Melanoma of the glans penis and urethra.

Primary melanoma of the glans or male urethra is a rare malignant tumor with high mortality. We searched PubMed and found 129 articles reporting on 220 patients. All articles were case reports or case series. Median patient age was 65 years. Median survival was 28 months, with 5-year survival in approximately 10%. All patients who survived over 5 years had a localized disease (stage I/A) with invasion depth <3-3.5 mm. Wide local excision with sentinel lymph node biopsy is the treatment of choice for patients with localized disease. For advanced disease, the prognosis is poor.

A new approach for transversalis fascia reinforcement in Lichtenstein's inguinal hernia repair.

Operations undertaken for inguinal hernia repair are the most common elective surgical procedures. According to the current guidelines, Lichtenstein's tension-free method is the gold standard for elective hernia operations. The most common types of implanted mesh are polypropylene and composite mesh. We herein present Lichtenstein's operation using a biological hemostatic mesh (Tachosil) used for transversalis fascia reinforcement, and our results after a 3-year follow-up period for 52 patients implanted with Tachosil mesh are reported. According to our results, the biological mesh can be safely implanted during hernia repair with the same recurrence rate and lower postoperative pain and complications compared to hernia repair with polypropylene mesh implantation.

Urinary retention presenting as complete bowel obstruction.

A 59-year-old male was admitted to hospital for clinical and radiological signs of large bowel obstruction with clinical signs of generalized peritonitis. As such, he was scheduled to undergo emergency exploratory laparotomy. During preoperative preparation, over 2000 mL of urine was obtained after catheterization. We suggested re-evaluation, and after several hours the symptoms resolved. Although rare, pressure from the distended bladder due to urinary retention can cause complete bowel obstruction and signs of peritonitis. If a large volume of urine is obtained during preoperative preparation for mechanical bowel obstruction, it is recommended to re-evaluate the patient to avoid unnecessary surgery and imaging studies.

Aortoduodenal fistula three years after aortobifemoral bypass: case report and literature review.

Secondary aortoenteric fistulas (SAEF) are a relatively rare but dangerous complication of aortal reconstructive surgery. We present a patient that underwent aortobifemoral bypass three years before developing the signs of aortoenteric fistula, and we reviewed the literature on the topic. Since the clinical signs are nonspecific, physicians should have a high index of suspicion for SAEF in patients who underwent aortal reconstructive surgery. The most useful diagnostic tools for stable patients are upper gastrointestinal endoscopy and computed tomography scan with contrast that can, in combination with history and clinical signs, enable accurate diagnosis in more than 90% of patients. Unstable patients with suspected aortoenteric fistula should undergo exploratory laparotomy. The treatment of choice is open surgery with graft excision, wide debridement of infected tissue, bowel repair or resection followed by an extra-anatomic bypass or in situ placement of a new graft. Early postoperative mortality remains high, around 30% in most analyses. Currently there are no guidelines for the diagnosis and management of SAEF, so individualized approach is necessary for each patient.

Differential diagnosis and clinical relevance of pneumobilia or portal vein gas on abdominal x-ray.

The purpose of the article is to present the differential diagnostic criteria between pneumobilia (air in the biliary system) and portal vein gas on abdominal x-ray. Differential diagnosis is essential because of its influence on patient management. Two patients are presented, one with pneumobilia and the other with portal vein gas on abdominal x-ray, with review of the relevant literature. Pneumobilia is often iatrogenic and even in cases of cholecystitis it is never a sole indication for emergency surgery. Patients with pneumobilia on abdominal x-ray can always be investigated further. On the other hand, the presence of air in portal vein is in most cases a sign of acute mesenteric ischemia. In adults with abdominal pain indicating intestinal ischemia (pain that is 'out of proportion' to clinical abdominal examination findings), it is an indication for emergency exploratory laparotomy. It is vital to act early when intestinal ischemia is suspected.

Fournier's gangrene: etiology and outcome analysis of 41 patients.

INTRODUCTION: Fournier's gangrene (FG) is the necrotizing fasciitis of the perineum and genital area with high mortality. MATERIALS AND METHODS: A retrospective review included 41 patients diagnosed with FG in our hospitals from 1995 to 2010, divided into survivors and nonsurvivors. We analyzed anamnestic, clinical and laboratory data. RESULTS: The mortality rate was 36.6% (15/41 patients). Elevated heart and respiratory rates, high serum creatinine, low serum bicarbonate, pre-existing kidney disease, and higher median extent of affected body surface were associated with higher mortality. Severe sepsis on admission and hypotension below 90 mm Hg were also predictive for higher mortality. The median FG severity index (FGSI) score was higher in nonsurvivors (11 compared to 6, p < 0.0001). No cases of testicular necrosis were noted. CONCLUSION: Besides standard clinical and laboratory parameters included in the FGSI calculation, higher extent of affected body surface area and presence of hypotension on admission were also positively associated with mortality.

