Clinical relevance and implications of antenatal hydronephrosis.

Detailed antenatal sonography was performed on 18766 pregnant women between 1990 and 1994. Antenatal hydronephrosis, defined as an antero-posterior diameter of the renal pelvis (APPD) greater than 5 mm, was detected in 100 cases (0.59%). Sixty four infants had postnatal hydronephrosis at one and/or six weeks after delivery; 21 of these had urological anomalies. Twelve infants had vesico-ureteric reflux. In all refluxing units the APPD of the renal pelvis was less than 10 mm. Three patients had obstruction at the pelviureteric junction (PUJ); all required surgery. Vesico-ureteric reflux is emerging as the most common urological finding in infants with antenatal hydronephrosis and is likely to be missed if kidneys with APPD of less than 10 mm are not further investigated. In contrast, pelvi-ureteric junction obstruction may be overdiagnosed, based only on drainage patterns of dynamic renogram studies.

Autoamputation of ovarian cyst in an infant.

A right ovarian cyst was detected in a 34-week-gestation fetus on antenatal ultrasound scan (USS). Postnatal USS confirmed the presence of the cyst and showed it to be 4.6 cm in diameter. The cyst failed to resolve after a period of conservative management, and therefore surgical removal was performed. During the operation a free autoamputated right ovarian cysts was found. The complication had not been detected preoperatively in spite of regular USS follow-up.

Prospective evaluation of ultrasonography and liver function tests for preoperative assessment of the bile duct.

Current means of predicting the presence of bile duct stones are sensitive but produce a large number of false-positive results, potentially leading to added morbidity from unnecessary invasive investigation. This study prospectively assessed 545 patients with gallbladder stones, including 55 patients with bile duct stones, to refine criteria for further investigation of the bile duct. The sensitivity, specificity, and positive and negative predictive values were calculated for bile duct dilatation (diameter abnormal if larger than 5 mm below age 50 years, normal value increasing by 1 mm per decade) and elevation of three liver function tests, singly or in combination. Depending on the number of abnormalities used the sensitivity ranged from 46 to 96 per cent and the positive predictive value from 35 to 77 per cent. All groupings gave at least 96 per cent negative predictive value for the absence of stones but none combined both high sensitivity and positive predictive value. The specificity was improved if the tests were done on the working day before operation. Refining criteria for predicting bile duct stones allows the selective use of cholangiography and may reduce the number of negative cholangiograms.

Assessment of the common bile duct before cholecystectomy using ultrasound and biochemical measurements: validation based on follow-up.

The selective use of operative cholangiography with cholecystectomy is controversial. We have combined measurement of the serum bilirubin, alkaline phosphatase and alanine aminotransferase with ultrasound measurement of the bile duct diameter to assess the common bile duct before cholecystectomy. Direct contrast cholangiography was not performed if the results of these measurements were normal on the day before operation. There were 253 patients assessed in this way before laparoscopic cholecystectomy. Patients with known bile duct stones were excluded, but those with a previous history of jaundice, pancreatitis or abnormal liver function tests were included. In 47 cases abnormalities were found and X-ray cholangiograms were performed; only six patients were found to have bile duct stones. Follow-up of all 253 patients, including repeating the preoperative measurements after 12 months in 93, found only two patients with evidence that common duct stones had been missed and these two stones passed spontaneously. No bile duct injuries have occurred. We conclude that preoperative assessment of the bile duct using ultrasound and liver function tests safely obviates the need for 'routine' operative cholangiography.

Pain quantum and wound healing: a comparison of interrupted inversion PDS and standard nylon sutures in abdominal skin closure.

Patients' postoperative pain experience during 5 days after hernia repairs or upper abdominal procedures was compared when skin closure was achieved by either full thickness interrupted sutures or subcuticular interrupted inversion sutures. Quantitative pain assessments were made using linear analogue charts and standardised analgesic requirements. Clinical advantage for the subcuticular technique was confirmed for the hernia group and possible advantage in the upper abdominal closure, suggested by lesser analgesic requirement. Statistical analysis has lent support to the hernia group findings but is less clear in the upper abdominal group. A comparison of wound healing, sepsis and cosmetic outcome showed no apparent advantage to either method. Economies and patient preference favoured the subcuticular method.

Fate of the testis following epididymitis: a clinical and ultrasound study.

The progress of 33 men suffering from acute epididymitis, the majority of whom were treated as hospital inpatients, was prospectively monitored in order to determine the incidence of complications, and to assess the prognostic implications of clinical and scrotal ultrasound features found at initial presentation. Serious testicular complications resulting in frank infarction, suppurative necrosis and late atrophy developed in 39%. Three factors were shown to have significant discriminant value in predicting an adverse outcome: severe degree of inflammation with induration of the spermatic cord; the presence of a coexistent bacterial urinary infection; and a uniformly reduced testicular echo pattern on the affected side as visualized on ultrasound. A more aggressive approach in addition to medical measures appears to be indicated in these patients. The rationale of early surgical decompression by epididymotomy and spermatic fasciotomy is discussed. Scrotal ultrasound should be considered as a routine investigation in the management of epididymitis.

Scrotal ultrasound.

Scrotal ultrasonography has been performed in 105 men with a variety of intrascrotal conditions. The range of pathology interpreted by this technique is presented and its diagnostic accuracy evaluated. The clinical application and usefulness of this noninvasive method of imaging scrotal contents is discussed.

Diaphyseal osteosarcoma.

Fifteen cases of diaphyseal osteosarcomas were found in a review of 157 cases of long bone osteosarcoma (9.5%) and two further examples were added. The clinical and histological features of the diaphyseal osteosarcomas were indistinguishable from those of the commoner juxta metaphyseal osteosarcomas. The radiological features, however, fell into four distinct patterns: Group I had the classical appearance of a conventional osteosarcoma; Group II showed dense cortical sclerosis with bony expansion but no soft tissue swelling or break of the cortex at presentation; Group III presented with a pathological fracture through a purely osteolytic lesion; Group IV usually had the classical appearances of an osteosarcoma in the diaphysis but had, in addition, dense separate sclerotic lesions which were proximal to the tumour in the humerus and distal to it in the femur. The importance of these four groups lies in the quite distinct differential diagnosis which each presents.

Sclerotic medullary spread in diaphyseal osteosarcoma.

Dense medullary sclerosis is reported in the shafts of long bones accompanying diaphyseal osteosarcoma. Histological evidence suggests that this indicates more extensive medullary spread of tumour than is readily apparent on standard radiographic examination. It would appear that these sclerotic lesions show active radio-isotopes retention following skeletal scintigraphy. The clinical and radiological features and prognostic implications of these findings are discussed.