The Comparison Study of Anatomic Vapor-incision Technique (AVIT) Using the 180W-XPS Greenlight Laser and Photoselective Vaporization of the Prostate for the Treatment of Benign Prostatic Hyperplasia.

OBJECTIVE: To prospective compared the preoperative parameters and postoperative functional outcomes between anatomic vapor-incision technique (AVIT) and the photoselective vaporization of prostate (PVP) with Greenlight 180W-XPS. METHODS: Total 174 BPH patients were enrolled in the study and 86 cases, 88 cases were underwent with traditional PVP and AVIT, respectively. The relevant pre-, intra-, and postoperative data were recorded and compared between the both groups. RESULTS: No significant differences were observed between both groups in baseline characteristics and no major complications (capsule perforation and TUR syndrome) occurred intraoperatively. In AVIT group, the energy consumption and energy density were greater than those in PVP group. The operative time and laser time were longer in AVIT group than it in PVP group. Compared to the AVIT group, the incidence of irritative symptoms after operation was higher in the PVP group. During the follow-up period, the functional outcomes (IPSS, QoL, prostate volume and PSA level) in both groups were significant improved compared to the baseline. The reduction of prostate volume and PSA level were significant greater in AVIT group than it in PVP group. CONCLUSION: Compared to PVP, AVIT is safe and efficacious treatment for BPH patients with more adenoma removal and more improvements of clinical outcomes. But the long-term follow-up data is needed to evaluate the functional outcomes and retreatment rates.

The Most Current Algorithms for the Treatment and Prevention of Hypertrophic Scars and Keloids: A 2020 Update of the Algorithms Published 10 Years Ago.

BACKGROUND: In 2010, this Journal published my comprehensive review of the literature on hypertrophic scars and keloids. In that article, I presented evidence-based algorithms for the prevention and treatment of these refractory pathologic scars. In the ensuing decade, substantial progress has been made in the field, including many new randomized controlled trials. To reflect this, I have updated my review. METHODS: All studies were evaluated for methodologic quality. Baseline characteristics of patients were extracted along with the interventions and their outcomes. Systematic reviews, meta-analyses, and comprehensive reviews were included if available. RESULTS: Risk factors that promote hypertrophic scar and keloid growth include local factors (tension on the wound/scar), systemic factors (e.g., hypertension), genetic factors (e.g., single-nucleotide polymorphisms), and lifestyle factors. Treatment of hypertrophic scars depends on scar contracture severity: if severe, surgery is the first choice. If not, conservative therapies are indicated. Keloid treatment depends on whether they are small and single or large and multiple. Small and single keloids can be treated radically by surgery with adjuvant therapy (e.g., radiotherapy) or multimodal conservative therapy. For large and multiple keloids, volume- and number-reducing surgery is a choice. Regardless of the treatment(s), patients should be followed up over the long term. Conservative therapies, including gel sheets, tape fixation, topical and injected external agents, oral agents, and makeup therapy, should be administered on a case-by-case basis. CONCLUSIONS: Randomized controlled trials on pathologic scar management have increased markedly over the past decade. Although these studies suffer from various limitations, they have greatly improved hypertrophic scar and keloid management. Future high-quality trials are likely to improve the current hypertrophic scar and keloid treatment algorithms further.

Multidisciplinary management of patients with pubic osteomyelitis, a rare but serious complication after surgery and radiation therapy for advanced gynaecological cancer.

Pubic osteomyelitis is a rare and often late-onset complication of radiation therapy and surgery for vulvar and vaginal carcinoma. It typically presents with vulvar pain, fever, vaginal discharge and/or gait disorders. Pubic osteomyelitis is often accompanied by fistulas or wound dehiscence in the pelvic area. Its accurate diagnosis and treatment are challenging and require a multidisciplinary team effort. In our patients, multiple combined surgical procedures, long-term antibiotic treatment and days to weeks of hospital admission were necessary to treat pubic osteomyelitis. We emphasise the importance of timely and adequate diagnosis and multidisciplinary approach resulting in a course of treatment that is as effective as possible, limiting the impact on quality of life, which is generally high in this group of patients.

Increase in early wound leakage in total knee arthroplasty with local infiltrative analgesia (LIA) that includes epinephrine: a retrospective cohort study.

