Cost analysis of pathology services comparing conventional 6-core transrectal biopsy versus transperineal saturation biopsy in diagnosing prostate cancer.

INTRODUCTION: Patients who are suspected of having prostate cancer from screening tests require a tissue biopsy to confirm the presence of cancer. This study aims to compare the cost and cancer detection rate of two different biopsy protocols: 6-core transrectal (TR) approach, and transperineal (TP) saturation biopsy. METHODS: In this descriptive, retrospective study, we selected all prostate biopsies received by the diagnostic pathology department of a tertiary hospital in Malaysia in the year 2020, from adult patients for analysis. Data on demographics, specimen preparation processes, and final histopathological diagnosis was extracted from the Laboratory Information System (LIS). The cost incurred for each biopsy diagnosed as cancer was calculated with the cost prices referenced from laboratory documentation. Statistical analysis was performed using SPSS, version 28. RESULTS: The total cost for detection of cancer using TR biopsy ranged from RM11.22 - RM271.02 with mean of RM47.53. The standard deviation, s is RM43.45. For TP biopsies, the total cost ranged from RM112.20 - RM349.56 with mean of RM160.85, standard deviation of RM80.37. TR biopsies had a detection rate of 43.2%, while TP biopsies had a 24.2% cancer detection rate. There is a 3.38-fold increase in costs between TR and TP biopsy. CONCLUSION: The results show a 3.38-fold increase in costs and a reduction in cancer detection rate when comparing TR and TP biopsy. The reason for the reduced detection rate is unascertained in this study.

CT assessment of the quality of omentoplasty and its implications for perineal wound healing.

PURPOSE: This study was designed to examine the impact of an omentoplasty and its quality on pelviperineal morbidity after abdominoperineal resection (APR) for rectal cancer. METHODS: This was a retrospective single-centre study of consecutive patients undergoing APR for primary or recurrent rectal cancer between 2000 and 2018. Quality of omentoplasty was categorised (sufficient vs insufficient) based on postoperative CT scans. Main study endpoints were perineal wound healing and perineal hernia. RESULTS: This study included 100 patients: 16 with a sufficient omentoplasty, 16 with an insufficient omentoplasty, and 68 without omentoplasty. Rate of pelviperineal complications within 30 days was 44%, 69% and 64% (P = 0.283), and delayed wound healing at 3 months was 19%, 54% and 27%, respectively (P = 0.109). Sufficient omentoplasty was not significantly associated with less delayed healing in multivariable analysis (OR 0.597; 95% CI 0.149-2.397). An insufficient omentoplasty demonstrated significantly higher rates of delayed healing at 6 months (46% vs 14%; P = 0.016) and chronic perineal sinus at 12 months (31% vs 3%; P = 0.008) compared with no omentoplasty. CONCLUSION: This relatively small series suggest that even a sufficient omentoplasty, as determined by postoperative imaging, does not reduce pelviperineal morbidity after APR for rectal cancer. The methodology of CT-based assessment of an omentoplasty as well as the correlation with postoperative outcomes has to be validated in future studies.

Anal Fistulas in Severe Perineal Crohn's Disease: Mri Assessment in the Determination of Long-Term Healing Rates.

Background & Aims: The European Crohn's and Colitis Organization recommends magnetic resonance imaging (MRI) of anal fistulas to decide on the drug/surgery strategy. No evidence is available on the long-term impact of MRI features on fistula healing. The aim of this study was to evaluate the benefit of combined drug/surgery strategies for the treatment of perianal Crohn's fistulas based on MRI factors at referral. Methods: The clinical event (anal abscess, new fistula tract, cellulitis), therapeutic intervention (introduction/optimization of immunosuppressant/biologics, anal surgery, intestinal resection, stoma), and MRI data were prospectively recorded for patients with Crohn's disease (CD) and anal fistulas. Healing was defined by fulfilment of all the following conditions: no discharge or pain, closure of the external opening of the fistula, no visible internal opening, no abscess, and no subsequent draining seton or drainage procedure performed during at least 1 year of follow-up. Results: Seventy CD patients with anal fistulas and MRI evaluations were followed for 70 months. The cumulative rates of fistula healing were 25%, 40%, 50%, and 70% at 12, 24, 36, and 72 months, respectively. Severe, complex, branched, and high fistulas were associated with a less favorable outcome. Surgical closure of the tract improved the healing rates better than treatment with biologics or thiopurines. Male sex, A1 luminal phenotype, and anal ulceration at referral were independently associated with a higher healing rate. Conclusions: Therapeutic strategies for perianal fistulizing CD require robust anatomical and healing evaluations. Combined strategies using biologics to improve both drainage and secondary closure of the fistula tracts merit further study.

