Fourniers gangrene as Amyands hernia complication.

INTRODUCTION: Fourniers gangrene is a rare but fast deteriorating and serious condition with high mortality. In most cases, it is characterized as necrotizing fasciitis of the perineum and external genitals. Amyands hernia is a rare condition where the appendix is contained in the sac of an inguinal hernia. Inflammatory alterations in the appendix account only for 0.1 % of the cases when Amyands hernia is verified. Fourniers gangrene as a complication of a late diagnosis of appendicitis located in the inguinal canal is described in the literature as rare case reports.   Case report: The case report of a 70-year-old patient with Fourniers gangrene resulting from gangrenous appendicitis of Amyands hernia.  Conclusion: Fourniers gangrene as a complication of Amyands hernia is a rare condition. Only sporadic case reports thereof can be found in the literature. Because of the rarity of this pathology and the lack of randomized controlled studies, it is difficult to determine the optimal treatment according to the principles of evidence-based medicine. An appropriate approach for this condition appears to be the combination of guidelines developed in Amyands therapy according to Losanoff and Basson, along with the recommended “gold standard” therapy for Fourniers gangrene. This means early and highly radical surgical debridement, adequate antibiotic therapy and intensive care.

Solifenacin is effective and well tolerated in patients with neurogenic detrusor overactivity: Results from the double-blind, randomized, active- and placebo-controlled SONIC urodynamic study.

AIMS: To investigate the effect on urodynamics of 4 weeks treatment with solifenacin succinate in patients with neurogenic detrusor overactivity (NDO) due to multiple sclerosis (MS) or spinal cord injury (SCI). METHODS: SONIC was a prospective, multicenter, double-blind, phase 3b/4 study investigating the efficacy and safety of solifenacin 10 mg in patients with NDO due to MS or SCI. Patients (n = 189) were randomized to placebo or active treatment (solifenacin 5 mg, 10 mg or oxybutynin hydrochloride 15 mg) for 4 weeks, after a 2-week, single-blind, placebo run-in period. The primary endpoint was change in maximum cystometric capacity (MCC) from baseline to end of treatment. The primary analysis compared solifenacin 10 mg versus placebo; all other comparisons were considered secondary. Secondary endpoints included changes in urodynamic parameters, patient-reported outcomes, and safety assessments. RESULTS: In the primary analysis, solifenacin 10 mg significantly improved mean change from baseline MCC versus placebo (P < 0.001) and was associated with improvements in bladder volume at first contraction and at first leak as well as detrusor pressure at first leak. Similar results were obtained for oxybutynin versus placebo. Patient perception of bladder condition significantly improved with solifenacin 10 mg versus placebo (P = 0.041). There was a clear improvement in quality of life (QoL) in the solifenacin arms versus placebo. The overall incidence of adverse events was low. CONCLUSIONS: In patients with NDO due to MS and SCI, 4 weeks of treatment with solifenacin 10 mg improved urodynamic variables and QoL versus placebo and was well tolerated. Neurourol. Urodynam. 36:414-421, 2017. © 2015 Wiley Periodicals, Inc.

[Sexual dysfunction in men after surgery of colorectal carcinoma. New developments in prevention and therapy]. / Sexuální dysfunkce u muzu po operacích kolorektálního karcinomu. Novinky v prevenci a terapii.

Current procedures in the treatment of rectal carcinoma respect preservation quality of life. Development of sexual dysfunction (SD) in men after iatrogenic damage to neurovascular structures has been reported in 21-38% and significantly decreases quality of life. The author summarizes new developments in the area of surgical anatomy of Denonvilliers' fascia, occurrence of accessory pudendal arteries (APA), and neural anatomy. Introduction of robotic nerve-sparing surgery along with application of new diagnostic perioperative methods such as Doppler diagnostics and Optical Coherence Tomography will allow precise perioperative identification of neurovascular structures. New approaches in the treatment of erectile dysfunction prevent cavernosal hypoxia after neurovascular damage. Decrease of pO2 leads to fibrosis of penile structures and development of venous leak. Early administration of phosfodiesterasis-5 (PDE5) inhibitors forms the basis of treatment. Besides inducing erection in spite of decreased pO2, inhibitors PDE5 also have protective effect on the smooth muscles and endothelia of the penis. Combination with intracavernously applied prostaglandin PGE1 or with statins (Atorvastatin) increases efficacy. Currently, there is no standardized procedure in penile rehabilitation. Early start of therapy is recommended. In case of permanent medication support, the dosage for achieving erection is lower than in non-rehabilitated patients. Complex sexologiceal care is essential. It is necessary to initiate educational campaign of sexologists, surgeons, oncologists and patients themselves. Patients must be well informed and referred to a sexologist prior the treatment of carcinoma. Late start of rehabilitation leads to irreversible structural changes that require increased doses of drug therapy.