Background and purpose - After introducing a new local infiltration anesthesia (LIA) protocol with addition of 30 mL ropivacaine 2% and 1 mg epinephrine, we noted an increase in early wound leakage. As wound leakage is associated with prosthetic joint infection, our department aims to minimize postoperative wound leakage. This study evaluates the incidence of early wound leakage and postoperative pain after knee arthroplasty (KA) following adjustment of the LIA protocol with addition of 30 cc ropivacaine 2% and 1 mg epinephrine. Patients and methods - In this retrospective medical dossier study all patients (n = 502) undergoing a primary total or unicondylar knee arthroplasty between January 1, 2018 and July 1, 2019 were included. Patients received an LIA protocol containing 120 mL 2 mg/mL ropivacaine (ROPI- group; n = 256). After October 30, patients received an LIA protocol containing 150 mL 2 mg/mL ropivacaine with 1 mg epinephrine in the first 100 mL (ROPI + group; n = 246). The primary outcome measure was early wound leakage (< 72 hours postoperatively), defined as wound fluid leaking past the barrier of the wound dressing. Secondary outcome measure, 10-point numeric rating scale (NRS) pain (< 72 hours postoperatively) was also assessed. Data was evaluated using logistic regression. Results - The incidence of wound leakage was higher in the ROPI + group: 24% versus 17% in the ROPI- group (p = 0.06). After adjusting for the differences between surgeons the relative risk of this increase was 1.4 (1.0-2.0). The ROPI + and ROPI- group were similar regarding postoperative pain assessment. Interpretation - Adjustment of the LIA protocol with 30 mL 2% ropivacaine and 1 mg epinephrine led to an increase in early wound leakage in knee arthroplasty but no difference in pain scores.

Approach Behavior Induced by 10.6-µm Laser Stimulation at Acupoint ST36 in a Rat Model of Incisional Pain.

Objective: Laser stimulation (LS) at both the injury site and specific acupoints may induce analgesic effects. The purpose of this study is to investigate the effects of LS at injury site or acupoint on analgesic-associated approach behavior and determine whether opioid receptors in the anterior cingulate cortex (ACC) were involved. Methods: The left hindpaw incision was established in rats. LS (10.6 µm) was performed at the ipsilateral (left) acupoint ST36 (Zusanli) or locally to the incision site. Characteristic guarding pain behavior was measured to assess incision-induced pain. A two-chamber conditioned place preference (CPP) paradigm was used to measure approach behavior induced by pain relief. To inhibit opioid receptors, naloxone was microinjected into the ACC before LS. Results: A delayed analgesic effect (24 h after treatment) was induced in both the LS groups (ST36 and incision site) as compared with the sham control or model groups (p < 0.05). An immediate (30 min after the end of the LS) decrease in guarding pain (p < 0.001) and CPP for the LS chamber (p < 0.001) were observed only in the ST36 LS group. The administration of naloxone in ACC inhibited the LS-induced analgesic effect and CPP (p < 0.05). Conclusions: Our results highlight the novel approach behavior of pain relief induced by 10.6-µm LS at ST36 in a rat model of incisional pain, and implicate ACC opioid receptor signaling in these actions.

The neurosurgical wound and factors that can affect cosmetic, functional, and neurological outcomes.

Surgically accessing pathological lesions located within the central nervous system (CNS) frequently requires creating an incision in cosmetic regions of the head and neck. The biggest factors of surgical success typically tend to focus on the middle portion of the surgery, but a vast majority of surgical complications tend to happen towards the end of a case, during closure of the surgical site incisions. One of the most difficult complications for a surgeon to deal with is having to take a patient back to the operating room for wound breakdowns and, even worse, wound or CNS infections, which can negate all the positive outcomes from the surgery itself. In this paper, we discuss the underlying anatomy, pharmacological considerations, surgical techniques and nutritional needs necessary to help facilitate appropriate wound healing. A successful surgery begins with preoperative planning regarding the placement of the surgical incision, being cognizant of cosmetics, and the effects of possible adjuvant radiation therapy on healing incisions. We need to assess patient's medications and past medical history to make sure we can optimise conditions for proper wound reepithelialisation, such as minimizing the amount of steroids and certain antibiotics. Contrary to harmful medications, it is imperative to optimise nutritional intake with adequate supplementation and vitamin intake. The goals of this paper are to reinforce the mechanisms by which surgical wounds can fail, leading to postoperative complications, and to provide surgeons with the reminder and techniques that can help foster a more successful surgical outcome.

