Intraoperative decision making in follicular lesions of the thyroid: is tumor size important?

BACKGROUND: Intraoperative decision making in treating follicular lesions of the thyroid remains controversial because there are no reliable preoperative or intraoperative factors predictive of malignancy. This study was undertaken to determine whether lesion size is a reliable factor that can be used to predict a final pathologic diagnosis of follicular carcinoma. STUDY DESIGN: This was a retrospective, case-matched control study. One hundred consecutive patients with follicular carcinoma were matched by gender, age, and date of operation with 100 patients with follicular adenomas. Seventy-nine matched pairs had pure follicular lesions and 21 matched pairs had oxyphilic variants of follicular lesions. After confirming adequate matching, lesion size was compared between groups. RESULTS: Regardless of whether all follicular lesions were analyzed or whether only pure follicular or oxyphilic variant lesions were compared, there was no significant difference in lesion size between the carcinoma and adenoma groups. The mean size of all follicular carcinomas was 31.5 +/- 1.7 mm and the mean size of all follicular adenomas was 30.8 +/- 1.5 mm (p = NS). When the proportions of the carcinoma and adenoma groups were indexed by five different size intervals and compared, there was again no significant difference in any category. CONCLUSIONS: On the basis of this case-matched control study, the size of a follicular lesion cannot be used to predict a final diagnosis of follicular carcinoma and is of no value when making intraoperative decisions about the extent of thyroid resection.     

Is stone diameter a variable in the decision process of employing a ureteral stent in patients undergoing uncomplicated ureterorenoscopy and associated intracorporeal lithotripsy?

Introduction

A number of randomized trials and meta-analysis in patients who underwent ureteroscopic stone removal investigated the effects of placing a ureteral stent at the end of the procedure on complication rates. However, none of these investigates the stone diameter and its possible influence on complication rates and, as such, if it should be considered a possible variable in the decision process of placing or not a ureteral stent.

Materials and methods

A bibliographic search covering the period from January 1990 to March 2012 was conducted in PubMed, MEDLINE and EMBASE. This analysis is based on the fifteen remaining studies which fulfilled the predefined inclusion criteria. All statistical evaluations were performed using SAS version 9.2. and by RevMan 5.0.

Results

A total of 1,416 patients were included. All the studies were published after 2000. Mean stone diameter ranged between 5.3 and 13.3 mm in the non-stented group and between 6.26 and 13.28 mm in the stented group. Meta-analysis showed that stone diameter was not statistically different for stented or non-stented subgroups, whereas surgical operative time was shorter for the non-stented subgroup. The effect of stone diameter, irrespectively if patients were operated with or without stents were grouped or considered separately, did not influence complications of fever, haematuria, unplanned medical visits after surgery and urinary tract infections.

Conclusions

Stone diameter is not a variable in the pre- or intraoperative decision process of placing or not placing a ureteral stent in patients undergoing uncomplicated ureterorenoscopy with intracorporeal lithotripsy.     

Family history in stone disease: how important is it for the onset of the disease and the incidence of recurrence?

The aim of this study was to evaluate the possible effect of a positive family history on the age at the onset of urinary stone disease and the frequency of subsequent symptomatic episodes relating to the disease. Between March 2006 and April 2009, patients with either a newly diagnosed or a previously documented stone disease were included in the study program. They were required to fill in a questionnaire and divided into two groups according to the positive family history of stone disease; group I comprised patients with a family history for urinary calculi and group II those without. Depending on the data obtained from questionnaires, all patients were evaluated in detail with respect to the age at the onset of the stone disease, stone passage and interventions over time, time to first recurrence (time interval between the onset of the disease and the first recurrence), number of total stone episodes and recurrence intervals. 1,595 patients suffering from urolithiasis with the mean age of 41.7 (14–69 years) were evaluated with respect to their past history of the disease. There were 437 patients in group I and 1,158 in group II. There was no statistically significant difference between the mean age value of two groups (P = 0.09). When both genders in group I were analyzed separately, female patients tended to have higher rate of family history positivity than males. Comparative evaluation of the age at the onset of the disease between the two groups did reveal that stone formation occured at younger ages in patients with positive family history [P = 0.01 (males), P = 0.01 (females)] and the mean age of onset of the disease was lower in males than females in group I (P = 0.01). Patients in group I had relatively more stone episodes from the onset of the disease [P < 0.01 (2–4 episodes), P < 0.01 (≥5 episodes)]. Male patients were associated with higher number of stone episodes (P = 0.01). Mean time interval between recurrences was noted to be significantly shorter in group I patients when compared with patients in group II [P < 0.01 (males), P = 0.02 (females)]. In conclusion, our results showed that urinary stone formation may occur at younger ages and that the frequency of symptom episodes may be higher in patients with a positive family history. We believe that the positive family history for urinary stone disease could give us valuable information concerning the onset as well as the severity of the disease.     