A randomized clinical trial comparing Ligasure versus stapled hemorrhoidectomy.

Stapled hemorrhoidectomy (SH) and Ligasure hemorrhoidectomy (LH) are standard for hemorrhoidal disease treatment, but the surgical principle is different. This randomized clinical trial compared the 2 methods. We included 98 patients with grade 3 hemorrhoidal disease: 46 patients treated by SH and 52 patients by LH. Incidence of complications, recurrence, postoperative pain, wound healing time, and time off everyday activity were observed. The follow-up period was 24 months. We found that LH has a significantly shorter wound healing time. The recurrence rate and the overall postoperative complication rate was higher after SH but not significantly (recurrence LH vs. SH: 1.9% vs. 11.1%; complications LH vs. SH: 13.5% vs. 23.9%). Postoperative pain level, analgesic consumption, and time off everyday activity were practically the same in both groups. Both procedures can be used to treat grade 3 hemorrhoidal disease with the same efficacy, but analysis of recurrence after SH is necessary.

An unusual cause of anuria and hydronephrosis in a 12-year-old girl.

A 12-year-old girl was admitted for abdominal pain and signs of acute kidney injury. Physical examination showed abdominal distension and a tumefaction in the lower abdomen. Laboratory and clinical findings were consistent with acute kidney injury. Abdominal ultrasonography showed an oval mass, which corresponded with hematometrocolpos, and right-sided hydronephrosis. Catheterization followed by cruciate hymenectomy was performed. The patient recovered completely. Imperforate hymen is an obstructive anomaly of the female reproductive tract of unknown etiology that can cause a variety of symptoms. It is a rare, but possible cause of acute kidney injury. Patient history data and genital examination findings are sufficient to establish the diagnosis. Abdominal ultrasonography is the most useful diagnostic modality.

Surgical treatment of pathologic fractures in patients with metastatic tumors.

The study presents results in treatment of pathologic fractures of long bones of all patients who underwent surgery in the last 10 years in our hospital. The study cohort comprised 133 consecutive patients divided in two groups who underwent surgery of long bone fractures caused by metastatic tumor or trauma. We used resection, open reduction and plating with bone cement application for pathologic fracture and some cases of femoral shaft fractures were stabilized with intramedullary nailing. Proximal femoral fractures were treated with hip arthroplasty or dynamic hip screw. There were 2 amputations performed: one case of pathologic fracture of tibia and one case of humeral fracture. The present study compares results between two group of patients. We noted: age, gender, fracture site, choice of the surgical procedure, hospital stay, need for analgesia after surgery, postoperative complications, and reached level of physical activity after surgery. The mean survival rate was 8.1 months. Seventeen patients experienced postoperative complications. We also found statistically significant improvement in functional scores (MSTS and TESS) in surgically treated patients with pathologic fractures. There are many different techniques of surgical treatment of pathologic fractures caused by skeletal metastases including arthroplasty or a combination of internal fixation combined with polymethyl methacrylate (PMMA) that provides immediate fixation and stability. The present study showed that surgical treatment of pathologic fractures caused by skeletal metastases in vast majority of cases provides bone healing after pathologic fracture, with significant improvement of physical activity and rehabilitation in the investigated group.

[Physiological and clinical outcome of open and closed hemorrhoidectomy compared with stapling method according to long]. / Usporedbe fizioloske i klinicke ucinkovitosti otvorene i zatvorene hemoroidektomije i staplerske hemoroidektomije po longu.

AIM OF STUDY: The aim of the study was to evaluate and inaugurate a new method for the treatment of hemorrhoidal disease with the usage of a stapling device (Long's method). PATIENTS: The study spanning two years (September 1999 to June 2001), included 97 hospitalized patients aged 19-75 years, 42 (43.3%) female and 55 (56.7%) male, exhibiting symptoms and signs of stage III hemorrhoidal disease. The patients were divided into three groups: (a) 35 patients treated with open hemorrhoidectomy for stage II hemorrhoidal disease; (b) 30 patients treated with closed hemorrhoidectomy for stage III hemorrhoidal disease; and (c) 32 patients treated for stage III hemorrhoidal disease by a stapling device, i. e. Long's method. RESULTS: Study results showed no statistically significant differences between either open or closed hemorrhoidectomy and Long's method in the following parameters: urinary retention, early bleedings during the first 48 hours, late bleedings, incontinence, anal stenosis, and relapses. Statistically significant differences between the groups of patients treated with either open or closed hemorrhoidectomy and those treated with Long's method were recorded in the following parameters: healing time, subjective feeling of pain, pain pro rata to quantity, and use of analgesics. CONCLUSION: Hemorrhoidectomy by Long's method is an ideal surgical procedure because it allows to realize to goals set on implementing new therapeutic methods: to achieve healing without relapse, to reduce postoperative pain, anal stenosis and incontinence after hemorrhoidectomy, to preserve the physiology of the anal canal, and to familiarize less skilled proctology surgeons with the simplicity of the method.