Effect of wound massage on neck discomfort and voice changes after thyroidectomy.

BACKGROUND: Neck discomfort and voice change are common complications after thyroidectomy. These symptoms might be due to damaged laryngeal nerves, intrinsic structures, or extralaryngeal muscles. They can also occur without injury to any structure as with wound adhesion after thyroidectomy. The objective of this study was to determine causes of neck discomfort and voice change after thyroidectomy and to evaluate the effect of wound massage on symptom relief. METHODS: Forty-five female patients who underwent total thyroidectomy were included (21 in the experimental group and 24 in the control group). Wound massage was used as an intervention to release surgical adhesion. After wound massage education, participants in the experimental group received wound massage from 4 to 12 weeks after thyroidectomy. Analysis was performed for both groups. RESULTS: No laryngeal pathology was found after thyroidectomy. The experimental group had significantly better recovery from surgical adhesion and subjective visual analog scale, voice impairment score, and swallowing impairment score (all P < .01) compared with the control group. Voice analysis results associated with laryngeal movement (speaking fundamental frequency, voice range profile maximum, voice range profile range) also indicated significant recovery (P < .01) in the experimental group. These results indicate that local adhesion after thyroidectomy might affect general movement of the larynx and that wound massage could help patients recover normal general movement of the larynx. CONCLUSION: Neck discomfort and voice change after thyroidectomy are related to local wound adhesion, possibly associated with impairment of laryngeal vertical movement. Release of wound adhesion could help patients recover from neck discomfort and voice changes after thyroidectomy.

Pitch Ointment: Applications in Scar and Wound Management.

There is a high incidence of household knife-related injuries requiring emergency department treatment in the U.S. The Pitch Ointment, a named formula developed by a compounding pharmacist, was used separately by two patients who suffered a knife injury in a finger and a foot. This formula combines Pinene (L-Alpha) 0.5% and Canada Balsam 5% in PracaSil-Plus, special ingredients with applications in scar and wound healing. The patients' level of satisfaction with the Pitch Ointment was very high since all 4 treatment satisfaction domains by the Treatment Satisfaction Questionnaire for Medication (effectiveness, side effects, convenience, global satisfaction) were rated over 85. These results are consistent with the clinical improvements observed in the before and after treatment photographs. The success of these case reports is evidence to suggest that the Pitch Ointment may be recommended by compounding pharmacists as a viable treatment option in scar and wound management.

Effects of three forms of local anesthesia on perioperative fentanyl-induced hyperalgesia.

Both local infiltration analgesia (LIA) and nerve block are common analgesic modalities for pain relief after surgery. The aim of the current study was to investigate the effects of those two modalities on pain behavior and the expression of pro-inflammatory cytokines such as interleukin (IL)-1ß and IL-6 and tumor necrosis factor-α (TNF-α) in the spinal cord and dorsal root ganglion (DRG) in a rat model of perioperative fentanyl induced hyperalgesia. Rats were injected with fentanyl (60 µg/kg) 4 times and received a plantar incision after the second injection or they received pre-incision LIA and sciatic nerve block (SNB) or post-incision LIA with levobupivacaine (0.5%, 0.2 mL). Mechanical and thermal nociceptive thresholds were assessed using the tail pressure test and paw withdrawal test on the day before drug injection, 1 and 4 hours after injection, and 1-7 days later. The lumbar spinal cord and dorsal root ganglia were collected from rats in each group to measure IL-1ß, IL-6, and TNF-α on the day before drug injection, 4 hours after injection, and 1, 3, 5, and 7 days later. Fentanyl and an incision induced a significantly delayed mechanical hyperalgesia in the tail and thermal hyperalgesia in both hind paws and up-regulation of pro-inflammatory cytokines in the spinal cord and dorsal root ganglia. Rats treated with pre-incision LIA and SNB or post-incision LIA had alleviated hyperalgesia and significantly reduced levels of IL-1ß, IL-6, and TNF-α compared to the control group. LIA and SNB partly prevented perioperative fentanyl-induced hyperalgesia and up-regulation of pro-inflammatory cytokines in the spinal cord and dorsal root ganglia.

The Influence of Preoperative Interventions on Postoperative Surgical Wound Healing in Patients Without Risk Factors: A Systematic Review.

