Epidemiology, Pattern, and Survival of Multiple Primary Malignant Neoplasms in Southeast Iran: Results of Kerman Population-Based Cancer Registry 2014-2020.

PURPOSE: Cancer survivors may experience a subsequent primary cancer that affects their survival and quality of life. This study aimed to investigate the epidemiology of multiple primary malignant neoplasms (MPMNs) in Kerman province, southeast Iran during 2014-2020. MATERIALS AND METHODS: In this retrospective cohort study, all patients who had been diagnosed with primary cancers and registered with the Kerman Cancer Registry Program (KPBCR) during 2014-2020 were included. MPMNs were defined as primary malignant tumors arising in different sites and/or were of different histological or morphological origins. If the second malignancy was diagnosed within the first six months from the diagnosis of the first tumor it was considered synchronous, and if after six months it was defined as metachronous. Logistic regression was used to analyze the relationship between age, sex, and primary cancer site with incidence and survival of secondary in the entire population. RESULTS: Of 26,315 patients registered with a primary cancer diagnosis, 492 (1.86%) developed subsequent primary cancers. The most common type of secondary cancer was skin and mucosa (n=131, 26.63%) followed by urogenital (n=115, 23.37%), followed by, gastrointestinal (n=62, 14.45%), and breast neoplasms (n=57, 11.59%). Most patients had metachronous tumors (n=350, 71.13%). The primary cancer site (Skin and mucosa, urogenital, and breast) was significantly associated with developing subsequent cancer among cancer survivors. The overall 5-year survival of MPMNs cases was over 50%. Older age at diagnosis (HR= 1.02) and having synchronous tumors (HR=1.41) were negatively associated with the survival time of patients with MPMNs. CONCLUSION: Both patients and physicians should be taught about the importance of prevention and the provision of care and screening services among cancer survivors. Studying the epidemiology, susceptibility, and risk factors of MPMNs among cancer survivors will open windows to a better understanding of this phenomenon and policy making.

A retrospective cohort study: evaluating the efficacy of standard versus tubeless percutaneous nephrolithotomy (PCNL) in pediatric patients up to 18 years old.

Percutaneous nephrolithotomy (PCNL) is an endourological method applied as the standard or tubeless method for kidney stone treatment. In a retrospective cohort study, 88 surgery units involving 75 children up to 18 years old with kidney stones who underwent the surgery for 8 years in Shahid Beheshti and Boo-ali hospitals in Hamadan with one of the two methods of standard or tubeless PCNL were evaluated and compared considering the success rate of operation, hemoglobin, hematocrit drop, need for medications, need for blood transfusion, duration of surgery, and the length of hospital stay. Among the 88 units studied, 47 cases were operated with the standard PCNL and 41 cases by tubeless method. In children operated by standard and tubeless PCNL, the complete success rate of operation was 87.2% and 100% (P = 0.006), the need for blood transfusion was 2.1% and 0% (P = 1.00), the need for opioids was 27.7% and 14.6% (P = 0.134), the decrease in hemoglobin was - 1.82 ± 0.94 and -1.30 ± 0.98 mg/dl (P = 0.024), the decrease in hematocrit was - 5.40 ± 2.66 and -3.52 ± 3.11 mg/dL (P = 0.003), the mean surgery duration was 109.30 ± 53.27 and 101.46 ± 31.92 min (P = 0.414), the duration of postoperative hospitalization was 3.38 ± 1.76 and 2.46 ± 1.27 days (P = 0.007), and the frequency of fever was 23.4% and 7.3% (P = 0.04), respectively. The success rate of kidney stone surgery in children with the tubeless PCNL is higher than the standard method, and its complications are lower.

Evaluating the Potential of a New Low-Profile Urinary Catheter in Preventing Catheter-Associated Urinary Tract Infections: A Prospective Randomized Blinded Clinical Trial.

