Outpatient transperineal prostate biopsy under local anaesthesia is safe, well tolerated and feasible.

BACKGROUND: Transperineal biopsy (TPB) of the prostate has been increasingly utilized as it has reduced infection risks. Traditionally however, it is performed under general anaesthesia, thus it carries a differing set of risks. Recently, new studies have performed TPB under local anaesthesia with success. In the present study, we explored our experience of performing TPB under local anaesthesia in an Australian cohort. METHODS: In this prospective study based at a metropolitan outpatient clinic, patients were provided with TPB under local anaesthesia. We assessed prostate cancer detection rates, complication rates and patient tolerability. Pain tolerability was assess using patient reported pain score on the visual analogue scale. Follow up data was collected at days 7 and 30 post-biopsy via telephone interview. RESULTS: A total of 48 patients were enrolled in this study between June 2020 and March 2021. Median age was 65.5 years and median PSA was 6.95 ng/mL. Clinically significant prostate cancer was detected in 58% of patients. During the procedure, pain scores were rated the highest during infiltration of local anaesthetic agent with a median score of 5. By the conclusion of the procedure, median pain score was 1. Vast majority of patients (85.4%) would opt for a repeat TPB under local anaesthesia should the need for prostate biopsy arise again. Two of our patients experienced infectious complications, and one experienced urinary retention. CONCLUSION: Our data is in line with currently available data and confirms that TPB under local anaesthesia can be achieved in a safe and tolerable manner.

Oncologic and Functional Outcomes of Pelvic Perineal Reconstruction by Perineal Colostomy and Malone Procedure After Abdominoperineal Resection.

