Shoulder periprosthetic joint infection caused by <Emphasis Type="Italic">Propionibacterium acnes</Emphasis>

Background

Propionibacterium acnes is increasingly recognized as an important cause of shoulder periprosthetic joint infection (PJI). We performed a retrospective cohort study of P. acnes shoulder PJI to analyze the clinical, diagnostic, and treatment characteristics.

Methods

Patients diagnosed with shoulder PJI caused by P. acnes were retrospectively analyzed in two university hospitals. Patient data were retrieved through chart review. The outcome was evaluated at patient follow-up visits.

Results

The study included 20 patients with shoulder PJI (median age, 65 years; range, 54–77 years); 75 % were males. The median time from prosthesis implantation to diagnosis of PJI was 34 months (range, 2–60 months). Most PJI (55?%) were diagnosed >24 months after arthroplasty, followed by delayed manifestation 3–24 months after arthroplasty in 30?%. The diagnosis of PJI was preoperatively confirmed in 50?% of patients and suspected in 20 %. Persistent pain was present in 90?%, local signs of inflammation in 60?%, and radiological signs of loosening in 70 % of patients. P. acnes was cultured in joint aspirate in 33?%, periprosthetic tissue in 60?%, and sonication fluid in 89?% of patients. In four patients, coinfection with coagulase-negative staphylococci was found. One-stage prosthesis exchange was performed in four patients (20?%) and two-stage exchange in 15 patients (75?%); in one patient the prosthesis was not re-implanted. After a median follow-up of 26 months (range, 12–47 months), 18 patients (90?%) showed no signs or symptoms of infection.

Conclusion

P. acnes PJI typically manifested several years after implantation. In 30?% of patients, PJI was not suspected before surgery. In patients with persistent pain or prosthesis loosening, low-grade PJI should be excluded, including infection caused by P. acnes.

     

Trajectories of musculoskeletal shoulder pain after spinal cord injury: Identification and predictors

Objective/Background

Although shoulder pain is a problem in up to 86% of persons with a spinal cord injury (SCI), so far, no studies have empirically identified longitudinal patterns (trajectories) of musculoskeletal shoulder pain after SCI. The objective of this study was: (1) to identify distinct trajectories of musculoskeletal shoulder pain in persons with SCI, and (2) to determine possible predictors of these trajectories.

Design/Methods

Multicenter, prospective cohort study in 225 newly injured persons with SCI.

Outcome Measure

Shoulder pain was assessed on five occasions up to 5 years after discharge. Latent class growth mixture modeling was used to identify the distinct shoulder pain trajectories.

Results

Three distinct shoulder pain trajectories were identified: (1) a “No or Low pain” trajectory (64%), (2) a “High pain” (30%) trajectory, and (3) a trajectory with a “Decrease of pain” (6%). Compared with the “No or Low pain” pain trajectory, the “High pain” trajectory consisted of more persons with tetraplegia, shoulder pain before injury, limited shoulder range of motion (ROM), lower manual muscle test scores, or more spasticity at t₁. Multiple logistic regression analysis showed two significant predictors for the “High pain” trajectory (as compared with the “No or Low pain” trajectory): having a tetraplegia (odds ratio (OR) = 3.2; P = 0.002) and having limited shoulder ROM (OR = 2.8; P = 0.007).

Conclusion

Shoulder pain in people with SCI follows distinct trajectories. At risk for belonging to the “High pain” trajectory are persons with tetraplegia and those with a limited shoulder ROM at start of active rehabilitation.     

Treatment for proximal humeral fractures with percutaneous plating: our first results

Propionibacterium acnes detection in culture media was previously considered a contamination but recently its infectious role was discovered in post-spinal surgery infections. P. acnes might be introduced during surgery. Its diagnosis is based on non-specific clinical signs, image indications of infection, and the conclusive microbiological sign. Furthermore, its diagnosis is difficult because of slow growth rate and low virulence, delaying its presentation. Usually, the infection is manifested after a couple of months or years. Here, a 65-year-old man presented with drainage at the site of instrumented spinal surgery performed 13 years ago. P. acnes infection was confirmed by culture with extended incubation. Our review of the literature revealed only two other reported cases of delayed P. acnes infection presenting a decade following a spinal surgery with instrumentation. This article sheds light on such delayed infections and discusses their presentation and management.     

