Precision surgery and genitourinary cancers.

The landscape of the surgical management of urologic malignancies has dramatically changed over the past 20 years. On one side, better diagnostic and prognostic tools allowed better patient selection and more reliable surgical planning. On the other hand, the implementation of minimally invasive techniques and technologies, such as robot-assisted laparoscopy surgery and image-guided surgery, allowed minimizing surgical morbidity. Ultimately, these advances have translated into a more tailored approach to the management of urologic cancer patients. Following the paradigm of "precision medicine", contemporary urologic surgery has entered a technology-driven era of "precision surgery", which entails a range of surgical procedures tailored to combine maximal treatment efficacy with minimal impact on patient function and health related quality of life. Aim of this non-systematic review is to provide a critical analysis of the most recent advances in the field of surgical uro-oncology, and to define the current and future role of "precision surgery" in the management of genitourinary cancers.

Predictive factors of speech understanding in adults with cochlear implants.

OBJECTIVE: The aim of this study was to analyse the factors that influenced speech recognition scores in quiet conditions and speech reception threshold levels (SRT) in fixed noise conditions, after cochlear implant (CI) surgery in adults with postlinguistic deafness. STUDY DESIGN: Combined retrospective and prospective study in a tertiary referral centre. METHODS: We included 66 patients that received implants between 2002 and 2013. We retrospectively collected speech recognition scores and 14 demographic, audiological, and technical factors, including gender, age at implantation, aetiology, hearing loss progression, preoperative Pure Tone Average (PTA), hearing loss onset age and duration, duration and use of hearing aids (HAs); implantation in the best or worst ear; implantation on the right or left side; use of HA after implantation; and the duration and type of CI. We prospectively tested a subgroup of 21 patients for SRT in fixed noise. RESULTS: The hearing loss duration significantly affected speech recognition scores in quiet conditions (H (4) = 10.567, p =0.032) and SRTs in fixed noise conditions (rs = 0.466, p = 0.033). The PTA of the better ear significantly affected only the SRT in fixed noise conditions (rs = 0.57 1, p = 0.007). CONCLUSION: The duration of hearing loss and the PTA of the best ear had significant effects on the outcomes of speech recognition and SRT in quiet and fixed noise conditions, respectively. These findings are important for counselling CI candidates. Further studies in larger study populations are warranted.

Otosclerosis: Shift in bone conduction after stapedotomy.

OBJECTIVES: To analyze changes in bone conduction (BC) thresholds before and after stapedotomy in patients with clinical otosclerosis with a focus on the Carhart notch, which is defined as a significant loss of BC at a certain audiometric frequency. METHODOLOGY: Retrospective case review of pure tone audiometry (PTA) in 213 patients who underwent a stapedotomy at a tertiary referral center between 2004 and 2011. The patients were grouped by age and the frequency of the Carhart notch. The non-operated ear was also evaluated. RESULTS: The Carhart notch was present on pre-operative audiometry in 158 (74%) patients at 0.5 (n = 18, 8.45%), 1 (n = 25, 11.70%), or 2 kHz (n = 115, 54.0%). We measured a mean postoperative improvement in BC of 7.5, 8.4, and 8.8 dB HL. Pre-operatively, 55 (25.8%) patients did not exhibit a typical notch configuration. The mean gain in BC, defined on PTA according to the AAO-HNS criteria (0.5, 1, 2 and 3, or 4 kHz), was 1.8 dB HL after stapedotomy. CONCLUSION: The Carhart notch was not solely related to the 2 kHz frequency. The greatest gain in BC after stapedotomy for otosclerosis occurred at the notch frequency.

Incidence of multiglandular disease in sporadic primary hyperparathyroidism.

