?Wirbelk?rperstabilit?t“ im spinalen Metastasenmanagement

BACKGROUND: Metastases are responsible for most tumor manifestations of the spine. About 25% are symptomatic; however, due to interdisciplinary management the tumor-associated mortality is regressing. Associated acute spinal cord injury (SCI) syndromes raise patient morbidity with a loss of independence and quality of life associated with a fair potential for recovery. Therefore, the management is focused on the avoidance of SCI. The assessment of mechanical stability of vertebral bodies is a central part of decision-making when considering operative therapy. This review gives an update on the current evidence-based data for metastasis management. DECISION MAKING: The NOMS concept is well established. Especially the parameters origin, neurologic symptoms, stability and vascularization are described and illustrated by clinical cases. OPERATIVE THERAPY CONCEPTS: Evidence-based operative therapy concepts are shown reflecting palliative and curative approaches. ASSESSMENT OF PARAMETERS FOR THERAPY ALGORITHM: Clinical and radiological parameters help to find the individual therapy. Generally a number of scores with significant time expenditure are needed. The spine instability neoplastic score (SINS) simplifies the management. Operative therapy shows the best results for the parameters pain and quality of life. However, potential perioperative and postoperative complications have to be estimated and should be avoided. Using these facts our therapy algorithm is helpful for therapy management. CONCLUSIONS: With rising life expectancy operative therapy is of increasing relevance. Decision-making uses information about tumor origin, neurologic symptoms, stability, prognostic factors and vascularisation to determine the individual therapy.     

The timing of drain removal—empiricism or science?

Surgical drains are commonly used in plastic surgery. Drains are subsequently removed at arbitrary volumes depending on local protocols. The rational for when to remove a drain has not been scientifically determined. We compared removal of drains at ≤30?ml/24?h vs. ≤50?ml/24?h for 158 wounds, in 90 patients. Postoperative complications, length of hospital stay and resulting cost–benefit were considered. Prospective data were collected for two consecutive similar cohorts of patients undergoing abdominoplasty, bilateral breast reduction and breast augmentation. In the first cohort, drains were removed when drainage was ≤30?ml/24?h and the second cohort when ≤50?ml/24?h. Demographics, days of drainage, surgeon grade and duration of postoperative hospital stay were recorded. Patient records were then analysed and complications recorded, including haematoma, infection, seroma, wound breakdown and fat necrosis. The median postoperative stay for all three operations for both drainage cohorts was similar with no statistically significant difference; however, the drainage time in breast augmentation was significantly less in the <50?ml/24?h group. There were no significant differences in outcome measures between the patients undergoing abdominoplasty, breast reduction or breast augmentation. Drain removal at ≤50 vs. ≤30?ml/24?h did not result in an increase in postoperative morbidity or adverse outcome in any of the three different operation types.     

Robotic partial cystectomy for lymphangioma of the urinary bladder in an adult woman

Lymphangioma of the urinary bladder is a very rare tumour in adulthood. Robotic partial cystectomy is evolving for treatment of a limited number of bladder tumours. We describe a case of an adult woman with a bladder dome lymphangioma for which robotic partial cystectomy was carried out.     

Current status of robot‐assisted partial nephrectomy

What's known on the subject? and What does the study add? The use of robotic assistance for the partial nephrectomy procedure has emerged as an alternative that may help some of the technical challenges of laparoscopic partial nephrectomy. The main concerns in laparoscopic partial nephrectomy relates to a steeper ‘learning curve’, prolonged warm ischaemia times and the potential for postoperative haemorrhage. The article delineates the dynamics of patient preparation, the surgical team, surgical technique & post‐operative care to conclude that robotic‐assisted partial nephrectomy is a viable alternative to both open and laparoscopic techniques. Partial nephrectomy has shown both improved overall patient survival and more effective preservation of renal function, when compared with radical nephrectomy. Robot‐assisted partial nephrectomy has several potential advantages over the laparoscopic approach. Robotic assistance allows urologists to perform this complex reconstructive procedure more quickly, with improved precision and dexterity, tremor elimination and improved visualization. The present article aims to delineate the dynamics of patient preparation and surgical team, surgical technique and postoperative care. The oncological outcomes and disease‐free survival of partial nephrectomy have been found to be equivalent to open partial nephrectomy [1–4].     

Western-designed total knee implants mismatch Saudi patient knees: Anatomical bony measurements documented by computed tomography

Objectives:To determine the anthropometric features of Saudi knees compared with knees of other ethnicities and reveal mismatches among different knee implant systems.Methods:All knee computed tomography images obtained between January 2016 and September 2016 for varying medical reasons in a tertiary care hospital in Southwestern Saudi Arabia were retrospectively evaluated. Patients aged <18 years, with trauma or soft tissue or bone tumors were excluded. Eleven parameters were measured for each knee joint.Results:We evaluated 100 knees of 50 Saudi patients (25 men, 25 women) aged 28-85 (mean, 57.3) years. No statistically significant differences were found in age and Sasaki angle measurements between male and female patients. All other parameters were significantly larger in male than female knees. Our measurements were close to those published for Chinese, Thai, and Korean patients; however, published measurements were larger for Caucasian and Indian knees than our measurements.Conclusion:The Saudi population has morphological features of knee bone anatomy that do not match with the widely available prostheses designed for Caucasian knees. As several studies of different ethnicities have documented considerable prosthesis mismatch; our study further indicates the need for new implant designs that take these variations into account.     

