Long-term outcome of retroperitoneoscopic partial versus total adrenalectomy in patients with Cushing's syndrome.

BACKGROUND: We analyze the long-term outcome of surgery for Cushing's syndrome (CS) and the influence of the extent of surgical resection on the duration of postoperative cortisone substitution. METHODS: One-hundred forty-one patients (129 female, 12 males; mean age: 45.7 ± 12.8 years) operated between January 2000 to June 2020 were included in the analysis. Patients suffered from manifest (124) or subclinical (17) CS due to benign unilateral adrenal neoplasia. All tumors were removed by the posterior retroperitoneoscopic approach. 105 patients had total (TA) and 36 partial (PA) adrenalectomies. All patients were discharged with ongoing corticosteroid supplementation therapy. RESULTS: Follow-up data could be obtained for 83 patients. Twenty-four (1 male, 23 females; mean age 42.3 years) underwent PA and 59 TA (6 males, 53 females; mean age 44.6 years). Mean follow-up time was 107 ± 68 months (range: 6-243 months). The median duration of postoperative corticosteroid therapy was 9.5 months after PA and 11 months after TA (p = 0.1). Significantly, more patients after total adrenalectomy required corticosteroid therapy for more than 24 months (25% vs. 4%; p = 0.03). Recurrent ipsilateral disease occurred in one case after partial adrenalectomy and was treated by completion adrenalectomy. A case of contralateral recurrence associated with subclinical Cushing's syndrome was observed after total adrenalectomy. CONCLUSIONS: The risk of local recurrence after partial adrenalectomy in CS is low. Cortical-sparing surgery may shorten corticosteroid supplementation therapy after surgery.

Imaging Correlations in Heterodyne Spectra for Quantum Displacement Sensing.

The extraordinary sensitivity of the output field of an optical cavity to small quantum-scale displacements has led to breakthroughs such as the first detection of gravitational waves and of the motions of quantum ground-state cooled mechanical oscillators. While heterodyne detection of the output optical field of an optomechanical system exhibits asymmetries which provide a key signature that the mechanical oscillator has attained the quantum regime, important quantum correlations are lost. In turn, homodyning can detect quantum squeezing in an optical quadrature but loses the important sideband asymmetries. Here we introduce and experimentally demonstrate a new technique, subjecting the autocorrelators of the output current to filter functions, which restores the lost heterodyne correlations (whether classical or quantum), drastically augmenting the useful information accessible. The filtering even adjusts for moderate errors in the locking phase of the local oscillator. Hence we demonstrate the single-shot measurement of hundreds of different field quadratures allowing the rapid imaging of detailed features from a simple heterodyne trace. We also obtain a spectrum of hybrid homodyne-heterodyne character, with motional sidebands of combined amplitudes comparable to homodyne. Although investigated here in a thermal regime, the method's robustness and generality represents a promising new approach to sensing of quantum-scale displacements.

Dynamical Two-Mode Squeezing of Thermal Fluctuations in a Cavity Optomechanical System.

We report the experimental observation of two-mode squeezing in the oscillation quadratures of a thermal micro-oscillator. This effect is obtained by parametric modulation of the optical spring in a cavity optomechanical system. In addition to stationary variance measurements, we describe the dynamic behavior in the regime of pulsed parametric excitation, showing an enhanced squeezing effect surpassing the stationary 3 dB limit. While the present experiment is in the classical regime, our technique can be exploited to produce entangled, macroscopic quantum optomechanical modes.

Squeezing a thermal mechanical oscillator by stabilized parametric effect on the optical spring.

We report the confinement of an optomechanical micro-oscillator in a squeezed thermal state, obtained by parametric modulation of the optical spring. We propose and implement an experimental scheme based on parametric feedback control of the oscillator, which stabilizes the amplified quadrature while leaving the orthogonal one unaffected. This technique allows us to surpass the -3 dB limit in the noise reduction, associated with parametric resonance, with a best experimental result of -7.4 dB. While the present experiment is in the classical regime, in a moderately cooled system our technique may allow squeezing of a macroscopic mechanical oscillator below the zero-point motion.

Nonoperative management of penetrating kidney injuries: a prospective audit.

