Maculopatía media paracentral aguda: a propósito de un caso y revisión de la literatura / Paracentral acute middle maculopathy: a clinical case report and review of the literature

Introducción: la maculopatía media paracentral aguda (PAMM) es una entidad descrita en la tomografía de coherencia óptica de dominio espectral (SD-OCT). Se caracteriza por la presencia de una banda hiperrefringente de localización parafoveal en las capas medias retinales y se manifiesta por la aparición de escotomas paracentrales. En este artículo se presenta un caso clínico con el diagnóstico de PAMM y una breve revisión de la literatura. Métodos: se solicitó consentimiento informado escrito del paciente bajo la aprobación del comité ético-cien-tífico de la Facultad de Medicina de la Pontificia Universidad Católica de Chile. La revisión de la literatura se realizó mediante una estrategia de búsqueda que incluyó los términos explicitados en las palabras clave. Resultados: el paciente consulta por un escotoma paracentral superior en el ojo derecho (OD). En la autofluorescencia se observó una lesión hipoautofluorescente parafoveal inferior del OD. La angiografía retinal mostró tenue filtración en la misma zona, sin signos de oclusión arterial. En la SD-OCT del OD, se observó una lesión hiperrefringente parafoveal inferior en las capas medias retinales. El estudio sistémico descartó causas infeccioso-inflamatorias y vasculares. A partir de lo anterior, se realizó el diagnóstico de PAMM. Conclusiones: la presentación clínica y los resultados obtenidos fueron concordantes con lo reportado en la literatura respecto a la PAMM. Actualmente el manejo se basa en buscar y controlar condiciones relacionadas, puesto que no se ha descrito tratamiento específico. En este caso, se descartaron causas secundarias y se decidió la observación clínica.

Background: Paracentral acute middle maculopathy (PAMM) refers to a recently discovered finding described in the field of spectral-domain optical coherence tomography (SD-OCT). The main hallmark of PAMM is a hyper-reflective band-like lesion involving the middle layers of the retina in a parafoveal position. Typically, patients present with an acute onset of paracentral scotomas. In this article, we report a clinical case of PAMM and a brief review of the relevant literature. Methods: To obtaining clinical information, the requirements included a written informed consent form and the approval of the Ethical-Scientific Committee of Pontificia Universidad Católica de Chile. The literature review was carried out using a search strategy that included the terms specified in the keywords. Results: The patient presented an acute history of a superior paracentral scotoma in the right eye (RE). Fundus autofluorescence uncovered a hypo-autofluorescent area at the inferior fovea in the RE. Fluorescein angiography excluded a retinal artery occlusion and showed a hyperfluorescent capillary leakage at the same location. SD-OCT revealed a hyper-reflective band-like lesion in the middle retinal layers. A complete search for infectious, inflammatory, and vascular causes ruled out secondary conditions. These results were consistent with a diagnosis of PAMM. Conclusions: Clinical presentation and laboratory findings were compatible with the actual evidence concerning PAMM. The current management consists of identification and treatment of related vascular and systemic associated factors because there is no specific treatment for this condition. In this case, a negative study of secondary aetiologies supported the decision of clinical observation.

Prediction model and web-based risk calculator for postoperative ileus after loop ileostomy closure.

