A case of systemic polyarteritis nodosa with spermatic cord involvement.

BACKGROUND: A 50-year-old man with a history of hyperlipidemia and hypertension presented to an emergency department after 10 days of fevers (temperature 40 degrees C), headache, malaise, myalgia, poor appetite, diarrhea, and weight loss of 6.35 kg. He would subsequently develop bilateral scrotal swelling and pain during his evaluation. INVESTIGATIONS: Physical examination, CBC, blood chemistry panel, measurement of erythrocyte sedimentation rate and C-reactive protein level, liver function profile, urinalysis, lumbar puncture, blood cultures, urine cultures, cerebrospinal fluid culture, stool analysis and cultures, multiple viral studies including hepatitis serologies, measurement of antineutrophil cytoplasmic autoantibody levels, urine protein electrophoresis, serum protein electrophoresis, CT of the head, chest, abdomen and pelvis, MRI of the brain, temporal artery biopsy and pathologic analysis, scrotal ultrasonography, right spermatic cord biopsy and pathologic analysis. DIAGNOSIS: Polyarteritis nodosa with involvement of both spermatic cords. MANAGEMENT: Prednisone 60 mg daily was started for presumed temporal arteritis, but was discontinued when no evidence of arteritis was found in the temporal artery biopsy specimen. When pathologic analysis of the spermatic cord biopsy tissue confirmed polyarteritis nodosa, prednisone 40 mg twice daily was administered and the patient's scrotal pain and swelling resolved quickly. Steroids were slowly tapered and discontinued over the next 18 months. He remained free of systemic symptoms, with normal results on physical examination and laboratory evaluation, including urinalysis, CBC, erythrocyte sedimentation rate and C-reactive protein level, 5.5 months after discontinuation of glucocorticoid therapy.

High rate of vaginal extrusion of silicone-coated polyester sling.

OBJECTIVES: To report the results of a pilot study evaluating the suitability of silicone-coated polyester as a suburethral sling material for female stress incontinence surgery. METHODS: Ten women with stress or mixed urinary incontinence were prospectively evaluated with history and physical examination, pad test, urodynamic studies, and the Incontinence-Quality of Life questionnaire. The 2 x 7-cm sling was secured with transvaginal bone anchors placed through an anterior vaginal wall incision. Patients were evaluated at 1, 6, and 12 months by history and physical examination, pad test, and the Incontinence-Quality of Life and Success Rate and Overall Patient Satisfaction questionnaires. RESULTS: Ten patients (mean age 62.3 years) underwent successful placement of the suburethral sling. The Incontinence-Quality of Life scores improved from a mean total score of 43.3 +/- 14.6 preoperatively to 97.7 +/- 14.4 at 1 year postoperatively (P <0.001). The Success Rate and Overall Patient Satisfaction questionnaires completed at 1 year demonstrated a mean satisfaction rating of 8.9 +/- 1.7 (scale 1 to 10), and the mean reported improvement in incontinence was 90% +/- 16.3%. The mean pad weight decreased from 103.1 +/- 33.2 g preoperatively to 1.6 +/- 1.01 g at 1 year (P <0.007). Two patients (20%) developed vaginal extrusion of the suburethral sling at 6 and 10 months. The slings were removed surgically. Both women healed without incident and reported continued continence at 1 year without additional surgical intervention. CONCLUSIONS: Placement of a suburethral sling using transvaginal bone anchors and silicone-coated polyester is an effective surgical treatment for stress urinary incontinence at 1 year. The high rate of vaginal extrusion in our series limits its utility.

Local hemostasis during laparoscopic partial nephrectomy using biodegradable hydrogels: initial porcine results.

BACKGROUND AND PURPOSE: Despite the advance of laparoscopic partial nephrectomy, significant technical limitations remain with regard to control of bleeding and closure of the collecting system. An attractive approach on the horizon for local hemostatic and wound control is the use of local tissue sealants. To date, sealants remain largely derived from natural biologic products and are difficult to apply laparoscopically with precise local control. In this study, we examined the novel strategy of forming occlusive tissue-adherent hydrogels utilizing a synthetic biodegradable polyethylene glycol-lactide copolymer (PEG-lactide) as an in situ occlusive barrier for hemostasis and wound control. Specifically, the objects of this study were to determine if PEG-lactide hydrogels could be formed intraperitoneally on renal tissue, to test the adhesiveness of the hydrogels to injured renal parenchyma, and to evaluate the ability of adherent hydrogel barriers to limit renal parenchymal bleeding and collecting system leakage following renal pole amputation or wedge excision. MATERIALS AND METHODS: Five kidneys from three female pigs were used in a nonsurvival study. A standardized model for laparoscopic partial nephrectomy was created by performing wedge excision or polar amputation under vascular control using a laparoscopic Satinsky clamp. Bleeding briskness following injury was assessed utilizing a scoring system and free blood quantitated comparing a conventional "clamp and wait" strategy with an adherent hydrogel strategy. For the hydrogel group, PEG-lactide hydrogel primer and macromer were applied through laparoscopic ports. The hydrogel was polymerized using a xenon light source, and the pedicle clamp was released to observe for bleeding. A subsequent opposite polar injury was created to confirm renal perfusion and the sites were compared. The kidneys were removed, and the adhesion of the hydrogel to the renal parenchyma was examined. RESULTS: The PEG-lactide macromer was effectively applied to five kidneys following partial nephrectomy. In all cases, successful intraperitoneal in situ polymerization was achieved, with resultant hydrogel formation. Polymeric hydrogel adhesion to the cut renal parenchyma was assessed semiquantitatively following vigorous cyclic washing. In all cases, polymer gels remained adherent without any evidence of peeling, delamination, or separation from the underlying tissue surface. In the control group, the mean bleeding score was 2.63 +/- 0.48 v 0.00 +/- 0.00 in the gel-treated group (P < 0.001). Blood loss in the control group was 56 +/- 5 ml v 0.00 +/- 0.00 in the gel-treated group (P < 0.001). In an ex vivo retrograde ureteral perfusion, no leakage was observed at pressure as high as 100 mm Hg. CONCLUSIONS: In this feasibility study, a biodegradable PEG-lactide polymer system photopolymerized rapidly in situ on exposed renal parenchymal surfaces, forming adherent hydrogel barriers. When applied during vascular clamping, an adequate physical bond and patch-like cap was created to prevent bleeding at physiologic renal perfusion pressures. Use of locally applied occlusive hydrogels holds promise for hemostasis and local wound control during laparoscopic urologic procedures.