OBJECTIVES: Multiple, minimally invasive surgical techniques have been developed over the last few decades for the management of sporadic primary hyperparathyroidism (PHTP). However, in cases with multiglandular disease, bilateral cervical exploration remains the gold standard. Therefore, it is important to have an accurate estimation of the incidence of multiglandular disease in sporadic PHTP. METHODOLOGY: 698 patients were treated for PHTP between 1993 and 2010 at the University Hospitals Leuven, using the bilateral cervical exploration method. After excluding cases of multiple endocrine carcinoma syndrome, the incidences of double adenoma and multiple gland hyperplasia were investigated in these patients. Age, gender, imaging results, serum calcium and parathyroid hormone concentrations were analyzed and compared to the data of 50 randomly-selected, PHTP patients with solitary adenomas. RESULTS: 6.6% and 2.4% of the patients with sporadic PHTP had double adenomas and multiple gland hyperplasia, respectively. The female/male ratio was 4.8 (38/8) and 1.8 (11/6), and the average age was 63 and 52 yrs for patients with double adenomas and multiple gland hyperplasia, respectively. The patients with solitary adenomas had a female/male ratio of 3.5, and an average age of 60 yrs. There were no significant differences in serum calcium or parathyroid hormone concentrations between patients with multiglandular disease and those with solitary adenomas. CONCLUSIONS: Multiglandular disease occurs in 9% of patients with sporadic PHTP, and cannot be excluded before surgery. This incidence must be considered when using minimally invasive techniques for treatment of sporadic PHTP. In cases of multiglandular disease, bilateral cervical exploration is indicated.

Noise exposure of care providers during otosurgical procedures.

OBJECTIVE: To monitor the noise exposure of care providers during otological surgery due to drilling and suction in the operating room. METHODS: A clinical study monitoring different standard otosurgical procedures was conducted; cochlear implantation (CI), mastotympanoplasty, and mastoidectomy alone. Noise exposure to the surgeon and assistant were monitored with wireless personal noise dosimetry and stationary sound monitoring. Both maximum peak level in dBC (Lpeak) and time-average sound pressure level in dBA (equivalent level or Leq) were measured during drilling episodes. Frequency analysis in one third octaves covering the frequency bands 6.3 Hz to 20 k Hz was performed using a sound analyzing program. RESULTS: When averaged over the entire procedure, the sound pressure level was highest for the surgeon and the assistant with values of 76.0 dBA and 72.5 dBA, respectively, during CI. Lpeak was 135.9 dBC. Leq for the stationary sound measurement was 74.2 dBA. During cortical bone work using a cutting burr, 84.6 dBA was measured. Mean values of L95% (estimation of the background noise) were between 55.8 dBA and 61.2 dBA. Frequency analysis showed the highest sound pressure level for all procedures was between 2.5 kHz and 3.15 kHz. CONCLUSION: This is the first study to use personal sound dosimetry to monitor noise exposure during otosurgical drilling. In accordance with other studies, the results presented show sound levels below international occupational noise level regulations. However, the measured noise exposure during drilling could have negative effects on care providers based on unfavorable acoustical comfort.

Tonsillectomy compared to acute tonsillitis in children: a comparison study of societal costs.

INTRODUCTION AND AIM: Tonsillectomy is one of the most commonly performed surgical procedures in children; its main indications are recurrent episodes of acute tonsillitis and adenotonsillar hypertrophy. The effectiveness of tonsillectomy for severe recurrent tonsillitis is generally accepted; however its socio-economic cost is less well investigated. This study aims to determine and compare the societal cost of a tonsillectomy and a severe throat infection. MATERIALS AND METHODS: The costs for both tonsillectomy and severe throat infection were evaluated. Costs of the surgical procedure and hospital stay were calculated based on resource use and personnel input at the participating hospital. The cost of work-related disability for both treatments was measured based on a questionnaire filled in by 275 parents of children undergoing a tonsillectomy. Data from two Belgian institutions (NIS and FOD) were used to calculate the cost of parents' absenteeism. RESULTS: An episode of acute tonsillitis in the child results in a longer period of parents' work absenteeism (mean of 3.1 +/- 0.3 days) compared to tonsillectomy (2.2 +/- 0.2 days). The cost of economic productivity loss amounts to 613 Euros (NIS) or 759 Euros (FOD) for acute tonsillitis and 435 Euros (NIS) or 539 Euros (FOD) for a tonsillectomy. The medical costs linked to the surgical procedure at the local department correspond to 535 Euros and for an acute tonsillitis to 46 Euros. CONCLUSIONS: From societal perspective, a tonsillectomy costs the equivalent of 1.4 times the cost of a severe throat infection. This indicates that in children suffering from recurrent acute tonsillitis, watchful waiting results in a higher cost compared to tonsillectomy, given the cumulative costs of parents' absenteeism.

