The 5-year outcome of patients having incomplete colonoscopy.

AIM: Incomplete colonoscopy indicated for the detection of neoplasia occurs in 2-23% of patients, but there is little information on the long-term outcome of such patients. METHOD: All patients who underwent colonoscopy over 5 years at the Royal Liverpool University Hospital with a follow-up of up to 5 years were identified. RESULTS: The risk of colorectal cancer (CRC) was 2.9% (312/10 580) for all patients undergoing colonoscopy. For a failed colonoscopy, the risk was five-fold higher [14.3% (99/693)]. The mean age of the patients was 61 years and 58% were female. Following incomplete colonoscopy the risk of finding additional CRC, advanced colonic neoplasia and extracolonic neoplasia on subsequent investigation was 6.2%, 3.2% and 1.9%. The diagnostic yield on subsequent investigation for CRC or colonic polyps was 7% for repeat colonoscopy, 13.4% for computed tomography colonography, 10.3% for standard computed tomography and 1.8% for barium enema. In the 363 patients who were not offered a subsequent investigation, there was no further instance of CRC or CRC-related mortality over a 36-month period. CONCLUSION: Although the risk of CRC is higher in patients who have had a failed colonoscopy, a protocol approach of subsequent investigation should not replace clinical assessment on whether another test is necessary in the light of the good outcome of patients who were not subsequently investigated.

The urachal flap: a previously unreported tissue flap in vesicovaginal fistula repair.

OBJECTIVES: Tissue interposition is an important part of vesicovaginal fistula (VVF) repair that has been shown to improve success rates. The most common interpositional flap used during a transabdominal VVF repair is the omental flap; however, in some cases, it cannot be used. The urachus is a well-vascularized tissue that is easily mobilized for interposition. We describe our experience using a urachal flap in VVF repair. METHODS: Patients undergoing VVF repair at our center were identified, and a retrospective chart review was performed. Patients who underwent a transabdominal repair with interposition of a urachal flap were included. RESULTS: Thirteen patients were identified between 2005 and 2009. All were evaluated with a history, physical, upper and lower tract imaging, and cystoscopy. Median patient age was 49 years (range, 31-88 years). Fistula etiology was hysterectomy in 11 and prolapse repair in 2. Five patients presented with recurrent fistulas having failed previous repair. Of 13 patients, 12 had successful repairs with our described technique, including 4 patients who failed previous repairs. There was no recurrence of fistula after median follow-up of 6 months (range, 2 weeks to 4 years). Two patients had preoperative and postoperative complaints of stress urinary incontinence that was mild and did not require surgery. CONCLUSIONS: Vesicovaginal fistulas can be a difficult challenge for the reconstructive surgeon. The urachal flap is a well-vascularized tissue flap that can be easily mobilized and interposed for VVF repair. Of 13 patients in this series, 12 were successfully repaired using this technique. We feel that further evaluation and usage of this tissue flap are indicated.

Outcome of penile revascularization for arteriogenic erectile dysfunction after pelvic fracture urethral injuries.

OBJECTIVE: To review our experience with penile revascularization for patients with bilateral occlusion of the deep internal pudendal arteries after pelvic fracture urethral injury (PFUI). MATERIALS AND METHODS: We identified 17 patients who had undergone penile revascularization with end-to-side anastomosis of the deep inferior epigastric artery to the dorsal penile artery from July 1991 to December 2010. Success was defined as achieving erections sufficient for intercourse with or without pharmacologic assistance. RESULTS: All patients had had a PFUI causing arterial insufficiency and erectile dysfunction not responsive to pharmacologic intervention. Of the 17 patients, 4 (24%) underwent revascularization before and 13 (76%) after PFUI repair. The mean age at revascularization was 32.7 years (range 17-54). At an average follow-up of 3.1 years, the surgery was successful in 14 of the 17 patients (82%). In patients with erectile dysfunction as an indication for surgery, successful erections were achieved in 11 of 13. For those who underwent revascularization to prevent ischemic stenosis of the urethral repair, 3 of 4 achieved successful erections, and all subsequent urethral surgeries were successful. The penile duplex ultrasound parameters showed clinically and statistically significant improvements after revascularization. No operative complications developed. The average hospital length of stay was 4.7 days. Four patients experienced early postoperative complications, including an abdominal wall hematoma requiring evacuation in one, penile edema in two, and a superficial surgical site infection in one. No late complications occurred. CONCLUSION: Penile arterial revascularization in select patients can allow for successful treatment of PFUIs and the refractory erectile dysfunction caused by them.