BACKGROUND: Postoperative ileus (POI) is a significant complication after loop ileostomy closure given both its frequency and impact on the patient. The purpose of this study was to develop and externally validate a prediction model for POI after loop ileostomy closure. METHODS: The model was developed and validated according to the TRIPOD checklist for prediction model development and validation. The development cohort included consecutive patients who underwent loop ileostomy closure in two teaching hospitals in Montreal, Canada. Candidate variables considered for inclusion in the model were chosen a priori based on subject knowledge. The final prediction model, which modelled the 30-day cumulative incidence of POI using logistic regression, was selected using the highest area under the receiver operating characteristic curve (AUC) criterion. Model calibration was assessed using the Hosmer-Lemeshow goodness-of-fit test. The model was then validated externally in an independent cohort of similar patients from the University of British Columbia. RESULTS: The development cohort included 531 patients, in whom the incidence of POI was 16·8 per cent. The final model included five variables: age, ASA fitness grade, underlying pathology/treatment, interval between ileostomy creation and closure, and duration of surgery for ileostomy closure (AUC 0·68, 95 per cent c.i. 0·61 to 0·74). The model demonstrated good calibration (P = 0·142). The validation cohort consisted of 216 patients, and the incidence of POI was 15·7 per cent. On external validation, the model maintained good discrimination (AUC 0·72, 0·63 to 0·81) and calibration (P = 0·538). CONCLUSION: A prediction model was developed for POI after loop ileostomy closure and included five variables. The model maintained good performance on external validation.

ANTECEDENTES: El íleo postoperatorio (postoperative ileus, POI) es una complicación importante tras el cierre de la ileostomía en asa, dada su frecuencia e impacto en el paciente. El propósito de este estudio fue desarrollar y validar externamente un modelo de predicción para el POI después del cierre de la ileostomía en asa. MÉTODOS: El modelo fue desarrollado y validado de acuerdo con la lista de verificación TRIPOD para el desarrollo y validación de un modelo de predicción. La cohorte de desarrollo incluyó pacientes consecutivos en los que se realizó el cierre de la ileostomía en asa en dos hospitales universitarios en Montreal, Canadá. Las variables candidatas consideradas para su inclusión en el modelo se seleccionaron a priori en función del conocimiento del problema. El modelo de predicción final, que modeló la incidencia acumulada a 30 días de POI mediante regresión logística, se seleccionó según el criterio del área más alta bajo la curva operativa del receptor (area under the receiver operating curve, AUC). La calibración del modelo se evaluó utilizando la prueba de bondad de ajuste de Hosmer-Lemeshow. El modelo fue posteriormente validado externamente en una cohorte independiente de pacientes similares de la Universidad de British Columbia. RESULTADOS: La cohorte de desarrollo incluyó a 531 pacientes, y la incidencia de POI fue de 16,7%. El modelo final incluyó cinco variables: edad, clasificación ASA (American Society of Anaesthesiologists), patología inicial y tratamiento, tiempo entre las dos intervenciones quirúrgicas y tiempo operatorio del cierre de ileostomía (AUC = 0,68; i.c. del 95%: 0,61 a 0,74). El modelo demostró buena calibración (P = 0,142). La cohorte de validación consistió en 216 pacientes, y la incidencia de POI fue de 15,7%. En la validación externa, el modelo mantuvo una buena discriminación (AUC = 0,72; i.c. del 95%: 0,63 a 0,81) y calibración (P = 0,538). CONCLUSIÓN: Se ha desarrollado un modelo de predicción de POI después del cierre de la ileostomía en asa que incluía cinco variables. El modelo mantuvo un buen funcionamiento en la validación externa.

The impact of complications after elective colorectal resection within an enhanced recovery pathway.

