Surgical treatment of rectourethral fistula / 现代泌尿外科杂志

Rectourethral fistula (RUF) has been difficult to manage in urology due to its special anatomical location,complicated condition and uncertain prognosis. With the increasing incidence of prostate cancer,the incidence of RUF as a serious complication is also rising. Major treatment methods of RUF include conservative treatment and surgical treatment such as transabdominal approach,trans-perineal approach,trans-sphincter approach and trans-anal approach. However,there is no explicit treatment protocol. In recent years,the application of modified York-Mason technique has achieved good results. This article details the key steps and surgical experience of the technique.

Resultados del tratamiento quirúrgico del cáncer de recto y ano en el Hospital Español / Results of the surgical treatment of rectal and anal cancer in the Hospital Español / Resultados do tratamento cirúrgico do câncer de reto e ânus no Hospital Español

La cirugía del cáncer de recto y ano se ha desarrollado considerablemente en las últimas décadas. En función de dichos avances, se ha observado una disminución en la morbimortalidad operatoria, así como también una mejoría en el pronóstico de estos pacientes. El objetivo del presente estudio es exponer y analizar los resultados del tratamiento quirúrgico del cáncer de recto y ano en un servicio universitario. Se realizó un estudio observacional, descriptivo y retrospectivo de todos los pacientes intervenidos por cáncer de recto y ano en el Hospital Español entre 2016 y 2020. Las variables registradas fueron: variables demográficas, clínico-oncológicas, relacionadas a la morbimortalidad operatoria y a la recidiva locorregional, y la sobrevida a 5 años. El procedimiento más realizado fue la resección anterior de recto (RAR) en 11 intervenciones (58%), mientras que las 8 restantes correspondieron a amputaciones abdominoperineales (AAP) (42%). Se diagnosticaron un total de 6 complicaciones intraoperatorias en 5 pacientes, siendo la perforación del tumor la más frecuente, y un total de 18 complicaciones postoperatorias en 11 pacientes, siendo la más frecuente la infección de la herida quirúrgica abdominal. La morbilidad operatoria mayor fue de 31,6% y la mortalidad operatoria a 90 días fue de 0%. La sobrevida global a 5 años fue de 63,2%. Los resultados quirúrgicos en la presente casuística fueron comparables con los de la bibliografía consultada. Destacamos la nula mortalidad a 90 días, con resultados oncológicos similares a los reportados en la literatura.

Rectal and anus surgery have been developed considerably in the last decades. Based on these advancements, it has been observed a decrease in the surgical morbidity and mortality, as well as an improved prognosis of these patients. The aim of the present study is to expose and analyze the results of the anus and rectal surgical treatment in a university service. An observational, descriptive and retrospective study was performed of all the intervened patients for rectum and anus cancer in the Hospital Español between 2016 and 2020. We recorded data about demographic, clinical-oncologic, related to the surgical morbidity and mortality, locoregional relapse and overall 5 year survival. The most performed procedure was the rectum anterior resection in 11 interventions (58%), while the 8 left corresponded to abdominoperineal resection (42%). There was a total of 6 intraoperative complications diagnosed in 5 patients, being the tumor perforation the most frequent one, and a total of 18 postoperative complications diagnosed in 11 patients, being the surgical wound infection the most frequent one. The serious surgical morbidity was 31,6%, while the surgical mortality rate at 90 days was 0%. Overall 5 year survival was 63,2%. The surgical results in the present study about the rectum and anal cancer were comparable with the results reported on the consulted bibliography. We highlight the null mortality within 90 days, with oncologic results similar to the ones reported in the literature.

