Effective control of recurrent and metastatic GU SCC by employing a multimodal approach in a patient with a history of radiation and transscrotal surgery for stage I seminoma.

This 68-year-old male, with a history of treated testicular seminoma, developed scrotal SCC 30 years later, with a metastatic SCC recurrence following another interval of 10 years. He exhibited good response to multimodal therapy, though subsequently underwent orchiectomy, revealing SCC invading his solitary testicle. This case presents a unique danger of adjuvant radiation in testicular cancer survivors, demonstrates the efficacy of multimodal therapy with GU SCC, and describes a highly unusual histologic finding.

Primary follicular lymphoma of the prostate presenting with elevated PSA and a PI-RADS 3 lesion on MRI: A case report.

Prostate cancer is the most common malignancy diagnosed in men. PI-RADS 3 lesions on multiparametric MRI, when histologically proven malignant, overwhelmingly represent prostatic adenocarcinoma. Primary lymphoma of the prostate, especially follicular lymphoma, is exceedingly rare. To our knowledge, its presentation with a PI-RADS 3 lesion and elevated PSA has not been previously described. We report the case of a 68-year-old, healthy male presenting with elevated PSA and lower urinary tract symptoms found to have a PI-RADS 3 lesion. Prostate biopsy revealed low-grade follicular lymphoma, and staging showed no other lesions. The patient is currently being managed with close surveillance.

Comparative Effectiveness Analysis of Resorbable Synthetic Onlay and Biologic Intraperitoneal Mesh for Abdominal Wall Reconstruction: A 2-Year Match-Paired Analysis.

BACKGROUND: Abdominal wall reconstruction persists as a challenging surgical issue with a multitude of management strategies available. The aim of this study was to examine the efficacy of resorbable synthetic mesh onlay plane against biologic mesh in the intraperitoneal plane. METHODS: A single-center, two-surgeon, 5-year retrospective review (2014 to 2019) was performed examining subjects who underwent abdominal wall reconstruction in the onlay plane with resorbable synthetic mesh or in the intraperitoneal plane with biologic mesh. A matched paired analysis was conducted. Data examining demographic characteristics, intraoperative variables, postoperative outcomes, and costs were analyzed. RESULTS: Eighty-eight subjects (44 per group) were identified (median follow-up, 24.5 months). The mean age was 57.7 years, with a mean body mass index of 30.4 kg/m2. The average defect size was 292 ± 237 cm2, with most wounds being clean-contaminated (48.9 percent) and 55 percent having failed prior repair. Resorbable synthetic mesh onlay subjects were significantly less likely (4.5 percent) to experience recurrence compared to biologic intraperitoneal mesh subjects (22.7 percent; p < 0.026). In addition, mesh onlay suffered fewer postoperative surgical-site occurrences (18.2 percent versus 40.9 percent; p < 0.019) and required fewer procedural interventions (11.4 percent versus 36.4 percent; p < 0.011), and was also associated with significantly lower total costs ($16,658 ± $14,930) compared to biologic intraperitoneal mesh ($27,645 ± $16,864; p < 0.001). CONCLUSIONS: Abdominal wall reconstruction remains an evolving field, with various techniques available for treatment. When faced with hernia repair, resorbable synthetic mesh in the onlay plane may be preferable to biologic mesh placed in the intraperitoneal plane because of lower long-term recurrence rates, surgical-site complications, and costs. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Law of Diminishing Returns in Ventral Hernia Repair: Fact or Fiction?