Lymph node staging in gastric cancer: is location more important than Number? An analysis of 1,038 patients

OBJECTIVE: To compare the impact of staging systems on the survival of 1,038 patients with gastric cancer undergoing resection for cure in a North American center. SUMMARY BACKGROUND DATA: In 1997, the American Joint Committee on Cancer (AJCC) and the Union Internationale Contre le Cancer redefined N stage in gastric cancer. The number of involved nodes rather than their location defines N, and a minimum of 15 examined lymph nodes is recommended for adequate staging. In the 1988 AJCC N-staging system, N1 and N2 node metastases were defined as within 3 cm or more than 3 cm of the primary; the 1997 AJCC N stages were defined as N1 = 1 to 6 positive nodes, N2 = 7 to 15 positive nodes, and N3 = more than 15 positive nodes. METHODS: Between 1985 and 1999, 1,038 patients underwent an R0 resection. Median and 5-year survival rates were compared and the Kaplan-Meier method was used to estimate median survival. RESULTS: The location of positive nodes did not significantly affect median survival when analyzed by the number of positive nodes. In contrast, the number of positive lymph nodes had a profound influence on survival. The new N categories served as a better discriminator of median survival when 15 or more nodes were examined. Survival estimates for stages II, IIIA, and IIIB were significantly influenced by examining 15 or more nodes. CONCLUSION: The number of positive nodes best defines the prognostic influence of metastatic lymph nodes in gastric cancer. Survival estimates based on the number of involved nodes are better represented when at least 15 nodes are examined.     

Is stone clearance after shockwave lithotripsy in patients with solitary upper-caliceal stone influenced by anatomic differences in the pelvicaliceal system?

PURPOSE: We investigated the effect of pelvicaliceal differences on stone clearance after extracorporeal shockwave lithotripsy (SWL) in patients with solitary upper-caliceal stones. PATIENTS AND METHODS: The clinical records of patients with solitary upper-caliceal stones who underwent SWL between 1996 and 2004 were reviewed. After excluding patients with hydronephrosis, significant anatomic abnormalities, non-calcium stones, metabolic abnormalities, recurrent stone disease, multiple stones, and previous renal surgery, 42 patients with a mean stone size of 153.47 mm2 (range 20-896 mm2) were enrolled in this study. They were divided into three groups according to stone burden (group 1 < or =100 mm2, group 2,101 mm2-200 mm2, and group 3 >200 mm2). Upper-pole infundibulopelvic angle (IPA), infundibular length (IL), and infundibular width (IW) were measured from intravenous urograms. Results: Of the total, 29 patients (69%) were stone free after SWL treatment. The differences in the upperpole IPA, IL, and IW of stone-free patients and patients with residual stones were not statistically significant (P = 0.85, P = 0.89, and P = 0.37, respectively). Again, there were no statistically significant differences in terms of upper IPA, IW, and IL in comparing the three groups divided by initial stone size. Conclusion: Upper-caliceal anatomy does not exert a significant impact on stone clearance after SWL for isolated upper-caliceal stones. To best of our knowledge, this is the first study to investigate the effects of pelvicaliceal anatomy on SWL treatment for upper-caliceal stones, so there is a need for further investigations to confirm our findings.     