BACKGROUND: Abdominoperineal resection is the standard curative surgical technique for locally advanced adenocarcinoma of the lower rectum and squamous cell carcinoma of the anal canal after chemoradiotherapy. However, it requires a definitive abdominal colostomy that modifies the body appearance. OBJECTIVE: The study aim was to evaluate the combination of abdominoperineal resection with perineal colostomy reconstruction and Malone antegrade continence enema. DESIGN: This was a retrospective study. SETTINGS: The study was conducted at the Toulouse Hospital Digestive Surgery Department. PATIENTS: All of the patients with advanced adenocarcinoma or squamous cell carcinoma who underwent abdominoperineal resection with perineal colostomy reconstruction and Malone antegrade continence enema (n = 80) between December 1999 and December 2016 were included. MAIN OUTCOME MEASURES: The main outcome was the 5-year overall survival rate. RESULTS: The 5-year overall survival was 74.89% (95% CI, 62.91%-83.50%), and the median recurrence-free survival was 107.6 months (95% CI, 65.1-198.1 mo). The median follow-up was 91.0 months (95% CI, 70.4-116.6 mo). R0 resection was obtained in 64 patients (80.0%). The median Cleveland Clinic Incontinence Score (to assess the functional outcomes) was 9.0 (interquartile range, 1.0-18.0), and it was lower in patients with advanced adenocarcinoma than with squamous cell carcinoma (7.0 (interquartile range, 2.0-18.0) vs 11.0 (interquartile range, 1.0-17.0); p = 0.01). Eleven patients (13.8%) reported perineal stains during the night, and 19 patients (23.8%) needed drugs to reduce colon motility. The rate of severe complications (Clavien-Dindo >II) was 11.7% (n = 9). Definitive colostomy was performed in 15 patients (18.8%). LIMITATIONS: This retrospective study included a small number of patients from a single center. Moreover, the functional outcome was tested with self-report questionnaires (risk of response bias). CONCLUSIONS: This study suggests that abdominoperineal resection associated with perineal reconstruction by perineal colostomy and Malone antegrade continence enema is safe and may improve patient quality of life. See Video Abstract at http://links.lww.com/DCR/B629. RESULTADOS ONCOLGICOS Y FUNCIONALES DE LA RECONSTRUCCIN PLVIPERINEAL MEDIANTE COLOSTOMA PERINEAL Y PROCEDIMIENTO DE MALONE DESPUS DE LA RESECCIN ABDOMINOPERINEAL: ANTECEDENTES:La resección abdominoperineal es la técnica quirúrgica curativa estándar para el tratamiento del adenocarcinoma localmente avanzado del recto inferior y el carcinoma a células escamosas del canal anal, después de radio-quimioterapia. Sin embargo, requiere una colostomía abdominal definitiva que modifica la apariencia corporal.OBJETIVO:El propósito del presente estudio fue el evaluar la combinación de la resección abdominoperineal con la confección de una colostomía perineal asociada a enemas de continencia anterógrada según Malone.DISEÑO:Estudio retrospectivo.AJUSTES:Servicio de Cirugía Digestiva del Hospital de Toulouse, Francia.PACIENTES:Se incluyeron todos los pacientes con adenocarcinoma avanzado o carcinoma de células escamosas que se sometieron a resección abdominoperineal con la confección de una colostomía perineal asociada a enemas de continencia anterógrada según Malone (n = 80) entre diciembre de 1999 y diciembre de 2016.PRINCIPALES MEDIDAS DE RESULTADO:El principal resultado fue la tasa de sobrevida global a 5 años.RESULTADOS:La sobrevida global a 5 años fue de 74,89% (IC del 95%, 62,91 a 83,50) y la mediana de supervivencia libre de recurrencia fue de 107,6 meses (IC del 95%, 65,1 a 198,1). La mediana de seguimiento fue de 91,0 meses (IC del 95%, 70,4-116,6). La resección R0 se obtuvo en 64 pacientes (80,0%). La mediana de puntuación de la escala de incontinencia de la Cleveland Clinic (para evaluar los resultados funcionales) fue de 9,0 [1,0; 18,0], y fue menor en pacientes con adenocarcinoma avanzado que con carcinoma de células escamosas (7,0 [2,0; 18,0] versus 11,0 [1,0; 17,0]; p = 0,01). Once pacientes (13,8%) refirieron manchado perineal nocurno y 19 pacientes (23,8%) necesitaron fármacos para reducir la motilidad del colon. La tasa de complicaciones graves (Clavien-Dindo > II) fue del 11,7% (n = 9). Se realizó colostomía definitiva en 15 (18,8%) pacientes.LIMITACIONES:Este estudio retrospectivo incluyó un pequeño número de pacientes y de un solo centro. Además, el resultado funcional se probó con cuestionarios de autoinforme (riesgo de sesgo de respuesta).CONCLUSIONES:Este estudio sugiere que la resección abdominoperineal asociada con la confección de una colostomía perineal asociada a enemas de continencia anterógrada según Malone es segura y puede mejorar la calidad de vida de los pacientes. Consulte Video Resumen en http://links.lww.com/DCR/B629.

Sectoral cancer detection and tolerability of freehand transperineal prostate biopsy under local anaesthesia.

BACKGROUND: To investigate the feasibility of a freehand transperineal (TP) systematic prostate biopsy protocol under local anaesthesia (LA) and the value of different sectors in diagnosing prostate cancer (PCa). METHODS: A total of 611 consecutive freehand TP biopsies under LA in 2 hospitals were prospectively evaluated. Cancer detection rate in each of the four different sectors (anterior, mid, posterior, basal) was recorded to evaluate the value of each sector. Procedure tolerability was assessed by pain score and complications were documented. RESULTS: Systematic biopsies were performed in 556 out of 611 men with a median of 20 (IQR 12-24) biopsy cores taken. The median PSA was 9.9 (Inter-quartile range[IQR] 6.4-16.2) ng/mL, and 89.0% were first biopsies. All PCa and ISUP grade group (GG) ≥ 2 PCa (HGPCa) were diagnosed in 41.4% (230/556) and 28.2% (157/556) biopsies respectively. 77.0% HGPCa was diagnosed in ≥2 sectors. Single-sector HGPCa was predominantly found in anterior or posterior sector. Omitting base sector would have missed 1.5% (1/65) HGPCa out of the 219 cases with ≥24-core biopsies performed. Further omission of mid sector would have missed 3.1% (2/65) HGPCa and 7.4% (7/94) ISUP GG1 PCa (in which 3/7 involved 2 sectors). LA TP biopsy was well tolerated and the mean pain scores of the different steps of the procedure were between 1.9-3.1 (out of 10). Post-biopsy fever occurred in 0.3% of patients (2/611) and no sepsis was reported. The risk of urinary retention in men with ≥20 cores in ≥60 ml prostate was 7.8% (14/179), compared with 1.7% (7/423) in other groups (p < 0.001). CONCLUSIONS: TP sectoral prostate biopsy under LA was well tolerated with minimal sepsis risk. Basal sector biopsies had minimal additional value to HGPCa detection and its omission can be considered.

