Laparoscopic management of paratubal and paraovarian cysts.

OBJECTIVES: To define the proportion, methods of diagnosis, and a simplified laparoscopic technique for treating paratubal and paraovarian cysts. METHODS: We conducted a prospective cross-sectional study in the Gynecologic Endoscopy Unit of Assiut University Hospital in Assiut, Egypt in 1853 patients undergoing video-assisted laparoscopy. Transvaginal ultrasonography (TVS) was performed to detect paratubal or paraovarian cysts. Tubal shape and patency were evaluated with hysterosalpingography (HSG) in the infertile group. Diagnostic laparoscopy was performed to confirm the diagnosis of paratubal or paraovarian cysts. Small cysts were punctured and coagulated, and larger cysts required cystectomy and extraction of the cysts by using bipolar electrosurgery. Cystectomy was preceded by endocystic visualization in all cases. The primary outcomes measured included (1) correlation of the preoperative TVS, HSG, or both of these, with the laparoscopic diagnosis; (2) estimation of the success of the laparoscopic management of paratubal cysts; (3) assessment of the value of endocystic visualization prior to cystectomy; and (4) evaluation of tubal patency after laparoscopic management. RESULTS: Laparoscopically, only 118 patients (15.7%) were proved to have paratubal or paraovarian cysts. Preoperatively, TVS confirmed paratubal or paraovarian cysts in 52 (44%) patients. Cysts less than 3 cm in size (34 cases) were treated with simple puncture and bipolar coagulation of the cyst wall, whereas larger cysts (84 cases) were treated by cystectomy. Endocystic visualization using the 4-mm rigid hysteroscope was performed in 84 (71%) patients with large cysts. Statistically significant improvement occurred in tubal patency after laparoscopic management. CONCLUSIONS: Sonographic diagnosis of not uncommon paratubal and paraovarian cysts is not always feasible and requires greater awareness and accuracy. The characteristic laparoscopic differentiation of ovarian cysts is the crossing of vessels over them. Endocystic-endoscopic visualization is a simple, valuable step prior to cystectomy. Bipolar coagulation or extraction of these cysts diagnosed at laparoscopy is easy, not time-consuming, and should be routinely performed in all cases following microsurgical laparoscopic principles.     

Gastrocystoplasty in patients with an areflexic low compliant bladder

AIM: This study was performed with the aim of evaluating gastrocystoplasty as a method of management of patients with an areflexic low compliant bladder. PATIENTS AND METHODS: We performed gastrocystoplasty in 30 patients (19 males and 11 females) with an areflexic low compliant bladder. The mean age of the patients was 23.4+/-11 years (range 4-32). The etiology of lower urinary tract dysfunction was myelodysplasia in 26 patients and spinal cord injury in 4. Twenty-three patients had normal renal function and 7 had impaired renal function (creatinine 2.0-5.0mg%). Additionally, 4 patients had an artificial urinary sphincter implanted and seven had an antireflux procedure performed. RESULTS: Renal function remained stable or improved in 29 patients. Postoperatively, there was a 225% increase from mean preoperative capacity and a 52% decrease from the preoperative end filling pressure. Nineteen patients voided spontaneously and 11 used clean intermittent catheterization to empty the bladder. Twenty-five patients were continent with augmentation alone, four with augmentation and artificial sphincter implantation while one remained incontinent, as sphincter implantation could not be performed due to the young age of the patient. Five patients (17%) had transient hematuria and dysuria after augmentation. There were no mortalities and complications included prolonged urinary leakage in one patient and mild gastric bleeding in another two. CONCLUSION: The use of the stomach for augmenting the areflexic low compliant bladder is clearly advantageous over other tissues as it increases bladder capacity and compliance with consequent achievement of continence and preservation of upper tracts. An artificial urinary sphincter can be safely implanted in the same session. Because of its inherent fibromuscular properties, the gastric patch contributes to the force of urination resulting in better bladder emptying. Patients with impaired renal function are protected from hyperchloremic metabolic acidosis.     

Preoperative beta-blocker use: impact of national guidelines on clinical practice