Does stone dimension affect the effectiveness of ureteroscopic lithotripsy in distal ureteral stones?

Objective To investigate whether stone dimension is a restrictive factor for ureterorenoscopic procedures. Materials and methods A group of 416 patients who had undergone ureterorenoscopic pneumatic lithotripsy (URS-PL) for lower ureteral stones between January 1999 and June 2006 in our clinic had been evaluated retrospectively. Two hundred and seventy (270, 64.9%) patients were men and 146 (35.1%) were women. The mean age of the patients was 36.61 (±12.43) years. Patients were grouped according to stone dimension; 193 patients with stones smaller than 1 cm being group 1 and 223 patients with stones ≥1 cm in dimension being group 2. Stone-free rate, operative time and rate of complications of the groups were compared. Pearson’s correlation test, χ² test, Fischer’s exact test and Student’s t-test were used for the statistical analysis. The p value was accepted as being meaningful if p < 0.05. Results For group 1, the mean operative time was 39.19 (±18.33) min. Proximal stone migration in five and false passage formation in three patients was observed. Three patients were stone-free after a second session of URS-PL. The cumulative stone-free rate was 97.4% (188/193). For group 2, the mean operative time was 48.5 (±11.31) min. About 208 (93.27%) patients were stone-free after the first session and an additional eight patients became stone-free after the second session of URS-PL. False passage, ureteral perforation, ureteral avulsion and stricture were observed in four, six, one and one patients, respectively. No proximal stone migration was observed. The cumulative stone-free rate was 96.86% (216/223). Conclusions The effectiveness of ureterorenoscopy (URS) in the treatment of distal ureteral stones was independent of stone dimension. However, the operative time was longer and the rate of perforation was higher in stones with a diameter ≥1 cm. On the other hand, the migration rate was higher in stones <1 cm in diameter. Generally speaking, there was no meaningful effect of stone dimension on complication rates.     

What is important to patients receiving extracorporeal shock-wave lithotripsy for urinary tract calculi?

INTRODUCTION: Patients' experience and expectations are paramount in the current era of clinical governance. However, there is lack of published information on patients' expectations from extracorporeal shock-wave lithotripsy (ESWL) treatment for renal stone disease. We conducted a survey to quantify what aspects of ESWL are important purely from the patients' prospective. PATIENTS AND METHODS: Postal questionnaires were sent out to all patients who attended our unit for ESWL treatment for renal stone disease. The questionnaire referred to 15 aspects of ESWL treatment. Patients were asked to rate each aspect based on a numerical scale from 1 to 10 (1--least important; 10--most important). RESULTS: We posted 340 questionnaires and received 208 valid replies (61%). Stone clearance was statistically the most important aspect of treatment. Staff attitude and explanation of the procedure and outcomes were rated highly. To our surprise, pain control was rated only 8th. CONCLUSIONS: Patients' priorities may be different to ours. Surveys like this allow ones to put the appropriate 'weight' on the results of patient satisfaction surveys in order to allocate resources and improve service appropriately.     

How effective is ureteroscopy in the treatment of pediatric stone disease?

Pediatric ureteroscopy has been increasingly used to manage both ureteral and renal stones. Unfortunately, there are no current standardized recommendations when treating pediatric stone disease so the modality chosen is left to the treating surgeon. A review of the current literature on pediatric ureteroscopy was used to compile this article. For the purposes of this review, the majority of series include stones ≤1 cm. Ureteroscopy is considered to be first-line therapy in treating mid- to distal ureteral stones and is rapidly evolving as an acceptable first-line therapy for renal stones as well. Limitations do exist and include stone composition, location, size, as well as the unique anatomic challenges faced by pediatric urologists in terms of anomalous kidneys and/or reconstructed urinary tracts. In conclusion, ureteroscopy can be considered first-line therapy for mid- or distal ureteral stones, however, it shares a similar efficacy rate as extracorporeal shock wave lithotripsy for the treatment of renal calculi. There is a need for direct comparison in the literature of all modalities treating pediatric stone disease to facilitate guidelines that help treating surgeons choose the most efficacious modality offering the highest success rates with the lowest morbidity.     

