Pituitary apoplexy: retrospective review of 30 patients--is surgical intervention always necessary?

The objective of this article is to review clinical outcomes in patients presenting with pituitary apoplexy and compare the results of conservative and surgical management. It took the form of a retrospective review of 30 patients (23M, 7F; age range: 17-86 years) with pituitary apoplexy diagnosed between 1988 and 2004. Presenting features included headache in 27 patients, 'collapse' in three and vomiting in 14. Complete blindness occurred in four patients, monocular blindness in two, decreased visual acuity in 12, visual field loss in 10 and ophthalmoplegia in 15. Only five had no initial visual deficit. CT was the initial mode of imaging in 22 patients: three such scans were initially reported as 'normal' and a further 10 as pituitary tumour only, with no haemorrhage. Ten patients proceeded to early pituitary surgery and 20 were managed conservatively. There was one death 24 days after admission in a patient with multiple co-morbidities. Of the six patients with blindness, three (two conservatively treated) regained partial vision. Of the remaining 19 patients with visual deficits, 10 (two surgically treated) recovered fully and eight (four surgically treated) partly so. At latest follow-up the following pituitary hormone deficiencies were identified: ACTH 19; TSH 20; testosterone 18; ADH (diabetes insipidus) eight. Later recurrence of a pituitary adenoma was observed in seven cases (including six of the 10 surgically treated patients). There was no evidence that those patients managed surgically had a better outcome. Early neurosurgical intervention may not be required in most patients presenting with pituitary apoplexy.     

Characteristics of benign neuroblastic tumors: Is surgery always necessary?

PurposeGanglioneuroma (GN) and ganglioneuroblastoma-intermixed (GNB-I) represent benign variants of neuroblastic tumors in children; however, differentiating from more aggressive histological variants of GNB including the nodular subtype (GNB-N) prior to resection can be challenging, even with biopsy. Currently, no standard treatment guidelines exist. The purpose of this study was to identify pre-operative characteristics of benign neuroblastic tumors and evaluate outcomes for patients who underwent surgical resection or observation.MethodsRetrospective chart review of children treated at a single institution between 2009 and 2019 for non-metastatic tumor with a tissue diagnosis of GN, GNB-N or GNB-I. Demographics, imaging, labs, operative details and outcomes were recorded and analyzed.ResultsOf 53 patients, 45% were male. The most common tumor location was abdomen (49%), followed by thorax (34%). Forty-five percent had at least one image defined risk factor. Biopsy was performed in 32% (17/53) and upfront surgery in 68% (36/53). Three patients (3/53, 5.6%) with biopsy demonstrating GN tumors were observed due to high surgical risk. Pathology of resected specimens demonstrated GN in 52% (26/50) and GNB-I or GNB-N in 48% (24/50). The majority of GNB tumors (75% (18/24) were GNB-I and 25% (6/24) were GNB-N. Therefore, 88% of the resected tumors were benign spectrum neuroblastic tumors (GN & GNB-I). Seven (7/50, 14%) patients experienced perioperative complication (temporary paralysis, Horner's syndrome, chylothorax, vocal cord paralysis). Recurrence was noted in 1 patient with GN (1/50, 2%) and 3 with GNB-N (3/50, 6%). There were no tumor-related deaths. Patients with GN were older than those with GNB (8.8 years (IQR 6–11.25) vs 5.6 years for GN (IQR 3–7); p = 0.01). GNB tumors were also more likely to have calcifications on imaging (63% vs. 38%, p = .01) and more commonly had MIBG avidity (88% vs 66%, p = .04). There were no significant differences in tumor size or symptoms at presentation.ConclusionsIn children with neuroblastic tumors, older age, CT without tumor calcifications, lack of MIBG avidity, and/or normal urine catecholamines may indicate benign GN. Close observation could be considered for asymptomatic patients meeting these criteria with biopsy-proven GN, with resection reserved for progressive growth or symptom development. However, larger, multicenter studies are needed for further validation.Level of evidenceIV.     

Is multichannel urodynamic assessment necessary before considering a surgical treatment of BPH? Pros and cons

Purpose

Lower urinary tract symptoms (LUTS) are common in middle-aged men and could be consequences of multiple etiologies responsible for bladder outlet obstruction (BOO), detrusor underactivity (DUA) and/or overactive bladder. When LUTS are suggestive of BOO secondary to benign prostatic hyperplasia, a surgical treatment can sometimes be consider. Even if multichannel urodynamic study (UDS) is currently the gold standard to properly assess LUTS, its use in non-neurogenic men is still a matter of controversy. Here, we aim to explore the evidence supporting or not the use of systematic multichannel UDS before considering an invasive treatment in men LUTS.