BACKGROUND: Poor wound healing and scar formation remain critical problems in daily surgical practice. Generally, most attention is paid to intra- and postoperative interventions to improve wound healing after surgery, while preoperative interventions remain unsatisfactorily explored. OBJECTIVES: In this systematic review, the available literature on the beneficial effects of preoperative interventions on wound healing and scar formation have been summarized and compared. METHODS: A comprehensive and systematic search has been conducted in MEDLINE, Pubmed, Embase, Web of Science, and Cochrane, supplemented by reference and citation tracking. All preoperative interventions and all clinically relevant outcome parameters have been considered for inclusion, due to the expected limited availability of literature. RESULTS: A total of 13 studies were included, which were all randomized trials. No cohort studies or retrospective studies have been identified. All studies described different preoperative interventions and outcome parameters and could hence not be pooled and compared. Eight studies showed significantly better wound healing after a preoperative intervention. The individual studies have been summarized in this review. CONCLUSIONS: This systemic review shows that preoperative interventions can be beneficial in improving wound healing and scar formation. In selected cases, wound healing was found to benefit from a higher preoperative body temperature, topical vitamin E application, and low patient stress levels.

Evolution of Various Components of Pain After Laparoscopic Cholecystectomy: Importance of Its Prognostication for Effective Pain Control Using a Local Anesthetic and for Making a Valid Practical "Discharge Criteria" Model Predicting Early Discharge of Patients.

OBJECTIVES: Pain continues to be the most important limiting factor affecting the early discharge of patients after laparoscopic cholecystectomy (LC). Our aim was to conduct a randomized case controlled study to predict the evolution of various components of postoperative pain by using ropivacaine 0.2% at intraperitoneal and intraincisional locations; and to further use this information to make a model predicting early discharge of patients. METHODS: Two hundred forty-four patients underwent elective four-port LC. Patients were triple blindly randomized. All patients received ∼23 mL of solution, of which 20 mL was given intraperitoneally and ∼3 mL was given intraincisionally. Solution was either normal saline or drug (0.2% ropivacaine) depending on the group (controls [n = 77], intraperitoneal group [n = 80], and intraincisional group [n = 87]). Five different pain scales were used for assessment of overall pain. Only those patients with a Visual Analog Scale (VAS) ≤3, Numeric Rating Scale (NRS) ≤3, Visual Descriptor Scale (VDS) ≤ "Slight Pain," Faces Pain Scale-Revised (FPS-R) ≤2, and Activity Tolerance Scale (ATS) ≤ "Can Be Ignored" along with absence of use of rescue analgesia and shoulder pain were considered for "Discharge Criteria." RESULTS: Incisional component of pain was found to be the main component of pain that predominated in the immediate postoperative period. However, it declined rapidly over 12 hours and was then dominated by the visceral component. Shoulder component peaked around the eighth postoperative hour. Seven percent of patients in controls could be discharged at the 12th postoperative hour and 18% at the 24th hour. In the intraperitoneal group, 18% and 61% patients could be discharged at the 12th and 24th hour, respectively, as compared with 57% and 78% in the intraincisional group using the "Discharge Criteria." "Discharge Criteria" was 100% effective in predicting patients' acceptance to go home. CONCLUSION: The effect of local anesthetic at intraincisional and intraperitoneal sites is additive with drug catering to different components of pain. We recommend using the "Abbreviated Discharge Criteria" routinely in practice to check for patients' eligibility to be discharged.

Antibiotic therapy for prevention of fistula in-ano after incision and drainage of simple perianal abscess: A randomized single blind clinical trial.