Open stone surgery in children: is it justified in the era of minimally invasive therapies?

OBJECTIVE: To review experience with open surgery for paediatric urolithiasis during a 10-year period. PATIENTS AND METHODS: The hospital records of patients up to 13 years old and treated between 1990 and 2000 for stones were reviewed; there were 310 patients (98 girls and 212 boys, aged 9 months to 13 years, mean 6.8 years). RESULTS: The commonest symptoms were renal-ureteric colic (26.7%), gross haematuria (19%), urinary retention (16.7%), and abdominal and/or flank pain (13.2%). Because of poverty and the resultant inability to pay medical fees, 19 children presented very late with pyonephrosis (resembling peritonitis in nine) and obstructive renal atrophy in 23. In 18 other patients the delay was caused by the disappearance of pain. Delayed presentation was the most important factor in developing complications from the stone. The stones were in the calyces in 15 patients, the pelvis in 113, the ureter in 56, the bladder in 71, the urethra in 17 and in a combination of sites in 38. The mean (range, median) stone size was 27 (9-75, 22) mm; 80 (25.8%) were complete staghorn stones. Indications for open surgery were a complex stone burden (62%), ESWL failure (14.5%), need for nephrectomy (1.9%), anatomical abnormalities (2.2%), and unavailability of minimally invasive alternatives (19%). All of the nephrectomized patients underwent unilateral stone removal and contralateral nephrectomy. For parents, the cost and reliability of the result were more important than other considerations, e.g. having a large or small incision. The overall stone-free rate at discharge was 95.4% (100% for single stones). In five cases (1.6%) a repeat open procedure was needed. The mean (range, median) hospital stay was 4 (1-13, 3) days. CONCLUSIONS: Arguments against open surgery for urolithiasis in adults should not be extrapolated to children, in whom open surgery is safe and effective. In Iran and many 'developing' countries, open surgery is less expensive, more effective, more dependable, and more easily available than minimally invasive alternatives. At least in such countries it deserves to be among the first-line therapies for paediatric urolithiasis, and urologists in less-developed countries should not decline to offer open surgery because it is almost obsolete in developed countries. Delayed presentation (through poverty and/or unawareness) contributes significantly to the morbidity of urolithiasis.     

Reporting the level of evidence in the Canadian Journal of Plastic Surgery: Why is it important?

The levels of evidence (LOE) table has been increasingly used by many surgical journals and societies to emphasize the importance of proper study design. Since their origin, LOE have evolved to consider multiple study designs and also the rigour of not only the study type but multiple aspects of its design. The use of LOE aids readers in appraising the literature while encouraging clinical researchers to produce high-quality evidence. The current article discusses the benefits and limitations of the LOE, as well as the LOE of articles published in the Canadian Journal of Plastic Surgery (CJPS). Along with an assessment of the LOE in the CJPS, the authors have provided recommendations to improve the quality and readability of articles published in the CJPS.     

How important is urinary cytology in the diagnosis of urological malignancies?

OBJECTIVE: To audit clinical usefulness of urine cytology examination in a subspecialised urological unit setting. PATIENTS AND METHODS: Data from the hospital information support system on urinary cytology examinations carried out at one centre was audited over a period of 15 months. Source of urine cytology specimens, clinical profile of patients and the findings of urinary cytology were analysed and collated. RESULTS: A total of 1400 urinary cytology specimen on 900 patients were requested during 15 months study period. Urologists requested 1092 (78%) and non-urologists (general practitioners, physician or general surgeons) requested 318 (22%) specimens. The majority of specimens, 1115 (80%) did not show any cytological evidence of malignancy. 83 specimens (6%) showed cytological evidence of malignant cells consistent with origin from a urothelial malignancy. Among this group 87% (72) were more than 50 years of age and 60 (72%) had history of gross heamaturia. 159 (11.35) cases were reported as being suspicious of malignancy or showing atypical cells requiring further evidence. A total of 43 (3.04%) specimens were poorly preserved or insufficient for diagnosis. The positivity rate amongst urologist and non-urologists request was 56% and 6% respectively (p=0.00001 value). The source in 37 (86%) specimens reported, as poorly preserved or insufficient for diagnosis was non-urologists compared to 6 (14%) from urologists with significant p value (0.00001). CONCLUSIONS: Urinary cytology for malignant cells is a contributory investigation in the diagnosis of urological malignancy. It should be only ordered in the proper clinical situation.     