[Treatment of male erectile dysfunction following spinal cord injuries using PDE5 inhibitors]. / Lécba erektilní dysfunkce muzu po poranení míchy inhibitory fosfodiesterázy 5.

UNLABELLED: The authors present results of a clinical study examining therapeutic effects of PDE5 inhibitors in the management of male erectile dysfunction following spinal cord injuries. The study was prospective, non-invasive, observational. AIM: The aim of the study was to determine efficacy and safety of tadalafil in the treatment of male erectile dysfunction following spinal cord injuries and to assess one-year treatment results. MATERIAL AND METHODS: 16 males, the mean age of 33 years, participated in a four-week assessment of tadalafil efficacy and safety. A paraplegic couple received 8 tablets of tadalafil 20 mg and recommendation of sexual intercourse twice a week. The males recorded the tablet intake in a "Diary". The following questionnaire scores were used in the assessment prior and after the four-week treatment period: IIEF-5 (International Index of Erectile Function), GAO (Global Assessment Question), SEP 2 a 3 (Sexual Encountner Profile, questions 2,3). A non-parametric test was used for statistical evaluation. RESULTS: In 94% of the males, the treatment resulted in improved erection quality (GAQ) and there was statistically significant improvement in ability for penis emission to vagina (SEP 2, p = 0.005). In 69% of the young disabled males, tadalafil-mediated erection was sufficient to perform a satisfactory intercourse (SEP3, p = 0.001). Based on the IIEF-5 questionnaire data, the erectile function score improvement was statistically significant, compared to that prior to therapy (p = 0.001). 75% of the paralyzed used the benefit of the long-acting PDE5 inhibitor and repeated the sexual intercourse within 36 hours of its intake. Undesirable effects were reported in 3 out of the 16 subjects and a single patient discontinued the treatment due to the side effects. 8 out of the 16 males (50%) continued the tadalafil treatment after one year of medication. The authors conclude that tadalafil treatment of male erectile dysfunction following spinal cord injuries is safe and effective and is well tolerated for over a year.

[Erectile dysfunction after traumatic pelvic injury]. / Erektilní dysfunkce po poranení pánve.

UNLABELLED: Erectile dysfunction is a serious consequence of pelvic injuries. The aim of the study was to review and assess erectile dysfunction rates in mono and polytraumatized males with the pelvic injury, and to highlight the impotence-type of the pelvic injury relation and to evaluate the therapeutic response of the patients. METHODS: In total, 231 mono- or polytraumatized males with the pelvic injury were mailed a private letter including the HEF-5 International Index of Erectile Function questionnaire. The AO classification was used to assess the relation of the pelvic injury type and the onset of the erectile dysfunctin. The c2 test was used to assess the statistical significance. The peroral treatment with the phosphodiesterase 5 (PDE5) inhibitors was the therapeutical method of first choice. The therapeutical effect was assessed using the IIEF 5 questionnaire. RESULTS: We concluded that the erectile dysfunction affects nearly a third (31.5%) of the males who suffered pelvic injuries. The fact, whether the patient suffered an isolated pelvic injury or a pelvic injury in a polytrauma, has no influence on the erectile dysfuntion onset (p = 0.218), however, the onset of impotence has a significant connection to the type of the pelvic injury. We confirmed a statistically significant increase in the erectile dysfuncion rates in patients with the pelvic ring injury type B and C (p = 0.023). The mean IIEF-5 score prior to the treatment initiation was 11.5. In 85% of the patients the peroral treatment of the erectile dysfunctin using the PDES inhibitors was successful and resulted in achievement of the pair sexual satisfaction. The score of the IIEF-5 questionnaire reached physiological values 23 (22-25) following the treatment. Based on the findings, the authors recommend, during their hospitalization, to inform the males who suffered the type B and C pelvic ring injury about a possibility of their sexual dysfunction, and to advise them to contact a sexual disorders specialist.

[Personal experience with injuries of the rectum and anus]. / Nase zkusenosti s poranením rekta a anu.

Authors analyze some new knowledge in treatment of rectal and anal injuries proceeded from own clinical experience in comparison with studies of a range of foreign authors published recently. During last ten years together 24 injured patients with this diagnose were operated in Traumatological Hospital Brno, primary reconstruction was performed in 10 patients, secondary reconstruction after precise examination of pelvic fundus pathophysiology in 14 patients, mostly transferred from other clinics. Authors prefer primary treatment in 3 hours after injury. This opinion is supported by control examinations after performed reconstructions.

Tumors of the rectum and anus.