A cirurgia do câncer retal e anal desenvolveu-se consideravelmente nas últimas décadas. Com base nesses avanços, observou-se diminuição da morbimortalidade operatória, bem como melhora no prognóstico desses pacientes. O objetivo deste estudo é apresentar e analisar os resultados do tratamento cirúrgico do câncer de reto e anal em um serviço universitário. Foi realizado um estudo observacional, descritivo e retrospectivo de todos os pacientes operados por câncer de reto e ânus no Hospital Espanhol entre 2016 e 2020. As variáveis ​​registradas foram: variáveis ​​demográficas, clínico-oncológicas, relacionadas à morbidade e mortalidade operatórias e recorrência locorregional. , e sobrevida em 5 anos. O procedimento mais realizado foi a ressecção anterior do reto (RAR) em 11 intervenções (58%) e as 8 restantes corresponderam a amputações abdominoperineais (AAP) (42%). Foram diagnosticadas 6 complicações intraoperatórias em 5 pacientes, sendo a perfuração tumoral a mais frequente, e um total de 18 complicações pós-operatórias em 11 pacientes, sendo a infecção da ferida operatória abdominal a mais frequente. A morbidade operatória maior foi de 31,6% e a mortalidade operatória em 90 dias foi de 0%. A sobrevida global em 5 anos foi de 63,2%. Os resultados cirúrgicos da presente casuística foram comparáveis ​​aos da bibliografia consultada. Destacamos a mortalidade nula em 90 dias, com resultados oncológicos semelhantes aos relatados na literatura.

Trans-anal surgery with the taTME technique for rectal gastrointestinal stromal tumors: a retrospective study.

PURPOSE: Rectal gastrointestinal stromal tumors (GISTs) surgery is often challenging owing to the anatomical constraints of the narrow pelvis and tumor hugeness. Despite the increasing number of patients undergoing trans-anal total mesorectal excision (taTME) globally, the feasibility of trans-anal surgery with the taTME technique for rectal GISTs remains unclear. We aimed to evaluate the feasibility of trans-anal surgery with the taTME technique for rectal GISTs. METHODS: Using a prospectively collected database, we retrospectively analyzed the clinical findings, surgical outcomes, pathological outcomes, urinary and anal functions, and prognoses of patients who underwent trans-anal surgery with the taTME technique for primary rectal GISTs at the National Cancer Center Hospital East from September 2014 to March 2020. RESULTS: Twenty-one patients with primary rectal GISTs were included in this study. The median distance from the anal verge to the lower edge of the tumor was 40 mm (range, 15-60 mm), and the median tumor size was 59 mm (range, 11-175 mm). Moreover, seven and 14 patients underwent one-team and two-team surgeries, respectively, with curative intent. Nineteen patients (90.5%) underwent anus-preserving surgery, and the urinary tracts were preserved in all cases. Two-team surgery showed a significantly lower blood loss volume and shorter operation time than one-team surgery (58 vs. 222 mL, P = 0.017; 184 vs 356 min, P = 0.041, respectively). The pathological negative-margin resection rate was 100%. During the follow-up period, no patient developed local GIST recurrence and one (4.8%) developed distant metastasis. CONCLUSION: Trans-anal surgery with the taTME technique is feasible for rectal GISTs, and two-team surgery may be more advantageous than one-team surgery in terms of operation time and blood loss.

Robotic vs. TaTME Rectal Surgery (ROTA STUDY) Matched Cohort Trial for Mid to Low Rectal Cancer Surgery Evaluation Trial in the Hands of an Experienced Surgeon.

Background: Recent novel surgical techniques for resection of low rectal cancer have been introduced and these approaches have the potential to overcome anatomical limitations like obesity, narrow male pelvis and bulky and low tumours. Two of these procedures are robotic low anterior resection (RLAR) and transanal total mesorectal excision (TaTME).Both approaches have distinct advantages and limitations. There has been no head to head trial comparing RLAR and TaTME for patients with mid to low rectal cancer undergoing surgery by experienced surgeons. Previous studies looking at the oncological outcomes of either TaTME or robotic TME included many centres where the surgeons were on a learning curve and hence the true oncological outcomes and clinical benefits can not be measured accurately. Method: The inclusion criteria include experienced surgeons defined as minimum of 60 prior procedures with RLAR or TaTME. Successful oncological and clinical outcomes are defined as circumferential resection margin (CRM) ≥1 mm with limited postoperative morbidity (absence of Clavien-Dindo grade III-IV complications within 30 days after surgery). Local and distal recurrence rates with DFS over 3 years will be measured as primary outcome.Data will be collected prospectively and entered in a dedicated database. Discussion: The primary objective of this study is to conduct a multicentre prospective trial to investigate clinical outcomes, in particular disease free survival (DFS) in patients undergoing RLAR and TaTME. The additional goal is to investigate other efficacy measures, complications rates, health economic aspects and patient reported health related quality of life.This paper describes an important trial conducted in expert centres to establish the needed knowledge for a detailed comparison of outcomes for TaTME versus RLAR.This trial is the first comparative study, comparing TaTME and RLAR, seeking to establish foothold for tailor-made surgical treatment of low rectal cancer patients. Trial registration: The trial is registered in clinicaltrials.gov September 2019. Clinicaltrials.gov id: NCT04200027.