Wound healing of metastatic perineal Crohn's disease using hyperbaric oxygen therapy: A case series.

BACKGROUND: Metastatic Crohn's disease (CD) is a rare manifestation of CD. It involves inflammatory skin lesions with histopathological findings (granulomas) similar to CD, without connection to the gastrointestinal tract. Hyperbaric oxygen therapy (HBO) has been suggested as a possible treatment option. OBJECTIVE: This study aimed to identify and treat a consecutive series of patients with biopsy-proven metastatic CD and monitor wound healing using prospectively acquired outcomes. METHODS: Pathology results of all patients with ongoing perineal wound-healing problems after proctectomy between 2005 and 2018 at the Amsterdam University Medical Centre were assessed for metastatic CD. Patients with a biopsy-proven diagnosis of perineal metastatic CD were offered HBO (40 daily sessions of 100% oxygen at 2.4 atmosphere absolute). Wound healing was monitored using photographs and standardised questionnaires (the Inflammatory Bowel Disease Questionnaire, EuroQol Visual Analogue Scale and the Female Sexual Function Index) at baseline and 1 and 3 months after HBO. RESULTS: Out of 13 patients in the cohort with persisting perineal wounds after proctectomy, six (46%) had biopsy results consistent with metastatic CD. Of these, three accepted treatment with HBO. All three patients were female. One patient had complete healing of her perineal wound; another patient showed initial improvement but had a flare of luminal and perineal disease at the 3-month follow-up. The third patient showed improvement solely in the questionnaires, with higher scores on all three questionnaires. CONCLUSION: A high rate of metastatic CD was found in patients with ongoing wound-healing problems after proctectomy, implying that the disease might not be as rare in these selected patients as previously thought. HBO might be beneficial in the treatment of metastatic CD.

The effect of acupressure applied to points LV4 and LI4 on perceived acute postpartum perineal pain after vaginal birth with episiotomy: a randomized controlled study.

PURPOSE: Acupressure can be used for alleviating perineal pain sustained after a vaginal birth with episiotomy. To evaluate if a 10-min acupressure application relieved perineal pain after vaginal birth with episiotomy and if the analgesic effect was maintained for up to 120 min. METHODS: A randomized controlled trial was conducted from January to May 2019 with 120 women. The participants were over 18 years old, had an episiotomy and experienced perineal pain ≥ 4, had not received anti-inflammatory medication or analgesics after childbirth, and were randomized to receive acupressure or ice-pack application on the perineum for 10 min or standard care. RESULTS: Immediately post-intervention, the women in the experimental groups had a significantly higher decrease in perineal pain. Within 120 min, there was a significant difference in the pain levels between the three groups. Each method (acupressure, ice package and control group) is evaluated for 30 min (VAS 3), 60 min (VAS 4) and 120 min (VAS 5). Comparing these 3 methods the acupressure has significantly reduced pain after the application (VAS 3 3.20 ± 1.28 vs. 3.77 ± 1.27 vs. 4.82 ± 0.93, respectively, VAS 4 2.65 ± 1.33 vs. 3.5 ± 1.37 vs. 4.62 ± 0.97, respectively, VAS 5 2.02 ± 1.44 vs. 3.5 ± 1.37 vs. 4.57 ± 0.93, respectively, p < 0.05) CONCLUSION: Effective pain relief is achieved by applying acupressure for 10 min to the perineum and is maintained between 30, 60, and 120 min.

