Analgesia and discharge following preincisional ilioinguinal and iliohypogastric nerve block combined with general or spinal anaesthesia for inguinal herniorrhaphy.

BACKGROUND: Preincisional ilioinguinal and iliohypogastric nerve block (IINB) reduces postoperative analgesics after inguinal herniorrhaphy. The effect of an IINB on postoperative pain and discharge profile was therefore studied in day-surgery patients undergoing inguinal herniorrhaphy with general or spinal anaesthesia. METHODS: Seventy ASA I-II adult patients scheduled for inguinal herniorrhaphy received an IINB before the surgical incision with 15 ml of 0.5% bupivacaine. In a randomized fashion half of them received general anaesthesia with spontaneous breathing via a laryngeal mask (GA-group) and the other half received spinal anaesthesia with 5 mg of bupivacaine diluted with sterile water to 2.5-ml volume (SPIN-group). In the postanaesthesia care unit (PACU), pain was assessed on a scale from 0 to 10 (VAS) and ketorolac 30 mg i.v. (VAS < 5), or fentanyl 0.05 mg i.v. (VAS > or = 5) was administered as scheduled. In the day surgery unit and at home the analgesic was a tablet of ibuprofen 200 mg + codeine 30 mg (VAS > or = 3). RESULTS: Patients in the SPIN-group reported lower postoperative pain scores at 30, 60 min (P < 0.0001) and 120 min (P < 0.05) after surgery, and longer time to first analgesic use (P < 0.0001). Patients in the GA-group had a shorter time to discharge without voiding (P < 0.001) and with voiding (P < 0.05). After discharge, there were no significant differences between the groups regarding pain scores at rest and at walking, or the doses of analgesic. Adverse events were rare in both groups. CONCLUSION: Only a relatively short immediate analgesic benefit could be demonstrated by a combination of IINB with spinal anaesthesia compared with IINB combined with general anaesthesia. The use of general anaesthesia facilitated an earlier postoperative discharge than spinal anaesthesia.

Effect of preincisional ilioinguinal and iliohypogastric nerve block on postoperative analgesic requirement in day-surgery patients undergoing herniorrhaphy under spinal anaesthesia.

BACKGROUND: By choosing spinal anaesthesia instead of general anaesthesia, and by infiltrating the wound area with local anaesthetic the need for postoperative analgesics may be reduced. An ilioinguinal and iliohypogastric nerve block (IINB) in inguinal herniorrhaphy was, therefore, studied in a day surgery setting in combination with a spinal block. METHODS: One hundred ASA I-II adult patients scheduled for inguinal herniorrhaphy were given spinal anaesthesia with hyperbaric 0.5% bupivacaine. In a randomized and blinded fashion half of them received an IINB 5 min before the surgical incision with 10 ml of 0.5% bupivacaine (B-IINB) and the other half with saline (S-IINB). All patients received ketoprofen 100 mg i.v. during surgery and another 100 mg 2-3 h postoperatively. The patients were observed for about 6 h in the day surgery unit before discharge. RESULTS: The results showed that in comparison with the S-IINB group, significantly fewer patients in the B-IINB group needed analgesics (P<0.01) and the amount required was also significantly less postoperatively, before discharge (about 6 h postoperatively) (P<0.05). The latency to the need for the first postoperative analgesic was shorter in the S-IINB patients (P<0.01). At home the VAS scores and the need for analgesics (oral ketoprofen 100 mg) were low with no differences between the groups. No complications occurred. CONCLUSION: It is concluded that no long-term analgesia could be demonstrated by a preincisional IINB performed during spinal anaesthesia in day-surgery inguinal herniorrhaphy patients. Thus, reduced analgesic requirement was seen only for about 6 h postoperatively.

Stress fracture of the medial malleolus.