Effect of adenotonsillectomy on the use of respiratory medication.

OBJECTIVE: Recurrent tonsillitis and upper respiratory tract obstruction due to adenotonsillar hypertrophy are the most common indications for (adeno)tonsillectomy ((A)TE). Symptoms of upper respiratory tract infection and obstruction can, however, be attributed to lower airway pathology and thus treated with respiratory medication - this is non-antimicrobial medication used for lower respiratory diseases like bronchitis, bronchiolitis, asthma and episodic wheezing. The aim of this study is to investigate the effect of the current (A)TE practice in Belgium on the use of respiratory medication in subjects aged 0-15. METHODS: Retrospective data on 11.114 subjects aged 0-15 years old who underwent (A)TE from January 1st 2002 until Sept 30th 2003 were retrieved from the database of the Christelijke Mutualiteit, the largest mutual health insurance society in Belgium. We compared the use of respiratory medication 12 months before and 12 months after (A)TE. RESULTS: Out of 11.114 subjects, 4.654 received at least one prescription for respiratory medication in the year before and/or after (A)TE. In this subgroup, the median respiratory medication use reduced with 32% in the year after surgery. CONCLUSION: Compared with the year before surgery, the median use of respiratory medication in subjects aged 0-15 drastically reduces in the year after (A)TE. A possible reason for this reduction is that children with upper airway obstruction and infections are often wrongly diagnosed as having lower airway problems.

Pre-operative imaging in primary hyperparathyroidism with ultrasonography and sestamibi scintigraphy.

PROBLEM/OBJECTIVE: Resection of pathological parathyroid glands is the only curative therapy in primary hyperparathyroidism. Adequate pre-operative localization of the pathological glands is very useful, whichever surgical technique is preferred. OBJECTIVES: The aim of our study was to evaluate and compare high resolution ultrasonography and sestamibi scintigraphy as pre-operative imaging techniques and to explore their relationship with certain demographic and biochemical variables. PATIENTS AND METHODS: Data from 368 patients with primary hyperparathyroidism referred for surgery were retrospectively analysed. The results of pre-operative imaging were compared with the operative findings and the anatomopathological report. RESULTS: In predicting the correct side of the lesion (right or left), ultrasonography had a positive predictive value (PPV) of 84%, whereas sestamibi imaging had a PPV of 93%. If both imaging techniques had a concordant positive result, the PPV was 99%. The PPV in predicting the correct quadrant, however, was only 61% for sestamibi scintigraphy and 40% for ultrasonography. CONCLUSIONS: In our study, sestamibi imaging was better than ultrasonography as a single pre-operative localization imaging method for primary hyperparathyroidism. A concordant positive result was exceedingly reliable in indicating the side of the lesion. It seemed far more difficult to predict the quadrant correctly, especially because of misinterpretation of the upper adenomas.

Antibiotic use and doctor visits are reduced after adenotonsillectomy.

OBJECTIVE: A tonsillectomy, with or without an adenotomy ((A)TE), is a common surgical procedure in children. The most important indications are recurrent tonsillitis and upper airway obstruction secondary to adenotonsillar hypertrophy. The aim of this study was to investigate whether the current (A)TE practice in Belgium reduced the need for medical care. STUDY DESIGN AND METHODS: The database of the Christelijke Mutualiteit, one of the most important health insurance organizations in Belgium, provided data on approximately 11,000 (A)TE's in children aged 0 to 15 years, performed by different ENT-specialists from Jan 1st 2002 to Sept 30th 2003. We compared the use of antibiotics during the 12 months before and the 12 months after (A)TE. We also compared the number of visits to pediatricians and general practitioners during the 12 months before and the 12 months after surgery. RESULTS: The median antibiotic use dropped from 4 boxes in the year before the operation to 1 box in the year after the operation. The median number of doctor visits also dropped from 7 visits in the year before to 4 visits in the year after (A)TE. CONCLUSION: Although there are no generally accepted guidelines on the indications for (A)TE in Belgium, the current practice effectively reduced the need for medical care.