Aim: To investigate the efficacy of a new low-profile catheter on incidence of the catheter-associated urinary tract infections (CAUTI) in comatose patients admitted to the intensive care unit. Background: Catheter-induced urothelial injury is a key component in the development of urinary tract infections in catheterized patients. Methods: In this prospective randomized blinded clinical trial, 80 patients requiring indwelling urinary catheterization were equally randomized to either the standard Foley catheter (control) or the low-profile catheter (experimental) group. The signs of urinary tract infection for comatose patients were considered (ie, ≥105 of colony-forming unit/milliliter of urine, hematuria, serum leukocytes, and body temperature) and recorded at baseline and on days 3 and 5 after catheterization. The analysis of covariance was applied by the SPSS-20 software at a 95% confidence level. Results: An increasing proportion of patients with elevated urinary colony counts were seen in the Foley catheter group compared with the low-profile catheter group (12.5% vs 5%). However, there were no between-group differences in the urinary colony counts and body temperature after controlling for antibiotic doses and fluid intake. Patients in the low-profile catheter group had significantly lower rates of hematuria and serum leukocytes than those in the Foley catheter group. Conclusion: A newly designed low-profile urinary catheter has demonstrated a trend toward reducing the incidence of CAUTI in patients with indwelling urinary catheters. Further studies with larger sample sizes and follow-up are needed to confirm the benefits.

Malignant pheochromocytoma with negative biochemical markers: Is it time to reclassify pheochromocytomas?

Pheochromocytomas are catecholamine producing tumors of adrenal gland generally diagnosed by presence of these markers in urine or plasma. However, a few may be marker-negative and challenging for clinicians. Several reports of these marker-negative pheochromocytomas may warrant necessity for a new classification of these tumors. Adrenergic blockade before surgery is one of the main reasons for recognition of these cases. We present a case of marker-negative pheochromocytoma which turned out to be malignant on its recurrence. To our knowledge, this is the only case of malignant marker-negative pheochromocytoma reported in literature so far.

Effect of intravenous acetaminophen versus fentanyl on postoperative pain after transurethral lithotripsy / Efeito do acetaminofeno versus fentanil intravenosos na dor pós litotripsia transuretral

Abstract Background: Postoperative pain is the most common postoperative complication. This study was conducted to assess the effect of acetaminophen versus fentanyl on postoperative pain relief in patients who underwent urologic surgeries. Methods: This clinical trial was conducted on patients aged 18-65 years. Patients were randomly assigned to receive either 2000 mg acetaminophen (propacetamol) or 2 mcg.kg-1 fentanyl intravenously, 15 min before the end of surgery. The postoperative pain was evaluated every 6 h for 24 h using the Visual Analog Scale. Total morphine dose taken in 24 h and hemodynamic status were evaluated. Results: Eighty patients were enrolled into the trial. The mean score of pain in 6, 12, 18, and 24 h after surgery was lower in the acetaminophen group than in the fentanyl group but the difference was not statistically significant except in 12 and 18 h after surgery (p < 0.05). The amount of administered morphine was higher in the fentanyl group than in the acetaminophen group, but the difference was not statistically significant. The hemodynamic status including systolic and diastolic blood pressure and heart rates were nearly the same in the two groups but the SpO2 mean was significantly higher in the acetaminophen group than the fentanyl group. Conclusions: This trial indicated that intravenous acetaminophen is as effective as intravenous fentanyl in pain relief after urologic surgeries (transurethral lithotripsy).

Resumo Justificativa: A dor pós-operatória é a complicação mais comum no período pós-operatório. Este estudo foi realizado para avaliar o efeito de acetaminofeno versus fentanil no alívio da dor pós-operatória em pacientes submetidos a cirurgias urológicas. Métodos: Este ensaio clínico foi realizado com pacientes cujas idades variou entre 18 e 65 anos. Os pacientes foram randomicamente designados para receber 2.000 mg de acetaminofeno (propacetamol) ou 2 mcg.kg-1 de fentanil por via intravenosa 15 min antes do final da cirurgia. A dor pós-operatória foi avaliada a cada 6 horas por 24 horas, utilizando a escala visual analógica. A dose total de morfina administrada em 24 horas e o estado hemodinâmico foram avaliados. Resultados: Oitenta pacientes foram incluídos no estudo. O escore médio de dor em 6, 12, 18 e 24 horas após a cirurgia foi menor no grupo acetaminofeno que no grupo fentanil, mas a diferença não foi estatisticamente significativa, exceto em 12 e 18 horas após a cirurgia (p < 0,05). A quantidade de morfina administrada foi maior no grupo fentanil que no grupo acetaminofeno, mas a diferença não foi estatisticamente significativa. O estado hemodinâmico, incluindo pressão arterial sistólica e diastólica e frequência cardíaca, foi quase o mesmo nos dois grupos, mas a média de SpO2 foi significativamente maior no grupo acetaminofeno que no grupo fentanil. Conclusões: Este estudo indicou que acetaminofeno intravenoso é tão eficaz quanto fentanil intravenoso no alívio da dor após cirurgias urológicas (litotripsia transuretral).

