Relationship of urogenital tuberculosis to tuberculosis of other organs,in old and new autopsy material

Based on more than 32 thousand autopsies performed at the János Hospital, Budapest, during the first sixty years of this century, in 835 cases attention has been focussed on the place of urogenital tuberculosis among other kinds of tuberculosis, on the kind of constellation and immunobiological condition it represents, as well as on its relationship to other forms of tuberculosis. These problems have been approached from several angles. p ]The observations tend to indicate that at least in postmortem material urogenital tuberculosis is one of the worst forms of organ tuberculoses and represents an unfavourable constellation in tuberculous disease.     

Donor pretreatment in an unselected series of cadaver renal allografts.

In a single center, an unselected non-exclusion series of 78 consecutive cadaver renal allografts in 76 recipients was studied. Since 1971, using kidneys obtained from donors pretreated with large doses of cyclophosphamide and methylprednisolone, excellent clinical results with 2-year graft-survival of 70% 5-year graft survival of 66% have been obtained. The improvement in results is believed to be aided by the reduction in allograft immunogenicity due to short-term donor pretreatment. In this series, poor tissue-matching grades are notable, heavily transfused patients are few, 33 patients were high risk, and 43 patients were presensitized. In spite of these negative selection factors, the results obtained in this pretreated series, with 18% of graft losses due to rejection, are superior to those obtained in patients who did not receive pretreated allografts during the same time period, with 34% of graft losses due to rejection, and 2-year and 5-year graft survivals of 57% and 53%, respectively.     

Outcome of endoscopic third ventriculostomy. Results from an unselected series with noncommunicating hydrocephalus

Summary Background. Endoscopic third ventriculostomy (ETV) has gained acceptance as the treatment of choice for noncommunicating hydrocephalus despite a relatively high failure rate and a higher surgical risk than the placement of a shunt. The benefits of shunt independence overcome both drawbacks. This argument also serves to consider candidates for ETV patients with a poor chance of success, a fact which may to a certain degree explain failure rates higher than 20% in most unselected series of patients with noncommunicating hydrocephalus.Method. From 1997 to 2003 sixty-six patients with suspected noncommunicating hydrocephalus were treated with ETV. Male and female patients were equally distributed. It is an adult-based series (median age 53 years). The etiology of hydrocephalus was a space-occupying lesion in 39 patients (59%) and primary aqueductal stenosis in 27 (41%). Forty-seven patients presented an acute form of hydrocephalus (71%), the remainder presented a chronic form of hydrocephalus. The morbidity and outcome of the procedure were reviewed. Criteria for success was shunt independence and failure was considered when any surgical manoeuvre was further required for the treatment of hydrocephalus. The outcome was evaluated using the Kaplan-Meier survival method.Findings. The probability of remaining with a functioning ETV at 5.7 years (mean follow-up period) is 71.6% (95% confidence interval: 60.5–82.8). Failure occurred in 18 patients (27.3%). If failure occurs, there is a cumulative probability of 90% (95% confidence interval: 84–97) that the failure declares itself during the first 16 days after surgery. There were transient complications in five patients (7.5%), permanent in one (1.5%) and no mortality related to the procedure.Conclusions. ETV had a 5-year success rate of 71.6% with a low rate of permanent complications. When ETV is successful, the result tends to hold up over time. Delayed failure is a rare event.     

Arthroscopic management of tibial plateau fractures: an unselected series.

The present series reports the results of arthroscopically assisted fixation of tibial plateau fractures. No effort was made to include or exclude any specific fracture type from the all-arthroscopic reduction technique. Fourteen of 17 tibial plateau fractures treated arthroscopically, with an average follow-up of 14.6 months (range, 5-30 months), were retrospectively evaluated. The average patient age was 43 years (range, 25-65 months). The average knee range of motion obtained was 5 degrees-126 degrees, with 9 of 14 patients regaining full symmetric motion. The Lysholm scale was administered to this group with 5 (36%) receiving an excellent rating, 6 (43%) receiving a good rating, and 3 (21%) receiving a poor rating. Two patients experienced complications: one had painful hardware requiring removal, and the other had an infection that resolved after appropriate treatment. The present report advances the treatment of tibial plateau fractures by documenting the feasibility of the arthroscopic management of many fracture types.     

