The final outcome of indeterminate cytology of thyroid nodules in a District General Hospital.

BACKGROUND: Diagnostic thyroid lobectomy is performed to resolve the dilemma of indeterminate (Thy3) cytology of thyroid nodules. But on final histology most nodules are benign thereby subjecting this group of patients to surgery with its associated risks. AIM: To determine the proportion of cancers in patients with indeterminate thyroid nodules. PATIENTS AND METHODS: This is a retrospective observational study of 621 patients who underwent fine needle aspiration cytology (FNAC) of their thyroid nodules over a 60 month period in a district general hospital. Patient demographics, cytology and final histology results were extracted from the hospital database. RESULTS: On final analysis, 48 patients had an indeterminate cytology (7.7%) and 12 patients had cancer in this group (25%) following diagnostic lobectomy. CONCLUSION: Till an alternative robust technology becomes widely available we need to continue to perform diagnostic lobectomy in patients with indeterminate cytology in view of the high incidence of thyroid cancer in this group of patients.

The surgical anatomy of the perineum.

The anatomy of the perineum and pelvis is complex. Those outside the specialist fields of colorectal surgery, urology and gynaecological surgery often have a less-than-complete understanding of the anatomical details of this region. The recent increase in complicated pelvic and perineal injuries caused by the detonation of Improvised Explosive Devices has brought into sharp focus, the importance of this area of surgical anatomy. The following article describes, in a systematic and detailed manner, the anatomy of the urogenital and anal regions of the perineum. The terminology in relation to the fascial layers and structures encountered in the perineum is elucidated. In addition, the surgical anatomy of the scrotum and its contents and the ligamentous support of the penis are described, with clear illustrations throughout. It is intended that this article will go some way towards clarifying the anatomy underlying the surgical management of complex perineal/pelvic injuries, and benefit both the specialist and non-specialist military surgeon.

A successful live donor kidney transplantation after large angiomyolipoma excision.

INTRODUCTION: Angiomyolipoma is the most common benign neoplasm of the kidney. Successful transplantation of an AML affected kidney has been reported. However it is still often seen as a contraindication to transplantation. PRESENTATION OF CASE: A 47-year-old female underwent assessment for a direct specified kidney donation to her husband who had end stage renal failure, due to adult polycystic kidney disease. Routine pre-operative CT angiography demonstrated a large 6cm×4cm AML arising from the upper pole of the right kidney. Right-side hand assisted retro-peritoneoscopic live donor nephrectomy with bench tumour excision was subsequently performed. Recipient implantation was unremarkable with no haemorrhage. DISCUSSION: Histology confirmed a 7cm AML. At 36 months follow up, the recipient's serum creatinine was 158µmol/l and eGFR 40ml/min without the need for dialysis at any stage. CONCLUSION: AML should not be a contraindication for specified live kidney donation, despite a size of 7cm.

Autogenous brachial-brachial fistula for vein access. Haemodynamic factors predicting outcome and 1 year clinical data.

UNLABELLED: Two-stage autogenous brachial vein-brachial artery access (ABBA) has been proposed as an option where adequate superficial vein is not available for the creation of conventional haemodialysis fistulae. METHODS: This report depicts the clinical outcome of a series of 17 consecutive patients who underwent ABBA in a single centre. Of the 17 patients, nine had had at least one previous arterioventricular (AV) fistula or graft, and eight were new to haemodialysis. Patencies were assessed using the Kaplan-Meier survival analysis. RESULTS: In 14 patients, the brachial vein was transposed (82%) and the time to transposition ranged from 4 to 26 weeks (median time: 6 weeks). The functional patency rate was 45.75% at 12 months. After stage one, all fistulas that went on to develop well had a brachial vein flow of at least 900 ml min(-1), and this was significantly higher than in fistulas that failed to develop (p=0.005). The maturation rate in our study was 65% and the median time to cannulation of the fistula was 8 weeks from the stage 1. Of the 17 patients, 12 (71%) experienced at least one complication. Ten (59%) demonstrated moderate-to-severe stenoses; eight of which necessitated angioplasty and/or percutaneous mechanical thrombolysis. CONCLUSIONS: ABBA was characterised by a high incidence of complications and a long period to achieve maturation. Despite close monitoring and a high rate of secondary interventions, the patency rate was low. With this experience, we now only consider it an alternative in patients without adequate superficial veins, who have had failed grafts or where there is a very high risk of infection.

Percutaneous nephrolithotomy in early pregnancy.

Most cases of urolithiasis in pregnancy are managed conservatively either with ureteric stents or percutaneous nephrostomy tubes, which need to be changed at regular intervals. Definitive management of the stone is usually delayed till after delivery. We describe a patient who presented with pyonephrosis in the fifth week of gestation, due to a stone obstructing the right ureteropelvic junction. This was managed by insertion of a nephrostomy tube. She declined nephrostomy tube/stent changes during the rest of her pregnancy and requested termination as an alternative. She successfully underwent percutaneous nephrolithotomy in the 14th week of pregnancy, with radiation exposure strictly localised to the kidney for 6 s. A healthy male baby was delivered at term.

Testis-sparing surgery for benign and malignant testicular tumours.

We report the technique of testis-sparing surgery in three young men with testicular tumours, two of which were found to be benign (Leydig cell tumour and benign teratoma) and one malignant (seminoma) on frozen section and final pathological evaluation. The principles of clamping the spermatic cord with a soft bowel clamp, testicular cooling with ice slush, tumour enucleation with clear margins, meticulous haemostasis and frozen section analysis were followed. Testicular preservation was successful in the patients with benign disease. The patient with seminoma was found to have a separate nodule of invasive, poorly differentiated seminoma in the residual testis, which had not been detected on preoperative ultrasound scanning. As a result he was converted to radical orchidectomy.