Percutaneous Nephrolithotomy Versus Laparoscopy in the Management of Large Proximal Ureteral Stones: The Experience of Two Different Settings.

PURPOSE: This study was conducted to compare the success rate and complications of percutaneous nephrolithoto-my (PCNL) and laparoscopic ureterolithotomy for the treatment of large proximal ureteral stones. MATERIALS AND METHODS: In this prospective cohort study, the success rate and complications in 52 patients under-going PCNL in Hamadan's Shahid Beheshti Hospital and 55 patients undergoing laparoscopic ureterolithotomy in Tehran's Shahid Labbafinejad Hospital were compared. All patients had large proximal ureteral stones. RESULTS: In the PCNL group, the mean age was 47.78 ±16.72 years, 75% were male, and 50% of calculi were on the upper right side and the rest on upper left side. The mean duration of surgery was 32 ± 9.4 minutes and success rate 100%. The mean stone size was 18.33 ± 2.63 mm in PCNL group and 21.29 ± 2.18 mm in laparoscopy group which was significantly different (P <.001). In the laparoscopy group, the mean age of patients was 42.92 ± 16.10 years and 83.6% were male. In this group, 46.6% of calculi were on the right side and the rest were on the left side. The mean duration of surgery was 107.43 ± 22.86 minutes and success rate was 100%. There was not a statistically significant association between surgical technique and age, gender, stone location, mean hospital stay length after surgery, degree of hydronephrosis and success rate (P >.05). However, surgery duration was significantly shorter in the PCNL group compared to the laparoscopy group (P <.001) and the decrease in hemoglobin, hematocrit and serum urea level was more pronounced in the PCNL group than in the laparoscopy group. CONCLUSION: PCNL and laparoscopic ureterolithotomy met with the same success rate in the treatment of upper large ureteral stones. However, the two methods should be utilized depending on the hospital facilities and equip-ment, surgical team qualifications, and patient conditions.

[Effect of intravenous acetaminophen versus fentanyl on postoperative pain after transurethral lithotripsy]. / Efeito do acetaminofeno versus fentanil intravenosos na dor pós litotripsia transuretral.

BACKGROUND: Postoperative pain is the most common postoperative complication. This study was conducted to assess the effect of acetaminophen versus fentanyl on postoperative pain relief in patients who underwent urologic surgeries. METHODS: This clinical trial was conducted on patients aged 18-65 years. Patients were randomly assigned to receive either 2000mg acetaminophen (propacetamol) or 2mcg.kg-1 fentanyl intravenously, 15min before the end of surgery. The postoperative pain was evaluated every 6h for 24h using the Visual Analog Scale. Total morphine dose taken in 24h and hemodynamic status were evaluated. RESULTS: Eighty patients were enrolled into the trial. The mean score of pain in 6, 12, 18, and 24h after surgery was lower in the acetaminophen group than in the fentanyl group but the difference was not statistically significant except in 12 and 18h after surgery (p<0.05). The amount of administered morphine was higher in the fentanyl group than in the acetaminophen group, but the difference was not statistically significant. The hemodynamic status including systolic and diastolic blood pressure and heart rates were nearly the same in the two groups but the SpO2 mean was significantly higher in the acetaminophen group than the fentanyl group. CONCLUSIONS: This trial indicated that intravenous acetaminophen is as effective as intravenous fentanyl in pain relief after urologic surgeries (transurethral lithotripsy).

Assessment of CEP55, PLK1 and FOXM1 expression in patients with bladder cancer in comparison with healthy individuals.

This case/control study is aimed at investigating the expression of CEP55, PLK1 and FOXM1 in bladder cancer tissues and comparing it with healthy tissue and their relationship with clinicopathological features of BC. Total RNA was extracted; then, gene expression was performed using real-time PCR relative to 18 s rRNA. 2-ΔΔCT method was used to calculate the relative expression of genes. A significant over expression of FOXM1, PLK1 and CEP55 was observed in tumor samples compared to adjacent and normal bladder tissues (all p = 0.001). Therefore, they may be supposed as potential candidate's biomarkers for early diagnosis and targets for cancer therapy.