PURPOSE: The role of nonoperative management for penetrating kidney injuries is unknown. Therefore, we review the management and outcome of penetrating kidney injuries at a center with a high incidence of penetrating trauma. MATERIALS AND METHODS: Data from all patients presenting with hematuria and/or kidney injury discovered on imaging or at surgery admitted to the trauma center at Groote Schuur Hospital in Cape Town, South Africa during a 19-month period (January 2007 to July 2008) were prospectively collected and reviewed. These data were analyzed for demographics, injury mechanism, perioperative management, nephrectomy rate and nonoperative success. Patients presenting with hematuria and with an acute abdomen underwent a single shot excretory urogram. Those presenting with hematuria without an indication for laparotomy underwent computerized tomography with contrast material. RESULTS: A total of 92 patients presented with hematuria following penetrating abdominal trauma. There were 75 (80.4%) proven renal injuries. Of the patients 84 were men and the median age was 26 years (range 14 to 51). There were 50 stab wounds and 42 gunshot renal injuries. Imaging modalities included computerized tomography in 60 cases and single shot excretory urography in 18. There were 9 patients brought directly to the operating room without further imaging. A total of 47 patients with 49 proven renal injuries were treated nonoperatively. In this group 4 patients presented with delayed hematuria, of whom 1 had a normal angiogram and 3 underwent successful angioembolization of arteriovenous fistula (2) and false aneurysm (1). All nonoperatively managed renal injuries were successfully treated without surgery. There were 18 nephrectomies performed for uncontrollable bleeding (11), hilar injuries (2) and shattered kidney (3). Post-nephrectomy complications included 1 infected renal bed hematoma requiring percutaneous drainage. Of the injuries found at laparotomy 12 were not explored, 2 were drained and 5 were treated with renorrhaphy. CONCLUSIONS: Penetrating trauma is associated with a high nephrectomy rate (24.3%). However, a high nonoperative success rate (100%) is achievable with minimal morbidity (9%).

Imaging-based feedback cooling of a levitated nanoparticle.

Imaging-based detection of the motion of levitated nanoparticles complements a widely used interferometric detection method, providing a precise and robust way to estimate the position of the particle. Here, we demonstrate a camera-based feedback cooling scheme for a charged nanoparticle levitated in a linear Paul trap. The nanoparticle levitated in vacuum was imaged using a complementary metal-oxide semiconductor (CMOS) camera system. The images were processed in real-time with a microcontroller integrated with a CMOS image sensor. The phase-delayed position signal was fed back to one of the trap electrodes, resulting in cooling by velocity damping. Our study provides a simple and versatile approach applicable for the control of low-frequency mechanical oscillators.

Super-resolution imaging of a low frequency levitated oscillator.

We describe the measurement of the secular motion of a levitated nanoparticle in a Paul trap with a CMOS camera. This simple method enables us to reach signal-to-noise ratios as good as 106 with a displacement sensitivity better than 10-16 m2/Hz. This method can be used to extract trap parameters as well as the properties of the levitated particles. We demonstrate continuous monitoring of the particle dynamics on time scales of the order of weeks. We show that by using the improvement given by super-resolution imaging, a significant reduction in the noise floor can be attained, with an increase in the bandwidth of the force sensitivity. This approach represents a competitive alternative to standard optical detection for a range of low frequency oscillators where low optical powers are required.

Radical radiation and oral and intra-vesical misonidazole for bladder cancer.

Patients with T2 grade 3 and T3 bladder cancer were entered into studies to evaluate the efficacy of 40 Gy in 2 Gy fractions (5/week) to the whole pelvis followed by 12 Gy in 6 Gy fractions (1/week) to a coned down volume plus oral and intravesical misonidazole (MISO). In a pilot study of 22 patients the complete response rate at cystoscopy at 6 months was 73% and the 5-year survival rate (life-table) with and without bladder preservation was 48% and 54% respectively. The 5-year bowel major complication rate (life-table method) was 8%. These results are statistically significantly improved over that seen in a series of historical controls. A prospective randomized trial has been completed comparing the above regimen with 40 Gy to the whole pelvis followed by 20 Gy to the coned down volume in 2 Gy fractions (5/week). Fifty-eight patients were entered and 53 are evaluable. The complete response rate at cystoscopy at 6 months is 69% (18/26) in the patients treated with MISO and 63% (17/27) in those treated without MISO. As this is an important prognostic indicator, it is unlikely that there will be an advantage in either group and this is supported by the initial follow-up data. The complete response rate at cystoscopy at 6 months is higher in both arms of this study than in the historical series.

Rebound effect of the allogenic T-cell response to donor and third-party lymphocytes after cyclosporine withdrawal in renal transplant recipients.

Mixed lymphocyte reaction (MLR) assays were performed serially over 24 months in 19 first cadaver renal transplant recipients. Immunosuppression consisted of cyclosporine, methylprednisolone and azathioprine. Cyclosporine was withdrawn at 6 months postoperatively. The MLR reactivity gradually decreased over the first 3 months following transplantation. However, there was a significant increase in MLR reactivity at 12 months postoperatively after the cyclosporine withdrawal. This rebound effect in MLR reactivity following cyclosporine withdrawal could account for the increased incidence of acute rejection episodes.

Chemotherapy, radical irradiation plus salvage cystectomy for bladder cancer--severe late small bowel morbidity.

A proportion of patients with invasive bladder cancer are treated with radical irradiation and salvage cystectomy. The use of neo-adjuvant chemotherapy is being widely investigated. Five patients with invasive bladder cancer at Groote Schuur Hospital have undergone salvage cystectomy after neo-adjuvant chemotherapy and radical irradiation. Two of these patients had severe small bowel morbidity while clear of carcinoma and this was fatal in one patient. In our historical series of 30 patients who had salvage cystectomy after radical irradiation alone, there was only one patient with similar small bowel morbidity. There may be an increase in small bowel morbidity from neo-adjuvant chemotherapy in patients who are treated to clinical tolerance by irradiation and who then require a cystectomy.