Prevalence of cerebral venous thrombosis with the use of oral contraceptive pills during the Holy month of Ramadan

Objectives:To identify the epidemiologic profile of cerebral vein thrombosis (CVT) among fasting women using oral contraceptive pills (OCPs) during the holy month of Ramadan.Methods:This retrospective study was conducted on all patients diagnosed with CVT and using OCPs from records at a tertiary care hospital in Riyadh, Saudi Arabia during 2016-2017. The study participants were categorized into 2 groups (an intermittently fasting group during the holy month of Ramadan and a non-fasting group).Results:Out of 108 female patients with CVT, 36.1% were secondary to OCP, of whom 41% participants were fasting. The most affected site was the transverse sinus. Holocephalic headache was more common amongst fasting group (68.8%) compared to non-fasting group (30.4%) (p=0.025). Dehydration (p=0.003) amongst the fasting group and protein S deficiency (p=0.027) in the non-fasting group were identified as the 2 prominent risk factors. Unfractionated heparin was the most common anticoagulant therapies used during the initiation phase for non-fasting (36.4%) and fasting groups (50%).Conclusion:All women who are using OCP should undergo formal written risk assessments for factors of CVT. Our study suggests that the negative effects of OCPs use might outweigh its benefits; thus, it should be prescribed with caution, more so in fasting patients.     

Comparable renal graft survival in African-American and Caucasian recipients

In past years, many pediatric transplant centers found African-American renal transplant recipients to have poor graft survival. Since 1991 anti-lymphocyte induction therapy has been routinely used for pediatric cadaveric (CAD) and living-related donor (LRD) renal allograft recipients at the University of Tennessee, Memphis. Sixteen African-American first renal allograft recipients received induction therapy: 11 CAD allografts (10 OKT3, 1 ATGAM) and five LRD (all ATGAM). Sixteen Caucasian recipients received induction therapy; 3 CAD (all OKT3), 1 living-unrelated donor (OKT3), and 12 LRD (9 ATGAM, 3 OKT3). Mean age at renal transplantation was 11.8 and 10.5 years for African-American and Caucasian recipients, respectively. Predicted graft survival (PGS) estimated by the Kaplan-Meier method for the African-American patients was 94% at both 1 and 3 years, and for Caucasian patients was 94% and 85% at 1 and 3 years, respectively. Eleven African-American CAD recipients had a PGS of 91% at 1 and 3 years. Renal allograft survival for African-American and Caucasian pediatric recipients at our center appears to be comparable. This could be due, in part, to the use of anti-lymphocyte induction therapy. However, other factors, such as improved compliance or better immunological and pharmacological monitoring, may also have contributed. Received April 18, 1997; received in revised form January 14, 1998; accepted January 19, 1998     

Durable efficacy of early postoperative radiation therapy for high-risk pT3N0 prostate cancer: the importance of radiation dose

Objectives. To determine the durable efficacy of early postoperative radiation therapy (RT) in patients with pT3N0 prostate cancer who were at an increased risk of biochemical failure. We also evaluated the long-term benefit derived from using higher RT doses.Methods. Seventy-nine patients with pathologic Stage T3N0 prostate cancer and high-risk postoperative features underwent RT within 6 months after surgery. No patient received prior hormonal therapy. Fifty-nine patients had positive surgical margin, 29 had pathologic seminal vesicle invasion, and 27 had persistently elevated postoperative prostate-specific antigen (PSA) levels. Freedom from biochemical relapse (bNED) was defined as an undetectable (less than 0.2 ng/mL) PSA level. Median follow-up time was 39 months, and the median radiation dose was 64.8 Gy. All patients were followed for at least 2 years to be considered biochemically controlled.Results. Patients receiving adjuvant RT for an undetectable pre-RT PSA level had a 3-year bNED rate of 90%, compared with 44% for those receiving salvage RT for a detectable level (P < 0.0001). In the group of adjuvant patients, RT doses more than 61.2 Gy resulted in a 3-year bNED rate of 90% compared with 64% for those receiving a lower dose (P = 0.015). The salvage patients irradiated with a dose of 64.8 Gy or greater had a 3-year bNED rate of 52% compared with 18% for those irradiated with lower doses (P = 0.048). Severe late RT-related complications were infrequent and did not correlate with dose.Conclusions. In patients with high-risk pT3N0 prostate cancer, an RT dose response may exist. Although some studies suggest limited durable efficacy for early postoperative RT, our data suggest that RT doses of 64.8 Gy or more appear superior to prevent future biochemical failures. A prospective randomized study evaluating a postoperative RT dose response is warranted.