Dilemmas in the management of rhinophyma in pigmented individuals.

Rhinophyma affects predominantly the Caucasian population and is rare in those with Fitzpatrick skin type IV-VI. Diagnosis is based on clinical evaluation. Prominent features include abnormal coloration and texture of skin, impaired vascularity, irregular nodular exophytic growth and telangiectasia. Management can be surgical or dermatological. Surgery remains the mainstay of treatment but achieving an acceptable aesthetic result can be challenging, particularly in those with pigmented skin. Postsurgical hyper- and hypopigmentation make for unpredictable outcomes requiring appropriate preoperative counselling. We present a case that exemplifies this issue and discuss our recommended approach to counselling, consenting and managing such dilemmas in these patients, and a proposal for further investigation into the role of autologous melanocyte transplantation in reducing the effect particularly of hypopigmentation on aesthetic outcomes in this group.

Assessing adherence to objective disease monitoring and outcomes with adalimumab in a real-world IBD cohort.

BACKGROUND: Data suggests that tight objective monitoring may improve clinical outcomes in IBD. AIM: To assess the adherence to serial tight objective monitoring(clinical and biomarkers) and its effect on clinical outcomes. METHODS: We retrospectively reviewed the chart of 428 consecutive IBD patients started on adalimumab between January 1,2015-January 1,2019 [338 Crohn's disease(CD), 90 ulcerative colitis(UC)]. Clinical symptoms(assessed by Harvey-Bradshaw-Index,partial Mayo),C-Reactive Protein(CRP), and fecal calprotectin(FCAL) assessments were captured at treatment initiation and at 3,6,9, and12 months. Dose optimization and drug sustainability curves were plotted by Kaplan-Meier method. RESULTS: Clinical evaluation was available in nearly all patients at 3(CD-UC:95-94%), 6(90-83%), 9(86-85%) and 12(96-89%) months. CRP testing frequency decreased in CD patients over time. Compliance to serial FCAL testing was low. Clinical remission at one-year was higher in patients adherent to early assessment visit at 3 months(p = 0.001 for CD and UC). Adherence to early follow-up resulted in earlier dose optimization in CD and UC patients(pLogrank=0.026 for UC & p = 0.09 for CD). Overall drug sustainability did not differ. CONCLUSION: Clinical & CRP, but not FCAL, were frequently assessed in patients starting adalimumab. Adherence to early objective combined follow-up visits resulted in earlier dose optimization, improved one-year clinical outcomes but did not change drug sustainability.

Ipsilateral ureteroureterostomy for ureteral duplication anomalies: predictors of adverse outcomes.

INTRODUCTION AND OBJECTIVE: Ipsilateral ureteroureterostomy (UU) has gained popularity for treating ureteral duplication (UD) associated with obstruction or vesicoureteral reflux (VUR). Several studies have demonstrated its high success rate and low morbidity. This study aimed to identify the predictors of adverse outcomes associated with UU. STUDY DESIGN: A retrospective chart review was conducted for patients with UD treated with UU at the study institution. Patients with less than 6 months of follow-up were excluded. Charts were reviewed for demographics, pre-operative imaging, surgical indications, operative notes, and follow-up data. Pre-operative and intra-operative variables were tested for association with adverse outcomes including unplanned surgery, worsening hydronephrosis, and febrile UTI recurrence. RESULTS: A total of 35 patients underwent UU for UD between 2009 and 2017 at the study institution. The majority (33/35) had a distal anastomosis. A concomitant re-implantation of the recipient ureter was performed in 9 (25.7%) patients. After a median follow-up of 36.7 months, adverse outcomes developed in 9 patients (25.7%). No further surgery was required in 88.6% of the subjects. Adverse outcomes were associated with female gender (p = 0.048) and hydronephrosis of both upper and lower moieties (p = 0.015) and were more likely associated with ectopic ureteroceles (50%, p = 0.074) and having a concomitant re-implant performed (44.4%, p = 0.19) (table). DISCUSSION: In this study, the low re-operation rates of UU for treating UD in patients with ectopic ureters or intravesical ureteroceles was demonstrated. The majority of patients with ectopic ureteroceles treated with UU and concomitant ureteral re-implantation had worsening hydronephrosis of both moieties and recurrent febrile UTI in the absence of mechanical obstruction. Interestingly, some of them had progression of hydronephrosis after excision of the upper pole. While worsening of hydronephrosis of the recipient moiety after UU was historically attributed to yo-yo reflux, most of the study patients did not have worsening hydronephrosis despite having distal anastomosis. Therefore, mechanical obstruction should be ruled out, and any underlying bladder dysfunction should be aggressively managed in patients with worsening hydronephrosis or recurrent UTI after UU before considering additional surgery. CONCLUSION: Ureteroureterostomy is a successful option for UD with a low risk of adverse events in patients with ectopic ureters or intravesical ureteroceles. However, it should be cautiously considered in patients with hydronephrosis of both moieties, with ectopic ureteroceles, or if a concomitant re-implant is needed.