BACKGROUND: Despite the implementation of enhanced recovery pathways (ERP), morbidity following colorectal surgery remains high. The aim of the present study was to estimate the impact of postoperative complications on excess hospital length of stay (LOS) in patients undergoing elective colorectal resection. METHODS: A retrospective study of patients undergoing elective colorectal surgery at a single institution from 2003 to 2010 was performed. Patients managed by an ERP were compared to conventional care (CC), matched by propensity score radius matching. Complications were defined a priori. Excess (independent effect on LOS from multivariate analysis) and attributable (absolute number of additional bed days) LOS of common postoperative complications determined the impact of complications on bed utilization. Multivariate analysis was performed using multiple linear regression. RESULTS: A total of 810 propensity-score-matched patients were included (ERP = 472, CC = 338). Complications were significantly lower in the ERP group compared to the CC group (20 vs. 31%, p < 0.001). Median LOS decreased from 7 days in the CC group to 5 days in the ERP group [adjusted decrease in mean LOS of 2.8 days (95% CI 0.8, 4.8)]. Anastomotic leak, myocardial infarction and C. difficile infection had the highest excess LOS for both the ERP and CC groups. However, impaired gastrointestinal function had a higher impact on the absolute number of hospital bed days in the ERP group, as high as anastomotic leak (72.7 vs. 73.5 days respectively), while in the CC group the impact of gastrointestinal dysfunction was less of that of anastomotic leak (50.6 vs. 78.9 days respectively). CONCLUSIONS: In the setting of an ERP, postoperative complications have significant impact on total bed utilization. Impaired gastrointestinal function, given its high incidence, accounted for almost the same number of additional hospital bed days as anastomotic leak in the ERP group and is a target for quality improvement.

Does experience matter? A meta-analysis of physician rating websites of Orthopaedic Surgeons.

PURPOSE: To perform a systematic review evaluating online ratings of Orthopaedic Surgeons to determine: (1) the number of reviews per surgeon by website, (2) whether the number of reviews and rate of review acquisition correlated with years in practice, and (3) whether the use of ratings websites varied based on the surgeons' geographic region of practice. METHODS: The USA was divided into nine geographic regions, and the most populous city in each region was selected. HealthGrades and the American Board of Orthopaedic Surgery (ABOS) database were used to identify and screen (respectively) all Orthopaedic Surgeons within each of these nine cities. These surgeons were divided into three "age" groups by years since board certification (0-10, 10-20, and 20-30 years were assigned as Groups 1, 2, and 3, respectively). An equal number of surgeons were randomly selected from each region for final analysis. The online profiles for each surgeon were reviewed on four online physician rating websites (PRW, i.e. HealthGrades, Vitals, RateMDs, Yelp) for the number of available patient reviews. Descriptive statistics, analysis of variance (ANOVA), and Pearson correlations were used. RESULTS: Using HealthGrades, 2802 "Orthopaedic Surgeons" were identified in nine cities. However, 1271 (45%) of these were not found in the ABOS board certification database. After randomization, a total of 351 surgeons were included in the final analysis. For these 351 surgeons, the mean number of reviews per surgeon found on all four websites was 9.0 ± 14.8 (range 0-184). The mean number of reviews did not differ between the three age groups (p > 0.05) with 8.7 ± 14.4, (2) 10.3 ± 18.3, and (3) 8.0 ± 10.8 for Groups 1, 2, and 3, respectively. However, the rate that reviews were obtained (i.e. reviews per surgeon per year) was significantly higher (p < 0.001) in Group 1 (2.6 ± 7.7 reviews per year) compared to Group 2 (1.4 ± 2.4) and Group 3 (1.1 ± 1.4). There was no correlation between the number of reviews and years in practice (R < 0.001), and there was a poor correlation between number of reviews and regional population (R = 0.199). CONCLUSIONS: The number of reviews per surgeon did not differ significantly between the three defined age groups based on years in practice. However, surgeons with less than 10 years in practice were accumulating reviews at a significantly higher rate. Interestingly nearly half of "Orthopaedic Surgeons" listed were not found to be ABOS-certified Orthopaedic Surgeons.

Study protocol evaluating the use of bowel stimulation before loop ileostomy closure to reduce postoperative ileus: a multicenter randomized controlled trial.