A proliferating trichilemmal cyst in the perianal region: A case report.

INTRODUCTION: Proliferating trichilemmal cysts (PTCs) are rare benign neoplasms originating from the follicular isthmus. They can undergo trichilemmal keratinization and malignant degeneration to form epidermoid carcinoma. They occur on the scalp in more than 90% of patients and are more common in elderly women. PRESENTATION OF CASE: A 56-year-old woman complained of perianal discomfort upon sitting. She presented with a perianal nodule of approximately 3 cm in diameter that had exhibited slow and progressive growth over 8 years. After surgical excision of the lesion with safety margins, histopathological examination showed that it was a proliferating trichilemmal cyst in the perianal region. DISCUSSION: There are no reports in the literature on PTC in the perianal region. The location with the highest prevalence is the scalp; other sites of occurrence are the neck, trunk, underarms, pubis, vulva, lower and upper limbs, upper lip, and gluteal region. CONCLUSION: The development of PTC in the perianal region is an exceptional occurrence, and when it does occur, surgical treatment should always be indicated because of the risk of malignant degeneration to form epidermoid carcinoma.

The clinical application of a silicate-based wound dressing (DermFactor®) for wound healing after anal surgery: A randomized study.

BACKGROUND: The object of the present study is to evaluate the feasibility of a silicate-based wound dressing (DermFactor®) in treating the wound of the patients after anorectal surgery. MATERIALS AND METHODS: The present study included 328 patients who received anal surgery during the period from March 2013 to June 2015. The patients were randomized to 2 groups. The patients (n = 162) in the control group received conventional dressing therapy, while those in the observation group (n = 166) were treated with the combination of conventional dressing therapy and the use of a silicate-based wound dressing (DermFactor®). The wound healing outcomes of the two groups were observed and compared with each other by statistical analysis. RESULTS: The average healing cycles in the observation group were 19.04 days for combined hemorrhoid patients, 23.72 days for anal fistula patients and 21.14 days for anal fissure patients, respectively, which were shorter than those in the control group (23.25 days for mixed hemorrhoid patients, 27.76 days for anal fistula patients and 24.32 days for fissure in ano patients, respectively). In addition, the observation group presented a significantly higher effective rate (80.4%) than the control group (70.4%). CONCLUSION: Our data demonstrated that the wound after anorectal surgery could be more effectively treated by using silicate-containing DermFactor®.

Association between Introduction of the Diagnosis-Related Groups System for Anal Operation and Length of Stay: Higher Effectiveness at Hospitals with Longer Length of Stay / 보건행정학회지

BACKGROUND: We investigated association between introduction of the diagnosis-related groups (DRG) system for anal operation and length of stay. Also, we investigated how it is different among hospitals with longer length of stay and among hospitals with shorter length of stay before introduction of the DRG system. METHODS: We used data from Health Insurance Review and Assessment which were national health insurance claim data. Total 13,111 cases of anal surgery cases were included which were claimed by hospitals since July 2012 to June 2014. Two-level multivariable regression was conducted to analysis the association between length of stay and characteristics of hospital and patient. RESULTS: Before introducing DRGs, the average length of stay was 5.41 days. After introducing DRGs, average length of stay was decreased to 3.92 days. After introducing DRGs, length of stay has decreased (β=−1.0450, p < 0.0001) and it was statistically significant. Among hospitals which had short length of stay (shorter than mean of length of stay) before introducing DRGs, effect of introducing DRGs was smaller (β=−0.4282, p < 0.0001). On contrary, among hospitals which had long length of stay (longer than mean of length of stay) before introducing DRGs, effect of introducing DRGs was bigger (β=−1.8280, p < 0.0001). CONCLUSION: Introducing DRGs was more effective to hospitals which had long length of stay before introducing DRGs.