Triangle tilt and humeral surgery: Meta-analysis of efficacy and functional outcome

AIM: To systematically review and analyze the overall impact and effectiveness of bony surgical procedures, the triangle tilt and humeral surgery in a comparative manner in permanent obstetric brachial plexus injury (OBPI) patients.METHODS: We conducted a literature search and identified original full research articles of OBPI patients treated with a secondary bony surgery, particularly addressing the limitation of shoulder abduction and functions. Further, we analyzed and compared the efficacy and the surgical outcomes of 9 humeral surgery papers with 179 patients, and 4 of our secondary bony procedure, the triangle tilt surgical papers with 86 patients.RESULTS: Seven hundred and thirty-one articles were identified, using the search term “brachial plexus” and obstetric or pediatric (246 articles) or neonatal (219 articles) or congenital (188 articles) or “birth palsy” (121 articles). Further, only a few articles were identified using the bony surgery search, osteotomy “brachial plexus” obstetric (35), “humeral osteotomy” and “brachial plexus” (17), and triangle tilt “brachial plexus” (14). Of all, 12 studies reporting pre- and post- operative or improvement in total Mallet functional score were included in this study. Among these, 9 studies reported the humeral surgery and 4 were triangle tilt surgery. We used modified total Mallet functional score in this analysis. Various studies with humeral surgery showed improvement of 1.4, 2.3, 5.0 and 5.6 total Mallet score, whereas the triangle tilt surgery showed improvement of 5.0, 5.5, 6.0 and 6.2.CONCLUSION: The triangle tilt surgery improves on what was achieved by humeral osteotomy in the management of shoulder function in OBPI patients.     

Nasal Methicillin-Resistant S. Aureus is a Major Risk for Mediastinitis in Pediatric Cardiac Surgery

Background: Mediastinitis caused by methicillin-resistant Staphylococcus aureus (MRSA) is a serious complication after pediatric cardiac surgery. An outbreak of surgical site infections (SSIs) provided the motivation to implement SSI prevention measures in our institution.Methods: Subjects comprised 174 pediatric patients who underwent open-heart surgery after undergoing preoperative nasal culture screening. The incidence of SSIs and mediastinitis was compared between an early group, who underwent surgery before SSI measures (Group E, n = 73), and a recent group, who underwent surgery after these measures (Group R, n = 101), and factors contributing to the occurrence of mediastinitis were investigated.Results: The incidence of both SSIs and Mediastinitis has significantly decreased after SSI measures. With regard to factors that significantly affected mediastinitis, preoperative factors were “duration of preoperative hospitalization” and “preoperative MRSA colonization,” intraoperative factors were “Aristotle basic complexity score,” “operation time,” “cardiopulmonary bypass circuit volume” and “lowest rectal temperature.” And postoperative factor was “blood transfusion volume.” Patients whose preoperative nasal cultures were MRSA-positive suggested higher risk of MRSA mediastinitis.Conclusions: SSI prevention measures significantly reduced the occurrence of SSIs and mediastinitis. Preoperative MRSA colonization should be a serious risk factor for mediastinitis following pediatric cardiac surgeries.     

Use of safety scalpels and other safety practices to reduce sharps injury in the operating room: What is the evidence?

Background

The occupational hazard associated with percutaneous injury in the operating room (OR) has encouraged harm reduction through behaviour change and the use of safety-engineered surgical sharps. Some Canadian regulatory agencies have mandated the use of “safety scalpels.” Our primary objective was to determine whether safety scalpels reduce the risk of percutaneous injury in the OR, while a secondary objective was to evaluate risk reduction associated with other safety practices.

Methods

We used evidence review methods described by the International Liaison Committee on Resuscitation and conducted a systematic, English-language search of Ovid, MEDLINE and EMBASE using the following search terms: “safety-engineered scalpel,” “mistake proofing device,” “retractable/removable blade/scalpel,” “pass tray,” “hands free passing,” “neutral zone,” “sharpless surgery,” “double/cutproof gloving” and “blunt suture needles.” Included articles were scored according to level of evidence; quality; and whether they were supportive, opposed or neutral to the study question(s).