AIM: Postoperative ileus is the most commonly observed morbidity following ileostomy closure. Studies have demonstrated that the defunctionalized bowel of a loop ileostomy undergoes a series of functional and structural changes, such as atrophy of the intestinal villi and muscular layers, which may contribute to ileus. A single-centre study in Spain demonstrated that preoperative bowel stimulation via the distal limb of the loop ileostomy decreased postoperative ileus, length of stay and time to gastrointestinal function. METHOD: A multicentre randomized controlled trial involving patients from Canadian institutions was designed to evaluate the effect of preoperative bowel stimulation before ileostomy closure on postoperative ileus. Stimulation will include canalizing the distal limb of the ileostomy loop with an 18Fr Foley catheter and infusing it with a solution of 500 ml of normal saline mixed with 30 g of a thickening agent (Nestle© Thicken-Up© ). This will be performed 10 times over the 3 weeks before ileostomy closure in an outpatient clinic setting by a trained Enterostomal Therapy nurse. Surgeons and the treating surgical team will be blinded to their patient's group allocation. Data regarding patient demographics, and operative and postoperative variables, will be collected prospectively. Primary outcome will be postoperative ileus, defined as an intolerance to oral food in the absence of clinical or radiological signs of obstruction, that either requires nasogastric tube insertion or is associated with two of the following on or after post-operative day 3: nausea/vomiting; abdominal distension; and the absence of flatus. Secondary outcomes will include length of stay, time to tolerating a regular diet, time to first passage of flatus or stool and overall morbidity. A cost analysis will be performed to compare the costs of conventional care with conventional care plus preoperative stimulation. DISCUSSION: This manuscript discusses the potential benefits of preoperative bowel stimulation in improving postoperative outcomes and outlines our protocol for the first multicenter study to evaluate preoperative bowel stimulation before ileostomy closure. The results of this study could have considerable implications for the care of patients undergoing ileostomy closure.

Phase II trial of short-course radiotherapy followed by delayed surgery for locoregionally advanced rectal cancer.

AIM: A prospective phase II study to investigate the feasibility and the rate of complete pathological response (ypT0) after short-course radiotherapy (SCRT) followed by surgery at 8 weeks. METHOD: Operable patients with localized rectal cancer staged T3-4N0/+ or T2N+ were eligible and received 25 Gy (in one-third of patients, the gross tumor volume received a simultaneous integrated boost up to a total of 30 Gy) in five consecutive fractions to the posterior pelvis followed by surgery 8 weeks later. Pathological response and surgical toxicity were assessed in all patients. RESULTS: Fifty-two patients (median age 68 years) completed the study. The median distance of the tumour from the anal verge was 6.5 cm. The median interval to surgery was 52 days. Three-quarters of patients underwent a low anterior resection. All underwent complete surgical resection and 100% had pathological negative margins. Ten per cent had stage ypT0 after radiotherapy. The median length of hospital stay was 8 days. Toxicity was comparable with the rates reported in the literature. CONCLUSION: In this study, SCRT followed by delayed surgery was feasible and had acceptable toxicity. All patients underwent complete surgical resection and 100% had negative pathological margins. The rate of ypT0 was 10%.

Short-term outcome after neoadjuvant high-dose-rate endorectal brachytherapy or short-course external beam radiotherapy in resectable rectal cancer.

AIM: Total mesorectal excision with preoperative radiotherapy reduces local recurrence in rectal cancer, but radiotherapy increases the risk of complications. This study compared the immediate postoperative outcome after external beam radiotherapy with outome after high-dose-rate endorectal brachytherapy (HDREBT). METHOD: Patients (n = 318) treated with preoperative HDREBT (6.5 Gy, daily, over 4 days) followed by surgery 4-8 weeks later were matched with 318 patients from the Swedish Rectal Cancer Register treated with short-course radiotherapy (SCRT; 5 Gy, daily, over 5 days) and surgery in the subsequent week and with 318 patients who had surgery only (i.e. no preoperative radiotherapy; RT-) All 954 patients were followed for 30 days after surgery. Complications were divided into surgical, cardiovascular and infectious. RESULTS: The SCRT group had fewer cardiovascular complications (3.1%) than did HDREBT (9.4%, P = 0.002) and RT- (7.2%, P = 0.03) groups. There was less perioperative bleeding in HDREBT patients (379.3 ml) than in SCRT (947.2 ml; P < 0.0001) or RT- (918.9 ml) patients, and the re-intervention rate was lower in HDREBT (4.1%) patients than in SCRT (14.2%; P = 0.005) and RT- (12.3%; P < 0.005) patients. The HDREBT group had fewer R2 resections than did the SCRT and RT- groups, but had a higher proportion of R0 resections compared with the RT- group (P = 0.03). CONCLUSION: No major differences in postoperative complications were found. HDREBT patients had a higher rate of cardiovascular complications, but less perioperative bleeding and fewer re-interventions. A longer interval between radiotherapy and surgery may be beneficial for tumour regression and this could be reflected in the number of radical resections.