STUDY OBJECTIVE: To determine if recommendations regarding perioperative beta-blocker therapy were followed by an increase in the number of eligible presurgical patients receiving beta-blockers and the number achieving the recommended heart rate (HR <60 beats per minute [bpm]). DESIGN: Retrospective, observational study. SETTING: Tertiary-care teaching hospital. MEASUREMENTS: The records of all 718 patients who underwent elective vascular surgery or coronary artery bypass grafting between January 2001 and March 2002 (pre-guideline) and those who did so between April 2002 and September 2003 (post-guideline) were reviewed. Percentage of eligible patients who received beta-blockers preoperatively and the target HR achieved in pre-guideline versus post-guideline patients were recorded. Differences were assessed using the unpaired t test and chi2 analysis. A P value of less than 0.05 is reported. MAIN RESULTS: Fifty percent of the post-guideline patients in the vascular surgery group were receiving beta-blockers at the time of preanesthetic evaluation versus 48% of pre-guideline patients (P = nonsignificant [NS]). Mean HR in the vascular surgery post-guideline beta-blocker group (70 +/- 14 bpm) was higher than in the pre-guideline beta-blocker group (65 +/- 11 bpm) (P < 0.01). Only 22% of those vascular surgery patients in the post-guideline group who were taking beta-blockers achieved the target HR of less than 60 bpm versus 29% of the vascular surgery patients taking beta-blockers in the pre-guideline group (P = NS). In the coronary artery bypass grafting group, 80% of post-guideline patients received beta-blocker before anesthesia assessment versus 75% of pre-guideline patients (P = NS). Mean HR in the post-guideline beta-blocker group (67 +/- 15 bpm) was similar to the pre-guideline beta-blocker group (64 +/- 13 bpm) (P = NS). Only 28% of the post-guideline patients who were receiving beta-blockers achieved the target HR of less than 60 bpm, which was not significantly different from the 17% achieved in the pre-guideline group (P = NS). CONCLUSION: At our institution, preoperative beta-blocker use was not significantly changed by publication of the recommendations.     

Dietary habits and prostate cancer detection: a case–control study

Background

Many studies have suggested that nutritional factors may affect prostate cancer development. The aim of our study was to evaluate the relationship between dietary habits and prostate cancer detection.

Methods

We studied 917 patients who planned to have transrectal ultrasonography–guided prostatic biopsy based on an elevated serum prostate-specific antigen (PSA) level, a rising serum PSA level or an abnormal digital rectal examination. Before receiving the results of their biopsy, all patients answered a self-administered food frequency questionnaire. In combination with pathology data we performed univariable and multivariable logistic regression analyses for the predictors of cancer and its aggressiveness.

Results

Prostate cancer was found in 42% (386/917) of patients. The mean patient age was 64.5 (standard deviation [SD] 8.3) years and the mean serum PSA level for prostate cancer and benign cases, respectively, was 13.4 (SD 28.2) μg/L and 7.3 (SD 4.9) μg/L. Multivariable analysis revealed that a meat diet (e.g., red meat, ham, sausages) was associated with an increased risk of prostate cancer (odds ratio [OR] 2.91, 95% confidence interval [CI] 1.55–4.87, p = 0.027) and a fish diet was associated with less prostate cancer (OR 0.54, 95% CI 0.32–0.89, p = 0.017). Aggressive tumours were defined by Gleason score (≥ 7), serum PSA level (≥ 10 μg/L) and the number of positive cancer cores (≥ 3). None of the tested dietary components were found to be associated with prostate cancer aggressivity.

Conclusion

Fish diets appear to be associated with less risk of prostate cancer detection, and meat diets appear to be associated with a 3-fold increased risk of prostate cancer. These observations add to the growing body of evidence suggesting a relationship between diet and prostate cancer risk.     

Rhabdomyosarcoma of the urinary bladder in adults: predilection for alveolar morphology with anaplasia and significant morphologic overlap with small cell carcinoma

Rhabdomyosarcoma (RMS) represents the most common malignant soft tissue tumor in children and adolescents with the urinary bladder representing a frequent site. Most of these urinary bladder tumors are embryonal RMS, predominantly the botryoid subtype. RMSs of the urinary bladder in adults are distinctively rare and the subject of only case reports. We report the clinicopathologic features of 5 bladder neoplasms with rhabdomyosarcomatous differentiation in adults and emphasize the differential diagnosis in the adult setting. The patients, 4 men and 1 woman, ranged in age from 23 to 85 years (mean 65.4 y). Gross hematuria was the most common initial symptom, although 2 patients had metastatic disease at presentation. Four cases were pure primary RMSs of the bladder and 1 case was a sarcomatoid urothelial carcinoma with RMS representing the extensive heterologous component. All 5 cases demonstrated a diffuse growth pattern (ie, non-nested), of which 4 cases had nuclear anaplasia (Wilms criteria without the atypical mitotic figure requirement); only 1 case (the sarcomatoid carcinoma) showed obvious rhabdomyoblastic differentiation (ie, strap cells). Three cases were of the alveolar subtype (1 admixed with embryonal histology) and 2 were RMS, not further classified. Microscopically, all tumors had a primitive undifferentiated morphology with cells containing scant cytoplasm, varying round to fusiform nuclei with even chromatin distribution, and frequent mitoses. The degree of morphologic overlap with small cell carcinoma of the bladder, a relatively more common round cell tumor in adults, was striking. The epithelial component of the sarcomatoid carcinoma was high-grade invasive urothelial carcinoma with glandular differentiation. No other case had previous history of bladder cancer or concurrent carcinoma in situ or invasive urothelial carcinoma. All tumors showed immunohistochemical expression for desmin, myogenin, and/or MyoD1. Synaptophysin was performed in 4 cases, and 3 showed weak cytoplasmic immunoreactivity. Two patients received chemotherapy, 2 underwent cystectomy, and 1 had transurethral resection alone. Outcome data were available in 4 cases, and all 4 died of disease (1, 4, 8, and 8 mo). In conclusion, (1) RMS of the urinary bladder in adults more commonly presents as a primitive round blue cell neoplasm that has significant morphologic and immunohistochemical overlap with small cell carcinoma of the bladder. (2) Although RMS in children generally have a botryoid embryonal histology with favorable outcome, bladder RMS in adults frequently demonstrates alveolar or unclassified histology, commonly with anaplasia, and have a uniformly aggressive clinical course.     