Results

Of 72 included citations, none was supportive of the use of safety scalpels. There was high-level/quality evidence (Cochrane reviews) in support of risk reduction through double-gloving and use of blunt suture needles, with additional evidence supporting a pass tray/neutral zone for sharps handling (4 of 5 articles supportive) and use of suturing adjuncts (1 article supportive).

Conclusion

There is insufficient evidence to support regulated use of safety scalpels. Injury-reduction strategies should emphasize proven methods, including double-gloving, blunt suture needles and use of hands-free sharps transfer.     

Can periprosthetic hip joint infections be successfully managed by debridement and prosthesis retention?

To evaluate the current literature about how successfully periprosthetic hip joint infections can be managed by debridement and prosthesis retention. A literature search was performed through PubMed until September 2013. Search terms were “DAIR (debridement, antibiotics, irrigation, and retention)” alone and in combination with “hip” as well as “hip infection + prosthesis retention”. A total of 11 studies reporting on 292 cases could be identified. Five different treatment modalities have been described with varying success rates (debridement-21% infection eradication rate; debridement + lavage-75% infection eradication rate; debridement, lavage, with change of modular prosthesis components-70.4% infection eradication rate; debridement, lavage, change of modular prosthesis components + vacuum-assisted closure-92.8% infection eradication rate; acetabular cup removal + spacer head onto retained stem-89.6% infection eradication rate). With regard to the postoperative antibiotic therapy, no general consensus could be drawn from the available data. Debridement, antibiotic therapy, irrigation, and prosthesis retention is an acceptable solution in the management of early and acute hematogenous periprosthetic hip joint infections. The current literature does not allow for generalization of conclusions with regard to the best treatment modality. A large, multi-center study is required for identification of the optimal treatment of these infections.     

Reverse shoulder arthroplasty. Part 2: Systematic review of reoperations,revisions, problems,and complications

Purpose:

Many factors influence the reoperations, revisions, problems, and complications of reverse shoulder arthroplasty (RSA). The purpose of this study was to compare those depending on the surgical approach, type of prosthesis, and indication for surgery through a comprehensive, systematic review.

Materials and Methods:

A literature search was conducted (1985 to June 2012) using PubMed, CINAHL, EBSCO–SPORTDiscus, and Cochrane Central Register of Controlled Trials. Levels I–IV evidence, in-vivo human studies (written in English with minimum of 2 years of follow-up and sample size of 10 patients) reporting reoperations, revisions, problems, and complications after RSA were included. The data obtained were analyzed depending on the surgical approach, type of prosthesis (with medialized or lateralized center of rotation), or indication for surgery.

Results:

About 37 studies were included involving 3150 patients (mean [SD] percentage of females, age, and follow-up of 72% [13], 71.6 years [3.8], and 45 months [20], respectively). Use of deltopectoral approach and lateralized prostheses had significantly higher risk of need for revision surgery (P = 0.008) and glenoid loosening (P = 0.01), but lower risk of scapular notch (P < 0.001), compared with medialized prostheses with same approach. RSA for revision of anatomic prosthesis demonstrated higher risk of reoperation (P < 0.001), revision (P < 0.001), hematoma (P = 0.001), instability (P < 0.001), and infection (P = 0.02) compared with most of the other indications.

Conclusions:

Lateralized prostheses had significantly higher glenoid loosening and need for revision surgery, but a significantly lower rate of scapular notching compared to medialized prostheses. The risk of reoperations, revisions, problems, and complications after RSA was increased in revision cases compared with other indications.

Level of Evidence:

Level IV.     