[Therapeutic factors affecting the healing process in patients with gangrene of the perineum]. / Facteurs thérapeutiques affectant la cicatrisation au cours des gangrènes du périnée.

Fournier gangrene is a rare and severe necrotizing fasciitis. It is burdened with high morbi-mortality, requiring early and massive medical and surgical management. Initial treatment is based on patient's resuscitation associated with surgical debridement. Subsequently, the main challenge is the healing process and its possible sequelae. Several therapeutic approaches are currently available to improve and accelerate the healing process. We conducted a retrospective study of 20 cases. The median age of our patients was 56 years. The study included 16 men and 7 women. Comorbidity was present in 15 patients. Antibiotic therapy was administered in all cases, with a median duration of 15 days. All patients underwent surgery. Iterative reviews were necessary in all patients, who needed, on average, 3 dressing changes. Colostomy was performed in 6 cases. Hyperbaric oxygen therapy was performed in 4 cases. Vacuum assisted closure was performed in 1 case. Soft tissue coverage was necessary in 2 cases. The mean duration of healing was 15 days with oxygen therapy versus 24 days in the absence of this treatment. The mean duration of hospitalization was 20 days. Four patients died. Healing process without sequelae is a therapeutic challenge. Despite the addition of new therapeutic approaches, outcomes are not satisfactory. However, multidisciplinary approach associated with oxygen therapy and vacuum assisted closure might improve patients outcomes.

[Acyclovir-resistant perineal HSV infection revealing chronic lymphoid leukaemia]. / Herpès chronique périnéal résistant à l'aciclovir révélateur d'une leucémie lymphoïde chronique.

BACKGROUND: Chronic HSV infection is a cause of chronic perineal ulcerations. We report a case of a chronic and refractory HSV infection revealing chronic lymphoid leukaemia. PATIENTS AND METHODS: An 85-year-old woman with an 8-month history of chronic perineal ulcerations was referred to our dermatology department. She had no previous medical history of herpes infection. Skin biopsies ruled out carcinoma but were consistent with HSV infection. A local swab was positive for HSV2. Treatment with valaciclovir and intravenous acyclovir (ACV) at the recommended doses was ineffective. Laboratory tests revealed type-B chronic lymphoid leukaemia. Molecular biology studies confirmed the presence of ACV-resistant HSV via decreased thymidine kinase activity (stop codon: M183stop). Foscarnet was administered for a period of 3 weeks with almost complete healing of the ulcerations. Treatment was stopped prematurely due to acute renal insufficiency and the remaining lesions were treated using imiquimod cream. Valaciclovir was prescribed to prevent further episodes. The condition recurred a mere 11 months later. DISCUSSION: The prevalence of ACV-resistant HSV is 0.32 % in immunocompetent patients and 3.5 % in immunocompromised patients. Insufficient dosing regimens or prolonged treatment with TK inhibitors result in the local selection of pre-existing mutant HSV viruses. Foscarnet, a DNA polymerase inhibitor, is the treatment of choice in HSV-resistant infections. ACV-resistant HSV is less virulent and replicates less, with reactivations being mainly due to wild-type HSV latent in the neural ganglia. Valaciclovir can be used as a preventive treatment. To our knowledge, this is the first case of ACV-resistant HSV infection revealing chronic lymphoid leukaemia. CONCLUSION: Chronic perineal ulcerations can be the first manifestation of immunodeficiency seen for example with haematological diseases. In the event of clinical resistance of an HSV infection to recommended thymidine kinase inhibitor regimens, the use of foscarnet should be considered.

Transperineal rectocele repair: a systematic review.