Spinal analgesia for laparoscopic colonic resection using an enhanced recovery after surgery programme: better analgesia, but no benefits on postoperative recovery: a randomized controlled trial.

BACKGROUND: This study was undertaken to determine the impact of an intrathecal mixture of bupivacaine and morphine, when compared with systemic morphine, on the quality of postoperative analgesia and other outcomes in the context of the enhanced recovery after surgery (ERAS) programme for laparoscopic colonic resection. METHODS: Fifty patients undergoing general anaesthesia were randomly allocated to receive either a spinal mixture of bupivacaine and morphine followed by oral oxycodone (spinal group) or patient-controlled analgesia (PCA group). The primary outcome was consumption of opioids during the first three postoperative days. Secondary outcomes were pain scores, return of bowel function and dietary intake, readiness to hospital discharge, and length of hospital stay. RESULTS: Postoperative opioid consumption in the spinal group was significantly less over the first three postoperative days (P<0.001). The quality of analgesia at rest in the first 24 h was better in the spinal group (P<0.005). Excessive sedation and respiratory depression were reported in two elderly patients with spinal analgesia. There were no differences between the two groups in other outcomes (return of bowel function and dietary intake, readiness to hospital discharge, and length of hospital stay). CONCLUSIONS: When ERAS programme is used for laparoscopic colonic resection, an intrathecal mixture of bupivacaine and morphine was associated with less postoperative opioid consumption, but has no other advantages over systemic opioids.

The effects of ultrasound on organoclay dispersion in the PP matrix.

PP/MMT nanocomposites were prepared by solution intercalation using sonication and quiescent conditions, and the effects on the morphological, thermal and mechanical properties were evaluated by WAXD, TEM, DMA, TGA and DSC analyses. The present study aims to clarify the effects of ultrasound use on the organoclay surface with different amounts of organic modifiers and on the exfoliation processes. The sonication process decreased around of 200 nm the aspect ratio of C15A organoclay. Besides, the effectiveness of the ultrasound process was only achieved with the C15A system because there is a small energetic barrier between their layers (clay with larger d 001). The sonication process increased the exfoliation and distribution of the C15A platelets in the PP matrix, increasing by 5% its reinforcement capacity. However, for I44P system, the use of ultrasound did not show any significant effect on the morphology and consequently on the final properties of the PP matrix. The T(c) temperature and the thermal stability of the PP nanocomposites were increased, independent of the clay type or of the ultrasound use.

Reference systems for the determination of 10B through autoradiography images: application to a melanoma experimental model.

The amount of (10)B in tissue samples may be determined by measuring the track density in the autoradiography image produced on a nuclear track detector. Different systems were evaluated as reference standards to be used for a quantitative evaluation of boron concentration. The obtained calibration curves were applied to evaluate the concentration of (10)B in melanoma tumour of NIH nude mice after a biodistribution study. The histological features observed in the tissue sections were accurately reproduced by the autoradiography images.

BNCT for skin melanoma in extremities: updated Argentine clinical results.