Evaluation of MicroRNA-99a and MicroRNA-205 Expression Levels in Bladder Cancer.

Bladder cancer is the second most common cancer in the genitourinary tract, showing often recurrence and progress into invasive states. Epigenetic changes, such as microRNA alteration are involved in bladder cancer tumorigenesis through a variety of signaling pathways. The epigenetic state depends on geographic and lifestyle conditions. The aim of this study was to investigate the expression level of microRNA-99a and microRNA-205 in bladder cancer in Iranian populations and to determine the relationship between their expressions with clinicophatological features. 36 patients with bladder cancer were included in the study. The control group was the healthy adjacent tissue of the same patients. Total RNA was extracted from approximately 50 mg tissue using TRIzol reagent. cDNA was synthesized and Real-Time PCR was carried out using specific primers. The Unisp6 rRNA was used as a reference gene. A significant decrease was found in the expression level of miR-99a in tumor samples, compared to healthy adjacent tissues (P<0.001). The increased expression level of miR-99a was significantly associated with muscle invasion (P=0.02). The receiver operating characteristic (ROC) analysis for miR-99a showed AUC value equal to 0.944, with specificity of 97%, sensitivity of 91%, and cut off value of 8.31 (P<0.001). A significant association was found between smoking and miR-99a (P=0.04) and miR-205 (P= 0.01) expression levels. Dramatic down-regulation of miR-99a in bladder cancer tissues confirmed the tumor suppressor role of miR-99a in bladder cancer. A higher amount of miR-99a expression was associated with invasive bladder cancer. According to ROC analysis, miR-99a could be considered as a valuable diagnostic biomarker.

Safety and Efficacy of Percutaneous Nephrolithotomy in Patients with Severe Skeletal Deformities.

PURPOSE: Treatment of renal calculi in patients with severe skeletal deformities can be challenging. We present our experience in order to provide an assessment of technical difficulties, associated complications, and outcomes of percutaneous nephrolithotomy (PCNL) as a treatment option in this special patient group. MATERIALS AND METHODS: Our study included eight patients treated with PCNL for renal stones. All had severe skeletal deformities including six with severe kyphoscoliosis, one with osteogenesis imperfecta, and another withrickets. After pre-operative evaluation the procedure was performed under fluoroscopic and/or ultrasonic guidance. In all but one case, PCNL was performed with the patient in the prone position. Silicone rolls and soft padded bolsters were used to obtain the best positioning for the procedure. Clearance rates and complications were assessed. RESULTS: Complete stone-free rate was achieved in six patients (75%) after first-PCNL. The two patients with residual stones underwent a second-look PCNL, after which one was completely cleared. The overall completestone-free rate after second PCNL was 87%. Only minor complications were seen in two patients (25%). CONCLUSION: We found PCNL to be safe and effective for managing kidney stones in patients with severe skeletal deformities.

Evaluation of zinc finger E-box binding homeobox 1 and transforming growth factor-beta2 expression in bladder cancer tissue in comparison with healthy adjacent tissue.

PURPOSE: The fifth most common cancer is allocated to bladder cancer (BC) worldwide. Understanding the molecular mechanisms of BC invasion and metastasis to identify target therapeutic strategies will improve disease survival. So the aim of this study was to measure expression rate of zinc finger E-box binding homeobox 1 (ZEB1) and transforming growth factor-beta2 (TGF-ß2) mRNA in tissue samples of patients with BC and its healthy adjacent tissue samples and their association with muscle invasion, size and grade of the tumor. MATERIALS AND METHODS: Tissue samples were collected from 35 newly diagnosed untreated patients with BC from 2013 to 2014. Total RNA was extracted from about 50-mg tissue samples using TRIzol reagent. TAKARA SYBR Premix EX Tag II was applied to determine the rate of mRNA expression by real-time polymerase chain reaction (PCR). To obtain final validation, PCR product of ZEB1 and TGF-ß2 were sequenced. STATA 11 software was used to analyze the data. RESULTS: The expression level of ZEB1 in tumor samples was significantly more than of in healthy adjacent tissue samples. Up-regulation of TGF-ß2 showed a strong association with muscle invasion (p=0.017). There was also demonstrated a relationship between over expression of ZEB1 with the tumor size (p=0.050). CONCLUSIONS: It looks ZEB1 and TGF-ß2 had a role in BC patients. In this study ZEB1 expression was higher in BC tissues than that of in healthy control tissues. There was demonstrated a markedly association between overexpression of TGF-ß2 and muscle invasion. Therefore, they are supposed to be candidate as potential biomarkers for early detection and progression of BC.