BACKGROUND: Transperineal rectocele repairs, either as isolated fascial repair or in combination with mesh augmentation, are hypothesized to reduce the risk of complications compared with alternative techniques. AIM: The aim of this study was to ascertain long-term success and complication rates following transperineal rectocele repairs. METHOD: A literature search of PubMed and Embase was performed using the terms 'transperineal rectocele', 'rectocele', 'transperineal' and 'repair'. Prospective studies, case series and retrospective case note analyses from 1 January 1994 to 1 December 2016 were included. Those that detailed outcomes of the transperineal approach or compared it to transanal/transvaginal approaches were included. The main outcome measures were reported complications and functional outcome scores. RESULTS: A total of 14 studies were included. Of 566 patients, 333 (58.8%) underwent a transperineal rectocele repair and 220 (41.2%) a transanal repair. Complications were identified in 27 (12.3%) of the 220 transanal repairs and in 41 (12.3%) of the 333 transperineal repairs. A significant complication following transperineal repair was noted in eight studies. There are not enough data to make a reliable comparison between mesh and non-mesh transperineal repairs or to compare biological and synthetic mesh use. LIMITATIONS: Outcome reporting differed between studies, precluding a full meta-analysis. CONCLUSION: Transperineal rectocele repair offers an effective method of symptom improvement and appears to have a similar complication rate as transanal rectocele repair. Concomitant use of synthetic and biological mesh augmentation is becoming more common; however, high-quality comparative data are lacking, so a direct comparison between surgical approaches is not yet possible.

Hydrocarbon Enema: An Unusual Cause of Chemical Burn.

Hydrocarbons are a wide-ranging group of flammable chemicals and are often used in suicide attempts either by ingestion or as an accelerant in self-immolation. In this case study, we present a 37-year-old female who suffered 6% TBSA partial-thickness burns to her perineum and buttocks, which she claims resulted from diarrhea after ingesting a bottle of lighter fluid. The patient underwent decontamination and medical treatment for her burns and during her inpatient stay, it became apparent that the burns were more likely sustained from an intentional rectal administration of lighter fluid. To our knowledge, this is one of the first reported cases of hydrocarbon enema. We review hydrocarbon poisoning, including both ingestion and dermal exposure, and discuss medical management.

Bullous acrodermatitis enteropathica: case report of a unique clinical presentation and review of the literature.

Acrodermatitis enteropathica is a rare autosomal recessive disease characterized by pink scaly plaques and erosions in the periorificial and acral regions. A mutation in a gene responsible for zinc transport results in significant zinc deficiency in individuals lacking oral supplementation. We present a female infant with acrodermatitis enteropathica with crusting of the periorificial regions along with perineal plaques. A delay in diagnosis and treatment led to the development of pronounced painful acral bullae. Although plaques and erosions in the periorificial and acral regions are most commonly observed, bullae should also be considered in the spectrum of clinical manifestations of acrodermatitis enteropathica. The rare bullous variant of acrodermatitis enteropathica can be distinguished histologically.

A conservative approach to perineal Fournier's gangrene.

Fournier's gangrene (FG) is a disease involving necrosis of perineum and external genitalia; in 95% of cases it is possible to diagnose the Fournier's gangrene just by physical examination. The clinical presentation of FG varies from an initial localized infection to large areas with necrotizing infection. The disease typically affect elderly men (6°-7° decade) with important systemic comorbidities; women are less frequently affected. Despite improvements in diagnosis and management, the mortality rate nowadays is between 20% and 43%. The severity and mortality of the disease is dependent upon the general condition of the patient at presentation and upon the rate of spread of the infection. Treatment involves a multidisciplinary approach: intensive systematic management, broad-spectrum antibiotic therapy, early surgical debridement (wide abscission of necrotic tissues and surgical drainage of peritoneum, scrotum, penis, and inguinal areas), hyperbaric oxygen therapy; surgery can eventually be repeated if necessary; reconstructive surgery has an important role in the final treatment of the disease. The technical difficulties frequently encountered and the inability to make a complete removal of the necrotizing tissues at the time of surgery in some cases has led to the application of combined techniques, in view of the enhancement effect of specific advanced medications, targeted antibiotic therapy and hyperbaric medicine. We have considered 6 patients affected by Fournier's gangrene treated at our institution; all the patients received treatment with the help of plastic surgeons of the same institution. After debridement, all the patients were treated with advanced specific dressings consisting of plates and strips made of calcium alginate, hydrogels and polyurethane and twodimensional cavity foams. Reconstructive surgery was necessary in one case. Hyperbaric oxygen therapy (HBO) has been performed in all cases. The multidisciplinary approach, the combined use of HBO therapy and the adoption of advanced specific dressings, have made possible the complete healing of the lesions in a shorter period, avoiding further surgery in 5 out of 6 patients.