Within a ten year period we have performed 433 radical operations on the rectum. An anterior resection of rectum was done in 110 cases, low anterior resection in 60 patients, very low anterior resection was done by stapler in 32 patients and was sewn by hand in 10 patients. Colo-anal anastomoses were performed 86 times and abdominoperineal amputation of rectum sec. Miles 20 times. Local transsphincteric procedures were used 14 times. In 12 patients the colo-anal anastomosis was performed either for recurrence of tumor or after a Hartmann's procedure. In the carcinoma of the lower half of the rectum there is still an unsolved question: whether to perform a low or a very deep low anastomosis or whether an extirpation of rectum with sparing the sphincters and sewing a colo-anal anastomosis is more beneficial. In the years 1980-1995 we treated surgically 64 patients with a tumor in anal area. All patient underwent preoperative radio- and chemotherapy. In our group adenocarcinoma was demonstrated in 6 patients, squamous carcinoma in 48 patients and squamous cells of the carcinoma in situ in 10 patients.

[Carcinoma of the lower half of the rectum]. / Karcinom dolní poloviny rekta.

Authors analyze the group of patients surgically treated for rectal carcinoma during ten-years long period. While the surgical tactic in upper part of the rectum is solved by the resection with straight anastomosis, in carcinomas of lower part of the rectum there is an open question there, to use the deep pelvic anastomosis after radical resection or to perform the rectal extirpation with saving of sphincters and using the coloanal anastomosis. The necessary requirement is complex preoperative examination of the tumor and of pelvic fundus physiology. For application of coloanal anastomosis the rigid indications are determined. Authors used this method in 107 patients of the monitored group. Early and delayed complications of these interventions are analysed, indication for temporary stomy and application of pouchs. In the group of patients with coloanal anastomosis no local recurrence was noted, in the group with deep pelvic anastomosis the locoregional anastomosis was found in 8% of patients.

[Does a pelvic compartment exist? Personal experience]. / Existuje pánevní kompartment? Nase zkusenosti.

The authors analyze a group of 7 patients transferred to their hospital for instable fractures of the pelvic circle and lumbar spine. The pelvic compartment was manifested 24-48 hours after injury. Early diagnostics are based on the use of new imaging techniques, spiral CT examination is preferred, and angiography in stabilized patients. Early surgical intervention is aimed at evacuation of haematomas, revision of vessels, release of the ureters and temporary nephrostomy.

[Our concept of defecography. Methods and reproducibility of results]. / Defekografie v nasem pojetí. Metoda a reprodukovatelnost výsledku.

Defecography is used in the Czech Republic only exceptionally. Since 1988 the authors made 402 defecographic examinations. They submit a detailed description of hitherto assembled experience and their own modification of the examination. As contrast material they use at present Micropaque susp. thickened by means of wheat bran. They administer it by means of a modified press for dough preparation. The X-rays are taken on a modified ordinary stool made from soft timber. For screening of uncovered places in the visual field they use individually placed copper plates 2 mm thick. For better evaluation of the X-rays the authors place during examination an X-ray contrasting net behind the patient. Pictures are taken at rest, during contraction, during modified Valsalva's manoeuvre and during all stages of defecation. The authors mention the most interesting pathological pictures they encountered so far--internal prolapse, levator hernia, rectocele, sphincter defect, various forms of prolapses and dyskineses of the pelvic floor. In the authors opinion the basic quantifiable parameters are the magnitude of the anorectal angles. They used the assessment method described by Mahieu, as well as the mediorectal angle which in their opinion is a reflection of the patient's somatotype and levator function. More than the absolute values of the angles they emphasize the difference of the two angles and change of the latter during contraction and defecation. In their opinion enlargement of the difference during contraction and diminution to values close to zero is normal. Converse values are according to the authors evidence of dyssynergy of the pelvic floor. Independent assessment of the angles and magnitude of the lift of the pelvic floor by three subjects are subjected to statistical analysis. They provide evidence of complete reproducibility of results of anorectal angles according to the authors' definition. The results of assessment can be used to investigate relations with parameters of anorectal manometry (AM) or transrectal sonographyy (TRS) in subsequent investigations.

[Problems with continence after deep pelvic anastomoses in rectal carcinoma]. / Problematika kontinence po hlubokých pánevních anastomózách pri Ca recti.

Based on the complex evaluation of the continence by anorectal manometry, EMG examination of sphincters, transrectal sonography, defecography and Colonic Transit Time examination, the analysis of the group of 15 patients partially incontinent after operation of carcinoma of the lower part of the rectum has been done. In these patients the deep pelvic anastomosis or coloanal anastomosis was performed. In none of the patients any serious organic damage of sphincters was manifested, the causes were dominantly extrasphincteric and functional, solvable well by conservative methods.

[Problems with continence in rectal injuries]. / Problematika kontinence pri poranení rekta.

