Preservation of the smooth muscular internal (vesical) sphincter and of the proximal urethra during retropubic radical prostatectomy: Description of the technique

We describe our technique for preservation of the smooth muscular internal (vesical) sphincter and proximal urethra during radical retropubic prostatectomy. The first steps of the prostatectomy reflect the standard retropubic prostatectomy; whereas for the final phases, the procedure continues in an anterograde manner with incision of the fibers of the detrusor muscle at the insertion of the ventral surface of the base of the prostate. At this level, the inner circular muscle of the bladder neck forms a sphincteric ring of smooth muscle that covers the longitudinally‐oriented smooth muscle component of the urethra that extends distally to the verumontanum; these two proximal structures represent the internal sphincter that envelops and locks the proximal urethra. A blunt dissection is continued until the ring‐shaped vesical sphincter is separated from the prostate and the longitudinally‐oriented smooth muscle component of the urethral musculature is identified. The base of the prostate is then gently separated from the urethra and from the bladder until the maximal length of the urethral musculature is isolated and preserved. Finally, a urethra‐urethral anastomosis is carried out and the ventral stitches are placed through the circular fibres of the bladder neck. In all cases we carry out circumferential biopsies of the proximal urethra and of the base of the prostate. The described technique is a feasible and safe method for preservation of the internal urethral sphincter. Despite the enthusiasm regarding our positive functional results, further studies with larger series are required to confirm these findings.     

Vocal fold augmentation by autologous fat injection with lipostructure procedure.

BACKGROUND: Fat is theoretically the ideal implant for vocal fold augmentation because it is soft, easily available and biocompatible. However, reabsorption is a frequent cause of long-term failure. OBJECTIVE: We prospectively tested Coleman's "lipostructure" technique used for facial recontouring in the treatment of glottic incompetence. STUDY DESIGN AND SETTING: Fourteen patients (aged 18-74 years, mean 48) with breathy dysphonia secondary to laryngeal hemiplegia (7) or anatomical defects (7) underwent vocal fold lipoinjection. Fat harvested by liposuction was centrifuged, and the fat cell layer injected into the vocalis muscle. The patients underwent pre- and postoperative videolaryngostroboscopy, maximum phonation time (MPT) measurements, GRBAS perceptual evaluations, and Voice Handicap Index (VHI) self-assessments. RESULTS: Voice quality improved soon after surgery and remained stable over 3-26 months (mean 10.6), being confirmed by the GRBAS, MPT and VHI evaluations ( P < 0.005). The results were best in the seven patients with paralytic dysphonia. CONCLUSION: Lipostructure is a valuable technique for voice rehabilitation in glottic incompetence.     

MRI of the Hip for the evaluation of femoroacetabular impingement; past,present, and future

The concept of femoroacetabular impingement (FAI) has, in a relatively short time, come to the forefront of orthopedic imaging. In just a few short years MRI findings that were in the past ascribed to degenerative change, normal variation, or other pathologies must now be described and included in radiology reports, as they have been shown, or are suspected to be related to, FAI. Crucial questions have come up in this time, including: what is the relationship of bony morphology to subsequent cartilage and labral damage, and most importantly, how is this morphology related to the development of osteoarthritis? In this review, we attempt to place a historical perspective on the controversy, provide guidelines for interpretation of MRI examinations of patients with suspected FAI, and offer a glimpse into the future of MRI of this complex condition. J. Magn. Reson. Imaging 2015;41:558–572. © 2014 Wiley Periodicals, Inc.     

Radiological contrast media in the breastfeeding woman: a position paper of the Italian Society of Radiology (SIRM), the Italian Society of Paediatrics (SIP), the Italian Society of Neonatology (SIN) and the Task Force on Breastfeeding,Ministry of Health,Italy

Objectives

Breastfeeding is a well-recognised investment in the health of the mother-infant dyad. Nevertheless, many professionals still advise breastfeeding mothers to temporarily discontinue breastfeeding after contrast media imaging. Therefore, we performed this review to provide health professionals with basic knowledge and skills for appropriate use of contrast media.

Methods

A joint working group of the Italian Society of Radiology (SIRM), Italian Society of Paediatrics (SIP), Italian Society of Neonatology (SIN) and Task Force on Breastfeeding, Ministry of Health, Italy prepared a review of the relevant medical literature on the safety profile of contrast media for the nursing infant/child.

Results

Breastfeeding is safe for the nursing infant of any post-conceptional age after administration of the majority of radiological contrast media to the mother; only gadolinium-based agents considered at high risk of nephrogenic systemic fibrosis (gadopentetate dimeglumine, gadodiamide, gadoversetamide) should be avoided in the breastfeeding woman as a precaution; there is no need to temporarily discontinue breastfeeding or to express and discard breast milk following the administration of contrast media assessed as compatible with breastfeeding.

Conclusions

Breastfeeding women should receive unambiguous professional advice and clear encouragement to continue breastfeeding after imaging with the compatible contrast media.