Quantitative tissue analyses of prostate cancer foci in an unselected cystoprostatectomy series

What's known on the subject? and What does the study add? Much of our understanding of the pathological basis of prostate cancer comes from our analysis of radical prostatectomy specimens. Prostate cancer diagnosed by transrectal ultrasonography‐guided biopsy is more likely to be posterior and basal in orientation rather than anterior or apical. Quantitative tissue analyses have not been undertaken both with details and in an unselected population, e.g. prostate specimens from autopsy cystoprostatectomy series from bladder cancer. Quantitative tissue analysis of incidentally detected prostate cancer such as largest cancer surface area, volume, site of origin, multifocality and laterality could be of paramount importance when trying to understand the findings of screen‐detected programmes and focal therapy. Cancers were found in 30% of prostates. In the 96 prostates, 215 cancer foci were identified (mean 2.24). Prostate cancer was multifocal in 60% and bilateral in 80% of cases. The site of origin was in the peripheral and transition zone (TZ) in 75% and 25%, respectively. Overall, 90% of cancer foci were clinically insignificant with volume of <0.5 mL and no grades 4–5. In all, 75% of the cancer foci were in the peripheral zone, the remainder were within the TZ. One third of cancer foci were anteriorly located beyond the area sampled by posterior biopsies. One fifth of cancer foci were ≤6 mm of the apex.

OBJECTIVE

• ? To describe multifocality, volume and location of prostate cancers incidentally found in cystoprostatectomy specimens. Quantitative tissue analysis of prostate cancer in a population free of the evaluation bias associated with prostate‐specific antigen level and biopsy is important as some men are likely to be offered tissue‐preserving therapeutic strategies in the future.

PATIENTS AND METHODS

• ? Cystoprostatectomy specimens for bladder cancer from 345 consecutive patients without clinically manifest prostate cancer were included.
• ? Cancers were found in 104/345 (30%) of prostates. Cases with largest cancer >2 mL (eight patients) were excluded from morphometric study. Quantitative tissue analysis of 3‐mm step‐sectioned glands included largest cancer surface area, volume, site of origin, multifocality and laterality.

RESULTS

• ? In the 96 prostates, 215 cancer foci were identified (mean 2.24). Prostate cancer was multifocal in 58% and bilateral in 79% of cases.
• ? Of the 215 cancers, 90% were <0.5 mL and 79% <0.2 mL. Overall, 88% of cancer foci were clinically insignificant with a volume of <0.5 mL and no grades 4–5.
• ? In all, 75% of the cancer foci were in the peripheral zone, the remainder were within the transition zone.
• ? One third of cancer foci were anteriorly located beyond the area sampled by posterior biopsies. One fifth of cancer foci were ≤6 mm of the apex.
• ? Limitations include the fact that cystoprostatectomy cancer foci are at an earlier stage than screened‐detected cancers.

CONCLUSION

• ? This detailed morphometric analysis of prostate cancer foci in a population that is free from the selection bias associated with screening can help inform our diagnostic and treatment strategies.

     

Enterocystoplasty and two-stage urethroplasty in urogenital tuberculosis. A case report.

A case of extensive urogenitary tuberculosis treated by enterocystoplasty and two-stage urethroplasty is reported. 10 years after the last surgical procedure, the evacuation of the bladder enlarged by the sigmoid colon through the reconstructed urethra is satisfactory. The low micturating pressure and the mucus secretion do not cause disturbances in micturation.     

Intracranial aneurysms. Age, sex, blood pressure, and multiplicity in an unselected series of patients.

All cases of intracranial aneurysm, arteriovenous malformation, and subarachnoid hemorrhage of undetermined etiology seen at one hospital over a 13-year period were reviewed to assess relationships between age, sex, systolic and diastolic blood pressure, and number of aneurysms. There were 350 patients, of whom 212 had aneurysms. The major findings were as follows: 1) Hypertension was not significantly more prevalent in the aneurysm population than in the age-matched general population, except for females aged 18 to 54 years (systolic pressure elevation of 10 to 15 mm Hg). 2) Under 55 years of age, both male and female hypertensive patients were twice as likely to have multiple aneurysms as normotensive patients. 3) Females were more likely than males to have multiple aneurysms. 4) For females but not males, increasing age, higher systolic pressure, and higher diastolic pressure all correlated with an increasing number of aneurysms. Hypertension appears to be more prevalent in certain subgroups of the total aneurysm population, although the individual relationships between hypertension, atherosclerosis, and aneurysms cannot be determined from either the present or previous studies. The possible role of familial factors, as well as implications for both diagnosis and further research, are briefly noted.     