Methods

The debate was presented with a “pro and con” structure. The “pro” side supported the systematic use of a multichannel UDS before considering a surgical treatment in men LUTS. The “con” side successively refuted the “pro” side arguments.

Results

The “pro” side mainly based their argumentation on the poor correlation of LUTS and office-based tests with BOO or DUA. Furthermore, since a multichannel UDS could allow selecting men that will most benefit of a surgical procedure, they hypothesized that such an approach could reduce the overall morbidity rate and cost associated with. The “con” side considered that, in most cases, medical history and symptoms were reliable enough to consider surgery. Finally, they underlined the UDS limitations and the frequent lack of alternative to surgery in this context.

Conclusions

Randomized clinical trials are being conducted to compare these two approaches. Their results would help the urological community to override this debate.

     

Strategy of treatment of patients with recurrent spontaneous pneumothorax: is active surgical treatment necessary?

The diagnostic accuracy of computed tomography in treatment of bullous disease as the most frequent cause of recurrent spontaneous pneumothorax was 55.5%, while that of roentgenography was 16%. The recovery of patients with recurrent spontaneous pneumothorax treated by active surgical measures takes place in 85% of cases, while with drainage of the pleural cavity--in 65%.     

Evaluation of grip strength in hook of hamate fractures treated with osteosynthesis. Is this surgical treatment necessary?

ObjectiveThe aim of this study was to evaluate the outcomes of open reduction and internal fixation (ORIF) in hamate hook fractures and review the literature on this surgical procedure.MethodsWe report the outcomes of ORIF of hamate hook fractures in 13 consecutive patients (12 men and 1 woman; mean age: 32 years (range, 22–48 years)). In eight patients (61%) the fracture was associated with ulnar nerve neuritis in Guyon's canal. We assessed the following clinical data: age, sex, mechanism of injury, side of the injured hand and associated lesions, fracture classification, average time from injury to correct diagnosis, surgical technique, complications, and length of follow-up.All patients underwent radiological imaging, including standard radiographs in two planes (anteroposterior and lateral projections), and a CT study. Functional outcomes evaluated were pain, range of motion, grip strength, Disabilities of the arm, shoulder and hand (DASH) and Mayo wrist score.ResultsThe mean follow-up was 36 months (range, 12–144 months). All 13 cases were treated with ORIF of the hook of the hamate. Mean VAS pain score was 5 preoperatively (4–9) and 1 (0–2) postoperatively. All patients returned to pre-injury level and only one patient felt pain on activity. Preoperative modified Mayo wrist score was 51 and the postoperative value was 94. All outcomes scores improved significantly from preoperative values. The patients who participated in sports postoperatively were able to do so at or near pre-injury levels. Postoperative average range of wrist motion was 76° in extension, 71° in flexion, 14° in ulnar deviation, and 21° in radial deviation.Mean grip strength in the hand with the hook fracture was 58 kg compared with 53 Kg in the unaffected hand. All patients returned to their pre-injury level of functioning after 10–12 weeks and there were no complications. Analysis of grip strength revealed values comparable with the unaffected hand.ConclusionORIF of hamate hook fractures is a safe and effective technique to restore normal grip strength and return to pre-injury level. In cases of ulnar nerve neuritis, neurolysis of the deep palmar branch is mandatory.Level of evidenceLevel IV, Therapeutic study.     

Benign breast papilloma: Is surgical excision necessary?

In many centers internationally, current standard of care is to excise all papillomas of the breast, despite recently reported low rates of upgrade to malignancy on final excision. The objective of this study was to determine the upgrade rate to malignancy in patients with papilloma without atypia. A retrospective review of a prospectively maintained database of all cases of benign intraductal papilloma in a tertiary referral symptomatic breast unit between July 2008 and July 2018 was performed. Patients with evidence of malignancy or atypia on core biopsy and those with a history of breast cancer or genetic mutations predisposing to breast cancer were excluded. One hundred and seventy‐three cases of benign papilloma diagnosed on core biopsy were identified. Following exclusions, the final cohort comprised of 138 patients. Mean age at presentation was 51. Mean follow‐up time was 9.6 months. The most common symptom was a lump (40%). Of the 124 patients who underwent excision, three had ductal carcinoma in situ and there were no cases of invasive disease, giving an upgrade rate to malignancy of 2.4%. Upgrade to other high‐risk lesions (atypical lobular and ductal hyperplasia and lobular carcinoma in situ) was demonstrated in 15 cases (12.1%). Benign papilloma was confirmed in 100 cases (81.5%), and 6 (4.8%) had no residual papilloma found on final excision. Twelve patients (8.7%) were managed conservatively. Of those, one later went on to develop malignancy. Patients with a diagnosis of benign papilloma without atypia on core biopsy have a low risk of upgrade to malignancy on final pathology, suggesting that observation may be a safe alternative to surgical excision. Further research is warranted to determine which patients can be safely managed conservatively.     