Inverted Meckel's diverticulum causing intussusception in an adult

Adult intussusception is rare, making-up only about 1% of the causes of bowel obstruction intussusception, secondary to an inverted Meckel's diverticulum, is also a rare occurrence. Chronic abdominal pain, lower gastrointestinal bleeding, and recurrent obstructive symptoms may lead to an unnecessary delay in diagnosis. This case report describes a rare cause of adult intestinal intussusception due to inverted Meckel's diverticulum. Intussusception was diagnosed on emergency ultrasound of the patient, who was successfully managed with surgery.     

Factors influencing the outcome of paediatric cardiac surgical patients during extracorporeal circulatory support

Background  

Veno-arterial extracorporeal membrane oxygenation (ECMO) is a common modality of circulatory assist device used in children. We assessed the outcome of children who had ECMO following repair of congenital cardiac defects (CCD) and identified the risk factors associated with hospital mortality.     

Anterior versus posterior approach in reconstruction of infected nonunion of the tibia using the vascularized fibular graft: potentialities and limitations

The potentialities, limitations, and technical pitfalls of the vascularized fibular grafting in infected nonunions of the tibia are outlined on the basis of 14 patients approached anteriorly or posteriorly. An infected nonunion of the tibia together with a large exposed area over the shin of the tibia is better approached anteriorly. The anastomosis is placed in an end-to-end or end-to-side fashion onto the anterior tibial vessels. To locate the site of the nonunion, the tibialis anterior muscle should be retracted laterally and the proximal and distal ends of the site of the nonunion debrided up to healthy bleeding bone. All the scarred skin over the anterior tibia should be excised, because it becomes devitalized as a result of the exposure. To cover the exposed area, the fibula has to be harvested with a large skin paddle, incorporating the first septocutaneous branch originating from the peroneal vessels before they gain the upper end of the flexor hallucis longus muscle. A disadvantage of harvesting the free fibula together with a skin paddle is that its pedicle is short. The skin paddle lies at the antimesenteric border of the graft, the site of incising and stripping the periosteum. In addition, it has to be sutured to the skin at the recipient site, so the soft tissues (together with the peroneal vessels), cannot be stripped off the graft to prolong its pedicle. Vein grafts should be resorted to, if the pedicle does not reach a healthy segment of the anterior tibial vessels. Defects with limited exposed areas of skin, especially in questionable patency of the vessels of the leg, require primarily a fibula with a long pedicle that could easily reach the popliteal vessels and are thus better approached posteriorly. In this approach, the site of the nonunion is exposed medial to the flexor digitorum muscle and the proximal and distal ends of the site of the nonunion debrided up to healthy bleeding bone. No attempt should be made to strip the scarred skin off the anterior aspect of the bone lest it should become devitalized. Any exposed bone on the anterior aspect should be left to granulate alone. This occurs readily when stability has been regained at the fracture site after transfer of the free fibula. The popliteal and posterior tibial vessels are exposed, and the microvascular anastomosis placed in an end-to-side fashion onto either of them, depending on the length of the pedicle and the condition of the vessels themselves. To obtain the maximal length of the pedicle of the graft, the proximal osteotomy is placed at the neck of the fibula after decompressing the peroneal nerve. The distal osteotomy is placed as distally as possible. After detaching the fibula from the donor site, the proximal part of the graft is stripped subperiosteally, osteotomized, and discarded. Thus, a relatively long pedicle could be obtained. To facilitate subperiosteal stripping, the free fibula is harvested without a skin paddle. In this way, the use of a vein graft could be avoided. Patients presenting with infected nonunions of the tibia with extensive scarring of the lower extremity, excessively large areas of skin loss, and with questionable patency of the anterior and posterior tibial vessels are not suitable candidates for the free vascularized fibular graft. Although a vein graft could be used between the recipient popliteal and the donor peroneal vessels, its use decreases flow to the graft considerably. These patients are better candidates for the Ilizarov bone transport method with or without free latissimus dorsi transfer.