Evaluation of miR-141, miR-200c, miR-30b Expression and Clinicopathological Features of Bladder Cancer.

Bladder cancer (BC) ranks the second most common genitourinary tract malignant tumor with high mortality and 70% recurrence rate worldwide. MiRNAs expression has noticeable role in bladder tumorigenesis. The purpose of this study was to assess miR-200c, miR-30b and miR-141 in tissue samples of patients with BC and healthy adjacent tissue samples and their association with muscle invasion, grade and the size of the tumor. Transurethral resection tissue samples were collected from thirty- five newly diagnosed untreated patients with BC from 2013 to 2014. The control group consisted of adjacent normal urothelium. All samples, observed by two pathologists, were diagnosed transitional cell carcinomas (TCC) with the proportion of tumor cells greater than 80%. Total RNA including miRNAs was extracted from about 50 mg tissue samples by applying TRIzol reagent. 2((-ΔΔ CT)) method was used to calculate relative quantification of miRNA expression. Two of 35 patients were females and the other 33 were males. Invasion to bladder muscle was observed in 13 (37%) cases. MiR-141, miR-200-c and miR30-b were up-regulated in 91%, 79% and 64% of malignant tissues, respectively. Down-regulation of miR-141 had a strong association with muscle invasion (P= 0.017). Significant inverse correlation between grading and miRNA-141 level was observed (P= 0.043).

Prostate cancer antigen 3 gene expression in peripheral blood and urine sediments from prostate cancer and benign prostatic hyperplasia patients versus healthy individuals.

PURPOSE: To determine the expression of prostate cancer antigen 3 (PCA3) gene in peripheral blood and urine sediments from patients with prostate cancer (PCa) and benign prostatic hyperplasia (BPH) and normal subjects. MATERIALS AND METHODS: A total number of 48 patients [24 with biopsy proven prostate cancer (PCa) and 24 with benign prostate hyperplasia (BPH)] were studied. Twenty-four healthy individuals were also recruited as control group. After blood and urine sampling, total RNA was extracted and cDNA was synthesized. Expression of PCA3 gene was assessed by quantitative reverse transcription polymerase chain reaction. RESULTS: Comparison of PCA3 gene expression between control and BPH groups indicated no statistically significant differences in both urine and blood samples. Patients with PCa demonstrated an increased PCA3 gene expression rate compared to control and BPH groups (10.64 and 7.17 folds, respectively). The rate of fold increased PCA3 gene expression in urine was 20.90, 20.90, and 20.35 in patients with PCa, BPH and normal subjects, respectively. CONCLUSION: Evaluation of PCA3 gene expression can be considered as a reliable marker for detection of PCa. Increased level of this marker in urine sediments is more sensitive than blood for distinguishing between cancerous and non-cancerous groups. 

Multiple endocrine neoplasia type IIa associated with Cushing's syndrome.

Multiple Endocrine Neoplasia type IIa (MEN IIa) is an autosomal dominant syndrome characterized by pheochromocytoma, medullary thyroid carcinoma and hyperparathyroidism. Pheochromocytoma occurs in approximately 50% of patients with MEN IIa. This tumor has the capacity to produce ACTH ectopically and manifests as the Cushing syndrome, although it is very rare. We report a 26-year-old woman patient with severe muscle weakness, skin lesions in extremities, hypertension, and new onset diabetes whose laboratory findings included hypokalemia, metabolic alkalosis, high serum level of cortisol, metanephrine, normetanephrine, calcitonin and bilateral adrenal mass in computed tomography as the first clinical manifestations of an ACTH-secreting pheochromocytoma. In the patients with hypertension, new onset diabetes and hypokalemia, the Cushing syndrome and pheochromocytoma should always be ruled out.

Comparison of the safety and efficacy of one-shot and telescopic metal dilatation in percutaneous nephrolithotomy: a randomized controlled trial.