Algorithm for the surgical management of mesenchymal tumors of the perineum in adults.

BACKGROUND: Perineal soft tissue tumors are rare, so that little is known about their management and the outcome of treatment. OBJECTIVE: The aim of this study is to describe the presentation, management, and outcome of the surgical treatment of soft tissue tumors and to provide a final decision algorithm. DESIGN: This is a retrospective study. SETTINGS: The study was conducted in a single tertiary care hospital with a dedicated unit on sarcoma. PATIENTS: Fifty-one consecutive patients from 1998 to 2013 were included. MAIN OUTCOME MEASURES: The primary outcomes measured are patient demographics, treatment decisions, and outcome of surgical treatment. RESULTS: Forty-nine patients presented with a primary soft tissue tumor, and 2 underwent simple excisions for isolated metastases. The median tumor size was 75 mm (50-110). Symptoms were nonspecific, and MRI had insufficient specificity for malignancy so that a preoperative biopsy was systematically performed according to European Society for Medical Oncology and National Comprehensive Cancer Network soft tissue tumor guidelines. Six benign soft tissue tumors (3 lipomas, 3 leiomyomas), 16 intermediate soft tissue tumors (12 aggressive angiomyxoma, 4 desmoid tumors), and 27 sarcomas were identified. Treatments and surgery were tailored from the beginning according to histology. All but 1 benign soft tissue tumor were treated by 'shelling out.' Aggressive angiomyxoma were treated with en bloc resection sparing uninvolved organs. Nonsurgical treatments were our first choice for desmoid tumors. Wide en bloc surgery was planned for all sarcomas (n = 27) after the induction treatment for 16 patients (chemotherapy, n = 12; radiotherapy, n = 4). In the sarcoma group, the 5-year estimated metastasis-free, local recurrence-free, and overall survival rates were 68.1% (95% CI, 50.7-91.5), 84.7% (95% CI, 66.7-100), and 85.7% (95% CI, 71.8-100). In the benign and intermediate tumor groups, there were no deaths, local recurrences, or progression. LIMITATIONS: This study was limited by the small number of patients, given the rarity of this disease in the perineum. CONCLUSION: We provide useful indications for the best strategy necessary to treat these rare tumors located in a complex site.

Effect of ear acupressure on acute postpartum perineal pain: a randomised controlled study.

AIMS AND OBJECTIVES: To explore the effect of ear acupressure in relieving perineal pain in women during the first 48 hours after delivery. BACKGROUND: Perineal pain is a common problem during postpartum, and different treatment modalities have been used for relief. Ear acupressure has been reported to have possible benefit on relieving acute postpartum perineal pain. DESIGN: This study was designed as a prospective, randomised controlled trial. METHODS: Chinese women with a singleton vertex foetus at the gestation of 37 weeks or above were recruited. One hundred and twenty six and 130 women were randomised into the intervention and control groups, respectively. Women in the intervention group received application of tapes and seeds on four designated acupressure points on both ears, while women in the control group received tapes on four irrelevant points. Both groups were instructed to stimulate the points in a similar fashion. Pain perception was assessed by the Verbal Descriptive Pain Scale and the Visual Analogue Scale, and the consumption of analgesics was also reviewed. RESULTS: No significant difference in perineal pain perception between the groups was observed in Verbal Descriptive Pain Scale. Although the mean Visual Analogue Scale and the accumulative mean consumption of paracetamol were generally lower in the intervention group, statistical significance was not reached. CONCLUSIONS: There is no evidence so far to conclude that ear acupressure can effectively relieve perineal pain based on the statistical results. Further research is suggested to explore whether the effectiveness of pain relief is affected by the frequency and duration of acupressure point stimulation. RELEVANCE TO CLINICAL PRACTICE: Training of midwives to perform this intervention is easy to achieve, but further evidence is required to prove its effectiveness.