Precision surgery and avoiding over-treatment.

Over-diagnosis and over-treatment are consequences of greater awareness about breast cancer, more intensive screening, and the resultant identification of more cases of breast cancer that are low or ultralow risk. This area represents an important opportunity to optimize the delivery of appropriate targeted therapy for breast cancer patients. Despite the evolution of breast cancer care over the last few decades and our ability to tailor treatment to biology, a one-size fits all approach is still prevalent in the local and regional management of and screening for breast cancer, failing to reflect the unique biology and tumor characteristics of each patient. In this review, we explore how we can use new tools to better define tumor biology and also how we can change current clinical practices based on already available data. Every surgeon should be knowledgeable about how to craft personalized breast cancer care in the areas of systemic therapy, adjuvant radiation therapy, management of ductal carcinoma in situ (DCIS), precision surgery, and breast cancer screening.

An unusual case of hamartomatous polyposis with malignancy complication in a patient with ulcerative colitis treated with golimumab.

We report an unusual case of hamartomatous polyposis with malignant complications in a patient with ulcerative colitis on golimumab and previous thiopurine therapy. This patient was evaluated for iron deficiency anemia and underwent hemicolectomy for extensive right-side predominant inflammatory pseudopolyps. Anemia persisted post-colectomy and subsequent gastroscopy showed a fungating polypoid lesion along with numerous carpet-like strawberry appearing polyps in the stomach extending from the gastro-esophageal junction to the distal part of the antrum, necessitating a gastrectomy. Histology showed extensive hamartomatous-like polyps with adenocarcinoma and nodal metastases. Presence of alopecia totalis and hamartomas in this patient raise the possibility of Cronkhite-Canada Syndrome although this may also represent an undescribed hamartomatous polyposis associated with ulcerative colitis. Even though thiopurine analogue and anti-tumor necrosis factor agents have not been associated with increased risk of solid tumors, immunosuppression in patients with extensive polyposis should be cautiously used due to the potential accelerated malignancy risk. This case also highlights the importance of performing additional imaging of the gastrointestinal tract, in inflammatory bowel disease patients with anemia, particularly if the severity is incongruent with disease activity.

Outcome of femoral fractures care as a measure of trauma care between level I and level II trauma systems in Israel.

