Perineal neoplasms.

Experience with 2 cases of neurally-derived perineal masses is described. A relevant review of the literature spanning 50 years revealed 36 cases of perineal neoplasm of diverse nature, disclosing that such lesions typically present as otherwise asymptomatic enlarging masses and may comprise a broad spectrum of neoplasia with diagnosis and prognosis often relating to the age of the patient. Management naturally relates to tissue type and degree of local involvement.     

女性生殖道和盆腔侵袭性血管粘液瘤的诊治进展

侵袭性血管粘液瘤是一种罕见的来源于间叶组织的肿物,好发于生育年龄女性,侵袭性和复发性是其重要特点。常见部位为外阴、阴道和盆腔。因其罕见,极易误诊。病理是诊断的金标准。手术切除是一线的治疗方法,但包括激素治疗、血管栓塞等在内的辅助治疗方法逐渐受到重视。AAM虽极易复发,但远处转移罕见。     

根治性前列腺切除术的进展

前列腺癌是欧美国家常见的男性肿瘤。前列腺癌发病率在我国各地呈逐年上升趋势。手术是前列腺癌治疗的重要手段 ,本文对近年来耻骨后、经会阴根治性前列腺切除术、标准腹腔镜和机器人腹腔镜根治性前列腺切除术研究等进展作一概述 ,包括根治术的必要性、手术方法与经验、神经保留技术和勃起功能障碍问题、并发症、手术效果、各种手术途径的优缺点及手术效果之间的比较     

Cellular Angiofibroma of Oral Mucosa: Report of Two Cases

Cellular angiofibroma is a benign vascular neoplasm that typically arises in the vulva, perineal, and paratesticular region. Microscopically the lesions exhibit multiple small, non-dilated capillary channels, many of which contain erythrocytes. The endothelial lining cells are prominent, with monomorphic oval nuclei. Interposed among the vessels are both delicate and mature collagen fibers with fibroblastic hypercellularity that is variable in older lesions where sclerosis is prominent. The lesions usually do not recur following simple excision. Recent evidence indicates that cellular angiofibromas may be cytogenetically related to spindle cell lipoma. This represents the first reported instances of cellular angiofibroma in the oral cavity.     

Aggressive angiomyxoma of the pelvis and perineum: a case report and review of the literature

Aggressive angiomyxoma is a rare mesenchymal tumour arising from soft tissue of the pelvis and perineum. Other features of this tumour are non-specific clinical signs, local invasion, a high local recurrence rate, and recurrence long after initial excision. We provide a case report with a review of the literature. A 57-year-old woman with a large bulky mass in the perineum was admitted to our institution. She had previously undergone iterative surgery for excision of pelvic and perineal masses. The preoperative diagnostic procedure is described as well as the therapeutic surgical approach (a double simultaneous laparotomic and perineal approach was opted for). The surgical procedure was difficult, time-consuming and dangerous owing to an extensive area of hard retroperitoneal sclerosis involving the low urinary viscera, the vaginal stump and the mesorectum. Radical excision of the mass favoured the re-establishment of the normal pelvic anatomy, resolution of the preoperative symptoms and complete recovery of working capability. Surgical excision is the gold standard in the treatment of aggressive angiomyxoma. This benign neoplasm may sometimes present a malignant course owing to involvement of pelvic viscera. It is also associated with a high late recurrence rate due to local aggressiveness, and longterm follow-up is therefore necessary.     

Prostatic leiomyosarcoma. Report of a case a review of the literature

A 48-year-old male with a leiomyosarcoma of the prostate is presented. The clinical presenting features were those of rapidly evolving prostatism and rectal symptoms (rectal bleeding, sense of rectal fullness and perineal pain). Arising from the smooth muscle cells of the prostate gland, this is a rare neoplasm that account for less than 0.1% of prostate malignancies, with a poor prognosis. It is often difficult to determine a definite origin, being necessary the differential diagnosis with pseudosarcoma, inflammatory fibrosarcoma, prostate abscess and other rare tumors. There is no established protocol of treatment. Combined modality therapy including radical surgery, radiation therapy and chemotherapy seems to be the best, although prognosis remains poor.     