Inflammation in uremic patients: what is the link?

Uremic patients suffer to an extremely high degree from cardiovascular disease. Cardiovascular disease results mainly from atherosclerotic remodeling of the arterial system. Inflammation is considered to contribute significantly to development of atherosclerosis, and albeit many different factors may lead to inflammation, generation of enhanced oxidative stress is believed to be an important common feature of pro-inflammatory causes. Studies in the general population without renal disease could clearly show that markers of inflammation, in particular C-reactive protein, predict the cardiovascular risk. In this review article, we discuss the presence and the predictive value of inflammation in patients with end-stage renal disease, and analyze whether uremic patients are exposed to specific pro-inflammatory and pro-oxidative conditions. Particular emphasis is set on oxidative stress induced by oxidatively modified lipoproteins and angiotensin II. Based on pathophysiological considerations valid for uremic patients, we discuss therapeutical options that might help to reduce cardiovascular disease in uremic patients.     

Which muscarinic receptor is important in the bladder?

Antimuscarinic agents are the most widely used therapy for urge incontinence, but have side effects such as constipation, tachycardia and dry mouth, resulting from a lack of selectivity for the bladder. M₂ receptors are the predominant cholinoceptors present in urinary bladder, but mainly the minor population of M₃ receptors mediate its contraction. M₂ receptors modulate detrusor contraction by several mechanisms, and may contribute more to contraction of the bladder in pathological states such as bladder denervation or spinal cord injury. Prejunctional inhibitory M₂ or M₄ receptors and prejunctional facilitatory muscarinic M₁ receptors in the bladder have all been reported. In clinical studies, tolterodine, a non-selective muscarinic antagonist, has been reported to be as effective as oxybutynin but inducing less dry mouth. Thus, although it is not certain which antimuscarinic drugs have the better efficacy and tolerability, the non-selective antimuscarinic drugs seem to be better than M₃-selective antagonists in their clinical efficacies. However, controlled release, or intravesical, intravaginal, or rectal administrations of oxybutynin have been reported to cause fewer side effects. Darifenacin, a new M₃ selective antagonist, has been reported to have selectivity for the bladder over the salivary gland in vivo. To verify which antimuscarinic drugs selective for the muscarinic subtypes have the best efficacy and tolerability, comparative clinical trials between M₃ selective antagonists and non-selective compounds, such as olterodine, are required in the future.     

Where is the true location of the femoral piriform fossa?

ObjectiveTo analyze knowledge of the anatomic location of the piriform fossa using a questionnaire with anatomic figures.Materials and methodsParticipants taking AO Trauma Brasil courses were requested to complete a questionnaire containing a photograph of the superior surface and a photograph of the lateral surface of the femur and answer a question asking which of four numbered points corresponded to the piriform fossa.ResultsJust 4.5% of respondents correctly chose point 2 (the piriform fossa) in both images, while 75.4% of respondents chose point 4 (the trochanteric fossa) as the correct anatomic structure. The subset of 4th-year residents’ answers was significantly different from those of the other subsets, with 7.5% of correct answers.ConclusionsThe low rate of correct answers indicates a tendency for the respondents to be influenced by illustrations in text books or examples in scientific publications that indicate the site of the piriform fossa incorrectly. Interest in the specialty of traumatology is possibly the reason why the subset of 4th-year residents had a better- than-average rate of correct answers.