Assessment and initial management of urologic trauma.

This article discusses the appropriate assessment, initial management, timely referral to a urologist for abdominal, bladder, urogenital, and renal/renal collecting system injury. Appropriate laboratory and physical examinations, as well as radiologic imaging, are paramount to obtaining accurate diagnosis and to providing appropriate treatment.

Correlation of CT scan versus plain radiography for measuring urinary stone dimensions.

OBJECTIVES: To correlate the measured dimensions of urinary stones from spiral non-contrast computerized tomography (CT) with that of plain radiography (KUB). METHODS: The transverse diameter as reported on CT was compared to the measured transverse diameter on KUB for 61 stones. The transverse and craniocaudal dimensions on CT were then re-measured for 30 urinary stones and again compared to the re-measured values for KUB. The craniocaudal dimension on CT was determined by measuring the stone on reconstructed coronal CT images. Measurements between imaging modalities were blinded and performed consecutively by a dedicated investigator. RESULTS: The mean transverse size of the stones on the initial CT report was 6.0 mm +/- 2.8 mm versus 5.6 mm +/- 2.3 mm on KUB (paired t-test, p = 0.05, 95% CI difference between the means -1.3 to 0.5). The stones were categorized in transverse size ranges of 1.0 mm to 5.0 mm, > 5.0 mm to 10.0 mm, and > 10.0 mm. A total of 14 stones failed to be put into the same size categories by the two methods. The largest difference in measurements was 5 mm. In the second analysis, where the CT dimensions were re-measured, the mean transverse dimension on CT was 4.5 mm +/- 2.1 mm versus 4.7 mm +/- 2.0 mm on plain radiography (paired t-test, p = 0.06, 95% CI difference between the means -0.02 to 0.6). Mean craniocaudal dimension of the stones on CT was 7.4 mm +/- 3.2 mm versus 6.0 mm +/- 2.7 mm on plain radiography (paired t-test, p = 0.0001, 95% CI between the means -2.0 to -0.9). When the stones were categorized in transverse size ranges of 1.0 mm to 5.0 mm, >5.0mm to 10.0mm, and >10.0mm, CT and KUB agreed for 30/30 stones. CONCLUSIONS: In this study, the initially reported CT transverse values were found to be significantly different from measured KUB values; moreover, large differences of up to 5 mm were found between the measurements. With fastidious measurement of stone dimensions on both CT and KUB, we found that the transverse dimension of stones measured by the two imaging modalities were similar. The craniocaudal measurements of the stones were found to be significantly different on CT versus KUB, with CT measurement being 1.4 mm larger on average.

Intact specimen extraction in laparoscopic nephrectomy procedures: Pfannenstiel versus expanded port site incisions.

OBJECTIVES: Laparoscopic nephrectomy is considered the standard of care for most Stage T1 and T2 renal tumors. Most centers perform intact extraction rather than morcellation. The extraction incision location varies, with no consensus on the best site. We compared the operative and perioperative parameters after transperitoneal laparoscopic nephrectomy procedures with intact specimen extraction through a Pfannenstiel (PFN) or expanded port site (EPS) incision. METHODS: The consecutive charts of 150 patients (March 2001 to October 2003) undergoing laparoscopic radical nephrectomy (LRN), laparoscopic nephroureterectomy, or laparoscopic donor nephrectomy with intact specimen extraction were reviewed. The specimens were extracted by way of a PFN or an EPS incision. Two analyses were completed. The first included only LRN, and the second included LRN, laparoscopic nephroureterectomy, and laparoscopic donor nephrectomy. RESULTS: In the LRN-only analysis, the PFN group had a shorter hospital stay (2.84 versus 3.37 days, P <0.05). This group also used significantly less morphine (23.7 versus 47.3 mg, P <0.006). The PFN group in the second analysis also used less morphine (26.3 versus 51.1 mg, P <0.002). Four extraction site complications were found; 1 patient in the PFN group developed cellulitis, and 3 patients in the EPS group developed an incisional hernia. CONCLUSIONS: This evidence suggests reduced morbidity with intact specimen extraction through a PFN incision compared with an EPS incision during laparoscopic nephrectomy procedures. Our practice has been modified on the basis of these data, and all specimens are now removed through a PFN incision when suitable. Urologists should consider PFN incisions for specimen extraction with laparoscopic nephrectomy procedures.

