[Bilateral ureterocele in adult--a case report and review of literature]. / Obustronna torbiel ujscia moczowodu u doroslego--opis przypadku i przeglad literatury.

Lower urinary tract symptoms in men are associated usually with the presence of bladder outlet obstruction, especially with benign prostatic hyperplasia. We present a case of a patient whose cause of urinary frequency, difficulty in starting micturition and feeling of incomplete emptying of the bladder was ureterocele, causing symptoms of bladder outlet obstruction. Treatment consisted of endoscopic electroresection of the cyst. Following treatment the complete resolution of symptoms reported before treatment was achieved.

[Iatrogenic ureteral injury in adults--diagnosis and treatment]. / Jatrogenne urazy moczowodów u doroslych--diagnostyka i leczenie.

Ureteral injuries are rare and a special group are iatrogenic ureteral injury. Such a situation may occur during open surgery, laparoscopic surgery and endoscopy. The mechanism typically includes cutting or ligation of the ureter or combination of both what may lead to urinary retention and tissue infiltration by urine. The priority is to prevent the incidence of injury. Even 75% of ureteral damage can be not identified during the surgery, when the injury occurred. The basis of treatment is to drain the urine, the urine leakage and ureter reconstruction.

Total thyroidectomy for multinodular goiter. possibility of implementation in a district hospital.

UNLABELLED: Increasing number of surgical subspecialities causes general surgeons have little experience with more complex procedures as total thyroidectomy. The aim of the study was to present the outcome of total thyroidectomy following its implementation in a district hospital where such procedure has not been performed previously. MATERIAL AND METHODS: 293 patients were operated on for goiter between 01.10.2008 and 30.09.2011 in the District Hospital in Proszowice by one contracted endocrine surgeon. Hemithyroidectomy was performed in 75 (23.7%) patients and total thyroidectomy in 191 (76.3%) patients for multinodular goiter and only the latter group was subjected for further analysis. RESULTS: There were no bilateral recurrent laryngeal nerve palsy. A unilateral transient recurrent laryngeal nerve palsy occurred in 6 patients (3.1%; 1.5% per risk) and postoperative hypocalcemia in 29 (15.7%) patients. 2 (1%) patients required wound revision due to a postoperative bleeding. Postoperative pathology revealed in 12 (6.2%) patients differentiated thyroid cancer. CONCLUSIONS: 1. Total thyroidectomy in a district hospital is still a safe way to operate on thyroid for nonmalignant disorders with low number of complications. 2. Total thyroidectomy is a definite surgical treatment in patients diagnosed by postoperative pathology with differentiated thyroid cancer.

Surgical management of mediastinal goiter: risk factors for sternotomy.

BACKGROUND AND AIMS: Mediastinal goiter constitutes an indication for surgical management. The procedure can most commonly be performed using the cervical access, but at times, a sternotomy or thoracotomy is necessary. The objective of the investigation was to analyze the prevalence and therapeutic results in patients with mediastinal goiter and to assess factors that affect the need of performing sternotomy in the course of mediastinal goiter surgery. MATERIAL AND METHODS: In the years 1984-2004, i.e., over 21 years, 11,849 patients with various types of goiter were operated on in the department. Mediastinal goiter was detected in 88 (0.76%) individuals. The analyzed material included 64 (72.7%) females and 24 (27.3%) males. The age of the patients ranged between 19 to 81 years, with the mean age of 61 +/- 13 years of life. The material was statistically analyzed. Risk factors for sternotomy were assessed using the multidimensional logistic regression method. RESULTS: The highest percentage of mediastinal goiter was noted in patients operated on due to recurrent goiter (3.86%). Goiter situated in the anterior mediastinum was noted in 61 (69.3%) individuals, while 27 (30.7%) patients demonstrated goiter located in the posterior mediastinum; of the latter, nine were previsceral and 18 retrovisceral. In the majority of cases, these were primarily cervical goiters, which descended from the neck to the mediastinum (53 patients). Aberrant adenomas were diagnosed in 32 (36.4%) individuals. Four patients presented with the superior cava vein syndrome. Primary goiters evaluated intraoperatively with blood supply originating from the mediastinal vessels were observed in 12 (13.6%) cases. In 27 (30.7%) patients, sternotomies were necessary. In the majority of cases, these were individuals with goiters showing additional blood supply originating from the mediastinal vessels, patients with aberrant adenomas in the mediastinum, especially in recurrent goiters, or else subjects with goiters situated in the posterior mediastinum as compared to anterior mediastinal goiters. No postoperative mortality during stay in a hospital was noted. CONCLUSIONS: Surgical management of patients with mediastinal goiter is the therapeutic modality that requires considerable experience of the surgical team, performed in specialized centers, and appropriate preoperative diagnostic management. Statistically significant risk factors for sternotomy are as follows: recurrent goiter, primary mediastinal goiter, posterior mediastinal location of goiter, and the presence of an aberrant adenoma situated in the mediastinum.