Vertebral tuberculosis in Gabon. Anatomo-clinical aspects, diagnostic and therapeutic problems, 107 cases from 1976 to 1986

This retrospective study covers a period of 10.5 years (february 1976 to november 1986). It concerns 107 patients who contracted tuberculous spondylitis and originated from different provinces of Gabon. The authors report their experiences in order to emphasize the frequency of the disease, diagnostic and therapeutic problems. In Gabon, tuberculosis of the spine occupies the third position (3%), after the pulmonary form (90%) and ganglionic form (3.8%). In also represents 83.6% of the osteoarticular tuberculosis. The average age is 22 years, 55% of the patients were less than 20 years. The zone of maximum predilection, in decreasing order, is thoracic spine (36.4%), lumbar spine (33.6%), thoraco-lumbar region (10.3%). The 107 patients totalized 257 vertebral bodies destroyed (an average of 2.4 bodies per patients). On the clinical field the sick seek advice at an advance stage of the disease with gibbosity (38.3%) and neurologic deficits (21.5%). The diagnosis proof often followed the therapeutic results. There were three therapeutic modalities: medical (all patients), surgical (6 patients) and orthopedic (44 patients). The therapeutic indications improved with the available of more material and qualified staff. In children the treatment remains classic. The authors discuss the surgical indications in adults. The therapeutic results in patients treated and followed for over one year were satisfactory. Unfortunately, most patients were lost to follow-up. They suggest public health means of decreasing the frequency of the disease.     

Ulcerative colitis. Mortality and surgery in an unselected population

125 patients with ulcerative colitis, considered to represent the unselected population of patients with this disease from a defined catchment area during the years from 1961 to 1983, were studied. The mortality from colitis was 5%, with no peroperative death after 1978. No prophylactic proctocolectomy was performed and there were no deaths in colorectal cancer. The cumulative operation frequency was 26%, and 37% in the subgroup of patients with total colitis. During the first 5 years of disease the operation frequency was 14%. It is concluded that, in a unselected population of patients with ulcerative colitis, satisfying results can be obtained at a community hospital, providing the surgical attitude to severe acute and disabling chronic disease is aggressive.     

Septic complications of intramedullary locked nailing in traumatology in a series of 1.474 nails from 1974 to 1989

Summary The authors present a computerized study of 1.474 locked nailings of fresh femoral and tibial fractures, carried out at the Strasbourg Traumatologic Center from 1974 to 1989. 70 septic complications were found, that is a global infection rate of 4.8%. 19 cases were superficial and 51 (3.4%) deep infections. The follow-up of 46 deep infections showed that in 32 cases the locked nailing remained stable and could be maintened until bone consolidation; in 14 cases of unstable nailing, a change of the method of treatment was necessary. 73% of the cases can be considered as benign infections, requiring no supplementary surgical operation except final removal of the nail. The 27% deep infections with severe osteitis and osteomyelitis, required repeated re-operations, with delayed recovery and permanent sequelae; however they only represent 1.1% of the total 1.474 nailings. During the study, two distinct periods can be differentiated: before 1984, period of perfecting the method, and after 1984, period of mastered operative technique, advent of systemic antibioprophylaxis and greater caution in the indications for nailing grade 3 open fractures. Between these two periods, the total infection rate went from 6.3% to 3.5%, the superficial infections from 2.2% to 0.6%, the infection rate in closed fractures from 4.3% to 2.2%, the deep infections in open femoral fractures from 5.9% to 2.2%. On contrary, the deep infection rate after nailing of open tibial fractures remained unchanged at 9% and increased dramatically with the grade of the soft-tissue lesions: 7.9% in 140 grade 1 open fractures, 15% in 99 grade 2 and 40% in 10 grade 3 open nailed tibial fractures. In conclusion, using the Gustilo classification, we recommend intramedullary locking nailing in fresh open grade 1, 2 and 3a femoral and tibial fractures, since it allows better bone and functional prognosis and ensures that infection risks are kept within reasonable limits. On the other hand, there is an absolute indication for primary external fixation in grade 3b and 3c open fractures especially of the tibia.