BACKGROUND: Repeated ventral hernia repair is associated with increased risk of complications and recurrence. The authors present the first study looking at how repeated ventral hernia repair affects quality of life, and whether there is a relationship between the number of prior repairs and quality-of-life improvement after surgery. METHODS: A retrospective chart review was conducted of patients undergoing ventral hernia repair between August of 2017 and August of 2019, who completed at least one preoperative and postoperative Abdominal Hernia-Q. Patients were split into four cohorts based on number of prior repairs (zero, one, two, or three or more). Categorical data were compared using chi-square and Fisher's exact tests, and continuous data were analyzed using Kruskal-Wallis tests. RESULTS: Ninety-three patients met inclusion criteria, with 19 (20 percent), 45 (48 percent), 15 (16 percent), and 14 patients (15 percent) in each cohort, ranging from zero to three or more prior repairs. Patients with more prior repairs were significantly more likely to be readmitted and undergo reoperation (p = 0.04 and p = 0.01, respectively), in addition to significantly higher cost of care (p = 0.004). Patients with three or more prior repairs had significantly lower preoperative quality of life when compared to patients with two or fewer prior repairs (p = 0.04). However, all patients reported a similar absolute level of quality of life postoperatively, irrespective of prior repairs (p = 0.34). CONCLUSIONS: Treatment of recurrent hernia remains a challenge because of poor clinical outcomes and higher risk of recurrence. This study shows that patients with multiple prior ventral hernia repairs report similar postoperative quality of life as patients undergoing primary repair. This information is valuable in determining appropriate surgical candidates and improving preoperative counseling. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Managing locoregional breast cancer recurrence after autologous free flap reconstruction: A retrospective review of 2,734 procedures.

INTRODUCTION: The 5-year incidence of locoregional recurrence (LRR) after mastectomy is 3-8 %. This study examines the incidence, modes of detection, and reconstructive options after loss of index reconstruction in the largest series of autologous free flap patients who subsequently developed LRR. METHODS: We identified patients undergoing muscle-sparing free transverse rectus abdominus muscle or deep inferior epigastric perforator flap reconstruction for breast cancer at our institution from 2005 to 2017 who subsequently developed LRR. The main outcomes were incidence of recurrence, primary mode of detection, surgical management, and patient and cancer-specific factors associated with surgical management and loss of index reconstruction. RESULTS: The incidence of LRR in this cohort was 3% (n=66 of 2240 flaps), and 71% (n=46) of recurrences were diagnosed on physical examination. 80% (n=53) of LRR required multidisciplinary management, whereas 56% (n=37) were managed surgically. Patients with postoperative radiation prior to recurrence, metastatic disease at diagnosis, nodal positivity, and chest wall involvement were less likely to be offered surgery (all p<0.05). Twelve patients lost their index reconstruction and five required subsequent advanced chest wall reconstruction. No differences were seen in terms of location of recurrence, detection of recurrence, or mortality between flap types (all p>0.05). CONCLUSION: Management of LRR is centered around early multidisciplinary involvement and often requires surgery. Removal of index reconstruction and/or advanced chest well reconstruction is indicated in select cases. Plastic surgeons should be aware of the indications and options that exist for management in these complex situations.

Resorbable Synthetic Ventral Hernia Repair in Contaminated Fields: Outcomes with Poly-4-Hydroxybutyrate Mesh.

BACKGROUND: Hernia repair in the setting of contamination poses unique challenges, including complications such as recurrence and mesh infection. The ideal contaminated hernia repair including type of mesh use remains controversial. Poly-4-hydroxybutyrate is a biosynthetic scaffold for soft-tissue reinforcement and hernia repair and is potentially useful in contaminated hernia repair. The authors aim to describe postoperative outcomes, recurrence, and patient-reported outcomes after contaminated hernia repair with poly-4-hydroxybutyrate. METHODS: Adult patients (≥18 years) undergoing a contaminated hernia repair with poly-4-hydroxybutyrate (Phasix) performed by a single plastic surgeon between January of 2015 and May of 2020 were identified. Patients with a ventral hernia defect and a Centers for Disease Control and Prevention wound class of II, III, or IV were included. Primary outcomes included recurrence, surgical-site infection, surgical-site occurrences, and surgical-site infection/occurrences requiring procedural interventions. As a secondary outcome, the authors assessed patient-reported outcomes as defined by the Abdominal Hernia-Q and Hernia-Related Quality of Life Survey. RESULTS: Sixty patients were included with a median age of 52.5 and body mass index of 31 kg/m2. Median defect size was 300 cm2. Twenty-eight patients (46.7 percent) experienced a complication. The most common complications were surgical-site occurrence [n = 20 (33.3 percent)] and surgical-site infection [n = 10 (16.7 percent)]. Median follow-up was 24.2 months, with a recurrence rate of 8.3 percent (n = 4). Overall patient-reported outcomes improved postoperatively, and improvement was not affected by the presence of a complication. CONCLUSIONS: Poly-4-hydroxybutyrate use in contaminated hernia repair shows promising results with an acceptable safety profile. Although complications are frequent in this complex cohort, patient-reported outcomes improvement was significant even in patients with complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Onlay Poly-4-Hydroxybutyrate (P4HB) Mesh for Complex Hernia: Early Clinical and Patient Reported Outcomes.