Carcinosarcoma of the prostate: a case report

A 63-year-old Japanese man with a 1-month history of dyschezia and dysuria was referred to our hospital. Transrectal ultrasonography and magnetic resonance imaging demonstrated a mass involving the prostate, measuring about 6.5 cm. The serum prostate specific antigen was 20.3 ng/ml. By the transperineal needle biopsy, it was suspected to be fibrosarcoma. Total pelvic exenteration was performed. Histopathological examination of the tumor revealed carcinosarcoma of the prostate. One month after the operation local recurrence was manifested by perineal pain. The recurrent tumor grew rapidly with severe pain. The patient's condition deteriorated, and finally he died of the disease nine months after the operation. Carcinosarcoma of the prostate is a rare neoplasm and very aggressive. There is no established protocol for its treatment and its prognosis is usually poor. This is the 49th case reported in the literature.     

Enlarging perineal endometrioma developing after colpoperineorrhaphy

Although endometriosis is not infrequent, the occurrence of perineal endometriomata is relatively rare and is generally attributed to seeding of endometrial cells to the perineal body during obstetrical trauma. A 45-year-old female with a history of a colpoperineorrhaphy during menses and a remote history of obstetric perineal trauma presented with an enlarging perineal mass. Excision of the mass led to a clinical and histopathologic diagnosis of perineal endometriosis. Elective surgery disrupting the vaginoperineal epithelium performed during menses may facilitate the seeding of endometrial cells to the perineal body and formation of perineal endometriomata.     

Lotus petal flap for unusual indication: A recto-vaginal fistula with perineal defect after vaginal delivery

Introduction and importanceThree to five percent of vaginal deliveries are complicated by third or fourth degree perineal laceration. Misdiagnosed perineal injuries may be associated with a poor sexual and psychological prognosis. Management of old perineal tears and laceration is challenging with a high failure rate. In such condition, interposition tissue technic or local flap can be a good surgical alternative. Lotus petal Flap, usually indicated in management of large perineal defect in gynecological oncology can be used.Case presentationWe report a case of 32-year-old women presenting complex and relapsed perineal fistula after vaginal delivery associated with perineal defect treated by lotus petal flap with a good outcome.DiscussionPerineal defects are commonly encountered after oncologic, traumatic or infectious perineal excisions and described as a challenging situation. In case of perineal defects after obstetrical tears, no validated surgical filler technics are recommended. Inspired from oncologic surgical technics to fill perineal defects, Lotus Flap can be used. Its advantages are to mobilize a satisfactory tissue volume to fill important perineal defect compared to the small bulbocavernous flap with a hidden scar comparing to gracilis muscle flap. This technic is associated with a good sexual and self-imaging outcome.ConclusionLotus petal flap may be required as a solution to manage perineal defect in case of perineal fistula. This technique provides aesthetic and good results for perineal reconstruction.     

结直肠间质瘤14例临床分析

目的探讨结直肠间质瘤的临床诊断、治疗和预后。方法回顾性分析中国人民解放军总医院1993年3月至2002年3月收治的14例结直肠间质瘤的临床、病理资料及随访结果。结果临床表现为消化道出血(7/14)、腹部不适(4/14)、腹部肿块(2/14),无症状1例。病变部位为结肠6例,直肠8例。14例均行手术治疗,诊断为良性2例,交界性1例,恶性11例。免疫组化CD117( )92%(13/14),CD34( )78%(11/14)。随访率71%,病人平均生存时间为56个月。结论低位直肠恶性间质瘤病人,宜经骶尾部或会阴部切口行直肠局部切除术。     

Previously undescribed treatment for persistent peritoneal-perineal fistula following proctectomy

Persistent perineal sinus is a common complication following proctectomy for inflammatory bowel disease. Complete excision of the sinus tract and obliteration of dead space have been stressed as important aspects of treatment. A patient is described in whom the perineal sinus persisted despite three surgical attempts at cure. Combined perineal exploration and laparotomy revealed a communicating peritoneal-perineal fistula. A combined perineal and peritoneal approach may be indicated in treating the perineal sinus that persists despite perineal excision.     