Immediate and Delayed Complications Following Endoscopic Skull Base Surgery

Objectives To characterize the temporal distribution and resolution rate of postoperative complications from endoscopic skull base surgery. Design Retrospective review of patients undergoing endoscopic resection of paranasal sinus or skull base neoplasm from 2007 to 2013. Setting Massachusetts General Hospital/Massachusetts Eye and Ear Infirmary Cranial Base Center. Participants Fifty-eight consecutive patients. Main Outcome Measures Postoperative complications were categorized as cerebrospinal fluid (CSF) leak, pituitary, orbital, intracranial, or sinonasal. Complications were temporally categorized as “perioperative” (within 1 week), “early” (after 1 week and within 6 months), or “delayed” (after 6 months). Results The most common perioperative complications were diabetes insipidus (19.0%), CSF leak (5.2%), and meningitis (5.2%), with resolution rates of 75%, 100%, and 100%, respectively. Overall, CSF leak occurred in 13.8% of patients and resolved in all cases. A total of 53.8% of all complications were evident within 1 week of surgery. Chronic rhinosinusitis was the most common delayed complication (3.4%). Hypopituitarism and delayed complications were less likely to resolve (p = 0.014 and p = 0.080, respectively). Conclusions Monitoring of complications after endoscopic skull base surgery should focus on neurologic complications and CSF leak in the early postoperative period and development of chronic rhinosinusitis in the long term. Late-onset complications and hypopituitarism are less likely to resolve.     

Peripheral blood markers and intraoperative pathology may be helpful in predicting non-Cutibacterium acnes shoulder periprosthetic joint infections

IntroductionThe purposes of this study were (1) to compare the preoperative complete blood count (with differential), c-reactive protein (cRP), erythrocyte sedimentation rate (ESR), and intraoperative pathology (frozen section) results of patients undergoing surgical treatment for shoulder PJI by C. acnes vs. non-C. acnes bacteria, and (2) to estimate sensitivity, specificity, and positive and negative predictive values of these parameters.MethodsBetween 2004 and 2016, 167 consecutive shoulder PJIs were treated surgically. Infected implants included hemiarthroplasty in 39, anatomic TSA in 92, and reverse TSA in 36 shoulders. Shoulders were categorized in one of 4 groups: irrigation and débridement (21), one stage reimplantation (14), two-stage reimplantation (124), and permanent resection (8). Medical records were reviewed to record microorganisms isolated, intraoperative pathology, and preoperative cell count, ESR, and c-RP. Shoulders were further grouped into those that were positive only for C. acnes (37 shoulders) and those that were positive for any other microorganism (130 shoulders). In order to calculate sensitivity, specificity, and predictive values, the same data was collected for a separate group of 700 shoulder arthroplasties that underwent revision surgery for noninfectious reasons during the same time period.ResultsFor the whole group of 167 infected shoulder arthroplasties, values were considered abnormal for leukocyte count in 15%, neutrophil count in 17%, ESR in 42%, cRP in 56% and pathology in 55%. Abnormal values were more common in the non-C. acnes group. The following positive predictive values were obtained: Leukocytes 47% (13% C. acnes, 43% other), ESR 65% (18% C. acnes, 62% other), cRP 70% (29% C. acnes, 66% other), and pathology 73% (30% C. acnes, 63% other). The following negative predictive values were obtained: Leukocytes 79% (94% C. acnes, 93% other), ESR 68% (86% C. acnes, 76% other), cRP 70% (88% C. acnes, 78% other), and pathology 87% (96% C. acnes, 91% other).ConclusionBacteria other than C. acnes were responsible for 75% of the shoulder PJI treated consecutively with surgery at a single institution over a 12-year period. Negative predictive values for cell count, ESR, cRP, and pathology ranged between 70% and 81%, but there were much lower for C. acnes infection. Obtaining these tests in the evaluation of a painful shoulder arthroplasty should not be discontinued, since their positive predictive value for non-C. acnes infections seem reasonable and their negative predictive value is high.Level of evidenceLevel III; Retrospective Comparative Study     

Do Current Recommendations for Upper Instrumented Vertebra Predict Shoulder Imbalance? An Attempted Validation of Level Selection for Adolescent Idiopathic Scoliosis

Background

Shoulder balance for adolescent idiopathic scoliosis (AIS) patients is associated with patient satisfaction and self-image. However, few validated systems exist for selecting the upper instrumented vertebra (UIV) post-surgical shoulder balance.

Questions/Purposes

The purpose is to examine the existing UIV selection criteria and correlate with post-surgical shoulder balance in AIS patients.

Methods

Patients who underwent spinal fusion at age 10–18 years for AIS over a 6-year period were reviewed. All patients with a minimum of 1-year radiographic follow-up were included. Imbalance was determined to be radiographic shoulder height |RSH| ≥ 15 mm at latest follow-up. Three UIV selection methods were considered: Lenke, Ilharreborde, and Trobisch. A recommended UIV was determined using each method from pre-surgical radiographs. The recommended UIV for each method was compared to the actual UIV instrumented for all three methods; concordance between these levels was defined as “Correct” UIV selection, and discordance was defined as “Incorrect” selection.