Comparison between the Valsalva maneuver and intraoperative traction measurements in pelvic organ prolapse assessment.

OBJECTIVE: To compare the assessment of pelvic organ prolapse (POP) between the Pelvic Organ Prolapse Quantification (POP-Q) system with Valsalva maneuver and intraoperative measurement with mechanical traction. METHODS: A prospective observational study included 100 women with POP attending a tertiary urogynecology clinic in the UK and undergoing vaginal prolapse surgical procedures between October 2011 and October 2014. The women were examined in the clinic using POP-Q with the Valsalva maneuver and in the operating theater under general anesthesia with mechanical traction. The two sets of measurements were compared. RESULTS: All POP-Q measurements obtained with traction demonstrated significantly higher descent as compared with those measured by Valsalva maneuver (mean differences: Aa 0.64 cm; Ap 1.32 cm; Ba 0.96 cm; Bp 1.34 cm; C 3.57 cm; D 3.40 cm; all P<0.001). The perineal body and total vaginal lengths did not differ significantly. CONCLUSION: Measurements of six POP-Q points obtained with traction showed a higher grade of POP than those assessed with Valsalva maneuver. On this basis, surgeons might decide on the extent of surgical procedure after examination under anesthesia; however, preoperative patient counselling would be essential to obtain consent for this approach. The clinical significance of the findings requires further evaluation.

A Prospective Assessment of Surgical Risk Factors in 114 Gluteal Fold Flap Reconstructions After Oncological Vulvoperineal Resection.

BACKGROUND AND AIM: To date, clinically relevant selection criteria have not been established for the use of the gluteal fold flap after oncological vulvoperineal resection. We prospectively assessed the surgical risk factors of this reconstructive technique in a large series. METHODOLOGY: From April of 2000 through December of 2015, 114 gluteal fold flaps were used for vulvoperineal reconstruction after excision of (pre)malignant skin disorders in 75 women. The possible influence of 10 patient-related and 6 procedure-related risk factors on flap-related postoperative complications was statistically analyzed. RESULTS: We observed a major complication in 13 flaps (11%) and a minor complication in 19 flaps (17%). Previous radiotherapy (P = 0.01) was associated with significantly more complications, and a rotation flap design rather than VY advancement (P = 0.02) was associated with major complications. Recurrent disease, multifocal tumor localization, incomplete removal of tumor, and bilateral flap procedure were found to be clinically relevant risk factors, but not significantly so. The same applied to recurrence of disease during postoperative follow-up. CONCLUSIONS: We identified surgical risk factors for gluteal fold flap use after oncological vulvoperineal resection. These observations may potentially allow for more favorable future surgical outcomes by adaption of selection of patients or procedure.

Perineal tap water burns in the elderly: at what cost?