BACKGROUND: Our hypothesis in this study was that the outcome of patients with femur fractures would be favorable in a level I trauma center (LITC). METHODS: A prospective multicenter cohort study. 5 LITC and 6 regional (level II) trauma centers (RTCs) were enrolled to participate in the study. A total of 238 patients suffering from a femoral fracture were recruited to the study. 125 patients were treated in LITCs and 113 in RTCs. Data were extracted from the emergency medical services ambulances, emergency department records, patient hospitalization and discharge records, operating room records, and the national trauma registry (for LITCs). A study questionnaire was administered to all participating patients at discharge, 6 weeks and 6 months postoperatively. The following parameters were studied: mechanism of injury, time from injury to the hospital, Injury Severity Score, classification of femoral fracture, additional injuries, medical history, time to surgery, implant type, skill level of the surgical team, type of anesthesia, length of stay and intensive care unit (ICU) stay, postoperative and intraoperative complications and mortality. RESULTS: There was a significant difference in the modality of patient transfer between the 2 study groups-with the LITC receiving more patients transported by helicopters or medical intensive care. Time to surgery from admission was shorter in the LITC. Length of stay, ICU stay, and mortality were similar. In the LITCs, 47% of the procedures were performed by residents without the supervision of an attending surgeon, and in the RTCs 79% of the procedures were performed with an senior orthopaedic surgeon. Intraoperative and immediate complication rates were similar among the 2 groups. CONCLUSIONS: A femoral shaft fracture can be successfully treated in an LITC and RTC in the state of Israel. Both research and policy implementation works are required. Also, a more detailed outcome analysis and triage criteria for emergency are desired. LEVEL OF EVIDENCE: II.

Tracing the trajectory of behavioral impairments and oxidative stress in an animal model of neonatal inflammation.

Exposure to early-life inflammation results in time-of-challenge-dependent changes in both brain and behavior. The consequences of this neural and behavioral reprogramming are most often reported in adulthood. However, the trajectory for the expression of these various changes is not well delineated, particularly between the juvenile and adult phases of development. Moreover, interventions to protect against these neurodevelopmental disruptions are rarely evaluated. Here, female Sprague-Dawley rats were housed in either environmental enrichment (EE) or standard care (SC) and their male and female offspring were administered 50 µg/kg i.p. of lipopolysaccharide (LPS) or pyrogen-free saline in a dual-administration neonatal protocol. All animals maintained their respective housing assignments from breeding until the end of the study. LPS exposure on postnatal days (P) 3 and 5 of life resulted in differential expression of emotional and cognitive disruptions and evidence of oxidative stress across development. Specifically, social behavior was reduced in neonatal-treated (n)LPS animals at adolescence (P40), but not adulthood (P70). In contrast, male nLPS rats exhibited intact spatial memory as adolescents which was impaired in later life. Moreover, these males had decreased prefrontal cortex levels of glutathione at P40, which was normalized in adult animals. Notably, EE appeared to offer some protection against the consequences of inflammation on juvenile social behavior and fully prevented reduced glutathione levels in the juvenile prefrontal cortex. Combined, these time-dependent effects provide evidence that early-life inflammation interacts with other developmental variables, specifically puberty and EE, in the expression (and prevention) of select behavioral and molecular programs.

Haptic computer-assisted patient-specific preoperative planning for orthopedic fractures surgery.

PURPOSE: The aim of orthopedic trauma surgery is to restore the anatomy and function of displaced bone fragments to support osteosynthesis. For complex cases, including pelvic bone and multi-fragment femoral neck and distal radius fractures, preoperative planning with a CT scan is indicated. The planning consists of (1) fracture reduction-determining the locations and anatomical sites of origin of the fractured bone fragments and (2) fracture fixation-selecting and placing fixation screws and plates. The current bone fragment manipulation, hardware selection, and positioning processes based on 2D slices and a computer mouse are time-consuming and require a technician. METHODS: We present a novel 3D haptic-based system for patient-specific preoperative planning of orthopedic fracture surgery based on CT scans. The system provides the surgeon with an interactive, intuitive, and comprehensive, planning tool that supports fracture reduction and fixation. Its unique features include: (1) two-hand haptic manipulation of 3D bone fragments and fixation hardware models; (2) 3D stereoscopic visualization and multiple viewing modes; (3) ligaments and pivot motion constraints to facilitate fracture reduction; (4) semiautomatic and automatic fracture reduction modes; and (5) interactive custom fixation plate creation to fit the bone morphology. RESULTS: We evaluate our system with two experimental studies: (1) accuracy and repeatability of manual fracture reduction and (2) accuracy of our automatic virtual bone fracture reduction method. The surgeons achieved a mean accuracy of less than 1 mm for the manual reduction and 1.8 mm (std [Formula: see text] 1.1 mm) for the automatic reduction. CONCLUSION: 3D haptic-based patient-specific preoperative planning of orthopedic fracture surgery from CT scans is useful and accurate and may have significant advantages for evaluating and planning complex fractures surgery.