Are Prophylactic Antibiotic Agents Indicated in Anorectal Surgery for Patients with Human Immunodeficiency Virus?

BACKGROUND: With increased survival among patients with human immunodeficiency virus (HIV), surgeons have been seeing more cases of anal dysplasia and cancer. There is, however, no data on the incidence of surgical site infections (SSIs) in HIV-positive patients undergoing elective anorectal procedures, nor on the administration of prophylactic antibiotic agents. We reviewed a HIV-positive population that has undergone elective anorectal biopsy of areas of dysplasia observed on office anoscopy to assess the need for antibiotic prophylaxis. PATIENTS AND METHODS: A retrospective chart review was performed of all HIV-positive patients seen as outpatients in the Colorectal Surgery Division from 2007-2016. Demographics, dates of surgery and follow-up, antibiotic prophylaxis, and pre-operative CD4 count and HIV viral load were recorded for 229 patients. Post-operative examination notes were reviewed to determine the presence of SSIs. The proportion of patients who received prophylaxis was assessed and the SSI rate was calculated. RESULTS: Surgical site infections occurred in 2 of 237 (0.8%) cases without antibiotic prophylaxis and in none of the 38 cases with prophylaxis. This infection rate was found to be lower than that of the general surgery population, with no statistical difference from hemorrhoidectomy patients without HIV. One SSI occurred in a 51-year-old male with a pre-operative CD4 count of 612 per microliter and viral load of zero. Another occurred in a 57-year-old female with an unknown CD4 count and viral load. A χ2 analysis showed the incidence of SSIs in the groups with and without prophylaxis was not significantly different (p = 0.563). CONCLUSION: Surgical site infection rates in HIV-positive patients undergoing biopsies for anal dysplasia were similar to patients without HIV undergoing similar minor anorectal procedures, and no difference was noted in the rate of SSI with the administration of prophylactic antibiotic agents. We do not recommend routine use of prophylactic antibiotic agents in this population.

Características clínicas asociadas al escurrimiento fecal ''soiling'' en pacientes operados de enfermedades anales / Clinical characteristics associated to fecal ''soiling'' in patients subjected to anal surgeries

Objetivo: Describir las características clínicas relacionadas con el escurrimiento fecal ''soiling'' que presentan los pacientes operados de enfermedad hemorroidal, fístula, fisura anal y drenaje de absceso. Sede: Unidad de Coloproctología del Servicio de Gastroenterología del Hospital General de México ''Dr. Eduardo Liceaga''. Diseño: Estudio de casos y controles. Análisis estadístico: Medidas de tendencia central, t de Student, cálculo de momios (odds ratio; OR) y análisis no paramétrico con χ². Pacientes y métodos: Se aplicó un cuestionario de ocho ítems a 132 pacientes que acudieron a la consulta externa de nuestra unidad. El manchado de ropa interior, eritema anal, cicatriz, prurito y utilización de material para proteger la región anal, así como el cambio de alimentación, la presencia de materia fecal en el ano y la limpieza de la región anal sin haber evacuado fueron las variables evaluadas y comparadas entre pacientes operados y no operados. Resultados: Se incluyeron 59 hombres y 73 mujeres con edad media de 45 años, 58 pacientes operados y 74 no operados. El manchado de ropa interior fue el síntoma más frecuente en los pacientes operados (37% versus 25%). Las otras variables con significancia estadística, al compararse ambos grupos, fueron: prurito, la presencia de una cicatriz y eritema anal. El OR para cirugía en pacientes con manchado de ropa fue 3.22 (95% IC 1.57-6.60), para prurito 2.24 (95% IC 1.11-4.52) y la presencia de una cicatriz anal 91.38 (95% IC 24.46-341.43). Conclusiones: El soiling caracterizado como manchado de la ropa interior se presenta en al menos un tercio de los pacientes operados de cirugía anal. La presencia de eritema, materia fecal en el ano y una cicatriz anal asociadas hacen pensar en esta alteración.

