Bilateral hand-assisted laparoscopic nephrectomy in adult polycystic kidney disease patients: a UK centre experience.

PURPOSE: We report our experience with bilateral hand-assisted laparoscopic nephrectomy in patients with adult polycystic kidney disease. MATERIALS & METHODS: Between November 2009 and November 2010, 3 patients with adult polycystic kidney disease underwent bilateral hand-assisted laparoscopic nephrectomy in our institution. Indications for bilateral nephrectomy included recurrent cyst hemorrhage, impaired gastrointestinal function and early satiety due to direct intestinal compression by large polycystic kidneys, and anatomical lack of space for future renal transplantation. We retrospectively reviewed the records of these patients and we are reporting our experience. RESULTS: All three patients successfully underwent bilateral hand-assisted laparoscopic nephrectomy with a mean operating time of 208 minutes (range 195 to 220). There were no conversions to open procedure. Blood loss was less than 100 ml in all cases. Mean renal unit size was of 2037 g (range 1798 to 2214). Hospital stay ranged from 10 to 12 days. One patient developed a chest infection postoperatively and suffered from a prolonged ileus. Another patient developed a retroperitoneal hematoma, which was treated conservatively. CONCLUSIONS: Bilateral hand-assisted laparoscopic nephrectomy is a feasible and safe procedure in adult polycystic kidney disease patients, which has potential benefits of a shorter hospital stay and reduced morbidity and mortality in comparison to open procedure.

Day case laparoscopic nephrectomy: initial experience.

RATIONALE: Laparoscopic nephrectomy tends to become the new gold standard surgical technique in a selected population (non-functioning kidney, localised renal cell carcinoma). Day surgery is a popular pathway of care and, procedures of ever-increasing complexity are being considered. OBJECTIVE: The aim of the study was to report the postoperative complications of day case laparoscopic nephrectomy, according to the Clavien system, and, to assess the feasibility of the procedure performed as a day case. MATERIAL AND RESULTS: This study included all the patients considered for day case transperitoneal laparoscopic nephrectomy between May 2008 and November 2009. Sixteen consecutive patients were enrolled in this retrospective study. There were ten procedures on the left hand-side and six on the right hand-side. Age ranges from 22 to 77 years old. Male to female ratio was 9:7. The preoperative diagnosis was non-functioning kidney in 9 cases and kidney tumour in the other 7 cases. All but two patients have been discharged in the same day (87.5%). The readmission rate was of 12.5%. One wheel-chair bonded patient was readmitted four days after the procedure, because of adynamic ileus, and another one three days later because of wound infection. There were two grade I and one grade IV complications (Clavien system). The patient readmitted with grade IV complication, wheel-chair bonded because of cerebral palsy, was not a typical day surgery patient. DISCUSSION: The vast majority of complications were minor and resulted in no residual disability. In our small series, the day case laparoscopic nephrectomy was feasible and safe.

Spontaneous intracerebral haemorrhage following evacuation of chronic subdural hematomas.

Spontaneous intracerebral haematoma (ICH) is an extremely unusual complication following the evacuation of a chronic subdural haematoma (CSDH). Good outcome is expected after the drainage of the CSDH and neurological deterioration is a cause for serious concern. Authors report three cases of spontaneous ICH away from the site of surgery following evacuation of a CSDH with a review of literature. Changes in cortical blood flow following decompression of a long standing CSDH may be responsible for the ICH.

Propionibacterium acnes causing delayed subdural empyema - a case report and review of literature.

The authors report a patient who presented with a delayed subdural empyema caused by Propionibacterium acnes following excision of a meningioma. This organism should be suspected in all patients with delayed empyema especially in the presence of implants and immunosuppression. The main features of this pathogen is discussed. Surgical drainage and high-dose intravenous penicillin should be the recommended therapy.

Efficacy of ADCON-T/N after primary flexor tendon repair in Zone II: a controlled clinical trial.

A prospective double-blind, randomized, controlled clinical trial was conducted to assess the use of ADCON-T/N after flexor tendon repair in Zone II. Forty-five patients with 82 flexor tendon repairs in 50 digits completed the study. ADCON-T/N was injected into the tendon sheath after tenorrhaphy in the experimental group while the control group was not treated with ADCON-T/N. ADCON-T/N had no statistically significant effect on total active motion at 3, 6 and 12 months but the time taken to achieve the final range of motion was significantly shorter in treated patients. ADCON-treated patients had a higher rupture rate but this was not significant.

Contribution of grade, vascular invasion and age to outcome in clinically localized renal cell carcinoma.