As part of phase I/II melanoma BNCT clinical trial conducted in Argentina in a cooperative effort of the Argentine Atomic Energy Commission (CNEA) and the Oncology Institute Angel H. Roffo (IOAHR), 7 patients (6 female-1 male) received eight treatment sessions covering ten anatomical areas located in extremities. Mean age of the patients was 64 years (51-74). The treatments were performed between October 2003 and June 2007. All patients presented multiple subcutaneous skin metastases of melanoma and received an infusion containing approximately 14 gr/m(2) of (10)borophenyl-alanine (BPA) followed by the exposition of the area to a mixed thermal-epithermal neutron beam at the RA-6 reactor. The maximum prescribed dose to normal skin ranged from 16.5 to 24 Gy-Eq and normal tissue administered dose varied from 15.8 to 27.5 Gy-Eq. Considering evaluable nodules, 69.3% of overall response and 30.7% of no changes were seen. The toxicity was acceptable, with 3 out of 10 evaluable areas showing ulceration (30% toxicity grade 3).

Tumor control and normal tissue complications in BNCT treatment of nodular melanoma: a search for predictive quantities.

A previous work concerning tumor control and skin damage in cutaneous melanoma treatments with BNCT has been extended to include doses, volumes and responses of 104 subcutaneous lesions from all patients treated in Argentina. Acute skin reactions were also scored for these patients, and cumulative dose-area histograms and dose-based figures of merit for skin were calculated. Broadening the tumor response analysis with the latest data showed that the (minimum or mean) tumor dose is not a good predictor of the observed clinical outcome by itself. However, when the tumor volume was included in the model as second explicative variable, the dose increases its significance and becomes a critical variable jointly with the volume (p-values<0.05). A preliminary analysis to estimate control doses for two groups of tumor sizes revealed that for small tumor volumes (< 0.1cm(3)) doses greater than 20 Gy-Eq produce a high tumor control (> 80%). However, when tumor volumes are larger than 0.1cm(3), control is moderate (< 40%) even for minimum doses up to 40 Gy-Eq. Some quantities based on skin doses, areas and complication probabilities were proposed as candidates for predicting the severity of the early skin reactions. With the current data, all the evaluated figures of merit derived similar results: ulceration is present among the cases for which these quantities take the highest values.

Dynamic infrared imaging of cutaneous melanoma and normal skin in patients treated with BNCT.

We recently initiated a program aimed to investigate the suitability of dynamic infrared imaging for following-up nodular melanoma patients treated with BNCT. The reason that makes infrared imaging attractive is the fact that it constitutes a functional and non-invasive imaging method, providing information on the normal and abnormal physiologic response of the nervous and vascular systems, as well as the local metabolic rate and inflammatory processes that ultimately appear as differences in the skin temperature. An infrared camera, with a focal plane array of 320 x 240 uncooled ferroelectric detectors is employed, which provides a video stream of the infrared emission in the 7-14 microm wavelength band. A double blackbody is used as reference for absolute temperature calibration. After following a protocol for patient preparation and acclimatization, a basal study is performed. Subsequently, the anatomic region of interest is subjected to a provocation test (a cold stimulus), which induces an autonomic vasoconstriction reflex in normal structures, thus enhancing the thermal contrast due to the differences in the vasculature of the different skin regions. Radiation erythema reactions and melanoma nodules possess typically a faster temperature recovery than healthy, non-irradiated skin. However, some other non-pathological structures are also detectable by infrared imaging, (e.g. scars, vessels, arteriovenous anastomoses and injuries), thus requiring a multi-study comparison in order to discriminate the tumor signal. Besides the superficial nodules, which are readily noticeable by infrared imaging, we have detected thermal signals that are coincident with the location of non-palpable nodules, which are observable by CT and ultrasound. Diffuse regions of fast temperature recovery after a cold stimulus were observed between the third and sixth weeks post-BNCT, concurrent with the clinical manifestation of radiation erythema. The location of the erythematous visible and infrared regions is consistent with the 3D dosimetry calculations.