Distal Interphalangeal Joint Arthrodesis Using Intramedullary and Interosseous Fixation.

Multiple fixation techniques have been developed for distal interphalangeal (DIP) joint arthrodesis. Delayed and nonunion rates varying from 0% to 20% have been reported. The senior author has refined a technique for DIP joint arthrodesis by using an intramedullary Kirschner wire and an interosseous wire for fusion of the DIP joint and interphalangeal (IP) joint of the thumb. In 24 joint arthrodeses in 19 patients, the nonunion rate was 4%, and the minor complication rate was 12%. The advantages of this technique include the absence of protruding hardware that would necessitate removal; consistency in achieving osteosynthesis, with a low nonunion rate; and technical simplicity.

Pedicled latissimus dorsi transfer for immediate soft-tissue coverage and elbow flexion.

This case report describes a new method of unipolar transfer of the latissimus dorsi for restoration of elbow flexion. The advantages of the technique are that it has superior resting tension compared to other unipolar transfers and provides more extensive soft-tissue coverage at the elbow than other unipolar or bipolar transfers. The disadvantage is that it does not restore the supinator function of the biceps. The technique is felt suitable for traumatic defects requiring extensive soft-tissue coverage as well as restoration of an active elbow flexor.

Modification interference analysis of a self-cleaving RNA from hepatitis delta virus.

A chemical modification-interference assay was used to evaluate the sequence requirements for self-cleavage of a 73-nucleotide self-cleaving RNA from the genomic hepatitis delta virus (HDV). Twenty-two nucleotides were categorized as individually essential for self-cleavage, shown by loss of activity when modified. All of these required nucleotides fell within 38 nucleotides downstream of the cleavage site, suggesting an essential structural or functional role for this region. Lesser effects were seen for nucleotides further 3' of the cleavage site, and a small number of nucleotides had a negligible effect on the extent of self-cleavage when modified. Several modifications increased the extent of self-cleavage, suggesting these nucleotides may act to inhibit the reaction when unmodified. The functional requirements for certain nucleotides are discussed in the light of structural probing data and conventional mutational analysis available for other HDV RNAs.

Inhibition of proteoglycan synthesis alters extracellular matrix deposition, proliferation, and cytoskeletal organization of rat aortic smooth muscle cells in culture.

Arterial proteoglycans have been implicated in several important physiological processes ranging from lipid metabolism to regulation of smooth muscle cell growth. Vascular smooth muscle (VSM) cells are the major producers of proteoglycans in the medial layer of blood vessels. To study functional consequences of alterations in VSM proteoglycan metabolism we used 4-methylumbelliferyl-beta-D-xyloside to inhibit proteoglycan synthesis in primary and early passage cultures of rat aortic smooth muscle cells. Biochemical analysis of cultures labeled with 35SO4 showed the drug inhibited synthesis of different classes of proteoglycans by 50 to 62%. Inhibition of proteoglycan synthesis resulted in reduced accumulation of extracellular matrix, as shown by immunofluorescent staining with antibodies to chondroitin sulfate, fibronectin, thrombospondin, and laminin. There was also an inhibition of postconfluent (multilayered) growth of the smooth muscle cells, and a change in the morphology of the cells, with no apparent effect on subconfluent growth. In addition, in drug-treated cells there was a reduction in the number of cytoskeletal filaments that contained alpha-actin, the actin subtype synthesized by differentiated VSM cells. This occurred even though the total content of alpha-actin in the cells was not reduced. The effects of the inhibitor on growth and morphology could be reversed by switching the cultures to normal medium and could be prevented by growing the cells on preformed VSM extracellular matrix. These observations suggest the vascular extracellular matrix may play a role in regulating the growth and differentiation of smooth muscle cells.