Is posterior leaflet preservation in the surgical treatment of rheumatic mitral insufficiency without left ventricular dysfunction necessary?

Preservation of the mitral valve leaflet and tensor apparatus during valve replacement is believed to maintain left ventricular performance. To determine the effect of posterior leaflet preservation in pure severe mitral insufficiency without left ventricular dysfunction 56 patients were operated on between 1993 and 2000. Twenty-three patients underwent mitral valve replacement with posterior chordal preservation and 33 patients underwent mitral valve replacement with chordal transection. Preoperative data in the both groups were similar. After 30days there were no mortalities observed. Dimensions of the left ventricle had significantly decreased within one group, but there was no difference in the other group. The improvement of the functional and cardiac performance in all patients was significant without any difference between the two groups. Actuarial freedom from death was not significantly different at 6yr (P=0.23). To preserve left ventricular function in pure severe mitral regurgitation without left ventricular dysfunction, mitral valve replacement is very effective with or without posterior leaflet preservation. But, it is difficult to suggest that posterior leaflet preservation alone can increase cardiac performance.     

Ileocecal duplication cysts: Is the loss of the valve always necessary?

Background

Ileocecal (IC) duplication cysts are enteric duplications located at the IC junction, not clearly identified in all the published series. The reported treatment is IC resection and ileocolic anastomosis. It is well known that the loss of the IC valve has several adverse effects. This study is aimed at demonstrating that cyst removal together with the common ileal wall and following enterorrhaphy is possible, safe, and effective in preserving the IC region.

Methods

Medical records of 3 patients who underwent surgery for IC duplication between 2003 and 2013 were retrospectively reviewed evaluating follow-up results.

Results

All patients had an antenatal diagnosis of intraabdominal cystic mass. In two cases associated malformations were reported. The lesions presented at newborn age with intermittent small bowel obstruction and required removal. No patients underwent IC resection. The diagnosis of duplication cyst was confirmed by histo-pathologic examination. The postoperative course was uneventful, even in the long-term follow-up.

Conclusions

Our conservative approach is a simple and safe technique, effective in avoiding the loss of the IC valve in children with duplication at the IC junction.     

Is high cord radical orchidectomy always necessary for testicular cancer?

BACKGROUND: Radical high cord inguinal orchidectomy remains the standard for diagnosis, staging and treatment of testicular neoplasms. Low cord orchidectomy is an alternative to the high cord orchidectomy. OBJECTIVE: To test the hypothesis that there is no difference in relapse rate or mortality between high and low cord orchidectomy for the treatment of testicular cancer. METHODS: A retrospective study was undertaken of all orchidectomies performed for testicular cancer at our hospital between 1981 and 2002. RESULTS: Overall, 120 high cord orchidectomies and 102 low cord orchidectomies were performed for testicular cancer between 1981 and 2002 at our hospital. Analysis showed that there was no significant difference in the mean age of the patients, the rate of relapse, mean time to relapse or survival between surgical approach for stage 1 tumours. For stage 2-4 tumours, there were not sufficient numbers to comment on the statistical significance of relapse or survival differences. CONCLUSIONS: The trend suggests that there is no statistically significant difference in the rate of relapse and mortality between high and low cord orchidectomy for clinically stage 1 tumours. We would, therefore, advocate either a high or low cord orchidectomy for clinically stage 1 tumours.     

Is it always necessary to treat a ureteropelvic junction syndrome?

The term ureteropelvic junction (UPJ) obstruction covers different morbid entities, and the old aphorism, “A UPJ is not a UPJ” remains true. Hydronephrosis is readily seen on antenatal ultrasonography but does not necessarily imply obstruction. Although most cases will resolve spontaneously, the probability of a significant pathology is related to the degree of pyelectasis, as seen on the third trimester study. Criteria of obstruction are difficult to define with precision, but two that are well-accepted are size of the renal pelvis (> 15 mm) and relative renal function, as determined by adequate isotopic studies. A new therapeutic standard has been established, and minimally invasive surgery has finally dethroned its open rival. Possibly facilitated by robotic assistance, laparoscopic dismembered pyeloplasty is the present gold standard, albeit endopyelotomy remains the least invasive with similar results in carefully selected patients.     