Objective: To describe the clinical characteristics related to soiling present in patients subjected to anal surgery due to hemorrhoidal disease, fistula, anal fissure, and abscess drainage. Setting: Coloproctology unit of the Gastroenterology Service of the General Hospital of Mexico ''Dr. Eduardo Liceaga''. Design: Cases and controls study. Statistical analysis: Central tendency measures, Student's t test, odds ratio (OR) and non-parametric analysis using χ². Patients and methods: We applied an eight-item questionnaire to 132 patients that came to the out-patient consultation of our unit. Soiling of underwear, anal erythema, scar, pruritus, use of material to protect the anal region, change in feeding habits, presence of fecal matter in the anus, and cleaning of the anal region without having defecated were the assessed variables and these were compared between operated and non-operated patients. Results: We included 59 men and 73 women, average age of 45 years, 58 operated and 74 non-operated. Soiling of underwear was the most frequent sign in operated patients (37% versus 25%). The other variables with statistical significance when comparing both groups were: pruritus, presence of a scar and anal erythema. The OR for surgery in patients with underwear soiling was 3.22 (95% CI 1.57-6.60); for pruritus, 2.24 (95% CI 1.11-4.52) and presence of anal scar, 91.38 (95% CI 24.46-341.43). Conclusions: Soiling of underwear was found in at least one third of patients subjected to anal surgery. The presence of erythema, fecal matter in the anus, and an anal scar should lead to consider this alteration.

The Effects of Early Ambulation on Urinary Retention and

INTRODUCTION: Urinary retention (UR) is one most common complication of anal surgery and its cause is multifactorial. Postdural puncture headache (PDPH) is caused by cerebrospinal fluid leakage after spinal anesthesia, therefore it may be aggravated by early ambulation. PURPOSE: To determine whether early ambulation (EA) vs. bed rest (BR) reduces the incidence of UR after anal surgery under spinal anesthesia, without causing PDPH. METHODS: In this prospective, randomized study, 107 patients undergoing anal surgery under spinal anesthesia were randomly assigned in the EA group (n=54) or the BR group (n=53). UR was defined as a voiding difficulty that needs catheterization. In the BR group, the patients were positioned flat in bed on the operation day. Anesthetic techniques (tetracaine injection using 24-gauge needle in sitting position, bupivacaine local infiltration) and postoperative pain therapy (intramuscular demerol injection every 6 hours, oral nonsteriodal antiinflammatory drug plus acetaminophen) were standardized. Perioperative intravenous fluids were restricted. RESULTS: Urinary retention and PDPH occurred in 32 (29.9%) and 7 (6.5%) patients, respectively. UR was significantly reduced in the EA group (10/54=18.5%) vs. the BR group (22/53=41.5%) (p=0.017, Chi-square). The incidence of PDPH, however, was not different between the two groups (5.6% in the EA vs. 7.5% in the BR group). CONCLUSIONS: Early ambulation has important implication on reducing the incidence of urinary retention after anal surgery under spinal anesthesia, without causing PDPH.

Comparison of Mepivacaine and Bupivacaine as an Adjuvant of Morphine for Benign Anorectal Surgery under Caudal Anesthesia

BACKGROUND/AIMS: The caudal anesthsia is most commonly used for benign anorectal surgery, The combination of long-acting anesthetics and opiates has been used for longer duration and successful control of postoperative pain. But the side effects of peridural anesthesics and morphine have commonly occured in caudal anesthesia. This study was performed to assess the difference in clinical effects between peridural mepivacaine and bupivacaine with morphine. METHODS: We evaluated the clinical effects in 60 patients who had anal operation with Jack-Knife position under caudal anesthesia. We divided randomly these 60 patients into two groups, M and B groups (in each group, 30 patients included). Group M (n=30) was given 2% mepivacaine 20 ml with morphine 2 mg caudally, and Group B (n=30) was given 0.5% bupivacaine 20 ml with morphine 2 mg in the same manner. We measured the onset time, duration, postoperative analgesia, and side effects including urinary retention. RESULTS: The onset time for analgesia was significantly shorter in group M than in group B. The duration of postoperative pain complaints was significantly longer in group M than in group B. The postoperative analgesic effects and side effects were not significantly different between two groups. CONCLUSIONS: Caudal mepivacaine and morphine mixture is effective for control of postoperative pain without significant side effects.