We studied eight patients who had a stress fracture of the medial malleolus. The main symptom was localized pain on the medial side of the ankle. The initial radiographs revealed the lesion for only three patients; for the other patients, the diagnosis was made with the use of isotope scans and was confirmed with computerized tomography scans, magnetic resonance images, or subsequent plain radiographs. One vertical fracture was treated initially with compression with AO screws. On the basis of our experience with stress fractures in other bones, drilling was performed to enhance the formation of bone in two patients who had delayed healing and who had had symptoms for eight and twelve months. The fractures healed four and five months after the drilling. The five patients who were managed non-operatively had to avoid running and jumping for at least three months (average, four months) so that healing could take place. All five of these fractures healed within five months.

Effects of oestrogen treatment on serum gonadotrophin bioactivity, immunoreactivity and isohormone distribution, and on immunoreactive inhibin levels, in prostatic cancer patients.

OBJECTIVE AND DESIGN: No data are available on effects of long-term exposure to oestrogen on bioactivity of gonadotrophins in men. We studied the effects of a 6-month oestrogen therapy on serum FSH and LH bioactivity (B), immunoreactivity (I) and isohormone distribution, and on serum I-inhibin levels, in patients with prostatic carcinoma. PATIENTS: Eleven men with advanced prostatic cancer were studied, each receiving 160 mg of polyoestradiol phosphate (Estradurin) once a month intramuscularly for 6 months. MEASUREMENTS: Serum samples were collected before, and after 2 and 6 months of oestrogen treatment. Serum B- and I-FSH levels were measured by immature rat granulosa cell bioassay and immunofluorometric (IFMA, Delfia) assay, respectively, and those of B- and I-LH by mouse interstitial cell bioassay and IFMA, respectively. Serum oestradiol (E2) concentrations were measured by IFMA assay, and serum testosterone (T) and inhibin levels by radioimmunoassay. Isoelectric focusing was used for fractionation of the FSH and LH isoforms. RESULTS: The pretreatment levels of B-FSH and I-FSH were 84.7 +/- 21.6 and 11.4 +/- 3.2 IU/l (mean +/- SEM), respectively, and the B/I ratio of FSH was 8.3 +/- 1.0. The pretreatment levels of B-LH and I-LH were 23.5 +/- 3.2 and 10.1 +/- 2.3 IU/l, respectively, and the B/I ratio was 3.0 +/- 0.4. After 6 months of oestrogen therapy, B-FSH and I-FSH decreased to 37.5 +/- 8.1 (P < 0.05) and 1.3 +/- 0.3 IU/l (P < 0.01), respectively, but the B/I ratio of FSH increased to 28.5 +/- 4.2 (P < 0.05). B- and I-LH levels decreased in 6 months to 7.4 +/- 0.9 and 2.3 +/- 0.5 IU/l (P < 0.01), respectively, but no change was found in the B/I ratio of LH. Serum T levels decreased from 19.0 +/- 2.6 to 2.7 +/- 0.9 nmol/l (P < 0.01) during the 6-month treatment, and the respective E2 levels increased from 0.2 +/- 0.01 to 4.4 +/- 0.5 nmol/l (P < 0.01). Serum I-inhibin levels were analysed from eight patients. The levels at 0, 2 and 6 months were 0.81 +/- 0.09, 0.50 +/- 0.03 and 0.54 +/- 0.01 microgram/l, respectively. Gonadotrophins in the pretreatment and 6-month samples of four patients were analysed by isoelectric focusing. In FSH of all subjects, and in LH of three subjects, a shift from acidic to more basic isoforms occurred after oestrogen therapy. This is in keeping with the increase of the B/I ratio of FSH. With LH, the isoform shift occurred between fractions with similar B/I ratios, and hence there was no shift in the overall B/I ratio. CONCLUSIONS: Oestrogen therapy of men suppressed bioactive and immunoreactive levels of gonadotrophins. The B/I ratio of FSH increased, and this increase was associated with a shift in the isohormone profile to more basic forms. In contrast, no change occurred in the B/I ratio of LH, even though changes in the isohormone profile were observed. Hence, not all changes in the isohormone distribution of gonadotrophins result in changes of the intrinsic in-vitro bioactivity.

Randomized controlled study of chemoprophylaxis in transurethral prostatectomy.