Applicability of intraoperative parathyroid hormone assay during total thyroidectomy as a guide for the surgeon to selective parathyroid tissue autotransplantation.

BACKGROUND: Intraoperative parathyroid hormone assay (IOPTH) has been suggested to have value in predicting the development of postoperative hypoparathyroidism after thyroid surgery. IOPTH has been validated in identification of patients at risk of postoperative hypocalcemia requiring early onset of calcium supplementation therapy and in improving selection of patients eligible for a safe early discharge. However, the value of IOPTH has not been assessed in a randomized study as a guide for the surgeon to parathyroid tissue autotransplantation (PA). The objective of this study was to evaluate the applicability of IOPTH in guiding the surgeon to selective parathyroid tissue autotransplantation during total thyroidectomy (TT). METHODS: Between January 2005 and December 2005, 340 patients qualified for total thyroidectomy (TT) who met the inclusion criteria were randomized to two equal-sized groups (n=170): group A, in which elective PA of at least one parathyroid gland was performed in all cases without IOPTH as a guide; and group B, in which selective IOPTH-guided PA was performed, if only the iPTH plasma level was <10 ng/L at 10-20 min after TT (before skin closure). The standard technique of PA consisting of implanting the parathyroid tissue into 10-20 sternocleidomastoid muscle pockets was used in both groups. IOPTH measurements were performed by the STAT-Intraoperative-iPTH-Assay. Serum calcium was routinely monitored at 4, 12, 24, 48, and 72 hr postoperatively. The incidence and severity of hypocalcemia and related symptoms were matched with the IOPTH results. On follow-up, serum calcium and plasma iPTH values were measured at 1, 3, and 6 months postoperatively. The primary end point was the success rate in preventing permanent postoperative hypoparathyroidism. The secondary end point was the use of postoperative medication for transient hypocalcemic symptoms. RESULTS: Twenty-one group B patients (12.3%) had plasma iPTH levels<10 ng/L at 10-20 min after TT (before skin closure) and they underwent selective IOPTH-guided PA. None of the patients from both groups experienced permanent postoperative hypoparathyroidism. Transient postoperative hypocalcemia occurred in 22.3% vs. 11.2% of patients (group A vs. B, respectively; p<0.05). The mean cumulated serum calcium values were significantly lower for group A vs. group B patients within the entire 3-month period after TT (2.12+/-0.09 mmol/L vs. 2.27+/-0.05 mmol/L, respectively; p<0.001). The mean oral calcium supplementation was significantly higher for group A vs. group B patients during the 3 months after TT (2.7+/-0.9 g/day vs. 0.9+/-0.4 g/day, respectively; p<0.001). CONCLUSIONS: IOPTH offers valuable information during TT, correctly identifying patients at risk of postoperative hypocalcemia. Selective IOPTH-guided PA in patients with plasma iPTH levels<10 ng/L at 10-20 min after TT reduces the risk of permanent postoperative hypoparathyroidism to zero, and this approach seems to be as effective as elective PA of at least one parathyroid gland without IOPTH guidance. Moreover, selective IOPTH-guided PA significantly decreases the incidence of transient postoperative hypoparathyroidism and the need for calcium supplementation therapy compared with elective PA without IOPTH.

Metastases to the thyroid gland: seventeen cases operated on in a single clinical center.