BACKGROUND: Much controversy exists regarding the role of antibiotics in the development of fistula in-ano after incision and drainage. We evaluated the role of postoperative antibiotics in the prevention of fistula in-ano after incision and drainage of perianal abscess. METHODS: In a randomized single blind clinical trial study, 307 patients were randomly selected from those referring for incision and drainage of perianal abscess at Shahid Faghihi Hospital, Shiraz, Iran, during September 2013 to September 2014. Patients were allocated randomly either to receive 7 days of oral metronidazole and ciprofloxacin in addition to their standard care or to only receive standard care without any antibiotics after they were discharged from the hospital. Patients were followed for 3 months and final results were evaluated. The study was registered at the clinical trial registry (www.irct.ir; Irct201311049936n7). RESULTS: Seven patients were lost to follow-up. Those who used prophylactic antibiotics (n = 155) had significantly lower rates of fistula formation compared with those who did not use any medication (n = 144; P < .001). Men had higher rates of fistula formation (P = .002). Patients who used more cigarettes had higher rates of fistula development (P = .001). In the univariate analysis, only postoperative antibiotic use showed a protective role against fistula formation (odds ratio = 0.426; confidence interval, 0.206-0.881). In the regression analysis postoperative antibiotic use remained protective against fistula development (odds ratio = 0.371; confidence interval, 0.196-0.703), furthermore male sex presented as a risk factor for developing fistula in-ano (odds ratio = 3.11; confidence interval, 1.31-7.38). CONCLUSION: Postoperative prophylactic antibiotic therapy including ciprofloxacin and metronidazole play an important role in preventing fistula in-ano formation. Considering the complications of fistula in-ano formation and the minor side effects of antibiotic therapy, based on our results, a 7-10 course of postoperative antibiotics is advised after incision and drainage of perianal abscess.

Effect of electroacupuncture on the cervicospinal P2X7 receptor/fractalkine/CX3CR1 signaling pathway in a rat neck-incision pain model.

Increasing evidence supports that acupuncture intervention is an effective approach for intraoperative and postoperative pain. Neuron-microglia crosstalk, mediated by the purinergic P2X7 receptor (R)/fractalkine/CX3CR1 cascade in the spinal cord dorsal horn, plays a pivotal role in pain processing. However, its involvement in the analgesic effect of electroacupuncture (EA) remains unclear. In this study, a rat neck-incision pain model was established by making a longitudinal incision along the midline of the neck and subsequent repeated mechanical stimulation. EA stimulation was applied to bilateral LI18, LI4-PC6, or ST36-GB34. The thermal pain threshold, cervicospinal ATP concentration, expression levels of purinergic P2XR and P2YR subunits mRNAs, and fractalkine, CX3CR1 and p38 MAPK proteins, were detected separately. The neck incision induced strong thermal hyperalgesia and upregulation of spinal ATP within 48 h. No significant change was found in thermal hyperalgesia after a single session of EA intervention. However, a single session of EA dramatically enhanced the neck incision-induced upregulation of ATP and upregulated the expression of P2X7R, which was reversed by two sessions of EA. Two sessions of EA at bilateral LI18 or LI4-PC6 attenuated hyperalgesia significantly, accompanied with downregulation of P2X7R/fractalkine/ CX3CR1 signaling after three sessions of EA. EA stimulation of LI18 or LI4-PC6 alleviates thermal hyperalgesia in neck-incision pain rats, which may be associated with its effects in regulating the neck incision-induced increase of ATP and P2X7R and subsequently suppressing fractalkine/CX3CR1 signaling in the cervical spinal cord.

Rubus occidentalis analgesic effect in a rat model of incisional pain.

BACKGROUND: The purpose of this study was to evaluate the analgesic effect of Rubus occidentalis extract (ROE) in a rat model of incisional pain. The involved mechanisms and proinflammatory cytokine response were also examined. MATERIALS AND METHODS: To investigate the analgesic effect, rats were intraperitoneally administered with normal saline or various doses of ROE before or after a plantar incision. To evaluate the involved mechanism, rats were intraperitoneally administered yohimbine, dexmedetomidine, prazosin, naloxone, atropine, or mecamylamine after a plantar incision; ROE was then administered intraperitoneally. The mechanical withdrawal threshold (MWT) was tested with von Frey filaments at various time points. To determine the inflammatory response, serum levels of interleukin (IL)-1ß or IL-6 were measured. RESULTS: The MWTs significantly increased at 15 min after postincisional administration of 300 mg/kg ROE when compared with those in the control group. This elevation was observed for up to 45 min. Overall, MWTs increased in proportion to ROE dosage; however, ROEs administered before the incision produced no significant change in the MWT. The analgesic effect of ROE was significantly antagonized by mecamylamine, naloxone, and yohimbine, and agonized by dexmedetomidine. Administration of ROE inhibited the postincisional increase in serum IL-1ß and IL-6. CONCLUSIONS: Intraperitoneal administration of ROE after surgery induces antinociceptive effects in a rat model of postoperative pain, and its effects on mechanical hyperalgesia may be associated with α2-adrenergic, nicotinic cholinergic, and opioid receptors.