Key Points:

? Breastfeeding is a well-known investment in the health of the mother-infant dyad. ? Breastfeeding is safe after administration of contrast media to the mother. ? There is no need to temporarily discontinue breastfeeding following administration of contrast media.     

Role of paravertebral block anaesthesia during percutaneous transhepatic thermoablation

Purpose

This paper discusses the technique and preliminary results of right thoracic paravertebral block (TPVB) for percutaneous thermal ablation of liver tumours.

Materials and methods

Between October 2011 and August 2012 we treated 36 lesions (25 hepatocellular carcinoma and 11 metastases) in 30 patients aged 47–85 years (mean 67.5). Patients received ultrasound (US)-guided injection of 7 ml of naropin 0.75 % in T7, T9 and T11 levels, below the costo-vertebral ligament, until we observed an anterior displacement of the parietal pleura. For the subcapsular lesions, a cervical right phrenic nerve block was associated. The level of analgesia was evaluated during and after the percutaneous procedures with the Numerical Rating Scale. Finally, we investigated statistical correlations between pain and lesions (histological type, site, dimensions), and ablation time and technique (microwave or radiofrequency ablation).

Results

Technical success was achieved in all patients. Despite the correct anaesthetic diffusion during the ablation, 10 patients (33.3 %) reported medium/severe pain and intravenous sedation was required. Pain was not found to correlate with any variable. No complications were observed.

Conclusions

In most cases, TPVB is a safe and effective technique for conscious anaesthesia during percutaneous thermal ablation of liver tumours. Failures probably derive from left sympathetic and parasympathetic fibre stimulation. We recommend performing a TPVB in the presence of the anaesthetist.     

Association between left ventricular regional sympathetic denervation and mechanical dyssynchrony in phase analysis: a cardiac CZT study

Purpose

To evaluate the relationships among myocardial sympathetic innervation, perfusion and mechanical synchronicity assessed with cardiac cadmium-zinc-telluride (CZT) scintigraphy.

Methods

A group of 29 patients underwent an evaluation of myocardial perfusion with ^99mTc-tetrofosmin CZT scintigraphy and adrenergic innervation with ¹²³I-metaiodobenzylguanidine (MIBG) CZT scintigraphy. The summed rest score (SRS), motion score (SMS) and thickening score (STS), as well as the summed ¹²³I-MIBG defect score (SS-MIBG), were determined. Regional tracer uptake for both ^99mTc-tetrofosmin and ¹²³I-MIBG was also calculated. Finally, the presence of significant myocardial mechanical dyssynchrony was evaluated in phase analysis on gated CZT images and the region of latest mechanical activation identified.

Results

Significant mechanical dyssynchrony was present in 17 patients (59 %) and associated with higher SRS (P?=?0.030), SMS (P?<?0.001), STS (P?=?0.003) and early SS-MIBG (P?=?0.037) as well as greater impairments in left ventricular ejection fraction (P?<?0.001) and end-diastolic volume (P?<?0.001). In multivariate analysis a higher end-diastolic volume remained the only predictor of mechanical dyssynchrony (P?=?0.047). Interestingly, while in the whole population regional myocardial perfusion and adrenergic activity were strongly correlated (R?=?0.68), in patients with mechanical dyssynchrony the region of latest mechanical activation was predicted only by greater impairment in regional ¹²³I-MIBG uptake (P?=?0.012) that overwhelmed the effect of depressed regional perfusion.

Conclusion

Left ventricular mechanical dyssynchrony is associated with greater depression in contractile function and greater impairments in regional myocardial perfusion and sympathetic activity. In patients with dyssynchrony, the region of latest mechanical activation is characterized by a significantly altered adrenergic tone.     

Combined radiofrequency ablation and ethanol injection with a multipronged needle for the treatment of medium and large hepatocellular carcinoma

Objective

To evaluate the efficacy and safety of combined radiofrequency ablation (RFA) and ethanol injection with a multipronged needle in the treatment of medium (3.1–5.0 cm) and large (5.1–7.0 cm) hepatocellular carcinoma (HCC).

Methods

A total of 65 patients with 67 HCC nodules were enrolled in this prospective study. All of them received the treatment of combined RFA and multipronged ethanol injection percutaneously.

Results

The average volume of injected ethanol was 14.4?±?4.1 ml (range, 9–30 ml). The average number of RFA electrode insertions was 1.7?±?0.8 (range, 1–4). The rate of initial local complete response (CR) was 94.0 % (63/67). After additional treatment, technical success was achieved in all HCC nodules. There were no treatment-related deaths, and major complications were observed in 3 (4.6 %) patients. After a mean follow-up of 20.0?±?7.6 months, local tumour progression was observed in 10 (10/67, 14.9 %) tumours, whereas distant recurrence developed in 32 (32/65, 49.2 %) patients. The 1-year and 2-year survival rates were 93.1 % and 88.1 %, respectively.

Conclusion

The combination of RFA and multipronged ethanol injection in the treatment of medium and large HCC is safe and effective with a high rate of local tumour control.