OBJECTIVE: To determine the relative prognostic importance of microvascular invasion in apparently localized renal cell carcinoma (RCC). PATIENTS AND METHODS: A retrospective clinical and pathological review was conducted of 176 consecutive patients identified from pathology records who had a nephrectomy for RCC with a median follow-up of 44 months. Vascular invasion was recorded and categorized by the level of microvascular invasion (MVI), renal vein invasion (RVI) and inferior vena cava invasion (IVCI). Tumour type, grade and size were also assessed. These variables were assessed by univariate and multivariate analysis to determine their effect on disease-free survival. RESULTS: In the univariate analysis tumour size, grade, vascular invasion and young age each predicted reduced disease-free survival. On multivariate analysis for all 176 patients, grade, vascular invasion and young age were the significant independent predictors of reduced disease-free survival. In a subgroup of 149 patients from whom those with very high risk determinants were excluded (those with grade 4 tumours and/or IVCI) most of the risk of metastasis could be accounted for by vascular invasion and young age alone (MVI vs no vascular invasion, hazard ratio 3.18, 95% confidence interval 1.29-7.84; RVI vs no vascular invasion 2.41, 0.989-5.89; and age per year 0.963, 0.94-0.992). CONCLUSIONS: Grade, vascular invasion and young age are the main independent predictors of relapse in clinically localized RCC after nephrectomy. For most patients, who do not have very high risk indicators, the main adverse predictors are vascular invasion and young age. These findings are important when selecting patients for trials of adjuvant therapy and have implications for pathological staging.

Venous thromboembolic prophylaxis for transurethral prostatectomy: practice among British urologists.

Venous thromboembolism (VTE) is an occasional cause of death after transurethral prostatectomy but there are no established guidelines for its prevention in relation to this operation. We assessed practice in the UK by mailing a questionnaire to 460 consultant members of the British Association of Urological Surgeons. 362 (79%) completed questionnaires were received. 280 of 362 (77%) respondents routinely used VTE prophylaxis with transurethral prostatectomy; 82 (23%) did not. 230 of the 280 urologists who took precautions used mechanical methods; 50 used low dose heparin, either with stockings or alone. This survey indicates that, despite a lack of clear evidence, most British urologists favour some form of precaution against VTE in patients undergoing transurethral prostatectomy.

The impact of endoscopic third ventriculostomy on the management of newly diagnosed hydrocephalus in infants.

OBJECTIVES: To evaluate the role of endoscopic third ventriculostomy (ETV) as a primary treatment for hydrocephalus in children less than 1 year old and to determine its impact as a whole on the reduction of shunts necessary in a new population of hydrocephalic infants. METHODS: Data were collected prospectively on 47 infants with newly diagnosed hydrocephalus of all aetiologies who were referred between 1st April 1998 and 30th September 2000. Twenty-one patients (median age 6 weeks, range 34 weeks of gestation to 10 months) underwent ETV, while the remaining 26 patients had insertion of a ventriculoperitoneal shunt. Anatomical criteria and demonstration of third ventricle outflow obstruction on preoperative magnetic resonance imaging were used to select patients for ETV. RESULTS: There was no mortality or major morbidity following ETV. The median follow-up period was 18 (range 8-36) months. During the follow-up period, the ETV remained patent in 7 (33%) of the 21 patients. Of the 14 patients with failed ETV, 11 had insertion of a ventriculoperitoneal shunt, while 3 have undergone successful redo ETV. Therefore, in total 10 patients (48%) of the ETV group remain shunt independent. The best results were obtained in patients with congenital aqueduct stenosis with 71% (5 of 7 patients) success rate, while patients with posthaemorrhagic hydrocephalus did particularly badly with only 1 of 10 patients having a successful ETV. Overall, 10 of 47 (21%) infants with newly diagnosed hydrocephalus have avoided a shunt. CONCLUSIONS: Our results suggest that the selective use of ETV as the primary treatment in infants with hydrocephalus is safe and can lead to a reduction in the shunted population of all newly diagnosed hydrocephalic infants by up to 21%. Success of ETV is aetiology, not age dependent.

Significance of CSF area measurements in cervical spondylitic myelopathy.

Mild clinical myelopathy can occur without cord compression, and asymptomatic cord compression seen on MRI is common. The aim of this study was to ascertain the MRI features which best correlate with early clinical myelopathy. The study was conducted on three groups: group A, 20 patients with clinical myelopathy and MRI evidence of cervical spondylosis; group B, 20 patients without myelopathy, but with other clinical and MRI evidence of cervical spondylosis; and group C, 10 normal volunteers with no MRI evidence of spondylosis. The cross-sectional area (CSA) of the spinal cord (SP-CSA), spinal canal (SC-CSA) and CSF space (CSF-CSA) were measured on T1-weighted axial images at the level of the most severe spinal canal stenosis. The severity of myelopathy was assessed using a simple scoring system giving a score from 0 (normal) to 11 (severe). Subjective demonstration of cord compression on sagittal images was an insensitive indicator of clinical myelopathy. All three measures of cross-sectional area were significantly smaller in Group A than in B (p<0.01). The reduction in SP-CSA was the only independent prognosticator for severity of myelopathy (p<0.005) accounting for 63% of the variation in myelopathy score. All three variables showed a significant correlation with the presence of myelopathy (p<0.01); however, logistic regression analysis showed a decrease in CSF-CSA to be the only independent significant prognosticator of the presence of clinical myelopathy (p<0.02). Reduction of the CSF space to less than 0.7 cm2 was associated with a 90% chance of clinical myelopathy (specificity 83%).