Perineal lipoma in association with scrotal anomalies in children

OBJECTIVE: To analyse the characteristics of the perineal lipoma and speculate on its development, as an associated perineal lipoma is implicated in the occurrence of scrotal anomalies in children. PATIENTS AND METHODS: Five children with a perineal lipoma in association with various scrotal anomalies were included in the study. We analysed the types of scrotal anomalies and their anatomical relationship with the perineal lipomas. RESULTS: One child had a supra-inguinal ectopic scrotum, and the others had penoscrotal transposition, either symmetrical or asymmetrical; they included two who had an accessory scrotum combined with a perineal lipoma. The perineal lipoma was on the ipsilateral side of the upward-positioned hemiscrotum in the ectopic scrotum or the asymmetrical penoscrotal transposition, or it was on the mid-perineum in the symmetrical penoscrotal transposition. CONCLUSIONS: The perineal lipoma can be found combined with various scrotal anomalies, including ectopic scrotum as well as an accessory scrotum or penoscrotal transposition; this is the first report describing a perineal lipoma associated with an ectopic scrotum. We speculate that the development of the perineal lipoma is closely related to scrotal anomalies, which result from early division and/or abnormal migration of the labioscrotal swelling. The concomitant perineal lipoma might be formed during the process, and might affect abnormal scrotal development.     

Perineal hernia after abdominoperineal amputation. Role of epiploplasty and/or irradiation]

Healing of the perineal wound after abdominoperineal amputation is a difficult technical problem for surgeons to resolve. The majority of current therapeutic protocols include pre- or post-operative radiotherapy, and most study results show a reduction in perineal relapses when compared with a control group, but at the price of delayed healing of the perineal wound. This delayed healing reaction varies with the radiation dose. The use of epiploplasty shortens the healing period, but when performed after pre-operative radiotherapy it can predispose to the development of a perineal hernia. Four cases of this complication are described. No standard procedure for treatment of these hernias exists, and although it is possible to use the uterus to fill the perineal cavity, the most effective method appears to be a double perineal and abdominal pathway using a plate.     

Radical prostatectomy in patients with previous groin hernia repair using synthetic nonabsorbable mesh

OBJECTIVE: Identification of patients in whom the perineal route is the optimal approach to perform radical prostatectomy. MATERIAL AND METHODS: During 1992-1999, 376 patients with prostate cancer underwent radical perineal prostatectomy. Four patients were identified in whom the perineal approach was indicated because of previous bilateral groin hernia repair using synthetic meshes. In addition, 1 patient underwent perineal prostatectomy elsewhere for similar reasons. RESULTS: The perineal approach offered an uneventful surgical solution for an adequate and straightforward radical perineal prostatectomy without complications and without biochemical recurrence during the follow-up. CONCLUSION: Radical perineal prostatectomy is suggested to be the optimal approach in patients with previous bilateral groin hernia repair using synthetic, nonabsorbable meshes.     

Small bowel occlusion due to giant perineal hernia: abdominal approach with plastic perineal reconstruction

A perineal hernia is defined as a protrusion of peritoneal or extraperitoneal content through a pelvic floor defect. A 64-year-old woman with a bowel occlusions due to a giant postoperative perineal hernia was admitted to our hospital. We describe abdominal approach with plastic perineal reconstruction.     

Pelvic reconstruction using vertical rectus abdominis musculocutaneous flaps

Coverage of complex perineal wounds resulting from surgical and radiation therapy results in significant morbidity. Acute complications occur in 25% to 60% of patients. Serious complications occur in 25% to 46% of patients. Musculocutaneous or omental flaps are used as primary or salvage procedures for nonhealing perineal wounds. Vertical rectus abdominis flaps are ideally suited to bring nonirradiated tissue into defects associated with radical surgical extirpation procedures and irradiated fields.A retrospective review of 73 cases using a vertical rectus abdominis flap for perineal reconstruction is reported. Acute perineal wound complications occurred in 17.8%, while serious complications requiring reoperation occurred in only 3.5%. There was 1 complete flap failure. Primary healing occurred in 84.9% of patients, with 94.5% of patients obtaining a healed perineal wound within 30 days. These results support the use of the transpelvic vertical rectus flap in difficult perineal wound reconstruction.     