BACKGROUND: Burn injuries are expensive to treat. Burn injuries have been found to be difficult to treat in elderly patients than their younger counterparts. This is likely to result in higher financial burden on the healthcare system; however, no population-specific study has been conducted to ascertain the inpatient treatment costs of elderly patients with hot tap water burns. METHODS: Six elderly patients (75-92 years) were admitted for tap water burns at Concord Hospital during 2010. All costs incurred during their hospitalization were followed prospectively, and were apportioned into 'direct' and 'indirect' costs. Direct costs encompassed directly measurable costs, such as consumables used on the ward or in theatres, and indirect costs included hospital overheads, such as bed and theatre costs. RESULTS: Three males and three females admitted with burns to the buttocks, legs or feet. Total burn surface area (TBSA) ranged from 9-21% (mean 12.8%). Length of stay ranged from 26-98 days (mean 46 days). One patient died, and four required surgical management or grafting. Total inpatient costs ranged from $69 782.33 to $254 652.70 per patient (mean $122 800.20, standard deviation $67 484.46). TBSA was directly correlated with length of stay (P < 0.01) and total cost (P < 0.01). CONCLUSION: Hot water burns among the elderly are associated with high treatment costs, which are proportional to the size of the burn. The cost of treating this cohort is higher than previously reported in a general Australian burn cohort.

An MRI-based assessment of standard and extralevator abdominoperineal excision specimens: time for a patient tailored approach?

BACKGROUND: The extralevator abdominoperineal excision (ELAPE) has been proposed as oncologically superior to standard abdominoperineal excision (SAPE). However, little is known regarding comparative margins achieved in ELAPE and SAPE. The purpose of this study was to compare patterns of tissue removal between these two groups that can aid patient selection. METHODS: Twenty APE specimens, comprising 10 SAPEs and 10 ELAPEs, were selected randomly from a single UK centre. Transverse slices of pathological specimens were matched to corresponding axial MRI images obtained from conventional pelvic MRI imaging. Measurements from the muscularis propria to the resection margin [muscularis to margin (MTM) distance] were recorded by height (from anal verge) and quadrant for each surgical group. MTM distances achieved on histopathological assessment were also compared to MRI assessed distances necessary to achieve a clear CRM. RESULTS: ELAPE specimens had a greater mean MTM distance than for SAPE (7.75 vs. 5.61 mm, p = 0.02). ELAPE had significantly greater MTM distances in lateral and posterior quadrants (p < 0.05) than SAPE at 30-49 mm. There was no significant difference in mean anterior distances (1.57 vs. 1.16 mm, p = 0.507) with the smallest difference at a height of 60-69 mm. Two (2 %) of pathological MTM distances within ELAPE group failed to achieve the minimum MRI assessed distance compared with 30 (23 %) in the SAPE group, which had higher CRM positivity. CONCLUSIONS: ELAPE appears to confer oncological benefit over SAPE but with notable exceptions, including tumours located above and below the puborectalis sling and anteriorly at the level of prostate where exenteration may be more appropriate.

Transperineal perineal ultrasound versus magnetic resonance imaging in the assessment of perianal Crohn's disease.

BACKGROUND: To assess the accuracy of transperineal ultrasound (TPUS), in comparison with magnetic resonance imaging (MRI), in classifying perianal Crohn's disease (CD) according to Parks' classification and the American Gastroenterological Association criteria. METHODS: Fifty-nine consecutive patients with confirmed or suspected perianal CD underwent TPUS and MRI within 10 days. An independent expert surgical evaluation, which took into account proctological and MRI findings, was used as the gold standard. Fistulae and perianal disease were classified according to Parks' classification and American Gastroenterological Association criteria, respectively. RESULTS: Forty-six patients showed 64 fistulae (9 intersphincteric, 34 transsphincteric, 2 suprasphincteric, 9 extrasphincteric, and 10 anovaginal) and 23 abscesses were also found. Fifty-one of 54 perianal fistulae (per-lesion sensitivity: 94.4%) and 9 of 10 anovaginal fistulae (sensitivity: 90.0%) were detected and 58 were correctly classified by TPUS (sensitivity: 90.6%; positive predictive value: 93.4%). Overall, TPUS correctly detected and classified the fistulae in 89% of patients and the agreement for classifying perianal fistulae between TPUS and MRI was excellent (K value: 0.783). In contrast, 11 of 23 abscesses were correctly diagnosed by TPUS (sensitivity: 47.8%); although 14 abscesses were diagnosed by TPUS, only 11 were confirmed by MRI (positive predictive value: 78.6%). Overall, TPUS correctly detected and classified fistulae and associated abscesses in 67.3% of patients. Agreement between MRI and TPUS in discriminating simple (15) and complex (29) perianal disease was fairly good (K value: 0.57). CONCLUSIONS: TPUS is a simple and accurate diagnostic method for classifying perianal fistulae in CD and could be used for the preliminary assessment and follow-up of perianal CD.