The morphological applicability of a novel endovascular aneurysm sealing (EVAS) system (Nellix) in patients with abdominal aortic aneurysms.

OBJECTIVE: Endovascular aneurysm sealing (EVAS) using the Nellix system is a promising alternative to endovascular repair (EVR) and open surgery for abdominal aortic aneurysms (AAA). The aim of this study was to investigate the proportion of patients with AAA who are morphologically suitable for treatment with Nellix. METHODS: Patients presenting with AAA were investigated at two regionalised vascular units. Separate cohorts were identified, who had undergone infrarenal EVR, open aneurysm repair, fenestrated endovascular repair (FEVR) or non-operative management. Pre-operative morphology was quantified using three-dimensional computed tomography according to a validated protocol. Each aneurysm was assessed for compliance with the instructions for use (IFU) of Nellix RESULTS: 776 patients were identified with mean age 75 ± 9 years. 730/776 (94.1%) had undergone infrarenal EVR, 6/776 (0.8%) open repair, 27/776 (3.5%) FEVR and 13/776 (1.7%) had been managed non-operatively. 544/776 (70.1%) of all AAA were morphologically suitable for Nellix. 533/730 (73.0%) of patients who had undergone infrarenal EVR were compliant with Nellix IFU, compared with 497/730 (68.1%), 379/730 (51.9%) and 214/730 (29.3%) with the IFU for Medtronic Endurant (p = .04) or Cook Zenith (p < .01) and Gore C3 Excluder (p < .01) endografts respectively. CONCLUSIONS: Nellix technology appears widely applicable to contemporary infrarenal AAA practice, and may provide an option for patients that are outside current EVR device instructions for use. However, formal outcomes study is still required, and will ultimately dictate the clinical relevance of this feasibility study. The major limitation to anatomic suitability for Nellix is currently the maximum patent lumen diameter of large AAA.

The Stoppa approach for acetabular fracture.

OBJECTIVE: Acetabular fractures pose a great surgical challenge for orthopedic trauma surgeons. We believe that the Stoppa approach with an iliac window extension, previously described as a modified Stoppa approach is adequate for the majority of acetabular fractures excluding those with predominant posterior wall involvement. In this paper we will present our experience in using the Stoppa approach, its indications, preparations, the detailed surgical approach, complications and the different tips used in this relatively modern approach. INDICATIONS: All simple and combined fracture types that involve the anterior column of the pelvis including the quadrilateral plate. CONTRAINDICATIONS: Posterior wall or extensive posterior column involvement. Transverse and T-fractures with mainly posterior displacement. SURGICAL TECHNIQUE: Suprapubic, intrapelvic approach, extending from the symphysis pubis anteriorly to the sacroiliac joint posteriorly. Superficial landmarks are identical to the Pfannenstiel approach, the rectus abdominis muscles are longitudinally dissected, the symphysis pubis is exposed and a sub-periosteal deep surgical dissection is carried out along the anterior column and the quadrilateral plate, and posteriorly toward the greater sciatic notch and the sacroiliac joint. RESULTS: In a 5-year review of 60 acetabular fractures that underwent open reduction and internal fixation using the modified Stoppa approach, there were 36% anterior column fractures, 28% both-column fractures, the rest being anterior column with posterior hemi transverse fractures, transverse and T-fractures. Any extension of the fracture to the iliac wing necessitated an additional lateral window (93% of cases). In cases with posterior displacement, an additional approach was utilized to address a posterior wall fracture. All fractures healed within 12 weeks. Mean Merle d'Aubigné score was 15.22. Postoperative radiological evaluation revealed anatomical reduction in 54% of the patients, satisfactory in 43%, and unsatisfactory in 3% of the patients. Overall there were 15 minor and major complications.