Re-operation for secondary hyperparathyroidism.

OBJECTIVE: In cases of re-operation for secondary hyperparathyroidism, to evaluate the extent to which the location of recurrent hyperplasia was predicted by (1) operative data from the first intervention, and (2) pre-operative imaging (before the re-operation). METHODS: The files of 18 patients undergoing surgery for recurrent secondary hyperparathyroidism were reviewed. The surgical findings were compared both with the report of the initial operation and with the results of pre-operative imaging (i.e. ultrasonography, Mibi scintigraphy or computed tomography). RESULTS: The location of the recurrent hyperplasia corresponded with the data for the primary intervention in about one-third of patients. There was a partial correlation in one-third of patients, and no correlation at all in one-third. Pre-operative imaging enabled better prediction of the location of recurrent disease. CONCLUSION: Surgeons should have both sources of information at their disposal when planning a re-intervention for secondary hyperparathyroidism. However, in our series, the predictive value of imaging was superior to that of information deduced from the previous surgical record.

Levothyroxine replacement therapy after thyroid surgery.

INTRODUCTION AND AIM: New entities, such as 'subclinical' over- and undersubstitution, are easily diagnosed after thyroid surgery due to improved testing methods, and the incidence of thyroidectomy with lifelong hormone substitution is increasing. Thus, there is a need to review conventional replacement therapy after thyroid surgery. We investigated the adequacy of our thyroid hormone replacement therapy for three months after total-, subtotal-, and hemithyroidectomy using an upper reference limit of thyrotropin (TSH) of 4.6 mU/L. MATERIALS AND METHODS: Eighty-seven patients undergoing thyroidectomy for benign thyroid pathology participated. Levothyroxine (L-T4) treatment began five days after surgery. Preoperatively euthyroid patients received 150 microg L-T4 daily following total thyroidectomy, 100 microg L-T4 after subtotal thyroidectomy, and 50 microg L-T4 after hemithyroidectomy. Preoperatively hyperthyroid patients received 100 microg L-T4 following total thyroidectomy and 50 microg L-T4 following subtotal thyroidectomy. An average of six weeks after surgery, thyrotropin (TSH) was measured (reference limits 0.15-4.60 mU/L), and necessary dose adjustments were made. RESULTS: Of the patients who were preoperatively euthyroid, 45% with total thyroidectomy, 42% with subtotal thyroidectomy, and 17% with hemithyroidectomy required L-T4 dose adjustments. Of the patients who were preoperatively hyperthyroid, 60% of those with total thyroidectomy and all of those with subtotal thyroidectomy required L-T4 dose adjustments. CONCLUSIONS: To avoid over- and undersubstitution after thyroidectomy, an optimal replacement therapy dose is necessary. A small majority of our preoperatively euthyroid patients received adequate therapy. Endocrinological follow-up six weeks after surgery revealed the need for L-T4 dose adjustments, especially in preoperatively hyperthyroid patients. When the extent of resection was similar for hyperthyroid and euthyroid patients, the same initial dose of L-T4 was justified.

Post-void residual urine volume is not a good predictor of the need for invasive therapy among patients with benign prostatic hyperplasia.

PURPOSE: We assessed the value of baseline PVR as predictor of the need for invasive therapy during long-term followup of patients with clinical BPH treated initially with alpha1-blockers or WW. MATERIALS AND METHODS: The records of a cohort of 942 patients with BPH treated with alpha(1)-blockers or WW were reviewed. Baseline I-PSS scores, PSA, prostate volume, uroflowmetry, pressure flow parameters and followup data were collected prospectively. Correlations between PVR and other baseline parameters were calculated. The 5-year cumulative risks of invasive therapy were calculated with the Kaplan-Meier method. After stratification of PVR by various cutoff levels (50, 100 and 300 ml), rate ratios between large and small PVRs were calculated using proportional hazards analyses. RESULTS: PVR has weak (-0.2

The middle ear of cleft palate patients in their early teens: a literature study and preliminary file study.

