Concurrent bariatric surgery and surgical resection of massive localized lymphedema of the thigh. A case report.

INTRODUCTION: Massive localised lymphedema (MLL) is considered a rare large, pendulous localised benign overgrowth of lymphoproliferative tissue commonly seen in patients with morbid obesity. Histologically, it may be mistaken for well-differentiated liposarcoma; hence, it is also known as pseudosarcoma. PRESENTATION OF CASE: We describe the successful management of MLL of the left medial thigh in a 35-year-old man weighing 220 kgs (BMI 80.8 kgs/m2). He underwent a concurrent laparoscopic sleeve gastrectomy with surgical resection of the MLL. He recovered well and during our last follow up six months after the operation, he is ambulating well and weighs 148 kgs (BMI 54.4 kgs/m2). DISCUSSION: MLL is a form of secondary lymphedema resulting in disruption or compression of normal lymphatic drainage due to fat accumulation in obese patients. Patients usually delay treatment for even up to a decade, when it becomes sufficiently large enough to restrict mobility and daily activities, or when it becomes infected. MLL is primarily a clinical diagnosis. A detailed history regarding its slow growth spanning over the years makes malignancy less likely. However, if left untreated, MLL may progress to angiosarcoma. Imaging studies such as computed tomography (CT) and a Magnetic Resonance Imaging (MRI) are usually performed to rule out malignancy or vascular malformations. A tissue biopsy is not recommended unless there are suspicious pigmented lesions. CONCLUSION: MLL remains to be underdiagnosed. Due to the obesity epidemic, clinicians must be aware of this once rare disease. The role of concurrent bariatric surgery with surgical resection of MLL warrants further studies.

Intravesical stent position as a predictor of quality of life in patients with indwelling ureteral stent.

PURPOSE: The internal drainage provided by a ureteral stent helps with the relief and prevention of ureteral obstruction. By definition, correct stent placement is one with a complete loop in both the renal pelvis and bladder. This prevents stent migration proximally or distally despite urinary flow, patient movement, and ureteral peristalsis. METHODS: We performed a comparative prospective cross-sectional study assessing the impact of intravesical stent position on the quality of life in 46 patients with a ureteral stent. This is done using the Ureteral Stent Symptom Questionnaire (USSQ). RESULTS: 52.5% of patients had an ipsilateral positioned intravesical stent, while the remaining had their stent positioned contralaterally. Intravesical stent position significantly influenced the quality of life. The USSQ score was worse for the contralateral group. Subscore analysis found that urinary symptoms and body pain index contribute significantly to the morbidity. Majority of patients in the ipsilateral group reported no discomfort as compared to the contralateral group. CONCLUSIONS: To the best of our knowledge, this is the first study assessing the impact of intravesical stent position on the quality of life in the Asian population. Intravesical stent position has a significant influence on patient's morbidity and quality of life in particular towards their urinary irritative symptoms and body pain. It is imperative to ensure correct distal placement of ureteric stent that does not cross the midline to the contralateral site. We believe that the USSQ should be used in daily clinical practice in assessing the symptoms related to indwelling ureteric stents.