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Complications septiques de l'enclouage centro-médullaire verrouillé en traumatologie dans une série de 1 474 enclouages de 1974 à 1989

Résumé Les auteurs présentent une étude informatisée de 1 474 enclouages centro-médullaires verrouillés de fractures récentes du fémur et du tibia, réalisés au Centre de Traumatologie de Strasbourg entre 1974 et 1989. Ils ont observé 70 complications septiques, ce qui correspond à un taux global d'infection de 4,8 %. 19 infections étaient superficielles et 51 (3,4 %) profondes. Dans les 46 cas revus d'infection profonde, l'enclouage est resté stable chez 32 patients et a pu être maintenu jusqu'à la consolidation ; dans 14 cas l'enclouage, devenu instable, a nécessité un changement de méthode de traitement. En ce qui concerne la gravité de l'infection, 73 % des cas sont à considérer comme bénins et n'ont nécessité aucune intervention secondaire si l'on excepte l'ablation finale du clou d'ostéosynthèse. Dans les 27 % de cas d'infection profonde compliquée d'ostéite parfois grave, des interventions itératives ont été nécessaires, ont retardé l'évolution et entraîné des séquelles définitives ; ils ne représentent cependant que 1,1 % de la totalité des 1 474 enclouages. Deux périodes de traitement ont été distinguées : avant 1984, période de mise au point, et après 1984, période de technique bien maîtrisée, d'antibioprophylaxie systémique et de plus grande prudence dans les indications d'enclouage des fractures ouvertes de grade 3. D'une période à l'autre, le pourcentage total d'infection est passé de 6,3 % à 3,5 %, les infections superficielles de 2,2 % à 0,6 %, le taux d'infection des fractures fermées de 4,3 % à 2,2 %, les infections profondes des fractures ouvertes du fémur de 5,9 % à 2,2 %. Par contre, le taux d'infection profonde dans l'enclouage des fractures ouvertes du tibia est resté inchangé à 9 % et a augmenté considérablement avec le degré d'atteinte des parties molles : 7,9 % dans 140 fractures ouvertes de grade 1, 15 % dans 99 fractures ouvertes de grade 2 et 40 % dans 10 fractures ouvertes de grade 3. Au total, s'appuyant sur la classification de Gustilo, les auteurs préconisent l'enclouage verrouillé des fractures ouvertes récentes du fémur et du tibia des grades 1, 2 et 3a, méthode qui leur a permis d'obtenir de bons résultats sur les plans osseux et fonctionnel et de maintenir le risque d'infection dans des limites raisonnables. Par contre, l'indication du fixateur externe immédiat devient absolue dans les fractures ouvertes de grade 3b et 3c, particulièrement au niveau de la jambe.

     

Frequency of impalpable prostate adenocarcinoma and precancerous conditions in Greek male population: an autopsy study

A series of 212 prostate specimens of men dead between August 2002-August 2004, have been sectioned in consecutive autopsies and subjected to whole mount analysis in purpose to determine the epidemiology of impalpable prostate cancer in Greece. Impalpable prostate carcinomas were found in 40 cases (18.8%) most in the peripheral region. In all, 29 of 40 impalpable cancers (70.7%) had volume less than 1 cm3. Most of impalpable carcinomas were of favorable (Gleason score 2-4) or intermediate (Gleason score 5 and 6) histological type (55 and 27.7%, respectively) while only five (12.5%) were undifferentiated (Gleason score 7 and 8). In all, 24 (60%) of the 40 impalpable carcinomas were multifocal and consisted of two or more foci, most of small size (<0.5 cm3). Most of the impalpable cancers found in this autopsy study were potentially insignificant tumors (relatively low volume, favorable or intermediate histological pattern and absence of invasiveness). Prostate intraepithelial neoplasia (PIN) coexisted with impalpable carcinomas, in almost half of the cancer-positive specimens. There was a positive correlation between PIN foci and coexistent cancer foci in most of the cases. Frequency rate and pathological features of both entities show significant variations in medical literature. Since the incidence of clinical prostate cancer in Greece is relatively low, and according to our autopsy findings, it is plausible that the frequency of clinical prostate cancer in a certain population could be related to the prevalent model of impalpable cancer as well as to the frequency and extend of the precancerous lesions.     