Total hip arthroplasty after prior surgical treatment of hip fracture is it always challenging?

Salvage total hip arthroplasty (THA) presents a viable solution for failed open reduction internal fixation. This study compares salvage THA in patients with prior femoral neck fractures vs patients with prior intertrochanteric fractures. One hundred fifty-four hips in 152 patients underwent conversion from open reduction internal fixation to THA. Eighty-three patients had previous femoral neck fractures, and 69 patients (71 hips) had prior intertrochanteric fractures. Salvage THA in patients with prior intertrochanteric fractures presented a more technically demanding procedure with longer operative times and larger amounts of blood loss. Although conversion THA presents a technically challenging procedure, it is safe and yields relatively few orthopedic complications.     

Is measurement of stone surface area necessary for SWL treatment of nonstaghorn calculi?

BACKGROUND AND PURPOSE: The size of urinary tract stones is usually assessed by the longest diameter (LD) alone. Logically, however, two-dimensional measurement of the stone surface area (SSA) susceptible to shockwaves would give more useful information for the planning of treatment by extracorporeal shockwave lithotripsy (SWL). This has been shown for staghorn calculi. The aim of this study was to determine for nonstaghorn kidney and ureter stones whether the LD alone identifies as reliably a subgroup of patients with a stone of a certain size as does the SSA. Furthermore, we sought to determine whether the LD alone indicates as reliably the number of patients who would be rendered stone free after one SWL session within a certain subgroup as would the SSA. PATIENTS AND METHODS: Retrospectively, SWL treatment and radiographic data of 330 patients who had undergone SWL for a single stone were analyzed. RESULTS: Ureteral stones were significantly smaller on average, and ureteral stone patients needed fewer SWL treatment sessions and fewer shockwaves to become stone free. Stratification of both kidney and ureteral stones by either LD or SSA resulted in comparable groups of patients. There were no significant differences in patient, stone, or treatment data. More importantly, the stone-free rates after one treatment did not differ significantly. CONCLUSION: The LD does accurately reflect the size of a nonstaghorn kidney or ureteral stones. Therefore, the measurement of LD, as generally practiced, appears clinically sufficient and appropriate for the assessment of stone size prior to SWL in both kidney and ureteral stones.     

Mild ductal atypia after large-core needle biopsy of the breast: is surgical excision always necessary?

BACKGROUND: The aim of the current study was to identify a select group of patients with mild atypia who do not need surgical excision after large-core needle biopsy (LCNB) of the breast. METHODS: Nineteen (70%) of 27 patients with ductal atypia found on LCNB had subsequent surgical excision. These 19 patients were retrospectively assigned to 3 groups according to the severity of the atypia found, which was compared with the final pathologic specimen after surgical biopsy. RESULTS: Cancer was identified through surgical biopsy in 6 (32%) of 19 patients. The severity of atypia seen on the LCNB specimen strongly correlated with subsequent cancer identification (P<.01). Two (33%) of 6 patients in group 2 (true atypical ductal hyperplasia [ADH]) and 4 (80%) of 5 patients in group 3 (severe ADH, borderline ductal carcinoma in situ) had cancer after surgical biopsy. No cancer was found after surgical biopsy in 8 patients in group 1 (mild atypia, not meeting criteria for ADH). CONCLUSIONS: The results of this study suggest that surgical excision can be avoided after LCNB of the breast in patients with only mildly atypical lesions that do not meet criteria for ADH. Patients with true ADH should continue to have surgical excision.     

Needle-tract implantation from hepatocellular cancer:Is needle biopsy of the liver always necessary?

Percutaneous needle biopsies are frequently used to evaluate focal lesions of the liver. Needle-tract implantation of hepatocellular cancer has been described in case reports, but the true risk for this problem has not been clearly defined. We retrospectively reviewed 91 cases of hepatocellular cancer during a 4-year period from 1994 to 1997. Data on diagnostic studies, therapy, and outcome were noted. Of 91 patients with hepatocellular cancer, 59 patients underwent percutaneous needle biopsy as part of their diagnostic workup for a liver mass. Three patients (5.1%) were identified with needle-tract implantation of tumor. Two patients required en bloc chest wall resections for implantation of hepatocellular cancer in the soft tissues and rib area. The third patient, who also received percutaneous ethanol injection of his tumor, required a thoracotomy and lung resection for implanted hepatocellular cancer. Percutaneous needle biopsy of suspicious hepatic lesions should not be performed indiscriminately because there is a significant risk for needle-tract implantation. These biopsies should be reserved for those lesions in which no definitive surgical intervention is planned and pathological confirmation is necessary for a nonsurgical therapy.