Prenatal diagnosis of suprasellar arachnoid cyst and postnatal endoscopic treatment.

Arachnoid cysts are benign developmental anomalies that occur in the cerebrospinal axis in relation to the arachnoid membrane. An antenatal ultrasound scan first raises the suspicion of arachnoid cysts, but misdiagnoses have been reported. Confirmatory antenatal magnetic resonance imaging (MRI) is very useful to delineate anatomical detail and help in correct diagnosis. This helps proper counselling and treatment planning. Controversy also surrounds the surgical management, in terms of both the indications and the procedures employed. We report the successful endoscopic treatment, in a neonate, of an arachnoid cyst diagnosed by antenatal ultrasound and MRI. In this case accurate diagnosis and detailed assessment led to objective counselling and helped to optimise neonatal management.

Epidermoid cysts of the testis: the case for conservative surgery.

The series comprises 6 patients (mean age, 21 years) who presented with an epidermoid cyst of the testis between 1991 and 1998. Pre-operative ultrasonography suggested the presence of a testicular cancer in 3 patients who underwent a radical orchidectomy. The ultrasound successfully predicted the true diagnosis in 3 patients who had a wedge excision of the cyst together with a cuff of normal surrounding tissue. All patients are free of disease with a mean follow-up of 3 years. With increasing awareness of the condition coupled with accurate pre-operative radiological imaging, local excision of an epidermoid cyst with preservation of the remainder of the testis is now a feasible and rational alternative to more radical surgery.

Role of transurethral biopsy sampling of the prostate to diagnose prostate cancer in men undergoing surgical intervention for benign prostatic hyperplasia.

PURPOSE: Newer minimally invasive surgical procedures are being used to treat men with significant benign prostatic hyperplasia (BPH). These modalities do not allow retrieval of prostate tissue for histologic review. The goal of our study was to assess the value of transurethral biopsies in detecting prostate cancer in men who would undergo surgical intervention for BPH. MATERIALS AND METHODS: Between September 1997 and January 1999, 422 men undergoing transurethral resection of the prostate (TURP) had transurethral biopsies obtained before completing the TURP. Pathology reports as well as prostate-specific antigen (PSA) results were reviewed and analyzed to determine when cancer was present. RESULTS: Pathological examination revealed that cancer was found in 53 men (12.5%). The transurethral biopsies detected cancer in 32 of 53 (60.4%). No cancers were found in the transurethral biopsy specimen only. Of the 21 cancers missed by transurethral biopsy, 7 were stage T1b. PSA level >10 ng/mL increased the likelihood of finding cancer. CONCLUSIONS: Transurethral biopsy sampling is unreliable for detecting prostate cancer in men with clinically significant BPH. Significant cancers are missed if transurethral biopsies are used to determine the presence of carcinoma before minimally invasive surgical therapy for BPH.

Traumatic priapism: an unusual cycling injury.

A case is reported of a 35 year old man who sustained an injury to the perineum in a cycling accident which resulted in a traumatic priapism. After confirmation of the diagnosis by Doppler sonography and angiography, therapeutic selective arterial embolisation was followed by successful detumescence of the penis and subsequent return of normal erectile function. It is suggested that percutaneous embolisation of the lacerated cavernosal artery is a safe and effective minimally invasive treatment for this uncommon condition.

Nail fold creation in complete syndactyly using Buck-Gramcko pulp flaps.

We have used the double pulp flap technique described by Buck-Gramcko for nail fold creation in 75 fingertips after separation of 38 complete syndactyly webs in 27 patients. The operative technique is described and the results are discussed. Nail patterns in these complex syndactyly webs are analysed and a classification is proposed.

Intracranial haemangioendothelioma mimicking a meningioma.

A 33-year-old man presented with a history of fits and on initial investigation was suspected of having a left frontal parafalcine meningioma. Initial surgical procedure to excise the lesion had to be abandoned owing to the extreme vascularity of the lesion. Histology revealed it to be a haemangioendothelioma. At a second operation the tumour was completely removed. The histology of this rather uncommon tumour is discussed and the literature is reviewed.

Low grade pilocytic astrocytoma presenting as a spontaneous intracerebral haemorrhage in a child.

A girl aged 13 years presented with spontaneous intracerebral haemorrhage. Initially, no cause could be found but she was later found to have a low grade pilocytic astrocytoma. This very uncommon presentation was not considered before surgery.