Point-of-care ultrasound of the heart and lungs in patients with respiratory failure: a pragmatic randomized controlled multicenter trial.

BACKGROUND: Point-of-care ultrasound is a focus oriented tool for differentiating among cardiopulmonary diseases. Its value in the hands of emergency physicians, with various ultrasound experience, remains uncertain. We tested the hypothesis that, in emergency department patients with signs of respiratory failure, a point-of-care cardiopulmonary ultrasound along with standard clinical examination, performed by emergency physicians with various ultrasound experience would increase the proportion of patients with presumptive diagnoses in agreement with final diagnoses at four hours after admission compared to standard clinical examination alone. METHODS: In this prospective multicenter superiority trial in Danish emergency departments we randomly assigned patients presenting with acute signs of respiratory failure to intervention or control in a 1:1 ratio by block randomization. Patients received point-of-care cardiopulmonary ultrasound examination within four hours from admission. Ultrasound results were unblinded for the treating emergency physician in the intervention group. Final diagnoses and treatment were determined by blinded review of the medical record after the patients´ discharge. RESULTS: From October 9, 2015 to April 5, 2017, we randomized 218 patients and included 211 in the final analyses. At four hours we found; no change in the proportion of patients with presumptive diagnoses in agreement with final diagnoses; intervention 79·25% (95% CI 70·3-86·0), control 77·1% (95% CI 68·0-84·3), an increased proportion of appropriate treatment prescribed; intervention 79·3% (95% CI 70·3-86·0), control 65·7% (95% CI 56·0-74·3) and of patients who spent less than 1 day in hospital; intervention n = 42 (39·6%, 25·8 38·4), control n = 25 (23·8%, 16·5-33·0). No adverse events were reported. CONCLUSIONS: Focused cardiopulmonary ultrasound added to standard clinical examination in patients with signs of respiratory failure had no impact on the diagnostic accuracy, but significantly increased the proportion of appropriate treatment prescribed and the proportion of patients who spent less than 1 day in hospital. TRIAL REGISTRATION: https://clinicaltrials.gov/ , number NCT02550184 .

[Sonography of the scrotum]. / Sonographie des Skrotalinhalts.

Ultrasonography (US) has become the method of choice for imaging in diseases affecting the scrotum. With the development of high resolution transducers using colour Doppler and pulsed Doppler, it is now possible to make accurate diagnoses. Sonography is able to distinguish immediately between intra- and extratesticular lesions. It is also possible to differentiate between cystic and solid tumours. Solid testicular tumours may be detected without difficulty and thus the patient's dignity is practically assured (98 % of solid testicular tumours are malignant). In cases of acute diseases of the scrotum, sonography nearly always permits a differentiation between torsion and inflammation, thus avoiding the risk of unnecessary operations. The review covers the introduction, anatomy, the scanning protocol for scrotal ultrasound and pathological changes. Testicular tumours and torsion are discussed in detail. Variations from the norm and pitfalls are outlined so as to help avoid making misdiagnoses.

Laparoscopic partial adrenalectomy in patients with aldosterone-producing adenomas: indications, technique, and results.

OBJECTIVES: To report the indications, technique, and results in patients with primary hyperaldosteronism due to aldosterone-producing adrenal adenoma treated by laparoscopic partial adrenalectomy. Laparoscopy has become the technique of choice in adrenal surgery, but adrenalectomy is the standard procedure. Only a few studies have reported on partial adrenalectomy, and the indications and technique have not yet been clearly defined. METHODS: From June 1995 to December 2001, 13 patients presented with hyperaldosteronism and a single adrenal adenoma (Conn's syndrome) and were treated with laparoscopic partial adrenalectomy. The mean age was 60 years, and the average tumor size was 2.1 cm in diameter. A transperitoneal approach was used in all patients, tumors were resected with safety margins by endoshears, and hemostasis was achieved by bipolar coagulation and finally by sealing with fibrin glue. RESULTS: All procedures were finished laparoscopically, and no conversion was necessary. No major intraoperative or postoperative complication was observed. The histologic examination showed adenomas with negative surgical margins in all cases. Postoperative computed tomography revealed a normal blood supply for the remaining adrenal tissue. Blood pressure and aldosterone levels were unremarkable at follow-up, and no local recurrence was observed. CONCLUSIONS: Laparoscopic partial adrenalectomy for aldosterone-producing adenomas is a minimally invasive procedure with a low complication rate. It provides the benefit of retaining functional tissue on the side of the affected adrenal gland. Therefore, we recommend laparoscopic partial adrenalectomy for patients with small, potentially benign, tumors of the adrenal gland, even with a healthy contralateral adrenal gland.

Laparoscopic nephron-sparing surgery for renal tumors.

OBJECTIVES: To report our experience with laparoscopic nephron-sparing surgery. Because of the widespread use of ultrasonography and computed tomography, laparoscopy is becoming more and more important in the surgical management of solid renal masses. Although laparoscopic radical nephrectomy has gained wide acceptance, laparoscopic nephron-sparing surgery for renal tumors is still rarely done. METHODS: From June 1994 to December 2000, we treated 51 patients presenting with small exophytic solid renal masses by laparoscopic wedge resection in two Austrian centers. Depending on the center, the retroperitoneal approach was used in 32 cases and the transperitoneal approach was used in 19. The mean age was 59.8 years, and the average tumor size was 2 cm in diameter. Wedge resection was performed with the UltraCision device, and hemostasis was achieved by bipolar coagulation and fibrin glue-coated cellulose. RESULTS: All procedures were finished laparoscopically, and no conversion was necessary. The mean operating time was 132 minutes (range 70 to 300), mean blood loss 282 mL (range 20 to 800), mean postoperative hospital stay 5.8 days (range 3 to 12). The histologic findings were renal cell carcinoma in 38 patients (76%), benign disease in 12 patients (24%), and secondary tumor in 1 patient. Neither distant nor local recurrences were observed by the last follow-up date. Three cases of urinary leakage and one of postoperative bleeding occurred. CONCLUSIONS: Laparoscopic nephron-sparing surgery for renal tumors is a technically difficult procedure, but excellent tumor control can be achieved. Nevertheless, currently, this procedure should be concentrated in centers with a high experience in laparoscopic surgery.