Results

One hundred seventy-one patients were included with 2.3 ± 1.1 year follow-up. For all methods, “Correct” UIV selection resulted in more shoulder imbalance than “Incorrect” UIV selection. Overall shoulder imbalance incidence was improved from 31.0% (53/171) to 15.2% (26/171). New shoulder imbalance incidence for patients with previously level shoulders was 8.8%.

Conclusions

We could not identify a set of UIV selection criteria that accurately predicted post-surgical shoulder balance. Further validated measures are needed in this area. The complexity of proximal thoracic curve correction is underscored in a case example, where shoulder imbalance occurred despite “Correct” UIV selection by all methods.

Electronic supplementary material

The online version of this article (doi:10.1007/s11420-015-9451-y) contains supplementary material, which is available to authorized users.     

Choledochoduodenostomy in the Management of Common Duct Stones or Associated Pathology – An Obsolete Method?

Choledochoduodenostomy (CDD) has been reported as a more effective treatment of CBD stones than T-tube drainage but it is regarded as a last resort or obsolete therapeutic method due to fears of higher mobidity, cholangitis, “sump” syndrome and liver dysfunction. We aimed to assess the aforementioned issues analyzing prospectively our experience from 1976 through Dec.92.Methods: CDD was performed in 89 females and 36 males, aged 60.2±8.7 years, 26 during repeat surgery. Duct stones were the indication in 94, Sphincter of oddi (SO) dysfunction in 23 and obstructive pancreatitis nodule in 8. Peroperative liver biopsies were obtained in 44 patients. The “follow-up” schedule (> 2.5 years in 110) included clinical interview and LFT''s on an yearly basis. Ultra sound (USG) was obtained every one or two years. ERC was done in 10 symptomatic patients and in 25 others for protocul purposes. Liver biopsies were taken four to nine years post surgery in 11 patients-five at relaparotomy for non-biliary causes and six percutaneously by fine needle. Ductal mucosa biopsy could safely be performed in one patient 10 years after surgery. The long-term results were classified as excellent, good, fair or poor. Poor meant the need for further invasive therapy (resurgery or EST).Results: There were two operative deaths (1.6%). The long-term results (123 survivors) were considered excellent in 89, good in 22, fair in 9 and poor in three. Three patients died from unrelated causes and eight others ceased the “follow-up” evaluation three to five years post surgery. All of them were considered as having excellent or good results. A widely patent anastomosis of approximately 20 mms without mucosal inflammatory changes was documented in every patient assessed via ERC. food “debris” was detected within the distal duct of four patients yet it was easily flushed through the stoma. Normal tissue patterns were observed in all long-term liver biopsies. Likewise the ductal mucosa biopsy failed to reveal any acute or chronic inflammatory changes.Conclusions: 1) CDD is ahighly effective short and long-term treatment of CBD lithiasis.2) It does not lead to bacterial or “chemical” cholangitis, to “sump” syndrome or to hepatic dysfunction, provided a wide anastomosis is accomplished.3) CDD should only be considered as obsolete after extensive, long-term, prospective, randomized assessments of laparoscopic or combined laparoendoscopic approaches have been shown to be as effective as or superior to CDD.     

Infection Prevention and Evaluation of Fever After Laparoscopic Hysterectomy

Background:

Surgical site infection (SSI) is a common complication of hysterectomy. Minimally invasive hysterectomy has lower infection rates than abdominal hysterectomy. The lower SSI rates reflect the role and benefit in infection control of having minimal incisions, rather than a large anterior abdominal wall incision. Despite the lower rates, SSI after laparoscopic hysterectomy is not uncommon. In this article, we review pre-, intra-, and postoperative risk factors for infection. Rates of postoperative fever after laparoscopic hysterectomy and when evaluation for infection is warranted in a febrile patient are also reviewed.

Database:

PubMed was searched for English-only articles using National Library of Medicine Medical Subject Headings (MESH) terms and keywords including but not limited to “postoperative,” “surgical site,” “infection,” “fever,” “laparoscopic,” “laparoscopy,” and “hysterectomy.”