OBJECTIVES: Middle ear disease is a frequent problem in young children with cleft palate (CP). Less is known about otological status in the adolescent CP population. The aim of this study is to provide an overview of current knowledge in the literature concerning the aetiology of middle ear disease in CP patients and the middle ear status of older children with CP, and to compare the situation in our centre to this background through an assessment of the otological status of patients in our CP population. MATERIAL AND METHODS: A literature review was conducted to summarise current knowledge about middle ear status in CP patients. A retrospective analysis was performed of the medical records of 20 CP patients between the ages of 10 and 15 who were treated and followed at the University Hospitals Leuven. The available otological data, otoscopic findings, information about hearing and surgery performed was collected for each patient when aged three and above ten years. RESULTS: Current knowledge indicates that middle ear function improves as CP patients get older. In our study, otoscopic appearance was acceptable in 63% of ears of children aged over ten years of age. Otitis media with effusion (OME) was far less frequent above this age than around the age of 3, with a decrease from 50% to 13% of all ears. Above the age of 10, tympanic perforations were present in 13% of ears and retraction of the tympanic membrane in 23%. CONCLUSIONS: Despite a very high incidence of OME in young CP patients, the long-term otological prognosis is not necessarily sinister. A favourable natural evolution, diligent otological follow-up, early diagnosis and treatment of middle ear disease with the use of tympanostomy tubes are the likely contributors to the acceptable otological result in older CP patients.

Recurrent pancreatitis after trimethoprim-sulfamethoxazole rechallenge.

We report a female patient who repeatedly developed pancreatitis after trimethoprim-sulfamethoxazole (TMP/SMX) use. During childhood she had undergone an ureterosigmoidostomy after which she had been on TMP/SMX 480 mg daily as prophylaxis for pyelonephritis for many years. The patient presented with abdominal pain caused by acute pancreatitis. No other cause, except for TMP/SMX use, could be identified. A causal relationship was confirmed by relapse of the pancreatitis after rechallenge. Our case is unique in demonstrating that acute pancreatitis related to the use of TMP/SMX may occur even after long-term treatment. We advise that the medication is discontinued immediately if a causal relationship with pancreatitis is suspected.

Completion thyroidectomy after the unexpected diagnosis of thyroid cancer.

The optimal surgical management of well-differentiated thyroid cancer (DTC) remains a controversial topic. Preoperative and peroperative investigations quite frequently fail to detect thyroid cancer in cold nodules, and only postoperative histological examination reveals malignancy. In these cases many physicians perform a completion thyroidectomy. Others recommend a conservative approach with close follow-up because of the increased risk of complications after re-operation. In our department, routine management includes completion thyroidectomy once the histopathological report concludes that there is carcinoma, except in cases of papillary carcinoma measuring less than 1 cm. The aim of our study was to determine the incidence of contralateral malignancy and of complications after completion thyroidectomy. We reviewed the records of 29 patients--25 women and 4 men-- who all underwent completion thyroidectomy because of an unexpected diagnosis of DTC. Residual malignancy was found in 12 patients (41.4%) after completion thyroidectomy. In ten patients (34.5%) the malignancy was localised in the contralateral lobe and two patients (6.9%) had lymph node metastases. Postoperative transient hypocalcaemia (< 8.0 mg/dl) occurred in five patients (17.2%) and permanent hypocalcaemia (lasting longer than 6 months) was a feature in two patients. One patient suffered transient laryngeal nerve injury occurred in one patient and there were no permanent lesions. In conclusion, we found residual DTC in 41.4% of patients undergoing reintervention. Because of the rather low re-operation rate, we prefer to perform a completion thyroidectomy to remove potential occult malignancy and to allow for postoperative 131I-treatment in all patients with a diagnosis of malignancy in their thyroid lobectomy specimen, with the exception of papillary carcinoma < 1 cm.

Endocrine approaches in the therapy of prostate carcinoma.