A simple technique for vascular control during hepatectomy: the half-Pringle

Persistent perineal sinus is a common and serious cause of morbidity after proctectomy for Crohn's disease. Recently we have performed excision and omentoplasty on 6 patients with persistent perineal sinus. The perineal sinus was completely excised and communication was established with the pelvis. In 4 patients, the left gastroepiploic vessels were divided close to their origins and in 2 other patients the right gastroepiploic vessels were divided. The omentum was brought down to the perineum and it was lightly sutured to the perineal skin. After a median follow-up of 28 months, the perineal sinus had healed in 5 patients. In 1 patient the omentum became necrotic and infected 1 month after omentoplasty, and this patient still has a complex sinus. Although the number of patients is small, omentoplasty may be an effective procedure for the treatment of persistent perineal sinus after proctectomy for Crohn's disease.     

改良的会阴操作法在经腹会阴联合直肠癌根治术中的应用

目的 比较两种会阴操作方法在经腹会阴联合直肠癌根治术(abdominoperineal resection,APR)中的应用.方法 回顾性分析2007-2009年收治的60例直肠癌患者的临床资料.60例直肠癌的肿瘤均位于直肠前壁,30例采用改良会阴操作法(改良组)实施APR手术,另30例采用传统会阴操作法(传统组)实施APR手术,比较两组手术的时间、会阴操作时的直肠(肿瘤)破裂、尿道(阴道)损伤、术后会阴并发症发生等情况.对数据进行t检验或χ2检验.结果 会阴操作时间:改良组平均为45(45±15)min,传统组平均为70(70±20)min,两组比较差异有统计学意义(t=5.48,P＜0.05);术中直肠(肿瘤)破裂:改良组2例,传统组5例,两组差异无统计学意义(χ2=0.64,P＞0.05);尿道(阴道)损伤:改良组无,传统组1例,两组比较差异无统计学意义(χ2=0,P＞0.05);会阴切口感染/裂开:改良组2例,传统组9例,两组比较差异有统计学意义(χ2=4.01,P＜0.05).结论 改良组会阴操作比传统组手术时间短,手术更安全,术后并发症少.

Abstract：

Objective To compare the safety and effectiveness of two methods of perineal dissection in 60 consecutive patients of rectal carcinoma undergoing combined abdominoperineal resection.Methods In this retrospective study from 2007 to 2009, 30 cases underwent Miles' operation using modified method of perineal dissection( MM group) and 30 cases undergoing Miles' operation using classic method of perineal dissection ( CM group). Operative time, accidental tumor ( or rectal) perforation during the procedure, iatrogenic injury to the urethra ( or vagina) and postoperative perineal complications were compared between the two groups. Results The mean perineal operative time was (45±15) min in MM group and ( 70 ± 20) min in CM group respectively ( t = 5. 48, P ＜ 0. 05 ). There were no significant differences in the rate of tumor ( or rectal) perforation and that of urethral (vaginal) injury. There were significant difference in the rate of postoperative perineal complications (χ2=4.01, P＜0.05).Conclusions Modified method of perineal dissection is effective and safe, and this method offers a new approach for the perineal dissection during Miles' operation.     

Substantiation of perineal access to internal pudendal artery

Perineal access to a. pudenda interna (API) was elaborated. Variants of the a. iliaca interna and her branches localization and topographic-anatomic peculiarities of perineal portion of API were studied. The proposed perineal (extraperitoneal) access to API is most expedient in the perineal region bleeding stopping. Morphometrical parameters of perineal portion of API permit to apply her for formation of vascular anastomosis in the procedure of revascularization of the descended colon while the intestinal continuity restoration.     

Pelvic leiomyoma presenting as perineal hernia

Primary perineal hernias are rare and can be a diagnostic challenge. We report the case of a 45-year-old female patient who presented with painless perineal swelling suggestive of perineal hernia. Computed tomography (CT) scanning revealed a pelvic mass herniating through the pelvic floor into the perineum. The lesion was completely excised by an abdominoperineal approach. Histopathological examination of the lesion revealed a leiomyoma. This case report suggests that the possibility of perineal herniation of a pelvic leiomyoma should be considered in a female patient with suspected primary perineal hernia. We recommend an abdominoperineal approach for the surgical management of such a lesion.