Conclusions:

Reducing hospital-acquired infections such as SSI is one of the more effective ways of improving patient safety. Knowledge and understanding of risk factors for infection following laparoscopic hysterectomy enable the gynecologic surgeon or hospital to implement targeted preventive measures.     

Surgical interventions for anterior shoulder instability in rugby players: A systematic review

AIM: To systematically evaluate the evidence-based literature on surgical treatment interventions for elite rugby players with anterior shoulder instability.METHODS: We conducted a systematic review according to the PRISMA guidelines. A literature search was performed in PubMed, EMBASE and Google Scholar using the following search terms: “rugby” and “shoulder” in combination with “instability” or “dislocation”. All articles published from inception of the included data sources to January 1^st 2014 that evaluated surgical treatment of elite rugby players with anterior shoulder instability were examined.RESULTS: Only five studies were found that met the eligibility criteria. A total of 379 shoulders in 376 elite rugby union and league players were included. All the studies were retrospective cohort or case series studies. The mean Coleman Methodological Score for the 5 studies was 47.4 (poor). Owing to heterogeneity amongst the studies, quantitative synthesis was not possible, however a detailed qualitative synthesis is reported. The overall recurrence rate of instability after surgery was 8.7%, and the mean return to competitive play, where reported, was 13 mo.CONCLUSION: Arthroscopic stabilization has been performed successfully in acute anterior instability and there is a preference for open Latarjet-type procedures when instability is associated with osseous defects.     

Editorial Commentary: An Alternative to Opioids? Adhesive Drapes and Chlorhexidine Skin Preparation May Reduce Propionibacterium acnes–Related Pain After Shoulder Surgery

Propionibacterium acnes has long been known to play a detrimental role in shoulder surgery. This thoughtful and revealing study found significant evidence of lower rates of P. acnes cultured during arthroscopic rotator cuff repair with the use of an adhesive drape and chlorhexidine skin preparation.     

Meta-analysis of antibiotic prophylaxis in breast reduction surgery

BACKGROUND:

Breast reduction surgery is a very common procedure; however, there is still no consensus as to whether antibiotics should be used perioperatively.

OBJECTIVE:

To review the world literature and perform a meta-analysis of studies comparing wound infection rates with antibiotic use in breast reduction surgery.

METHODS:

A literature search was performed using the MEDLINE, Cochrane Database of Systematic Reviews, Cochrane Database of Clinical Trials, Embase and CINAHL databases. Subject headings and relevant subheadings for “Breast”, “Breast Reduction”, “Reduction Mammaplasty”, “Mammaplasty” were combined with “Antibiotics” and “Antibacterial Agents”. The list of titles was assessed by the study’s authors and abstracts were reviewed. All relevant articles were then independently reviewed by the two primary authors, and Jadad scoring was used to assess the quality of the included articles.

RESULTS:

From the original search, three randomized controlled trials were included in the meta-analysis of preoperative antibiotics. The meta-analysis revealed a 75% reduction in wound infections with preoperative antibiotics (OR 0.25 [95% CI 0.09 to 0.72]). Because only one randomized controlled trial analyzed postoperative antibiotics, no meta-analysis could be performed.

CONCLUSIONS:

Preoperative antibiotics should routinely be used before breast reduction surgery. The use of postoperative antibiotics remains controversial. Additional randomized studies investigating postoperative antibiotics are needed.     

Neutrophil Priming by Cytokines in Patients With Obstructive Jaundice

Patients with obstructive jaundice frequently suffer postoperative complications. We have investigated the relationship of obstructive jaundice to the neutrophil oxidase response and the “priming” of the response by the cytokines TNFα, interleukin-1 (IL-1), IL-6, and IL-8. On stimulation with f-met-leuphe (fmlp), the respiratory burst in neutrophils from jaundiced patients was greatly increased compared with controls (p < 0.01), jaundiced patients having the highest respiratory burst levels were those with the poorest prognosis. Neutrophils from controls were primed by all the cytokines tested, whereas “jaundiced” cells were primed only by IL-1, and not by TNFα, IL-6, or IL-8, which in fact produced slight inhibition. We conclude that neutrophils from obstructive jaundiced patients have raised oxidative responses which may be due to “pre-priming” in vivo by cytokines, such as IL-6, IL-8, or TNFα. This exaggeration of the oxidative response in circulating neutrophils may contribute to the peri-operate complications of patients with obstructive jaundice.     