Key Points

? Combined radiofrequency ablation and multipronged ethanol injection is a new therapeutic strategy ? Treatment is safe and effective for medium and large hepatocellular carcinoma (HCC) ? A multipronged needle allows for a homogeneous ethanol distribution     

Inhibition of the chemokine receptor CXCR2 prevents kidney graft function deterioration due to ischemia/reperfusion

BACKGROUND: Ischemia/reperfusion (I/R) injury after organ transplantation is a major cause of delayed graft function. Following I/R, locally produced CXC chemokines attract and activate granulocytes, which in turn promote graft damage. METHODS: We examined the involvement of granulocyte recruitment via the CXCR2 pathway in a rat model of 4 hours cold ischemia followed by kidney transplantation. Serum creatinine and intragraft granulocyte infiltration were monitored in the early phase posttransplant. A CXCR2 inhibitor, repertaxin, was given to recipients before transplantation (at -24 hours or -8 hours or -2 hours), immediately before reperfusion and 2 hours later. RESULTS: An increase of granulocyte chemoattractant CINC-1/interleukin-8 (IL-8) mRNA expression after I/R both in syngeneic and allogeneic transplantation was associated with a marked infiltration of granulocytes in renal tissue. In syngeneic transplantation, Lewis rats given 15 mg/kg repertaxin 24 hours before surgery had granulocyte graft infiltration and serum creatinine levels significantly reduced in respect to vehicle-treated animals. Intermediate effects were observed with 5 mg/kg, whereas the dose of 30 mg/kg had toxic effects. We found that reducing the pretreatment time to 8 hours before surgery was still effective. Prevention of granulocyte infiltration and serum creatinine increase was also obtained in allogeneic transplantation, when Brown Norway recipients of Lewis kidneys were given 15 mg/kg repertaxin starting 8 hours before surgery. CONCLUSION: Repertaxin treatment of the recipient animal was effective in preventing granulocyte infiltration and renal function impairment both in syngeneic and in allogeneic settings. The possibility to modulate I/R injury in this rat model opens new perspectives for preventing posttransplant delayed graft function in humans.     

Regional Variation and Use of Exception Letters for Cadaveric Liver Allocation in Children with Chronic Liver Disease

The Pediatric End-Stage Liver Disease (PELD) score was designed to reduce subjectivity in liver allocation and to advantage patients with a higher probability of waiting list mortality. The aims of this study were to determine the impact of PELD implementation for children with chronic liver disease and to assess whether PELD met its goal of standardization of liver allocation for children. This study used data reported to the United Network for Organ Sharing (UNOS) registry for children with chronic liver disease receiving primary cadaveric liver transplant between January 2000 and December 2001 (pre-PELD) and March 2002 and July 2003 (PELD). PELD reduced the percentage of children transplanted while in an intensive care unit and as status 1. A calculated PELD score was used for allocation in only 52% of recipients. Thirty percent were status 1 at transplant and PELD scores granted by exception were used for allocation in 18% of patients. There was regional variation in PELD score at allocation and use of exception scores with a significant relationship between PELD score and percentage of exception cases. Regional variation suggests that PELD has not resulted in standardization of listing practices in pediatric liver transplantation.     

Achievement of trifecta in minimally invasive partial nephrectomy correlates with functional preservation of operated kidney: a multi-institutional assessment using MAG3 renal scan

Purpose

To validate and compare the values of “MIC” and “trifecta” as predictors of operated kidney functional preservation in a multi-institutional cohort of patients undergoing minimally invasive PN.

Methods

We retrospectively reviewed records of consecutive cases of minimally invasive PN performed for cT1 renal masses in 4 centers from 2009 to 2013. Inclusion criteria consisted of availability of a renal scan obtained within 2 weeks prior to surgery and follow-up renal scan 3–6 months after the surgery. The primary endpoint of the study was to compare the degree of ipsilateral renal function preservation assessed by MAG3 renal scan in relation to achievement of MIC and trifecta.

Results

Total of 351 patients met our inclusion criteria. The rates of trifecta achievement for cT1a and cT1b tumors were 78.9 and 60.6 %, respectively. The rate of MIC achievement for cT1a tumors and cT1b tumors was 60.3 and 31.7 %, respectively. On multivariable linear regression model, only the degree of tumor complexity assessed by R.E.N.A.L nephrometry score [coefficient B ?1.8 (?2.7, ?0.9); p < 0.0001] and the achievement of trifecta [coefficient B 6.1 (2.4,9.8); p = 0.014] or MIC (coefficient B 7.2 (3.8,0.6); p < 0.0001) were significant clinical factors predicting ipsilateral split function preservation.

Conclusions

Achievement of both MIC and “trifecta” is associated with higher proportion of split renal function preservation for cT1 tumors after minimally invasive PN. Thus, these outcome measures can be regarded not only as markers of surgical quality, but also as reliable surrogates for predicting functional outcome in the operated kidney.