[Medical research through historical resources. Talking objects: a case of a parasitic perineal monstrosity]. / La ricerca medica attraverso la ricerca storica: mostri e mostruosità. Di una mostruosità parassitaria felicemente risolta con operazione chirurgica.

A case of a parasitic perineal monstrosity from the collection of the Pathology Museum of the University of Florence, is described on the basis of the original medical records and illustrations. The surgeon Giorgio Pellizzari (1814-1894) first reported this extraordinary case of sacrococcygeal teratoma containing a rudimentary inferior limb. Reader of Descriptive Anatomy, Pellizzari was a well-known Anatomy Dissector and Curator of the Physiological Museum of the Regio Arcispedale di Santa Maria Nuova in Florence. This report underlines the importance of studying the archive material in order to thoroughly comprehend a single museum talking object. This handling of matters will help to turn anatomical collections into a unique teaching toolfor modern medical practice and a noteworthy documentation of scientific, artistic and historical value. Through analysis of the original catalogue and investigation by means of modern scientific techniques, discovering the story behind the object becomes afeasible challenge.

[Hyperbaric oxygen in the treatment of perineal Crohn's disease era of infliximab: a renewal interest?]. / L'oxygénothérapie hyperbare dans le traitement de la maladie de Crohn perineale a l'ère de l'Infliximab : un regain d'intérêt ?

BACKGROUND: Despite the growing number of therapeutic methods and the recent introduction of new drugs more active in the therapeutic arsenal, lesions of the ano-perineal Crohn's disease remains difficult to support. Hyperbaric oxygen (HBO) was made before the era of infliximab, an interesting therapeutic approach in which the current position remains unclear. AIM: To assess HBO efficacy in the treatment of anal fistulas refractory Crohn's disease. METHODS: Literature review. RESULTS: Hyperbaric oxygen therapy was used in the 90's when the biotherapy was not part of the armamentarium for Crohn's disease. Research conducted has identified only nine publications evaluating the efficacy of hyperbaric oxygen therapy in the treatment of anal fistulas refractory Crohn's disease. Among the nine publications, we have retained only four: two clinical trials and two clinical cases. The total number of patients was 22: 12 women and 10 men. The average age of patients was 37 years. The average number of session was 42 sessions. Remission was observed in 15 patients (68.18%) whereas with Infliximab rate is 66%. Adverse events were observed in 2 patients (16.6%). Indeed, instead of considering them as two different alternatives, it should be combined to obtain a synergy to increase response rates, shorten the healing and especially to decrease the recurrence rate. CONCLUSION: Only a prospective randomized controlled trial (with two arms: biotherapy versus biotherapy associated with hyperbaric oxygen therapy) could accommodate this technique in the armamentarium of perineal lesions of Crohn's disease.

[MRI navigated stereotactic prostate biopsy: fusion of MRI and real-time transrectal ultrasound images for perineal prostate biopsies]. / MRT-navigierte stereotaktische Prostatabiopsie : Echtzeitfusion von MRT und transrektalem Ultraschall zu perinealen Prostatastanzbiopsien.