Biological mesh reconstruction of perineal wounds following enhanced abdominoperineal excision of rectum (APER).

INTRODUCTION: An abdominoperineal excision of rectum (APER) may be required for rectal tumours less than 6 cm from the anal verge. Recently, the cylindrical APER has been used to prevent the "surgical waist" and so decrease margin involvement. However, removal of the levators leaves a large defect. Myocutaneous flaps [e.g. vertical rectus abdominis (VRAM)] are often used to fill the cylindrical resection defect, but have disadvantages associated with operative time, expertise and morbidity. We report our early experience of pelvic floor reconstruction with a biological mesh following cylindrical APER. METHODS: Data on consecutive patients having cylindrical APER between January 2008 and November 2010 were collected. Outcomes were compared between a VRAM reconstruction group and a mesh group. RESULTS: In 15 consecutive patients with low rectal cancer, five patients had VRAM pelvic floor reconstruction prior to ten patients having biosynthetic mesh repairs. The median operative time for the VRAM cohort was 405 min, compared with 259 min for the mesh (p = 0.0013). The median length of postoperative stay was 20 days for VRAM and 10 days for the mesh group (p = 0.067). There were four early complications for the VRAM group compared with seven for the mesh cohort (p = 0.37). The median cost per patient for the VRAM cohort was £11,075 compared to a median cost of £6,513 for the Mesh (p = 0.0097). CONCLUSION: The use of a biological mesh for pelvic floor reconstruction following cylindrical APER is feasible with morbidity comparable to VRAM reconstruction. There is significant cost-saving using a biosynthetic mesh, mainly due to reduced length of stay.

Agreement and reliability of pelvic floor measurements during contraction using three-dimensional pelvic floor ultrasound and virtual reality.

OBJECTIVES: Virtual reality is a novel method of visualizing ultrasound data with the perception of depth and offers possibilities for measuring non-planar structures. The levator ani hiatus has both convex and concave aspects. The aim of this study was to compare levator ani hiatus volume measurements obtained with conventional three-dimensional (3D) ultrasound and with a virtual reality measurement technique and to establish their reliability and agreement. METHODS: 100 symptomatic patients visiting a tertiary pelvic floor clinic with a normal intact levator ani muscle diagnosed on translabial ultrasound were selected. Datasets were analyzed using a rendered volume with a slice thickness of 1.5 cm at the level of minimal hiatal dimensions during contraction. The levator area (in cm(2)) was measured and multiplied by 1.5 to get the levator ani hiatus volume in conventional 3D ultrasound (in cm(3)). Levator ani hiatus volume measurements were then measured semi-automatically in virtual reality (cm(3) ) using a segmentation algorithm. An intra- and interobserver analysis of reliability and agreement was performed in 20 randomly chosen patients. RESULTS: The mean difference between levator ani hiatus volume measurements performed using conventional 3D ultrasound and virtual reality was 0.10 (95% CI, - 0.15 to 0.35) cm(3). The intraclass correlation coefficient (ICC) comparing conventional 3D ultrasound with virtual reality measurements was > 0.96. Intra- and interobserver ICCs for conventional 3D ultrasound measurements were > 0.94 and for virtual reality measurements were > 0.97, indicating good reliability for both. CONCLUSION: Levator ani hiatus volume measurements performed using virtual reality were reliable and the results were similar to those obtained with conventional 3D ultrasonography.

