Spontaneous partial rupture of the upper renal tract

Spontaneous partial rupture of upper renal tract is rare and is usually associated with urolithiasis. Other causes include instrumentations, trauma, pelvic cancer, retroperitoneal fibrosis, fluid overload, and pregnancy. We report two cases (46-year-old and 41-year-old men) of upper renal tract rupture. The first case had rupture of the ureter proximal to stone impaction and the second case had fornicial rupture secondary to stone impaction at the uretero-vesical junction. In contrast to ureteral rupture, fornicial extravasation is more common and the symptoms are always mild. The mechanism of ureteral rupture can be explained as either pressure around the ureteral wall due to stone impaction, or a tear caused by pressure during the passage of the stone. Fornicial rupture occurs when intra-pelvic pressure is greater than 35cm H2O. It is important to distinguish true rupture of the ureter from fornicial tear with extravasation, because both the outcome and treatment are different.

Methylene blue for sentinel lymph node localisation in breast cancer surgery: Experience of RIPAS Hospital

Introduction Axillary lymph node dissection (ALND) is a standard procedure in the management of breast cancer for diagnosis of axillary node metastasis and for local control. The aim of this study was to investigate the ease and the effectiveness of using methylene blue dye in the localisation of sentinel lymph node (SLN) and biopsy (SLNB) in patients undergoing surgery for breast cancer at RIPAS Hospital. Materials and Methods Twenty-five patients with confirmed fine needle aspiration cytological diagnosis of breast cancer, who were undergoing planned mastectomy and axillary node clearance, were included in the study. Four to five milliliters of methylene blue dye was injected into the peri-tumour area 20 to 30 minutes preoperatively before surgical incision was made. All SLNs were submitted for intra-operative frozen section analysis. All patients underwent mastectomy and Level II axillary clearance. Results Methylene blue dye staining and localisation of SLNs were positive in 22 (88%) patients, out of which 10 (45.45%) patients had SLN which were positive for metastasis. In three patients (12%), the dye failed to reach the axilla with one patient having micro-metastasis in the axillary lymph nodes. The mean duration to SLN harvesting was 20 min (range 15 to 25 min) after injection of the methylene blue. Complications included blue discolouration of urine (28%), post-operative fever (4%), tattooing near the scar (4%) and a small area of skin necrosis near the scar (4%). Conclusions In our setting, SLNB using methylene blue dye is also an effective method for accurately identifying SLNs in breast cancer patients and provide an accurate pathological staging without having to do a formal axillary clearance.

Primary angiosarcoma of the breast

Breast cancer is increasing and is the most common cancer among females in Brunei Darussalam. Most are ductal carcinoma. We report a case of a 40-year-old woman who was diagnosed with primary angiosarcoma of the right breast, a rare condition. To the best of our knowledge this is the only reported case in Brunei Darussalam. She underwent lumpectomy followed by mastectomy as the resection margins were not clear. No adjuvant therapy was given because the size of tumour was small, there was no residual tumor in mastectomy specimen and she had no distant metastasis.

Evaluation of the RIPASA Score: a new appendicitis scoring system for the diagnosis of acute appendicitis

Introduction: We recently developed a scoring system for diagnosis of acute appendicitis. This study prospectively evaluates the Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) score for the diagnosis of acute appendicitis in patients presenting to the Accident & Emergency department or the Surgical wards with right iliac fossa pain. Materials and Methods: From November 2008 to April 2009, consecutive patients presenting to the Accident & Emergency department or the surgical wards with right iliac fossa pain were recruited for the study. The RIPASA score was applied but the decision for radiological investigations or emergency appendicectomy was made based on clinical judgement. Receiver operating curve (ROC), sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the new scoring system were derived. Ethical approval for the study was obtained from the Medical & Health Review Ethics Committee. Results: Within six months, 144 consecutive patients with a mean age of 29.5 ± 13.3 yrs were recruited to the study. Ninety-eight patients underwent emergency appendicectomy of which 79 were confirmed histologically for acute appendicitis. The observed negative appendicectomy rate was 19.4%. The optimal cut-off threshold score from the ROC was 7.5, with a sensitivity of 97.5%, specificity of 81.8%, PPV of 86.5%, NPV of 96.4% and a diagnostic accuracy of 91.8%. The predicted negative appendicectomy rate was 13.5%, which is a 5.9% reduction from the observed rate of 19.4% (p=0.3). Conclusion: The RIPASA score is a more suitable appendicitis scoring system developed for our local settings with a population that is reflective of our region in South-east Asia and has high sensitivity, specificity and diagnostic accuracy.