Boron biodistribution study in colorectal liver metastases patients in Argentina.

Ex-situ BNCT for multifocal unresectable liver metastases employing whole or partial autograft techniques requires knowledge of boron concentrations in healthy liver and metastases following perfusion and immersion in Wisconsin solution (W), the procedure employed for organ preservation during ex-situ irradiation. Measurements of boron concentration in blood, liver and metastases following an intravenous infusion of BPA-F in five colorectal liver metastases patients scheduled for surgery were performed. Tissue samples were evaluated for boron content pre and post perfusion and immersion in W. Complementary histological studies were performed. The data showed a dose-dependent BPA uptake in liver, a boron concentration ratio liver/blood close to 1 and a wide spread in the metastases/liver concentration ratios in the range 0.8-3.6, partially attributable to histological variations between samples. Based on the boron concentrations and dose considerations (liver < or =15 Gy-Eq and tumor> or =40 Gy-Eq) at the RA-3 thermal neutron facility (mean flux of about (6+/-1) x 10(9) n cm(-2)s(-1)), ex-situ treatment of liver metastases at RA-3 would be feasible.

Biodistribution studies of boronophenylalanine-fructose in melanoma and brain tumor patients in Argentina.

A study of the (10)B-enriched p-boronophenylalanine-fructose complex ((10)BPA-F) infusion procedure in potential BNCT patients, including four melanoma of extremities and two high-grade gliomas (glioblastoma and ganglioglioma) was performed. T/B and S/B ratios for (10)B concentrations in tumor (T), blood (B) and skin (S) were determined. The T/B ratio for the glioblastoma was in the 1.8-3.4 range. The ganglioglioma did not show any significant boron uptake. For the nodular metastasic melanoma T/B values were between 1.5 and 2.6 (average 2.1+/-0.4), corresponding to the lower limit of the mean values reported for different melanoma categories. This result might suggest a lower boron uptake for nodular metastasic melanomas. S/B was 1.5+/-0.4. An open two-compartment pharmacokinetic model was applied to predict the boron concentration during the course and at the end of a BNCT irradiation.

First BNCT treatment of a skin melanoma in Argentina: dosimetric analysis and clinical outcome.

A Phase I/II protocol for treating cutaneuos melanomas with BNCT was designed in Argentina by the Comisión Nacional de Energía Atómica and the medical center Instituto Roffo. The first of a cohort of thirty planned patients was treated on October 9, 2003. This article depicts the protocol-based procedure and describes the first clinical case, treatment regime and planning, patient irradiation, retrospective dosimetric analysis and clinical outcome. Considering the low acute skin toxicity and the complete response in 21 of the 25 subcutaneous melanoma nodules treated, a second irradiation was performed in a different location of the extremity of the same patient. The corresponding clinical outcome is still under evaluation.

Experience with the Ultrex and Ultrex Plus inflatable penile prosthesis: new implantation techniques and surgical outcome.

The Ultrex and Ultrex Plus penile prosthesis incorporate sequential design modifications that afford important functional advantages that reduce the potential for mechanical failure. This retrospective study reviews our experience with these models emphasizing innovations in surgical technique and postoperative results. Implantation of Ultrex (31%) and Ultrex Plus (69%) penile prosthesis was performed in 90 impotent men with organic erectile dysfunction following comprehensive multi-disciplinary evaluation. During a follow-up interval of 7-50 months, postoperative outcome was assessed. Of this group, 10% underwent simultaneous explant of another malfunctioning inflatable device or conversion from a semi-rigid prosthesis due to patient preference. Of the remainder, 20% selected implant surgery as their primary therapy while 73% were initially treated with various nonsurgical options prior to implantation. In all patients we employed a single peno-scrotal incision and applied the concept of controlled radial dilatation of all compartments. In our last 32 consecutive patients including eight with previous radical pelvic surgery, we utilized the preperitoneal distention balloon (PDB) facilitating safe and non-traumatic creation of the prevesical space for reservoir insertion. Post operative complications occurred in 8% of patients including pump infection and corporal deformity requiring reimplantation with AMS 700 CX cylinders, or self-contained unitarian prosthesis as a salvage procedure. Satisfactory, functional and anatomic outcome was reported in 95% of patients. Interim advances incorporated into the Ultrex and Ultrex Plus prosthesis have markedly reduced mechanical failure during our follow-up interval of up to 50 months. Importantly, controlled, non-traumatic radial dilatation of the prevesical space by the PDB may encourage broader use of the multicomponent inflatable models, particularly in a setting of pelvic fibrosis due to previous pelvic surgery or radiation.