Laparoscopic partial nephrectomy. The European experience.

Laparoscopic partial nephrectomy is technically difficult but oncologically effective. The operation should be performed in centers with expertise. Hemostasis can be achieved using bipolar coagulation and fibrin glue-coated cellulose. Further studies will determine whether less invasive alternatives (focused ultrasound, cryotherapy) will meet the high standard of open (or laparoscopic) nephron-sparing surgery for small renal cell carcinoma.

Laparoscopic surgery for stage T1 renal cell carcinoma: radical nephrectomy and wedge resection.

OBJECTIVES: Renal cell carcinoma (RCC) is likely to become one of the most important indications for laparoscopic surgery. We herein report our experience. METHODS: From April 1994 until April 1999, 98 patients presenting with RCC were treated laparoscopically by either radical nephrectomy (RN; n = 73) or wedge resection (WR; n = 25). The mean age was 62.3 years. The mean tumour diameters were 3.8 cm (RN) and 1.9 cm (WR). All tumours were clinical stage T1 lesions. The transperitoneal approach was used for RN in all patients. For WR either the transperitoneal or the retroperitoneal approach was used. In 15 patients, the adrenal gland was removed simultaneously. The specimen was entrapped in an organ bag and removed intact through a small muscle-splitting incision in the lower abdominal wall. RESULTS: RN: The mean operating time was 142 (range 86-230) min, the mean blood loss was 170 (range 0-1,500) ml, and the mean postoperative hospital stay was 7.4 (range 3-32) days. Minor complications occurred in 4.0% of the patients, while major complications were seen in 8.0% of them. WR: The mean operating time was 163.5 (range 90-300) min, the mean blood loss was 287 (range 20-800) ml, and the postoperative hospital stay was 8.0 (range 3-8) days. Minor complications: 4%, major complications: 8%. Histology revealed RCC stage T1 in 77 patients, stage T3a in 7, and stage T3b in 3 patients, oncocytoma in 2 patients, angiomyolipoma in 2, renal adenoma in 1, renal metastasis in 1, multilocular cysts in 4, and renal abscess in 1 patient. Over mean follow-up periods of 13.3 and 22.2 months for RN and WR, respectively, neither local recurrences nor metastases have been observed among patients with histologically confirmed RCC. CONCLUSIONS: Laparoscopic surgery for clinical stage T1 RCC is safe and efficient. Excellent tumour control can be achieved. However, longer follow-up periods will be necessary to confirm these results.

Laparoscopic radical nephrectomy: a single-center experience of 51 cases.

A modified technique of laparoscopic radical nephrectomy for treatment of renal cell carcinoma makes surgery easier, faster, and safer in terms of tumor cell spillage. We report our experience with this procedure in 51 consecutive cases. A transperitoneal approach was used in all cases. The average patient age was 62 years. The solid renal mass diameter was between 2 and 9 cm. Extrafascial mobilization of the kidney included limited lymph node dissection. In six patients the adrenal gland was removed simultaneously. The specimen was removed intact through a small muscle-splitting incision in the lower abdominal wall. The procedure was successful without conversion to open surgery in all 51 patients. The average operating time was 125 minutes, and the average postoperative hospital stay was 7.2 days. Major complications were seen in 4% of patients. Neither local recurrences nor metastases were observed in the following 7.9 (1-19) months. In our experience, laparoscopic radical nephrectomy is safe and efficient. Removing the specimen intact through a small muscle-splitting incision reduces operating time, avoids tumor cell spillage, and allows exact pathological staging.

Adrenalectomy--still a must in radical renal surgery?

OBJECTIVE: To investigate the incidence of adrenal involvement and survival in patients with renal cell carcinoma. PATIENTS AND METHODS: A retrospective, multicentre trial was initiated by the Austrian Association of Urologic Oncology (AUO); between January 1980 and December 1984, 225 patients were eligible for the study. All patients had unilateral renal tumours and nephrectomies were performed either with (group A, 109 patients) or without (group B, 116 patients) adrenalectomy. The two groups were matched for sex, age, laterality and nodal status. The mean follow-up time was 78 months. RESULTS: The location of the intrarenal tumour had no significant effect on adrenal involvement. By univariate and multivariate analysis (Cox's proportional hazards model) significant differences in outcome were found only for pT stages. The mean survival times of patients in group A were 122.9 months in those with stage pT1/2, 76.6 months with stage pT3 and 75.3 months with stage pT4. In group B, survival times were 109 months in those with stage pT1/2 (not significant) and 111 months in stage pT3 (P = 0.0076). Eight patients had adrenal involvement and died from their tumours after a median of 15.3 months (range 4-63). The slightly longer survival of patients in group B with stage T1/2 tumours and the significantly better survival of patients with stage T3 disease may be attributable to statistical bias, but there was no benefit from adrenalectomy. CONCLUSION: The effect of adrenalectomy on the prognosis was at best comparable to that of lymphadenectomy and no curative effect was demonstrated. The removal of a healthy adrenal may be detrimental and cause subsequent problems in those patients requiring hormone replacement.