BACKGROUND: While mesh re-enforcement and advanced surgical techniques are cornerstones of complex ventral hernia repair (CVHR), the risk of complications and recurrence is common. We aim to evaluate the efficacy, safety, and patient reported outcomes (PROs) of patients undergoing CVHR with onlay Poly-4-hydroxybutyrate (P4HB). METHODS: Adult (>18 y old) patients undergoing VHR with P4HB (Phasix) in the onlay plane by a single surgeon from 01/2015 to 05/2020 were reviewed. VHR was considered complex if patients had significant co-morbidities, large abdominal wall defects, a history of extensive abdominal surgery, and/or concurrent intra-abdominal pathology. A composite of postoperative outcomes including surgical site occurrences (SSO), surgical site infection (SSI), and surgical site occurrences requiring procedural intervention (SSOpi), as well as PROs as defined by the Abdominal Hernia-Q (AHQ), were analyzed. RESULTS: A total of 51 patients were included with average age and body mass index of 56.4 and 29.9 kg/m2. Median follow up was 20 mo with a hernia recurrence rate of 5.9% (n = 3). 21 patients had an SSO (41.2%), 8 had an SSI (15.7%), and 6 had an SSOpi (11.8%). There was an association with Ventral Hernia Working Group ≥ 2 and development of SSO. There was a significant improvement in overall PROs (P < 0.0001) with no difference in those patients with and without complications (P > 0.05). CONCLUSION: For hernia patients with large defects and complex intra-abdominal pathology, a safe and effective repair is difficult. The use of onlay P4HB was associated with acceptable postoperative outcomes and recurrence rate.

CemOrange2 fusions facilitate multifluorophore subcellular imaging in C. elegans.

Due to its ease of genetic manipulation and transparency, Caenorhabditis elegans (C. elegans) has become a preferred model system to study gene function by microscopy. The use of Aequorea victoria green fluorescent protein (GFP) fused to proteins or targeting sequences of interest, further expanded upon the utility of C. elegans by labeling subcellular structures, which enables following their disposition during development or in the presence of genetic mutations. Fluorescent proteins with excitation and emission spectra different from that of GFP accelerated the use of multifluorophore imaging in real time. We have expanded the repertoire of fluorescent proteins for use in C. elegans by developing a codon-optimized version of Orange2 (CemOrange2). Proteins or targeting motifs fused to CemOrange2 were distinguishable from the more common fluorophores used in the nematode; such as GFP, YFP, and mKate2. We generated a panel of CemOrange2 fusion constructs, and confirmed they were targeted to their correct subcellular addresses by colocalization with independent markers. To demonstrate the potential usefulness of this new panel of fluorescent protein markers, we showed that CemOrange2 fusion proteins could be used to: 1) monitor biological pathways, 2) multiplex with other fluorescent proteins to determine colocalization and 3) gain phenotypic knowledge of a human ABCA3 orthologue, ABT-4, trafficking variant in the C. elegans model organism.