Authors analyse the group of 17 patients operated for rectal and anal injury. In this group 7 patients were operated primarily after injury and in 11 patients the secondary reconstruction was performed. Authors called the attention to the high diagnostic difficulty before the planned and indicated secondary reconstruction. Based on assessment of own clinical material and conforming with literature, authors conclude that secondary reconstruction are more difficult, and this difficulty is the higher, the less qualified the primary treatment was performed.

[Associated injuries of the pelvis]. / Sdruzená poranení pánve.

In last three years 27 injured patients were operated in Traumatological hospital Brno for associated pelvic trauma. This trauma was associated with injury of urinary tract in 8 patients, with traumatic lesion in area of the colon in 6 cases and with injured big vessels of the retroperitoneum in 8 patients. The urgent operation was performed in 44%. Authors put stress in diagnostic analysis and early indication of surgical operation on careful anamnestic clinical examination, they utilize the contribution of the sonographic and CT examination with contrast, in indicated cases the selective angiography and retrograde urethrocystography, too. Authors prefer early reconstructional operations.

[Pitfalls of deep pelvic anastomoses in rectal carcinoma]. / Uskalí hlubokých pánevních anastomóz u karcinomu rekta.

Authors analyse a group of patients operated for colorectal carcinoma in their hospital during ten-years period 1982-1991. 421 patients were operated for ca recti, in more as 65% of cases the sphincter saving operation was preferred. The used method was elaborated by Hojo and Kaso from Japan. The contraindication of sphincter, and insufficiency of sphincter, objectively rectomanometrically detectable. The resection of urinary bladder was contemporary performed in 15 patients, the hysterectomy with adnexotomy in 8 patients, the vaginal resection in 5 cases and the resection of small intestine in 8 cases. The resection of os sacrum to S 3 was performed in 3 patients. The radical resection with establishment of the deep pelvic anastomosis is burdened by certain number of early and delayed complications, too. Authors analyse its causes, possible corrections, but also its prevention.

[Treatment of polytraumatized patients: our experience.]. / Péce o polytraumatizované pacienty: nase zkusenosti.

Authors evaluate their experience in treatment of patients with polytrauma during last 10 years. They use the 5 level classification applicated particularly in German and Austrian traumatologic centres. Authors initiated in their workplace the computer assessment ISS - Injury Severity Score, Apache II -Acute Physiology and Chronic Health Evaluation II. The care for polytrauma requires the highly qualified individual approach and should be subordinated to threatening or developed complications. The question of timing of emergent operations in polytraumatized patients is solved that was one of research projects of this institution, too. The reconstructional operations are preferred with regard to retaining of function and life quality of patients. Key words: increasing number of polytraumas, classification, diagnostic and therapeutic methods, results.

Simple flap valve for continent urinary diversion.

OBJECTIVE: To provide a stable continence mechanism in patients with urinary diversion by creating a flap valve from the ileal wedge, sutured into the grooves of the reservoir mucosa. PATIENTS AND METHODS: The valve's efficacy and stability were confirmed previously in an experimental study using five dogs. The valve was used in 22 patients with ileocaecal pouches and as a continence mechanism for cystostomy in two paraplegic women. RESULTS: Continence was achieved in all but two patients. In these exceptions the valve was found to be abnormally short (only 2 cm). Re-operation restored one patient to continence but the second patient refused further surgery. There were no problems with either catheterization of the valve or with epithelialization of the serosal surface of the valve. CONCLUSION: The valve is easy to construct and requires only a small intestinal segment; it has long-term mechanical and functional stability and can be easily catheterized. The valve provides continence even with increasing reservoir content and will accept a large catheter, which seems to be important in preventing lithiasis.

An alternative in surgical treatment of post-irradiation vesicovaginal and rectovaginal fistulas: the seromuscular intestinal graft (patch).

The excellent results experienced with the use of seromuscular intestinal grafts in certain types of urological plastic operations encouraged us to use it (as a patch) also in the surgical management of vesicovaginal and rectovaginal fistulas. With this method, we treated 4 patients with post-irradiation fistulas who had previously undergone 1 or 2 operations. The seromuscular intestinal graft served as a direct partial wall replacement of the bladder or rectum. At the same time, it also supported the nutrition of the compromised tissues surrounding the fistula. There were no complications with epithelialization of the denuded muscular surface of the seromuscular intestinal graft (patch) facing into the bladder.

Surgical treatment of the atonic bladder ("vesical cap").

As demonstrated in animal experiments and in five patients with atonic bladders, "vesical cap" surgery causally solves detrusor impairment by functionally reinforcing it with a vital muscle layer from an ileal seromuscular flap. All other genuine components of the bladder are kept intact, which is very beneficial for bladder function.