Planned cesarean section versus planned vaginal delivery: comparison of lower urinary tract symptoms

We compared the prevalence and risk of lower urinary tract symptoms in healthy primiparous women in relation to vaginal birth or elective cesarean section 9 months after delivery. We performed a prospective controlled cohort study including 220 women delivered by elective cesarean section and 215 by vaginal birth. All subjects received an identical questionnaire on lower urinary tract symptoms in late pregnancy, at 3 and 9 months postpartum. Two hundred twenty subjects underwent elective cesarean section, and 215 subjects underwent vaginal delivery. After childbirth, the 3-month questionnaire was completed by 389/435 subjects (89%) and the 9-month questionnaire by 376/435 subjects (86%). In the vaginal delivery cohort, all lower urinary tract symptoms increased significantly at 9 months follow-up. When compared to cesarean section, the prevalence of stress urinary incontinence (SUI) after vaginal delivery was significantly increased both at 3 (p < 0.001) and 9 months (p = 0.001) follow-up. In a multivariable risk model, vaginal delivery was the only obstetrical predictor for SUI [relative risk (RR) 8.9, 95% confidence interval (CI) 1.9–42] and for urinary urgency (RR 7.3 95% CI 1.7–32) at 9 months follow-up. A history of SUI before pregnancy (OR 5.2, 95% CI 1.5–19) and at 3 months follow-up (OR 3.9, 95% CI 1.7–8.5) were independent predictors for SUI at 9 months follow-up. Vaginal delivery is associated with an increased risk for lower urinary tract symptoms 9 months after childbirth when compared to elective cesarean section.     

The effects of bilateral caudal epidural S2–4 neuromodulation on female sexual function

This is a pilot study to evaluate the effects of caudal epidural S2–4 neuromodulation on female sexual function in a population of women with voiding dysfunction. We prospectively studied 36 consecutive female patients who underwent caudal epidural sacral neuromodulation. Patients received the Female Sexual Function Index (FSFI) questionnaire preoperatively and 6 months postoperatively. Six months after permanent implantation, the overall score on the FSFI improved by 52% (p = 0.05). Results were better in patients who underwent the treatment for voiding dysfunction compared to those who had pain as their primary complaint. In this group, the overall score improved by 157% (p = 0.004). Stimulation of S2–4 by bilateral caudal epidural neuromodulation in this small group of women with voiding dysfunction, retention, and/or pelvic pain resulted in self-reported improvements in sexual function. Further studies are needed to evaluate the potential role of S2–4 sacral stimulation in the treatment of female sexual dysfunction.     

Noninvasive Pancreatic Cystic Neoplasms can be Safely and Effectively Treated by Limited Pancreatectomy

Background Appropriate management of cystic lesions of the pancreas is controversial. Major pancreatectomies (pancreaticoduodenectomy or distal pancreatectomy with splenectomy) are the commonly used procedures, even though most cystic lesions are noninvasive neoplasms. We tested the adequacy of limited pancreatectomies in the treatment of pancreatic cystic lesions. Methods Data from 109 patients who underwent surgical resection of a pancreatic cystic lesion at National Taiwan University Hospital from 2001 to 2007 were retrospectively reviewed. Major pancreatomies (n = 79) constituted pancreaticoduodenectomy and total/distal pancreatectomies, while other resection procedures (n = 30) represented limited pancreatectomies. Clinicopathologic features were compared between the major and limited groups. Results There were no statistically significant differences in sex, age, presence of symptoms, cyst diameter, minor or major treatment complications, or pancreatic leakage between the two groups. Cystic lesions located in the neck/body/tail rather than in the head/uncinate process were significantly more often treated with limited pancreatectomy (P = .02). Both groups had similar pathologic distribution of cystic lesions, with the exception of nine invasive neoplasms. The latter were treated with major pancreatectomy. No recurrence was noted in 100 patients with noninvasive cystic neoplasms after major or limited pancreatectomy. Conclusions Noninvasive pancreatic cystic neoplasms can be safely and effectively treated by limited pancreatectomy.     