Spiral computed tomography for staghorn calculi.

OBJECTIVES: To assess the utility of spiral computed tomography (CT) with three-dimensional reconstruction for preoperative planning of percutaneous nephrostolithotomy in patients with complex branched calculi (full staghorns). METHODS: Patients with complex branched stones were imaged with spiral CT with three-dimensional reconstruction. These images were compared with standard imaging modalities, including excretory urography and plain radiographs, for planning percutaneous access for nephrostolithotomy. The utility of the scan was evaluated. RESULTS: Ten patients with branched calculi were studied. Anatomic abnormalities were present in 5 patients. Excellent three-dimensional images were obtained in all patients without any complications related to the study. In 1 patient with multiple calculi in a horseshoe kidney, the three-dimensional image indicated a branched stone. The spiral CT scan was not helpful in directing percutaneous access in any patient. In a single patient, residual fragments noted during nephrostolithotomy were located by reference to the spiral CT scan. CONCLUSIONS: Spiral CT scans with three-dimensional reconstruction provide three-dimensional imaging of branched renal calculi. This modality provides minimal additional information over that obtained from standard radiographic studies for guiding nephrostolithotomy and cannot be recommended as a routine preoperative study. It was helpful in 1 patient to locate a residual fragment.

Induction androgen deprivation plus prostatectomy for stage T3 disease: failure to achieve prostate-specific antigen-based freedom from disease status in a phase II trial.

OBJECTIVES: There is interest in treating prostate cancer with induction androgen deprivation prior to radical prostatectomy. Data on long-term prostate-specific antigen (PSA)-based survival analyses among patients treated with neoadjuvant hormonal therapy (NHT) and prostatectomy are limited. In 1991 we instituted a pilot study for T3 disease based on endorectal coil magnetic resonance imaging (eMRI), mandatory negative laparoscopic nodal dissection prior to hormonal manipulation, and prostatectomy followed by pathologic and PSA-based outcome determinations. METHODS: Of 26 patients, 21 had negative laparoscopic lymphadenectomy followed by 4 months of NHT (leuprolide +/- flutamide) prior to radical prostatectomy. eMRI was performed at the time of diagnosis and following hormonal treatment. Serum PSA was determined at 3-month intervals. Prostatectomy specimens were evaluated by 3-mm whole-mount step sections. RESULTS: Prior to prostatectomy, biochemical response was documented in all patients and downsizing was observed by eMRI in 57%. Pathologic downstaging to a lower stage (T2c or lower) was achieved in 48%. However, the actuarial 3-year freedom from biochemical relapse rate was only 24%. CONCLUSIONS: Using laparoscopy to exclude node-positive patients and 4 months of NHT appears to result in pathologic and initial biochemical evidence of regression. These factors have not translated into improved freedom from biochemical relapse among patients with Stage T3 disease treated with NHT and prostatectomy. Recent data strongly suggest a beneficial effect in patients with clinical T2 disease treated with NHT and radical prostatectomy. The NGT and radical prostatectomy approach appeared to offer no clear advantage when compared with PSA-based benchmarks achieved with conformal irradiation or NHT followed by external beam treatment among patients with clinical T3 disease.