007 to 85.7% (72/84) in 2008 (P < 0.0001), and the percentage of patients undergoing surgery rose from 55.4% (n = 62) in 2007 to 71.2% (n = 84) in 2008 (P < 0.01). In 2008, female patients were more likely to have surgery, an increase from 37.1% to 66.2% (P < 0.001), and were more likely to have a laparoscopic procedure, an increase from 50% to 98% (P < 0.0001). The rate of histologically confirmed appendicitis did not increase significantly (50/122 vs 57/118; P = 0.25), but the number of patients with a normal appendix either left in situ because it was macroscopically normal or found to be histologically normal following excision, increased significantly, from 9.01% in 2007 to 21.2% in 2008 (P < 0.01). The diagnostic value of pelvic ultrasound decreased from 75.6% of examinations in 2007 to 54.5% in 2008 (P = 0.039). Conclusion An increase in laparoscopic procedures has resulted in more operations in women, an associated higher negative appendicectomy rate and decreased usefulness of pelvic ultrasound. Increased use of laparoscopy needs to be balanced against the diagnostic benefits of ‘negative’ laparoscopy.     

Penile frenuloplasty: a simple and effective treatment for frenular pain or scarring

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Frenuloplasty, using common plastic surgical techniques for scar lengthening, is a commonly performed operation amongst urologists for isolated frenular pathology. However, there is very little data in the urological literature regarding either technique or assessment. The only other published study was a questionnaire follow‐up with a 23% response rate and the technique used was not clarified. Other studies describe expensive, rarely used procedures and are hampered by small patient numbers or short‐term follow‐up only. Our study validates the common practice of using plastic surgical techniques for scar lengthening. We have 100% clinical short‐term follow‐up (3 months) and 91% long‐term follow‐up (up to 10 years) showing high patient satisfaction scores and low complication and re‐operation rates. This provides an evidence base from which to counsel patients who are keen for foreskin sparing surgery for frenular pathology. The extra addition of our grading system allows patients to be risk‐stratified as to the risk of re‐operation depending on their status at presentation and underlying pathology.

OBJECTIVE

• ? To assess the long‐term patient satisfaction and outcomes for penile frenuloplasty when offered as an alternative to circumcision for frenular pain and/or scarring.

PATIENTS AND METHODS

• ? Data was prospectively collected over 10 years, for a total of 106 men.
• ? The nature of the frenular problem was graded.
• ? Techniques of V‐Y plasty, Z‐plasty or a combination of the two were used.
• ? All patients were reviewed at 3 months and contacted via questionnaire ≥1 year after surgery. The questionnaire assessed satisfaction, cosmetic appearance, pain on intercourse, need for subsequent surgery and if they would recommend the procedure to a friend.

RESULTS

• ? Follow‐up was 100% (106/106) at 3 months and 91% (96/106) ≥1 year.
• ? Patient satisfaction and cosmesis scores both averaged 8.9/10.
• ? Need for subsequent circumcision was 8% (9/96).
• ? There were minor complications (bruising/infection/partial dehiscence) in 8% (9/96) of patients.
• ? 97% (84/87) of patients would recommend the procedure to a friend.

CONCLUSIONS

• ? Penile frenuloplasty is a safe alternative to circumcision.
• ? There are high patient satisfaction rates after surgery.
• ? Low numbers of patients require a completion circumcision after penile frenuloplasty.