BACKGROUND AND AIMS: In spite of its rich vasculature, the thyroid gland is rarely the site of metastatic disease. The incidence of such metastases differs depending on the type of the analyzed material. In clinical papers, the incidence is low and, according to various sources, amounts to 2-3% of all malignant tumors of the thyroid. Most commonly, the primary tumor is located in the breast, bronchi, gastrointestinal system, (the colon, esophagus, or stomach) and kidneys. Usually, metastatic thyroid disease is identified upon autopsy, and only sporadic cases are encountered in clinical material. The authors present their experience in treating metastatic disease involving the thyroid gland based on the analysis of their clinical material consisting of patients operated on in a single center. MATERIALS AND METHODS: Seventeen patients presented with metastatic tumors of the thyroid. The material was further analyzed retrospectively. The group included four men and 13 women, with the male to female ratio of 1:4.25. The age of the patients ranged from 46 to 76 years, with the mean age amounting to 62+/-9.78 years. Eleven patients were diagnosed based on fine needle aspiration biopsy (FNAB). RESULTS: In 13 patients, the primary lesion was a clear cell carcinoma of the kidney, in one breast cancer, in another one uterine carcinoma. In two patients, no primary focus location was established. All the patients were treated surgically. Twelve patients were consistently followed up after the surgery. Of this group, seven are still alive, including five individuals with metastases of renal carcinomas, but without recurrent disease. Five patients died due to disseminated neoplastic disease. No data are available on three patients. The mean follow-up time after thyroid surgery was 3.9 years. The longest followed-up survival time was 11 years. CONCLUSIONS: The most commonly clinically detected and treated surgically metastatic lesion of the thyroid gland is clear cell cancer of the kidney. In cases of renal cancer metastases to the thyroid gland, a total thyroidectomy seems to be warranted, although it does not affect the survival time.

Minimally invasive video-assisted parathyroidectomy versus open minimally invasive parathyroidectomy for a solitary parathyroid adenoma: a prospective, randomized, blinded trial.

BACKGROUND: A variety of minimally invasive parathyroidectomy (MIP) techniques have been currently introduced to surgical management of primary hyperparathyroidism (pHPT) caused by a solitary parathyroid adenoma. This study aimed at comparing the video-assisted MIP (MIVAP) and open MIP (OMIP) in a prospective, randomized, blinded trial. MATERIALS AND METHODS: Among 84 consecutive pHPT patients referred for surgery, 60 individuals with concordant localization of parathyroid adenoma on ultrasound and subtraction Tc99m-MIBI scintigraphy were found eligible for MIP under general anesthesia and were randomized to two groups (n = 30 each): MIVAP and OMIP. An intraoperative intact parathyroid hormone (iPTH) assay was routinely used in both groups to determine the cure. Primary end-points were the success rate in achieving the cure from hyperparathyroid state and hypocalcemia rate. Secondary end-points were operating time, scar length, pain intensity assessed by the visual-analogue scale, analgesia request rate, analgesic consumption, quality of life within 7 postoperative days (SF-36), cosmetic satisfaction, duration of postoperative hospitalization, and cost-effectiveness analysis. RESULTS: All patients were cured. In 2 patients, an intraoperative iPTH assay revealed a need for further exploration: in one MIVAP patient, subtotal parathyroidectomy for parathyroid hyperplasia was performed with the video-assisted approach, and in an OMIP patient, the approach was converted to unilateral neck exploration with the final diagnosis of double adenoma. MIVAP versus OMIP patients were characterized by similar operative time (44.2 +/- 18.9 vs. 49.7 +/- 15.9 minutes; P = 0.22), transient hypocalcemia rate (3 vs. 3 individuals; P = 1.0), lower pain intensity at 4, 8, 12, and 24 hours after surgery (24.9 +/- 6.1 vs. 32.2 +/- 4.6; 26.4 +/- 4.5 vs. 32.0 +/- 4.0; 19.6 +/- 4.9 vs. 25.4 +/- 3.8; 15.5 +/- 5.5 vs. 20.4 +/- 4.7 points, respectively; P < 0.001), lower analgesia request rate (63.3% vs. 90%; P = 0.01), lower analgesic consumption (51.6 +/- 46.4 mg vs. 121.6 +/- 50.3 mg of ketoprofen; P < 0.001), better physical functioning aspect and bodily pain aspect of the quality of life on early recovery (88.4 +/- 6.9 vs. 84.6 +/- 4.7 and 90.3 +/- 4.7 vs. 87.5 +/- 5.8; P = 0.02 and P = 0.003, respectively), shorter scar length (17.2 +/- 2.2 mm vs. 30.8 +/- 4.0 mm; P < 0.001), and higher cosmetic satisfaction rate at 1 month after surgery (85.4 +/- 12.4% vs. 77.4 +/- 9.7%; P = 0.006). Cosmetic satisfaction was increasing with time, and there were no significant differences at 6 months postoperatively. MIVAP was more expensive (US$1,150 +/- 63.4 vs. 1,015 +/- 61.8; P < 0.001) while the mean hospital stay was similar (28 +/- 10.1 vs. 31.1 +/- 9.7 hours; P = 0.22). Differences in serum calcium values and iPTH during 6 months of follow-up were nonsignificant. Transient laryngeal nerve palsy appeared in one OMIP patient (P = 0.31). There was no other morbidity or mortality. CONCLUSIONS: Both MIVAP and OMIP offer a valuable approach for solitary parathyroid adenoma with a similar excellent success rate and a minimal morbidity rate. Routine use of the intraoperative iPTH assay is essential in both approaches to avoid surgical failures of overlooked multiglandular disease. The advantages of MIVAP include easier recognition of recurrent laryngeal nerve (RLN), lower pain intensity within 24 hours following surgery, lower analgesia request rate, lower analgesic consumption, shorter scar length, better physical functioning and bodily pain aspects of the quality of life on early recovery, and higher early cosmetic satisfaction rate. However, these advantages are achieved at higher costs because of endoscopic tool involvement.