We studied 599 evaluable patients with benign prostatic hypertrophy at 7 urological units. Before transurethral prostatectomy the patients were randomized into 3 groups: group 1--197 patients given single-dose ceftriaxone (2 gm.), group 2--203 patients given 160/800 mg. trimethoprimsulfamethoxazole and group 3--199 controls given no antimicrobial prophylaxis. Patients with a preoperative indwelling catheter, positive urine culture, signs of active infection or preoperative antibiotic treatment were excluded. Postoperative infectious complications were demonstrated in 15 of 197 (7.6%), 25 of 203 (12.3%) and 43 of 199 (21.6%) patients in the study groups, respectively. The difference in infectious complications between groups 1 and 3 was statistically highly significant (p < 0.01) and between groups 2 and 3 it was significant (p < 0.05). Single-dose antibiotic prophylaxis proved to be useful in the prevention of serious infectious complications after transurethral prostatectomy.

Polyestradiol phosphate (160 mg/month) or LHRH analog (buserelin depot) in the treatment of locally advanced or metastasized prostatic cancer. The Finnprostate Group.

The clinical efficacy, cardiovascular complications and mortality of polyestradiol phosphate (PEP) 160 mg/month i.m. were compared with the luteinizing hormone releasing hormone (LHRH) analog, buserelin, in a prospective, randomised multicentre study including 147 patients with prostatic cancer. The cumulative non-progression rate at three years was 0.53 in the PEP group and 0.70 in the LHRH group. The mortality from cardiovascular diseases was the same in the two treatment groups. The parenterally given PEP was not associated with an increased risk of cardiovascular complications. The dosage of PEP 160 mg monthly seems, however, to be insufficient in the treatment of prostatic cancer.

Clean intermittent self-catheterization after urethrotomy for recurrent urethral strictures.

Although endoscopic optical urethrotomy is the primary treatment for urethral stricture, it is associated with a high recurrence rate, and the essential problem is how to stop the scar from shrinking after cutting. In a controlled study the effect of treatment of recurrent urethral stricture by internal urethrotomy followed by clean intermittent self-catheterization (CIC) for 6 or 12 months was compared in 25 and 24 patients, respectively. Patients learnt easily how to perform CIC: only one patient was not able to do it at home. All patients were evaluated by uroflowmetry before and immediately after urethrotomy, and 3, 6, 9 and 12 months later. Recurrence was defined as the need for further treatment. There was no difference in the recurrence rate between the two groups, but the maximum flow rate was significantly lower at 12 months in the patients who had ceased catheterization at six months. Complications included in two patients asymptomatic bacteriuria and in 10 patients symptomatic urinary infection. CIC is a very satisfactory method of managing patients with recurrent stricture, it is easy to learn, it prevents a decrease in the maximum flow rate and can thus be applied to most patients instead of regular bouginage. On the basis of the present study we could not determine any optimal time for the duration of CIC after urethrotomy, or whether it has any effect on the natural course of the disease.

Can fine needle aspiration biopsy detect incidental prostatic carcinoma (T1) prior to TUR?

The purpose of this study was to find out whether randomly taken fine needle aspiration biopsy (FNA) can detect incidental prostatic carcinoma prior to transurethral resection (TUR) and what are the effects of local tumor stage and grade on detection rate. Biopsies were taken from 344 patients, who came to hospitals for elective TUR without clinical evidence of prostatic carcinoma. Histologic examination of the TUR material showed prostatic carcinoma in 49 cases (14%). Sufficient material for cytologic examination was found in 343 cases. Of the 16 cases of T1a carcinoma in histologic examination, cytology found only 1, which was a G3 carcinoma. Of 33 T1b carcinoma in histologic examination, cytology found 6 and an additional 7 were suspect findings. Out of 6 G3 tumors in histologic examination, cytology showed 4. In our hands the proportion of false-negative cytologic findings in randomly taken FNA was so large that routine use of random FNA prior to TUR or as a screening procedure cannot be recommended, but positive FNA finding can be regarded as cancer.

Orchiectomy versus oestrogen in the treatment of advanced prostatic cancer.