     

Use of a mixture of lignocaine and bupivacaine vs lignocaine alone for male circumcision under local anaesthesia in Rakai, Uganda

Study Type – Therapy (case control) Level of Evidence 3a What's known on the subject? and What does the study add? Local anaesthetic drugs block the generation and the conduction of nerve impulses, presumably by increasing the threshold for electrical excitation in the nerve by slowing the propagation of the nerve impulse, and by reducing the rate of rise of the action potential. Lignocaine/Lidocaine has a rapid onset action and an intermediate duration of efficacy whereas Bupivacaine has a slower onset of action with a long duration of efficacy. A combination of the two drugs creates a mixture that has a short onset of action together with a long duration of action both of which are desirable qualities in provision of effective local anaesthesia. Documenting whether use of lignocaine alone predisposes men to more pain during and after surgery will inform policy makers on the type of local anaesthesia to recommend for male circumcision, especially as circumcision programs roll out. This is important since pain has been associated with reduced acceptance of the male circumcision procedure and therefore can negatively influence male circumcision roll out programs.

OBJECTIVE

• ? To assess self‐reported pain control during and after surgery with a mixture of lignocaine and bupivacaine compared with lignocaine alone among male circumcision (MC) service recipients in Rakai, Uganda.

PATIENTS AND METHODS

• ? The two formulations of local anaesthesia for MC were used alternatively at weekly intervals in 360 patients; 179 received lignocaine alone and 181 received the lignocaine and bupivacaine mixture (LBmix).
• ? The proportions of men reporting pain during or after surgery, and the need for additional anaesthesia during surgery were determined for the LBmix vs lignocaine using Poisson adjusted rate ratios (RRs).
• ? Characteristics including age, weight, surgeon (medical officer vs clinical officer), surgical method and duration of surgery were compared between the arms using two‐sample t‐tests and chi‐square tests.

RESULTS

• ? Patient and provider characteristics were comparable between the two anaesthetic groups.
• ? A higher proportion of patients reported pain during surgery in the lignocaine group (adjusted RR 11.6, 95% confidence interval [CI] 3.5–37.9, P < 0.001), required additional anaesthesia (adjusted RR 4.8, 95% CI 1.4–17.1, P= 0.015), and were more likely to report pain during the immediate postoperative period (adjusted RR 3.4, 95% CI 2.3–5.0, P < 0.001).
• ? These differences were particularly marked among patients with MC times longer than the median (adjusted RR 13.4, 95% CI 3.1–57.0, P < 0.001).

CONCLUSION

• ? The LBmix significantly reduced pain associated with MC and the need for additional anaesthesia during MC.

     

Low levels of physical activity in back pain patients are associated with high levels of fear‐avoidance beliefs and pain catastrophizing

Background and Purpose. Fear‐avoidance beliefs are important determinants for disability in patients with non‐specific low‐back pain (LBP). The association with self‐reported level of physical activity is less known. The aim of the present study was to describe the level of physical activity in patients with chronic non‐specific LBP and its relation to fear‐avoidance beliefs and pain catastrophizing. Method. A cross‐sectional study on 64 patients with chronic non‐specific LBP in primary healthcare. The variables measured and the questionnaires used were: level of physical activity (six‐graded scale); activity limitations (Roland Morris Disability Questionnare (RDQ)); fear‐avoidance beliefs (Tampa Scale of Kinesiophobia (TSK) 13‐item and sub‐scales ‘activity avoidance’ and ‘somatic focus’); and pain catastrophizing (Pain Catastrophizing Scale (PCS)). The level of physical activity was dichotomised into low and high physical activity. Individual median scores on the TSK and PCS scales were used to group the patients into different levels of fear‐avoidance beliefs and pain catastrophizing. Univariate logistic regressions were used to calculate odds ratios for having low physical activity. Results. Patients with low physical activity had significantly higher scores in fear‐avoidance beliefs and pain catastrophizing (p < 0.05). Odds ratios for low level of physical activity were between 4 and 8 (p < 0.05) for patients with high fear‐avoidance beliefs or medium/high pain catastrophizing. Conclusions. This study indicates that it seems important for physiotherapists in primary care to measure levels of fear‐avoidance beliefs or pain catastrophizing. In particular, the two subscales of the TSK could be of real value for clinicians when making treatment decisions concerning physical exercise therapy for patients with chronic LBP. Copyright © 2007 John Wiley & Sons, Ltd.