Long-term control or possible cure? Treatment of stage D2 prostate cancer under chemotherapy using cisplatin and estramustine phosphate followed by maximal androgen blockade

Metastatic prostate cancer (PC) is incurable by androgen deprivation therapy alone, due to the presence of androgen-independent/supersensitive cells in hormone-naive PC. A 67-year-old man was diagnosed with PC (Gleason score, 5 + 4) with multiple bone metastases. He was treated by chemohormonal therapy with cisplatin and estramustine phosphate (EMP) followed by maximal androgen blockade, and showed a complete response. As of the time of writing, no clinical or prostate-specific antigen recurrence has been observed for over 15 years, despite cessation of the treatment. This is the first report to indicate a possible cure of metastatic PC by chemohormonal therapy combined with appropriate anti-tumor drugs targeted to both androgen-independent and -dependent clones before the hormone-refractory state.     

Retroportal Hepaticojejunostomy for Extended Resection of Hilar Bile Ducts

High hepatic duct resection sometimes is unavoidable in achieving curative resection of hilar cholangiocarcinoma, as tumor cells can extend further than expected along the bile ducts from the macroscopically evident cancer. In patients undergoing left hemihepatectomy with caudate lobectomy whose bile duct must be severed at the subsegmental bile duct levels, the orifices of the posterior bile ducts would lie behind the right portal vein. Conventional hepaticojejunostomy would be risky in such cases because an anastomosis performed in the usual manner would be subjected to strain. Instead, between 2002 and 2004, three patients underwent retroportal hepaticojejunostomy using a jejunal limb mobilized and positioned behind the hepatoduodenal ligament. Primary tumors were classified as type IV in the Bismuth–Corlette classification. Tension-free hepaticojejunal anastomosis was performed successfully in all three patients; insufficiency of the hepaticojejunostomy did not develop. Neither early nor late complications directly related to this method occurred. Retroportal hepaticojejunostomy, thus, permits more peripheral resection of the hepatic duct while providing a sufficient operative field for safe, tension-free anastomosis. This technique is very useful for patients undergoing left hemihepatectomy requiring high hilar resection of the bile duct.     

A screening questionnaire to predict no return to work within 3 months for low back pain claimants

The objective of the present study was to develop a short prediction questionnaire for estimating the risk of no return to work (RTW) within 3 months of sick leave to facilitate triage and management of a patient population of subacute low-back pain (LBP) sufferers. We conducted a prospective study with a 3-month follow-up on 186 patients with LBP introducing a claim for sickness benefits to the largest sickness fund in Belgium. Patients completed a screening questionnaire within 2 weeks after claim submission. All patients were invited for clinical assessment, at 6–8 weeks of sick leave, by the medical adviser. Patients’ work status was recorded by the sickness fund. About 20% of the patients did not resume work at 3 months’ sick leave. They were more likely to experience pain below the knee, to have an own previous prediction of a 100% no RTW and to have a severe interference of pain on daily activities. The screening tool based on these three items correctly classified 73.7% of the non-resumers and 78.4% of the resumers at a cut-off score of 0.22. The findings of this study provide evidence of the utility of a short screening questionnaire for future use in intervention studies in a social security setting.     

Intraoperative radiotherapy for oncological and function-preserving surgery in patients with advanced lower rectal cancer

Backgrounds Pelvic autonomic nerve preservation (PANP) with lateral lymph node dissection (LLND) has been introduced in rectal cancer surgery in Japan; however, its indication has not been standardized yet. Materials and methods Forty-four patients with advanced lower rectal cancer were randomized to either the standard treatment group (control group) or the intraoperative radiotherapy (IORT) group. All patients underwent potentially curative resection of the rectum with total mesorectal excision. The control group underwent bilateral LLND and limited PANP. The IORT group underwent bilateral LLND, complete PANP, and IORT. Patients allocated to the IORT group received IORT to the bilateral preserved pelvic nerve plexuses. Patients’ clinicopathologic parameters, postoperative complications, voiding function, and prognosis were compared between the two groups. Results Among 44 patients enrolled, three patients were excluded from the analysis, resulting in 19 patients in the IORT group and 22 patients in the control group. Patients’ demographic and pathological parameters and postoperative complications were well balanced between the two groups. Oncological outcomes including overall and disease-free survival were also similar. Local recurrence was observed in one patient in each group. Among the 34 patients not complicated with intrapelvic abscess, the mean duration of urinary catheter indwelling was 8 days in the IORT group and 13 days in the control group (p = 0.055). In the long term, medication for urination was necessitated in four patients in the control group, whereas in none in the IORT group (p = 0.059). Discussions Oncological outcomes in the IORT group are equal to those in the control group, and voiding functions in the IORT group are superior to those in the control group. These results suggest that IORT may be useful to expand the indication of complete PANP with LLND for advanced lower rectal cancer.     