Minimizing X-ray exposure during percutaneous nephrolithotomy (PCNL) is challenging. Using the single semirigid dilator, also called "one-shot" or "one-stage" is a good alternative to routine telescopic metal dilators to reduce X-ray exposure. Our aim was to compare the single semirigid one-shot dilator with a telescopic metal dilator in PCNL. The intraoperative status was evaluated in 100 consecutive patients randomly assigned to two equal groups undergoing PCNL either with the one-shot (group A) or telescopic technique (group B). No significant difference in stone burden and location existed between the groups (P > 0.05). The mean age of group A and group B was 44.8 ± 15 and 45.6 ± 14 years, respectively (P = 0.78). The mean operation time was 51.14 ± 40.85 min in group A and 57.00 ± 38.85 min in group B (P = 0.46). The mean X-ray exposure time was 41.2 ± 17 and 48.4 ± 15 s in group A and group B, respectively (P = 0.03). The stone-free rate was 94 % (n = 47) in group A and 84 % (n = 42) in group B (P = 0.10). The mean hemoglobin drop was 1.26 ± 0.09 and 1.44 ± 0.11 g/dl in group A and group B, respectively (P = 0.09). The one-shot technique is feasible, safe, and well tolerated in patients undergoing PCNL. In addition to lack of complications, the method also provides less radiation exposure for urologists and nursing teams.

Complications of entry using Direct Trocar and/or Veress Needle compared with modified open approach entry in laparoscopy: six-year experience.

PURPOSE: To compare the results obtained from three routine laparoscopic entry techniques, including Direct Trocar (DT), Veress Needle (VN), and Open Approach (OA). MATERIALS AND METHODS: Safety and efficacy of three main laparoscopic entry techniques were evaluated prospectively in 453 consecutive patients who had undergone laparoscopy either with DT, VN, or modified OA technique in recent six years. RESULTS: Of 453 patients, 105 (23.2%) were operated on with the DT, 168 (37.1%) with the VN, and 180 (39.7%) with the modified OA technique. Statistical differences were seen among the groups in terms of mean age (P = .003), male-to-female ratio (P < .001), indications for the operation (P < .001), and mean trocar insertion time (P < .001). Three major complications (1 colon perforation and 2 iliac artery injuries) occurred in DT and one (iliac artery injury) in VN group, and modified OA group had no major complication (P = .04). Four major complications required laparotomy. Minor complications were seen in 6 (5.8%), 9 (5.4%), and 17 (9.4%) patients (P = .274) and gas leakage in 4 (3.8%), 16 (9.5%), and 27 (15%) patients (P = .01) in DT, VN, and modified OA groups, respectively. CONCLUSION: Although DT and VN are rapid and relatively safe, they can be associated with major complications. Therefore, modified OA seems to be safe, feasible, and most acceptable due to less major complications.

The feasibility of regional anesthesia in the percutaneous nephrolithotomy with supracostal approach and its comparison with general anesthesia.

There are various approaches for the percutaneous nephrolithotomy (PCNL). Supracostal approach is a well known technique for doing of it. This approach is being done commonly under general anesthesia (GA). In this retrospective study, we evaluated the feasibility of supracostal PCNL under regional anesthesia (RA) and compared it with the same procedure under GA. Since March 2000 to March 2005, a total of 123 renal stone cases underwent PCNL with supracostal access in our center. GA was selected in 69 cases (56 %) (Group 1), spinal anesthesia (SA) in 45 cases (36.5 %), and epidural anesthesia (EA) in 9 cases (7.5 %) (Group 2). The operative time, success rate, hospital stay, and ensuing complications were compared between group 1 and group 2. There were no significant differences between groups 1 and 2 among surgical parameters, including age, stone area, anesthesia time, and hospitalization time (P > 0.05). There was no difference in the rate of complications or success rate between GA and RA cases (P > 0.05). Overall complete stone free rate, regardless of stone size, in relation to type of anesthesia was as follows: 88.4 % for GA, 88.9 % for EA, and 91.1 % for SA (P > 0.05). Conversion to GA was not needed in any patient with RA. The results showed that the supracostal PCNL with regional anesthesia was feasible but without evident advantages versus general anesthesia in this population, and possible advantages of the procedure in patients with pulmonary co-morbidities have still to be evaluated. The anesthesia related complications of RA were negligible and easily controllable.