Economic burden of hepatitis C-associated diseases in the United States.

There are approximately 100 drugs in development to treat hepatitis C. Over the next decade, a number of new therapies will become available. A good understanding of the cost of hepatitis C sequelae is important for assessing the value of new treatments. The objective of this study was to assess the economic burden data sources for hepatitis C in the United States. A systematic literature search was conducted to identify studies reporting the costs of hepatitis C sequelae in the United States. Over 400 references were identified, of which 50 were pertinent. The costs were compiled and adjusted to 2010 constant US dollars using the medical component of the consumer price index (CPI). The cost of liver transplants was estimated at $201 110 ($178 760-$223 460), hepatocellular carcinoma (HCC) at $23 755-$44 200, variceal haemorrhage at $25 595, compensated cirrhosis at $585-$1110, refractory ascites at $24 755, hepatic encephalopathy at $16 430, sensitive ascites at $2450, moderate chronic hepatitis C at $155, and mild chronic hepatitis C at $145 per year per person. All studies were traced back to a handful of publications in the 1990s, which have provided the basis for all sequelae-based cost estimates to date. Hepatitis C imposes a high economic burden. Most cost analysis is more than 10 years old, and more research is required to update the sequelae costs associated with HCV infection.

[Membranous glomerulonephritis as a paraneoplastic manifestation of melanoma]. / Glomérulonéphrite extramembraneuse paranéoplasique au cours d'un mélanome.

BACKGROUND: Membranous glomerulonephritis (MG) is generally idiopathic. Causes of secondary MG (15 % of cases), namely solid or haematological cancers, are common, with parallel development between the two diseases suggesting paraneoplastic syndrome. However, paraneoplastic syndrome is rare in melanoma. We report a case of a patient with stage III melanoma presenting MG developing in parallel to the melanoma. PATIENTS AND METHODS: A 61-year-old man was referred for melanoma on the right side with a Breslow index of 3mm, and without ulceration. While the patient had no adenopathy, he was presenting severe hypertension diagnosed two months earlier as well as diffuse pitting oedema, with weight gain of 15kg in one month. Additional treatment of the patient's melanoma included extended excision, examination of the two right axillary sentinel nodes (positive), and axillary lymph node dissection revealing four more metastatic nodes. A thoracic-abdominal-pelvic CAT scan showed no further metastasis. Investigation of the oedema revealed nephrotic syndrome with hypoalbuminaemia of 14g/L and proteinuria of 5g/24h. Renal biopsy resulted in the diagnosis of MG. Histological and immunohistochemical examination (HMB-45, Melan A, S100 protein) showed no tumour cells in the kidney, and urinary cytology was negative. Non-tumoral causes of MG were thus ruled out. The oedema regressed rapidly following surgical treatment of the melanoma, with no specific renal or oncological treatment being given. Two years after axillary lymph node dissection, the patient was in complete remission of his melanoma and renal tests showed spontaneous regression of nephrotic syndrome, with disappearance of the oedema, normalisation of blood pressure and gradual correction of serum albumin (40g/L) and proteinuria (1g/24h). DISCUSSION: Paraneoplastic MG has been described particularly in patients with gastrointestinal and pulmonary cancer. To our knowledge, this is only the second case associated with melanoma. Our report suggests the need for routine cutaneous examination as part of the initial investigations for MG.

Household characteristics and allergen and endotoxin levels in Aleppo, Syrian Arab Republic.