Perineal hernia in women : assessment with evacuation fluoroscopic cystocolpoproctography.

The aim of this study is to assess the usefulness of fluoroscopic cystocolpoproctography in the treatment of female pelvic organ prolapse. The presence or absence of rectocele, enterocele, sigmoidocele, and the cystocele on cystocolpoproctography was retrospectively analyzed in 46 consecutive patients. A rectocele was detected in 4.5% of the patients, postvaginal hernia in 19.7%, cystocele in 3.0%, complete rectal prolapse in 53.0%, massive rectal prolapse in 10.6%, and incomplete rectal prolapse in 4.5% of the patients on cystocolpoproctography. Perineal hernia can include a combination of cystocele, rectocele, uterine prolapse, enterocele and rectal prolapse. Accurate diagnosis of the coexisting abnormalities is essential in planning reconstructive procedures so that the risks of recurrence and reoperation can be minimized. Fluoroscopic cystocolpoproctography provides direct visualization and quantification of female pelvic organ prolapse, information that usually can only be inferred by physical examination.

The assessment of levator muscle strength: a validation of three ultrasound techniques.

Levator ani muscle function is traditionally evaluated by palpation or perioneometry. Recently, three different techniques of performing this task by translabial ultrasound have been described. The authors intended to validate these new methods by correlating results with assessments performed by perineometry and palpation. One hundred consecutive women were evaluated prospectively by a physiotherapist and a gynecologist. The physiotherapist undertook an assessment by palpation (Oxford grading) and perineometry (Peritron). The gynecologist performed translabial ultrasound. Both were blinded against each other's results. Correlations between ultrasound and palpation were between 0.52 and 0.62, with displacement of the bladder neck agreeing most closely with palpation. As regards perineometry, correlations were 0.38 to 0.52, and again bladder neck displacement agreed best with the physiotherapeutic assessment. All correlations were highly significant. It appears that the assessment of levator function by ultrasound correlates strongly with vaginal palpation of muscle strength and perineometry.

Necrotising soft tissue infections of the perineum and genitalia. Bacteriology, treatment and risk assessment.

Necrotising soft tissue infections of the perineum and genitalia are associated with a high rate of mortality and morbidity. We reviewed the records of 29 consecutive patients to investigate the possible correlation between clinical outcome and number of types of bacteria cultured, focus of infection, presence of diabetes, patient age, renal function and delay until presentation. The patients had an average of 3.9 bacterial organisms cultured intra-operatively (range 1-9). Patients with a rectal focus of infection had a greater number of bacteria and required longer hospitalisation and more operative procedures than patients with dermal or urethral foci. Those over the age of 60 had significantly longer hospital stays and higher mortality. Diabetes and impaired renal function did not increase mortality or morbidity. Suprapubic cystostomy was required in 24 patients (83%), diverting colostomy in 9 (31%) and orchiectomy in 3 (10%). Six patients (21%) died despite broad spectrum antibiotics and aggressive and frequent surgical debridement.

Anorectal incontinence and rectal prolapse: differential assessment of the innervation to puborectalis and external anal sphincter muscles.

The innervation of the puborectalis and external anal sphincter muscles was studied in 32 patients with idiopathic (neurogenic) faecal incontinence, 12 of whom also had complete rectal prolapse, using transcutaneous spinal stimulation, transrectal pudendal nerve stimulation, single fibre EMG, anorectal manometry, and measurement of perineal descent. Fourteen normal subjects served as controls. Significant increases in the spinal motor latencies from L1 to the puborectalis and external anal sphincter muscles were shown in all 32 incontinent patients (p less than 0.01). The single fibre (EMG) fibre density was increased in the puborectalis muscle in 60% and in the external anal sphincter in 75% of patients. An increased pudendal nerve terminal motor latency was found in 68% of patients; 69% had an abnormal degree of perineal descent and all had reduced anal canal contraction pressures. These data show that the different innervations of the puborectalis and external anal sphincter muscles are both damaged in patients with anorectal incontinence.