Penile shortening complaints in males with erectile dysfunction: a narrative review on penile lengthening procedures during penile prosthesis surgery

Patients complaining of short penile length pose a challenge in urology practice. Those men who present seeking penile lengthening surgery usually overestimate ''normal'' penile length, and may in often cases relate their penile length with the degree of masculinity and self-esteem. Penile prosthetic devices are the gold standard treatment of erectile dysfunction (ED) after failure of conservative options. Penile shortening is the most prevalent long-term complaint after successful inflatable penile prosthesis (IPP) placement. This has a significant impact on patient’s overall satisfaction and quality of life. Using PubMed, we performed a thorough literature review of the current procedures of preservation or enhancement of penile length as well as reported perioperative protocols in patients undergoing penile prosthesis (PP) insertion. Keywords used were “penile lengthening”, “penile enhancement”, “penile girth”, “inflatable penile prosthesis” and “glans augmentation”. Several surgical techniques can be offered in the setting of penile shortening concurrently with PP insertion, e.g., sub-coronal approach of PP placement, sliding technique, modified sliding technique (MoST), multiple-slide technique (MuST), and tunica mesh expansion procedure (TMEP). Adjuvant techniques can also improve subjective penile length include, ventral phalloplasty, suprapubic lipectomy, suspensory ligament release and use of expanding penile implants. Preoperative protocols including use of a vacuum erectile device, traction therapy also seem to improve postoperative outcomes, minimizing postoperative pain, and encouraging the early device use. Currently, there is no consensus among experts on a particular lengthening procedure or when they can be performed to optimize outcomes. Furthermore, it is imperative to set proper expectations before surgery, with extensive patient and partner counseling. When used in the properly selected patient, penile lengthening procedures show promising results with minimal complication rates.     

Comparison Between Transverse Mini-Incision and Longitudinal Mini-Incision for the Resection of Locally Advanced Colonic Cancer

We performed a retrospective review of non-overweight (body mass index ≤ 25 kg/m²) patients scheduled to undergo a curative resection of locally advanced colon cancer via a transverse mini-incision (n = 62) or a longitudinal mini-incision (skin incision ≤7 cm, n = 62), with the latter group of patients randomly selected as historical controls matched with the former group according to tumor location. Extension of the transverse mini-incision wound was necessary in 3 patients (5%). Both groups were largely equivalent in terms of demographic, clinicopathological, and surgical factors and frequency of postoperative complications. Postoperative analgesic was significantly less (P = 0.04) and postoperative length of the hospital stay was significantly shorter (P < 0.01) in the transverse mini-incision group. Concerning a mini-incision approach for locally advanced colonic cancer, a transverse incision seems to be advantageous with regard to minimal invasiveness and early recovery compared with a longitudinal incision.Key words: Colonic cancer, Colectomy, Transverse incision, Mini-laparotomyAs a useful alternative to laparoscopic-assisted surgery, we have performed a longitudinal mini-incision (skin incision, <7 cm) for the resection of locally advanced colonic cancer in non-overweight (body mass index <25.0 kg/m²) patients since 2000 and have demonstrated satisfactory outcomes in terms of technical feasibility and safety, minimal invasiveness, and oncological safety.^1–5 The “longitudinal short” or “transverse” incision has been proposed as part of an enhanced recovery after surgery (ERAS) clinical care protocol,⁶ which was developed firstly and mainly for open colectomies. The use of such incision types is considered to reduce postoperative pain, leading to a more rapid return of patient mobility. However, a “transverse mini-incision” has rarely been evaluated, probably because many surgeons likely believe a curative colectomy via such an incision type would be difficult to perform. In April 2009, we began using a “transverse mini-incision” for the curative resection of locally advanced colonic cancer as an alternative approach to the previously used “longitudinal mini-incision.” We herein report the results of a comparison between “transverse mini-incision” and “longitudinal mini-incision” for the resection of locally advanced colonic cancer in terms of technical feasibility and safety as well as minimal invasiveness.