A simple technique ligating the corresponding inflow and outflow vessels during anatomical left hepatectomy

Background Massive bleeding remains one of main factors of morbidity and death in liver resections. For this reason, the Pringle maneuver or total vascular exclusion is commonly used during liver resection. However, ischemic damage is still a major problem. Some surgeons used the “glissonean” approach for bleeding control, but the technique is tedious and also time consuming, with high incidence of bile leaks in the postoperative period. The aim of this paper is to describe a new bleeding control technique, rapid ligation of the corresponding inflow and outflow vessels without hilus dissection before the parenchyma transection during anatomical left liver resection and to analyze the feasibility, blood loss, transfusion requirements, and postoperative complications. Materials and methods During the past 18 years, we used the new hemorrhage control technique in left liver resection in 630 patients with malignant or benign tumors. Results The median blood loss in all 630 patients was 110 ± 250 ml (range 50–750), and no patient required blood transfusion. The median total operative time was 77 ± 35 min (range 25–155). No bile leaks and liver failure of the patients occurred postoperatively. There was no death within 30 postoperative days. Conclusion The rapid ligation of the corresponding inflow and outflow vessels without hilus dissection before the parenchyma transection is a feasible, safe, and bloodless technique during the left liver resection. A commentary on this paper is available at     

High concentrations of landiolol,a β<Subscript>1</Subscript>-adrenoceptor antagonist,stimulate smooth muscle contraction of the rat trachea through the Rho-kinase pathway

Purpose Gradually progressing contraction of airway smooth muscle is suggested to be due to the Rho-kinase signaling pathway. In our preliminary study in rat tracheas, landiolol, a β₁-adrenoceptor antagonist, at high doses caused gradually progressing contraction, and this contraction reached a plateau after 20 min. Therefore, this study was carried out to clarify whether landiolol could stimulate the Rho-kinase pathway or the phosphatidylinositol (PI) response in the rat trachea. Methods Seventy-eight male Wistar rats weighing 250–350 g were used for the experiments. Their tracheas were cut into 3-mm-wide ring segments or 1-mm-wide slices. Measurements of isometric tension and [³H] inositol monophosphate (IP₁) production were conducted, using these tracheal rings or slices. Data values are expressed as means ± SD, and statistical significance (P < 0.05) was determined using analysis of variance (ANOVA). Results Landiolol (700 μM)-induced contraction was completely inhibited by fasudil at 30 μM, while the landiolol-induced contraction was not inhibited by 4-diphenylacetoxy-N-methyl-piperidine methobromide (4-DAMP), ketanserin, or nicardipine. Landiolol did not stimulate IP₁ production. Conclusion These results suggest that high concentrations of landiolol could cause airway smooth muscle contraction through the Rho-kinase pathway, but not through the PI response coupled with muscarinic M₃ receptors, 5-HT receptors or the activation of L-type Ca²⁺ channels.     

Current status of high-intensity focused ultrasound for prostate cancer: Technology,clinical outcomes,and future

Based on a review of recently published articles, we evaluated the current status of high-intensity focused ultrasound (HIFU) as a primary treatment option for localized prostate cancer and as a salvage therapy when radiation has failed. With mid-and long-term progression-free survival rates around 70%, negative postoperative prostate biopsies almost 90%, and an excellent morbidity profile, primary HIFU appears to be a valid alternative to active surveillance protocols in low-risk patients and standard therapies in patients with life expectancies of 10 or fewer years. Moreover, HIFU has a considerable potential for local-only recurrence after radiation failure. HIFU is a recent technology, and many improvements will undoubtedly expand its future indications and use for the management of prostate cancer.