At present, the management of non-organ confined prostate cancer, whether it is a recurrence or metastasis, continues to evolve based on prostate cancer detection using prostate-specific antigen and the development of medications as alternatives for the classical orchiectomy, which induced irreversible implications for quality of life. Diethylstilbestrol therapy was associated with cardiovascular side-effects; GnRH agonists were able to create a castration level, but again considerable side-effects were described. Combination therapies using antiandrogens and GnRH agonists do not improve survival and have additional toxicity. GnRH antagonists, which also suppress FSH, represent the latest class of agents introduced for hormonal treatment, but phase III studies with survival data are not yet available. In spite of all these achievements, hormonal manipulation has resulted in only modest improvements during recent decades and new targets are needed to improve the clinical outcome. Selectively modifying the androgen receptor is currently one of the most promising developments.

Prognostic role of prostate-specific antigen and prostate volume for the risk of invasive therapy in patients with benign prostatic hyperplasia initially managed with alpha1-blockers and watchful waiting.

OBJECTIVES: To investigate the prognostic role of prostate-specific antigen (PSA) level and prostate volume (PV) for the need for benign prostatic hyperplasia (BPH)-related invasive therapy among patients initially treated with an alpha1-blocker or watchful waiting (WW) in real-life clinical practice. METHODS: Data were collected from 2264 consecutive patients with clinical BPH. Patients initially treated with an alpha1-blocker or WW were included in this study. They were stratified by baseline PSA level (less than 1.5, 1.5 to less than 3.0, 3.0 to 10.0 ng/mL) and PV (less than 30 and 30 to 200 cm3), and analyzed for the time to BPH-related invasive therapy. RESULTS: Of the 2264 patients, 389 treated with alpha1-blockers and 553 who chose WW were included. Across the PSA and PV strata, the alpha1-blocker group had worse symptoms, peak flow, postvoid residual urine volumes, and obstruction than did the WW group. Increasing PSA levels produced an increase in the 5-year cumulative risk of invasive treatment: 20%, 34%, and 44% in the alpha1-blocker and 8%, 9%, and 15% in the WW group for a PSA level of less than 1.5, 1.5 to less than 3.0, and 3.0 to 10.0 ng/mL, respectively. The hazard ratio for the highest compared with the lowest PSA strata was 2.8 for alpha1-blocker and 2.7 for WW patients. An increasing PV increased the 5-year cumulative risk from 21% to 35% in the alpha1-blocker group and 8% to 11% in the WW group. The hazard ratio for the large versus small prostates in the alpha1-blocker group was 1.8 and in the WW group was 1.0. CONCLUSIONS: A higher PSA level and larger PV resulted in a greater risk of BPH-related invasive therapy that was more pronounced in the alpha1-blocker than in the WW patients. However, symptom severity, flow parameters, and obstruction grade may have contributed to the difference in risk between the two treatment groups.

Brown tumour: presenting symptom of primary hyperparathyroidism.

The skeletal lesions of primary hyperparathyroidism, including brown tumour, are rare nowadays, with the practice of checking serum calcium levels leading to an earlier diagnosis of hyperparathyroidism. Clinical, laboratory, radiographic and histological investigations can lead to a correct diagnosis. Treatment of brown tumour focuses on the hyperparathyroidism, and is usually followed by a regression of the brown tumour. The diagnosis of hyperparathyroidism and brown tumour should be considered in patients with hypercalcaemia and an osteolytic expansive bone lesion. We present a patient where a brown tumour of the mandible was the presenting symptom of primary hyperparathyroidism.

Handling and reporting of biopsy and surgical specimens of testicular cancer.

This paper is the result of a meeting of the European Association of Pathologists, Uropathology Division in Florence 2003. The aims of this meeting were to establish: guidelines for specimen handling by urologists and minimum requirements for data accompanying testicular specimens submitted to pathologists; a consensus on techniques for processing specimens by pathologists; the essential information required from pathology reports; areas where our standard practice is traditional rather than evidence based and where further studies are required. The general aims of histopathology are to give or confirm a diagnosis; assess established prognostic markers; identify changes associated with treatment; provide information for audit (i.e. imaging, urology and pathology) and maintain a permanent record (slides/blocks).