Few data are available from Eastern Mediterranean countries about levels of domestic allergens and endotoxins. Dust samples were collected from mattresses and floors of 457 homes in the Syrian city of Aleppo and analysed for antigens and endotoxins. The most important predictors for detectable levels of house-dust mite allergen Der p 1 were Arabic-style houses (OR 3.21) and newer houses (OR 1.56). In homes without cats, rubber mattresses were associated with detectable cat allergen Fel d 1 in mattress dust (OR 1.6). Cockroach allergen Bla g 2 was significantly more likely to be detected in houses over 20 years old than newer houses. Endotoxin levels were significantly higher in wool/cotton mattresses and older houses.

Neonatal atrial fibrillation after surgical repair of tracheoesophageal fistula with esophageal atresia.

Atrial fibrillation is rare in childhood that had not been reported in neonates with normal cardiac morphology and function. The authors present a newborn who underwent surgical repair of a tracheoesophageal fistula with esophageal atresia at the age of 2 days and experienced atrial fibrillation 16 days after the procedure. A report of 35 pediatric patients in a single center over a period of 22 years identified atrial fibrillation in children with a variety of ailments including congenital cardiac anomalies before and after corrective surgery, rheumatic valve disease, Marfan's syndrome with mitral regurgitation, infective endocarditis, cardiomyopathy, endocardial fibroelastosis, paroxysmal atrial tachycardia of infants, and cardiac tumors [2]. All these patients had underlying cardiac disease.

Intraoperative cone-beam CT for image-guided tibial plateau fracture reduction.

OBJECTIVES: A mobile isocentric C-arm was modified in our laboratory in collaboration with Siemens Medical Solutions to include a large-area flat-panel detector providing multi-mode fluoroscopy and cone-beam CT (CBCT) imaging. This technology is an important advance over existing intraoperative imaging (e.g., Iso-C(3D)), offering superior image quality, increased field of view, higher spatial resolution, and soft-tissue visibility. The aim of this study was to assess the system's performance and image quality in tibial plateau (TP) fracture reconstruction. METHODS: Three TP fractures were simulated in fresh-frozen cadaveric knees through combined axial loading and lateral impact. The fractures were reduced through a lateral approach and assessed by fluoroscopy. The reconstruction was then assessed using CBCT. If necessary, further reduction and localization of remaining displaced bone fragments was performed using CBCT images for guidance. CBCT image quality was assessed with respect to projection speed, dose and filtering technique. RESULTS: CBCT imaging provided exquisite visualization of articular details, subtle fragment detection and localization, and confirmation of reduction and implant placement. After fluoroscopic images indicated successful initial reduction, CBCT imaging revealed areas of malalignment and displaced fragments. CBCT facilitated fragment localization and improved anatomic reduction. CBCT image noise increased gradually with reduced dose, but little difference in images resulted from increased projections. High-resolution reconstruction provided better delineation of plateau depressions. CONCLUSION: This study demonstrated a clear advantage of intraoperative CBCT over 2D fluoroscopy and Iso-C(3D) in TP fracture fixation. CBCT imaging provided benefits in fracture type diagnosis, localization of fracture fragments, and intraoperative 3D confirmation of anatomic reduction.

The use of intraoperative three-dimensional imaging (ISO-C-3D) in fixation of intraarticular fractures.

INTRODUCTION: The purpose of this study was to analyse the applicability and advantages of the intraoperative use of a mobile isocentric C-arm with three-dimensional imaging (Siremobil ISO-C-3D) in fixation of intraarticular fractures. METHODS: After the fixation was judged to be satisfactory relying on the images provided by routine fluoroscopy, intraoperative CT visualisation with ISO-C-3D was performed to evaluate the fracture reduction and implant position. Intraoperative revision was performed based on the additional information ISO-C-3D provided beyond routine fluoroscopy. ISO-C-3D was used on a series of 72 closed-intraarticular fractures in 70 patients. Fracture distribution was: calcaneus (25), tibial plateau (17), tibial plafond (12), acetabulum (11), distal radius (3), ankle Weber-C (3) and femoral head (l). The primary outcome measure was revision rate after final ISO-C-3D data acquisition and prior to wound closure. Secondary objectives were to measure the additional time required for ISO-C-3D use and to determine the rate of further re-do surgeries. RESULTS: Eight out of 72 (11%) fracture fixations were judged by the surgeon to require intraoperative revision following ISO-C-3D imaging. Prior to leaving the operating room, the surgeon was satisfied with fracture alignment in all the procedures. The mean additional operative time using ISO-C-3D was 7.5 min (8.2% of the mean total operative time). No patient required re-do surgery. CONCLUSION: : Intraoperative three-dimensional visualisation of intraarticular fractures enables the surgeon to identify inadvertent malreductions or implant malpositions which may be overlooked by routine C-arm fluoroscopy and hence may eliminate the need for re-do procedures. ISO-C-3D adds little operative time and may preclude the need for pre-operative and post-operative CT-scans in selected cases.