Urothelial atypia concomitant with primary bladder tumour. Incidence in a consecutive series of 500 unselected patients

A consecutive series of 500 primary bladder tumours from a single clinic is presented, with distribution of the tumours according to T category and histologic type and grade. Mucosal biopsies were obtained from pre-selected sites at initial cystoscopy or initial transurethral resection of the tumour in 396 cases. In 54% of the patients with grade III tumour there was concomitant urothelial atypia, either carcinoma in situ (urothelial atypia grade III, 30%) or urothelial atypia grade II (24%). In 30% of the patients with invasive grade II bladder tumour and in 14% of those with noninvasive grade II tumour there was concomitant urothelial atypia, mostly grade II. Since concomitant urothelial atypia predicts new tumour growth after successful transurethral surgery or radiotherapy, mucosal biopsies should be performed at preselected sites during initial cystoscopy or transurethral tumour resection in order to identify high-risk patients.     

The management of IIB osteosarcoma. Experience from 1976 to 1985

From 1976 to 1985, 75 IIB osteosarcomas have been treated out of a total of 98 osteosarcomas at the authors' institution. Because of the effective chemotherapy including high-dose methotrexate administered during this time period, the surgical management changed, and only ten patients out of the 75 IIB osteosarcomas required an amputation. The overall result of 76.7% of disease-free, three-year survival was equally distributed regardless of the surgical procedure. Endoprosthesis, resection with or without grafts, and rotationplasties, as well as amputations, revealed similar results. No negative influence from the limb-sparing surgery could be observed.     

The feasibility of adopting laparoscopic incisional hernia repair in general surgery practice: early outcomes in an unselected series of patients

A laparoscopic approach to incisional hernia repair has been shown to be safe and effective in selected patients. We report our early outcomes following laparoscopic ventral/incisional hernia repair (LVHR) in an unselected series of patients encountered in general surgery practice. All patients referred with incisional hernia were offered a laparoscopic repair using prosthetic mesh. Patients were not excluded from laparoscopic approach on the basis of age, previous surgery, defect size, intraperitoneal mesh, body mass index (BMI), comorbidities, or abdominal wall stomas. We followed 28 consecutive patients who underwent LVHR (17 primary, 11 recurrent hernias). Laparoscopic repair was completed in 27 patients with a mean operative time of 141.6 +/- 11.9 minutes. There were no intraoperative complications. The mean size of the abdominal wall defects was 153.4 +/- 27.5 cm and the mean mesh size was 349.2 +/- 59.1 cm. The mean hospital stay was 3.7 +/- 0.3 days. Nine patients developed large wound seromas; all spontaneously resolved. Our experience suggests that LVHR is feasible as a primary approach to most incisional hernias encountered in general surgery practice.     

Survey of mycobacteria isolated from urine and the genitourinary tract in south-east England from 1980 to 1989.

Between 1980 and 1989, the Public Health Laboratory Service Regional Tuberculosis Centre, Dulwich, received cultures of mycobacteria isolated from urine and the genitourinary tract of 1392 new patients: 803 isolates were members of the tuberculosis complex (753 M. tuberculosis, 45 M. bovis, 4 M. africanum) and 589 were various species of environmental mycobacteria. The incidence of the latter isolations varied by region and by year and, with 17 exceptions (13 from endometrial curettings, 2 from hydrocele fluid, 1 from a scrotal abscess and 1 from a kidney), all isolations of environmental mycobacteria were from urine; very few of them appeared to be clinically significant. Those that could be significant included 1 isolate from a kidney, 1 from a post-renal transplant patient and 4 from patients with AIDS, 3 of whom had disseminated mycobacterial disease. Reports of clinically significant isolations of environmental mycobacteria from the genitourinary tract are reviewed.