The primary clinical efficacy of orchiectomy and the combination therapy of intramuscular polyoestradiol phosphate 80 mg monthly and oral ethinyl oestradiol 0.15 mg daily was evaluated by progression and cancer mortality rates in a series of 277 prostatic cancer patients representing part of the Finnprostate study. After a follow-up of 5 years there was a significant difference between the groups in terms of progression rate and prostatic cancer deaths. The oestrogen combination was more effective in delaying progression of the disease. The overall mortality rate was similar in both groups. About one-third of the patients were alive after 5 years.

Intravesical chemotherapy (mitomycin C) versus immunotherapy (bacillus Calmette-Guérin) in superficial bladder cancer.

Both intravesical mitomycin C (MMC) and bacillus Calmette-Guérin (BCG; Pasteur strain F) were effective in the present prospective randomized multicenter study consisting of 91 patients with frequently recurrent superficial (Ta-T1) bladder cancer. The result was in favour of BCG, as shown by the measurements with complete response (CR), disease-free interval and recurrence rate. CR of 58% with MMC and 40% with BCG were reached in 22 instillation series on carcinoma in situ of 18 patients. Due to side effects, MMC instillations were discontinued in 8.6%, and BCG instillations in 19.6%, respectively. After the 2-year follow-up also 1 case of pulmonary tuberculosis occurred in the BCG group.

Efficacy and side-effects of prazosin as a symptomatic treatment of benign prostatic obstruction.

This randomized double-blind crossover trial was conducted to assess the effects of prazosin, an alpha 1-adrenoceptor blocking drug, on the voiding of 35 patients with benign prostatic obstruction. Maximum and mean flow rates, residual urine, blood pressure and heart rate were measured at baseline and 2, 4, 6, and 8 weeks after starting the treatment with placebo or prazosin. At 4 weeks the treatments were switched over. The patients filled micturition charts at home and scored their voiding associated feelings. The maximum and mean flow rates increased significantly during prazosin treatment, as also did the maximum and mean voided volumes. Residual urine decreased and voiding improved subjectively but these changes were not statistically significant. Blood pressure was lowered and heart rate increased. Prazosin caused postural dizziness more often than placebo. Prazosin seems to offer an alternative to improve voiding in some patients with prostatic obstruction.

Effect of mitomycin C and doxorubicin instillation on carcinoma in situ of the urinary bladder. A Finnish multicenter study.

During long periods of buffered instillations of mitomycin C (MMC) and doxorubicin (adriamycin; ADM) on carcinoma in situ (TIS), the complete response was 82% for MMC and 80% for ADM. Even the frequency of progression was about the same (20% in both groups). The differentiation grade was shown to be of great prognostic value. No progression occurred in grade 1 and 2 contrary to 38% in grade 3 cancers. The cytological primary diagnosis of TIS was equally able to predict the prognosis as the histological verification. An interesting phenomenon was the fluctuation to the cytological picture during the treatment. The change of instillation drug might be useful in cases of stable disease, though not in chemical cystitis. The addition of methylprednisolone can relieve bladder irritation.

Intravenous indomethacin in the treatment of ureteric colic. A clinical multicentre study with pethidine and metamizol as the control preparations.

The analgesic effects of intravenously administered indomethacin, pethidine and metamizol were compared in a series of 169 patients with ureteric colic. Complete pain relief was obtained in 59% in the indomethacin group, in 52% in the pethidine group and in 44% in the metamizol group. The observed side effects were not serious. On the basis of the study results indomethacin can be recommended as an alternative drug in the treatment of ureteric colic.

Leydig cell tumor with gynecomastia. Report of a case with electron microscopy.

A case of Leydig cell tumor is reported and discussed. The tumor, 1.5 cm in diameter, was located in the capsule of the right testis. Gynecomastia present for 3 months was almost absent 4 months postoperatively. Preoperative hormone analysis revealed a low concentration of serum testosterone, which was normalized 1 week postoperatively. In electron microscopic examination, several intracytoplasmic microbody-like structures and 'tigroid' mitochondria were noted. These findings are similar to the three earlier descriptions of Leydig cell tumors.