BACKGROUND: A key challenge for prostate cancer (PC) therapy is to exactly diagnose tumor lesions. In this context we describe a new stereotactic prostate biopsy system, which integrates pre-interventional MRI with peri-interventional ultrasound for targeted perineal prostate biopsies. Furthermore, the novel system allows exact documentation of biopsies in three dimensions. PATIENTS AND METHODS: Stereotactic biopsy was performed in 50 consecutive men with suspicion of PC [median age 67 years (42-77), mean PSA 8.9±6.8 ng/ml, and mean prostate volume 51±23.7 ml]. Twenty-five of these patients (50%) had already had a negative transrectal ultrasound (TRUS)-guided biopsy. All men underwent multiparametric, contrast-enhanced 3T MRI without endorectal coil. Suspicious lesions were marked before the obtained data were transferred to a novel stereotactic biopsy system. Using a custom-made biplane TRUS probe mounted on a stepper, 3-D ultrasound data were generated and fused with the MRI. As a result, suspicious MRI lesions were superimposed onto the TRUS data. Next, 3-D biopsy planning was performed including systematic biopsies from the peripheral zone of the prostate. According to local standards patients were treated with perioperative quinolone antibiotics and applied a rectal enema the evening before the procedure. Perineal biopsies were taken under live US imaging, and the location of each biopsy was documented in an individual 3-D model. Feasibility, safety, target registration error, and cancer detection were evaluated. RESULTS: The median number of biopsies taken per patient was 24 (12-36). In 27 men of the initial cohort of 50 consecutive patients presented here, biopsy samples showed PC (54%). In patients undergoing their first biopsy, cancerous lesions were diagnosed in 13 of 19 patients (68%). The result was positive in 36% of men undergoing a re-biopsy without previous cancer diagnosis (9/25). A positive correlation between MRI findings and histopathology was found in 72%. In MRI lesions marked as highly suspicious, the tumor detection rate was 100% (13/13). Looking at single cores from highly suspicious lesions, 40 of 75 (53%) biopsies were positive. The target registration error of the first 1,159 biopsy cores was 1.7 mm. Regarding adverse effects, one patient experienced urinary retention and one patient a perineal hematoma. Urinary tract infections did not occur. CONCLUSION: Perineal stereotactic prostate biopsies guided by the combination of MRI and ultrasound allow effective examination of suspicious MRI lesions. Each biopsy core taken is documented accurately for its location in 3-D enabling MRI validation and tailored treatment planning. The morbidity of the procedure was minimal.

Anal canal mucinous adenocarcinoma with invasion of gluteus and perineum treated with surgery and hyperbaric oxygen therapy.

The case of a 66-year-old female patient with late diagnosis of giant anal canal mucinous adenocarcinoma invading the gluteal and vulvar regions is reported. Because of the patient's severe clinical status and disease morbidity, surgical resection of the lesion was accomplished, with no adjuvant chemo- or radiotherapy. In the postoperative period, the patient received hyperbaric oxygen therapy, which facilitated and even accelerated local healing. Total closure of the raw flesh area was achieved, with no recurrence signals of cancer being detected after one-year follow-up. We are convinced that, in this difficult case, hyperbaric oxygen therapy played a crucial role in patient recovery and wound healing, allowing for early closure with good progression.

[Efficiency of Cikatridina spray for healing of episiotomy and perineal ruptures].

UNLABELLED: Episiotomy is the most common surgical intervention during childbirth. Cikatridina spray allows treatment of this primary contaminated surgical wound and assist its primary healing. The aim of this study is to determine the effectiveness of aid healing of episiotomy, and spontaneous perineal ruptures after normal and operative vaginal delivery. MATERIAL AND METHODS: The study included 90 women after spontaneous or operative vaginal delivery with episiotomy or a spontaneous perineal rupture treated with Cikatridina spray. Control group of 90 women was used to compare the efficency. The status of the wound was determined on the first, third, fifth and 30th day after birth, according to presence of the following symptoms: redness, swelling, pain, exudation, epithelization, open wound. RESULTS: Symptoms of redness, swelling and pain in the group treated with Cikatridina spray after normal birth resolved on the third postpartum day in 100% of cases. Same symptoms after operative vaginal birth persist in average 9% of women and resolved on the 5th day When comparing treated patients with Cikatridina spray with perineal ruptures and the control group in 100% were reported no symptoms in the study group compared with the control group where the redness, swelling persist in 20% and 85.7% epithelization is showing at 5 postpartum day. There was one open episiotomy of a patient from a control group after operative vaginal birth healed in 26 days. CONCLUSIONS: Cikatridina spray effectively eliminates symptoms of redness, swelling and pain regardless of perineal trauma and the method of delivery. There is an earlier epithelization after using the Cikatridina spray. Open and infected perineal wounds are treated with conventional medicines.