A randomised study on a new cost-effective algorithm of quick intraoperative intact parathyroid hormone assay in secondary hyperparathyroidism.

BACKGROUND AND AIMS: The use of intraoperative intact parathyroid hormone (iPTH) assay in secondary renal hyperparathyroidism (SHP) has been limited by the relatively low cost effectiveness of the assay in improving the success rate for primary bilateral neck exploration. The study aimed at determining, in a prospective, randomised trial, the cost effectiveness and impact of the routine employment of a "six-sample" versus "two-sample" algorithm of the intraoperative iPTH assay during surgery for SHP on intraoperative decision making and surgical success rate. PATIENTS AND METHODS: One hundred and two consecutive patients with severe SHP and qualified for subtotal parathyroidectomy were randomly allocated to two equal-sized groups: group A, in which the intraoperative iPTH serum level was determined in six consecutive samples: preoperative, pre-excision, 5, 10, 20 and 60 min, and group B, in which the intraoperative iPTH serum level was determined twice only: preoperatively and 10 min. The STAT intraoperative intact-PTH immunoassay was employed. In group B, in patients with serum iPTH decrease lower than 60% of the baseline at 10 min, an additional measurement was performed at 20-min post-excision. If a decrease of 80% or more of the baseline was not obtained, the exploration was extended in search of remaining hyperfunctioning parathyroid tissue. RESULTS: The surgical success rate was 96.1% and 98.0% (in group A and B, respectively). The impact of the intraoperative iPTH assay on surgical decision making was demonstrated in 13.7% and 15.7% (in group A and B, respectively). The assay was helpful in identifying patients with supranumerary hyperfunctioning parathyroid tissue (5.9% vs 7.8% in group A and B, respectively), patients with fewer than four parathyroid glands (3.9% vs 5.9% in group A and B, respectively) and patients with remaining hyperfunctioning parathyroid tissue suspected to be located within the mediastinum in cases of negative bilateral neck exploration who benefit from transcervical thymectomy. The diagnostic accuracy of the intraoperative iPTH assay was 100% in both groups. The accuracy of two-sample algorithm increased from 96% to 100% if an additional serum iPTH determination was performed in borderline cases with an iPTH drop lower than 60% of the baseline at 10 min. The cost-effectiveness analysis showed significant savings in group B, equal to Euro 87.6 per patient, with the unchanged diagnostic accuracy of the two-sample algorithm. CONCLUSIONS: The intraoperative iPTH assay in patients operated on for secondary hyperparathyroidism offers support in surgical decision making in the majority of patients, allowing for correct identification of patients with supranumerary ectopic hyperfunctioning parathyroid glands, and in patients with fewer than four parathyroid glands. It also correctly identifies patients who do not benefit from blind thymectomy. The two-sample algorithm, extended to include three determinations in selected cases, has the same 100% diagnostic accuracy as the six-sample algorithm, the former being a much more cost-effective procedure.

Significance of vascular endothelial growth factor and epidermal growth factor in development of papillary thyroid cancer.