Osteoid osteoma: CT-guided radiofrequency ablation using a water-cooled probe.

BACKGROUND: The purpose of this study was to assess the safety and efficacy of computed tomography (CT) guided percutaneous radiofrequency (RF) ablation of osteoid osteoma by using the water-cooled probe. METHODS: During the period from July 2002 to February 2006, fifty-one patients with osteoid osteomas localized in femur (29), tibia (10), calcaneus (2), talus (2), metatarsus (2), humerus (1), sacrum (1), scapula (1), olecranon (1), patella (1) and thoracic vertebra (1) were treated with CT-guided RF ablation using the Cooltiptrade mark Tyco Healthcare probe. Mean age was 20 (range, 3.5-57 years) and male to female ratio was 36/15. Mean follow-up period was reported 2 years (range, 9-51 months). The procedures were carried out under general anesthesia and the patients were discharged from the hospital within 24 h. RESULTS: Technical failure was reported in only one procedure. Pain disappeared postoperatively in all the patients within 2-3 days and no patients needed analgesic treatment after a week. All patients were allowed fully weight bear and function without limitation after the procedure. Recurrence of the pain was observed in one patient who was treated successfully with a second ablation. Our primary and secondary clinical success rates were 98 and 100% respectively. In one case, wound infection was observed after the procedure as the only post-operative complication in our series. CONCLUSION: CT-guided percutaneous RF ablation of osteoid osteomas using the water-cooled probe is a safe, effective and minimally invasive procedure with high success rate and lack of relapses.

Should the presence of congenital para-ureteral diverticulum affect the management of vesicoureteral reflux?

PURPOSE: The presence of congenital para-ureteral diverticulum (PUD) has been presumed to lower the resolution rate of vesicoureteral reflux (VUR). PUD is considered an important cause of distortion of the vesicoureteral junction and persistence of VUR. Early surgery has been recommended based on this assumption. However, the scientific evidence supporting this approach is weak. We have been managing this group of patients more conservatively in the last 7 to 8 years on the premise that the presence of PUD is not per se an indication for surgery. To test this hypothesis, we performed a retrospective cohort study to compare the outcome of VUR in children with and without PUD. MATERIALS AND METHODS: We identified 141 consecutive patients with VUR associated with PUD between 1990 and 2004. Of the patients 57 with duplication, ureterocele, neurogenic bladder or outlet obstruction were excluded from study. Median age of the remaining 84 patients at diagnosis was 2.9 years and 56 (69%) were males. Reflux was bilateral in 4 patients, and low (I to II), intermediate (III) and high (IV to V) grade in 39%, 35% and 26%, respectively. Followup was 3 to 168 months (median 47). The outcome was compared to a control group of 95 patients (150 units) with primary VUR and no PUD. The baseline parameters and followup were comparable in both groups. RESULTS: Overall, VUR resolved in 43%, persisted in 27% and was surgically corrected in 30% of the units with PUD. In the 25 patients (26 units) who underwent surgical intervention breakthrough urinary tract infection or new renal scars were the indication in only 5. The remainder were operated on because of persistent VUR and the presence of PUD, mainly before 1997. The incidence of breakthrough urinary tract infection or new renal scar was similar in the controls (6% in PUD group vs 10% in controls, p = 0.7). The resolution rate was 60% for low grade, 39% for intermediate grade and 22% for high grade VUR. These figures were not significantly different from those of the control group in which the resolution rates were 52%, 28% and 33% for comparable grades (p = 0.9). Kaplan-Meier analysis and log rank test did not show any difference in resolution of VUR in the 2 groups (p = 0.84). Multivariate analysis identified grade as the only variable affecting resolution (p = 0.028). The size of PUD did not affect the likelihood of resolution. CONCLUSIONS: The outcome of VUR is similar in children with or without PUD. Therefore, treatment of these patients should not differ. Surgery should be reserved for patients with breakthrough infection or renal scar progression.