BACKGROUND AND AIMS: Vascular endothelial growth factor (VEGF) induces proliferation of endothelial cells, stimulates angiogenesis and increases vascular permeability. Epidermal growth factor (EGF) induces proliferation of epidermal cells and stimulates epidermal migration. Increased VEGF and EGF expression have been associated with poor clinical outcome in many malignancies. Several recent reports have shown overexpression of VEGF and EGF in papillary thyroid cancer (PTC). The study aimed to determine the intensity of expression of VEGF and EGF in patients with PTC and to find any correlation between the intensity of the expression and staging of the disease at the moment of surgery PATIENTS AND METHODS: The study comprised a group of 48 consecutive patients with PTC who underwent radical surgery. The group consisted of 11, 25, eight and four patients at pT1N0M0, pT2N0M0, pT3N1M0 and pT4N1M0 stages, respectively. The control group was composed of 20 healthy bone marrow transplant donors, age-, gender- and BMI-matched with PTC patients. The immuno-chemiluminescence enzyme linked immunoassay (ELISA) method was used to determine the expression and level of VEGF and EGF in serum samples. Patients' characteristics, serum levels of VEGF and EGF, final histology and pTNM were analysed. RESULTS: The mean serum level of VEGF and EGF was remarkably higher in PTC patients than in controls. A negative correlation between staging in pTNM classification and the mean serum VEGF level (r=-0.5168; P<0.05) as well as a positive correlation between staging in pTNM classification and the mean serum EGF level (r=0.6104; P<0.05) in PTC patients was observed. CONCLUSIONS: Both VEGF and EGF play an important role in PTC growth. However, the intensity of their expression is variable, depending on the stage of the disease. The highest intensity of VEGF expression is characteristic for low-stage T1N0M0 disease, whereas the highest intensity of EGF expression is more often found at locally advanced pT3 and pT4N1M0 stages of the disease. Further long-term follow-up studies are required to demonstrate the prognostic value of VEGF and EGF in PTC, particularly in identification of patients with expected poor prognosis or shorter recurrence-free survival.

[The role of prophylactic examinations in detecting thyroid disorders. Preliminary results]. / Rola badan profilaktycznych w wykrywaniu schorzen gruczolu tarczowego. Doniesienie wstepne.

PREFACE: Nonpalpable nodules in the thyroid are frequent and estimated to be found in 50% of people above 50 year of age when goiter in adult population is found in 4-10%. Thyroid nodules in 5% are of neoplastic character and their diligent investigation is necessary with USG, FNA and certain biochemical factors evaluation. Screening is an important part of diagnosing thyroid gland. MATERIAL AND METHODS: Prophylactic examination donated by Krakow's City Government was performed in 140 persons aged 18-71 among whom 93.3% were women. Clinical examination, USG, FNA (when it was necessary), and TSH serum level evaluation were conducted in these patients. RESULTS: In 42.2% (group I) no abnormalities were detected. In 28.5% (group II) USG revealed thyroid nodules when clinical examination was negative. In 29.3% (group III) the presence of palpable nodules was confirmed by USG. In consecutive groups I-III following factors were presented: mean age, frequency of performed FNA's and thyroids volume. CONCLUSION: USG is an efficient method in prophylaxis of thyroid disorders.

[Differentiated thyroid cancers. Etiopathogenic and clinical data, prognostic factors and surgical treatment]. / Wysokozróznicowane raki tarczycy. Dane etiopatogenetyczno-kliniczne, czynniki rokownicze i taktyka operacyjna.

Thyroid cancer is the most common among endocrine malignant neoplasm. The cause of its grow is as well the external factors influence and primary malfunction of thyroid cells. The most common is papillary cancer but in the regions where iodine level is low the incidence of follicular cancer increases. The postoperative procedures depend on the type and stage of cancer. Nowadays centers which deal with thyroid cancer treatment are for primary radical surgery as it is followed by lower possibility of missing the cancer in the thyroid remnant, easier postoperative follow up and supplementary treatment management.

[Thyroiditis in patients operated on for goiter]. / Zapalenie tarczycy u chorych operowanych z powodu wola.

UNLABELLED: The paper is aimed at evaluating the frequency of incidence and the thyroiditis type in patients operated on for goiter. In the years 1989-2000, 5149 patients were operated on because of different thyroid disorders. The clinical data of 66 patients with thyroiditis, diagnosed in a post-operating histopathological examination, were subject to a retrospective analysis. There were 64 women and 2 men, aged from 22 to 70, on an average 50.1 years old. There were determined the preoperative diagnosis, the thyroid function--basing upon the levels of TSH and thyroid hormones, the type of operation effected as well as post operative complications. Then, there was also measured the weight of the resected lobes. The prevalent indication for the surgery was non-toxic goiter; instead, toxic goiter was such an indication only in a few cases. In most patients, the thyroid function revealed euthyreosis. The following complications were observed: transient hypocalcemia [two patients], transient paralysis of recurrent laryngeal nerve on one side [one], and wound suppuration [one]. The following types of thyroiditis were found in histopatological examination: Hashimoto (59 patients), Riedl (3 patients), de Quervain (2 patients) and non-specific thyroiditis (2 patients). CONCLUSIONS: 1. Thyroiditis is a rare case in patients operated on for goiter. 2. The most frequent pathological finding is Hasimoto disease.