Size and geometry of hepatic radiofrequency lesions.

AIM: To report and compare the size and geometry of hepatic radiofrequency (RF) lesions using the currently available commercial devices. METHODS: A literature search was carried out for the period from January 1st 1990 to June 15th 2003. The commercial suppliers were asked to provide all available data. For each electrode and protocol, size and geometry of single-cycle thermal lesions were registered. RESULTS: No information at all on size and geometry of the inducible lesions was available for 17 of the 28 current commercial electrodes. Many descriptions of RF lesions are limited to the mean transverse diameter. With normal blood flow, diameter of lesions is often smaller than suggested by the length of the electrode tip or the diameter of the deployed prongs. Lesions are rarely perfect spheres but either ellipses or flattened spheres. Distortion of the RF lesion by nearby blood vessels is very common. Fusion of thermal zones between prongs of expandable electrodes can be incomplete. Blood flow interruption using a Pringle maneuver yields larger lesions that are less distorted and more complete. CONCLUSIONS: There is insufficient experimental data for many electrodes that are currently used in patients. RF companies should provide these data before releasing electrodes for use. For those electrodes for which data exist, coagulation lesions are often smaller, less spherical, less complete and less regular than generally presumed. Accurate knowledge of size and geometry of RF lesions is crucial to prevent local recurrence.

Mentored retroperitoneal laparoscopic renal surgery in children: a safe approach to learning.

OBJECTIVE: To review the feasibility of introducing advanced retroperitoneal renal laparoscopic surgery (RRLS) to a paediatric urology division, using the mentorship-training model. Although the scope of practice in paediatric urology is currently adapting endoscopic surgery into daily practice, most paediatric urologists in North America have had no formal training in laparoscopic surgery. METHODS: The study included four paediatric urologists with 3-25 years of practice; none had had any formal laparoscopic training or ever undertaken advanced RRLS. An experienced laparoscopic surgeon (the mentor) assisted the learning surgeons over a year. The initial phases of learning incorporated detailed lectures, visualization through videotapes and 'hands-on' demonstration by the expert in the technique of the standardized steps for each type of surgery. Over 10 months, ablative and reconstructive RRLS was undertaken jointly by the surgeons and the mentor. After this training the surgeons operated independently. To prevent lengthy operations, conversion to open surgery was planned if there was no significant progression after 2 h of laparoscopic surgery. RESULTS: Over the 10 months of mentorship, 36 RRLS procedures were undertaken in 31 patients (28 ablative and eight reconstructive). In all cases the mentored surgeons accomplished both retroperitoneal access and the creation of a working space within the cavity. The group was able to initiate ablative RRLS but the mentor undertook all the reconstructive procedures. After the mentorship period, over 10 months, 12 ablative procedures were undertaken independently, and five other attempts at RRLS failed. CONCLUSION: Although the mentored approach can successfully and safely initiate advanced RRLS in a paediatric urology division, assessing the laparoscopic practice pattern after mentorship in the same group of trainees is warranted. Ablative RRLS is easier to learn for the experienced surgeon, but reconstructive procedures, e.g. pyeloplasty, require a high degree of skill in laparoscopic technique, which may only be acquired through formal training focusing primarily on suturing techniques.