The treatment of clinically fixed inguinal lymph node metastases from carcinoma of the penis by chemotherapy and surgery.

A 50-year-old patient with carcinoma of the penis was referred for therapy of clinically fixed and ulcerated right inguinal adenopathy and mobile left inguinal adenopathy. He was treated initially by weekly infusions of methotrexate and bleomycin which resulted in clinical mobility and a decrease in size of his right sided adenopathy and re-epitheliazation of the overlying ulcer. A right- and subsequently a left-sided inguinal lymphadenectomy were performed. The patient remained clear of disease at follow-up 44 months after therapy.

Choriocarcinoma and transitional cell carcinoma of the bladder--a case report and review of the clinical evolution of disease in reported cases.

The sixth reported case of choriocarcinoma associated with transitional cell carcinoma (TCC) of the bladder is described. A 67-year-old female presented with haematuria and was found to have a bladder tumour with both poorly differentiated TCC and trophoblastic elements. The tumour was confirmed as being limited to the bladder at laparotomy. The patient was treated with combination chemotherapy but, after an initial response, relapsed and died of disease. Postmortem examination revealed multiple metastatic choriocarcinoma and no TCC. A review of the clinical evolution in the reported cases suggests that transitional cell carcinoma is the cell of origin of these tumours by the process of progressive retrodifferentiation.

Neo-adjuvant chemotherapy and radical irradiation for locally advanced bladder cancer--a phase 2 study.

Eighteen patients with T3 or T4 bladder cancer were treated with neo-adjuvant chemotherapy and radical irradiation. The tumour response was assessed after two cycles of chemotherapy and two further cycles of chemotherapy were given to patients with responding tumours. Each cycle of chemotherapy consisted of cisplatin (60 mg/m2) as well as methotrexate and vinblastine. After chemotherapy, a complete response (CR) was obtained in four (22%) patients and a partial response in eight (44%) of patients. After irradiation, a complete response was obtained in 12 (67%) patients. Four of the 12 patients who achieved a CR relapsed at a minimum follow-up of 3 years. The 3-year continuously disease-free survival rate (with preserved bladders) is 44%. (95% confidence interval = 21-65%.) Altogether, 11 patients are alive (including three who have undergone salvage cystectomy) for an overall 3-year survival rate which is 61%. This approach to therapy is feasible but the local control rate is unsatisfactory.

Is preliminary binephrectomy necessary in patients with autosomal dominant polycystic kidney disease undergoing renal transplantation?

Patients with end-stage chronic renal failure due to autosomal dominant polycystic kidney disease who underwent renal transplantation with or without preliminary binephrectomy were retrospectively studied to determine the effect of binephrectomy on outcome. Nineteen patients were identified. Thirteen patients had no surgery prior to transplantation and six underwent preliminary binephrectomy. One patient died as a result of the nephrectomy. Twenty-one renal allografts were performed on 18 patients of whom seven have died of sepsis; 10 have functioning grafts and one has returned to dialysis. Patients not undergoing preliminary binephrectomy had a statistically significant (p less than 0.05) increase in mortality and morbidity due to septic complications related to polycystic kidney disease. Indications for bilateral nephrectomy should be reconsidered.

Where is the bladder neck following needle suspension operations?

Bladder neck suspension operations are commonly performed for stress incontinence. Cure is achieved by increasing proximal urethral pressure by repositioning the bladder neck in a supported retropubic position. A prospective study of 25 consecutive cases assessed the position of the bladder neck radiologically pre- and postoperatively and correlated this with the symptomatic cure or failure of surgery. The final position of the bladder neck relative to the inferior border of the symphysis pubis showed no correlation with the symptomatic outcome. Three cases of "failed" surgery showed greater elevation of the bladder neck than that achieved in women enjoying symptomatic cure, suggesting that the absolute amount of elevation achieved may not be of paramount importance. This report suggests that continence after surgery is not solely related to the anatomical position of the bladder neck relative to the sacral plane, but is more likely due to increased proximal urethral pressure during stress.

Primary chemotherapy for stage 2 testis cancer.

To evaluate the efficacy and toxicity of primary chemotherapy in patients with stage 2 (retroperitoneal lymph node metastases) testis cancer, 20 consecutive patients referred to Groote Schuur Hospital between September 1992 and March 1994 were reviewed. There were 10 patients with non-bulky non-seminomatous germ cell tumour (NSGCT), 5 with bulky NSGCT and 5 with bulky seminoma. The treatment regimen consisted initially of 4 cycles of cisplatin, etoposide and bleomycin. Patients with NSGCT and a residual mass after chemotherapy subsequently underwent retroperitoneal lymph node dissection (RPLND) and those with seminoma underwent a low dose of irradiation to the mass. In 7 (70%) of the 10 patients with non-bulky NSGCT, there was a complete response to chemotherapy and 3 patients underwent limited RPLND. One patient relapsed at follow-up but remains clear of disease after salvage therapy. The survival rate is 100% at a median follow-up of 60 months (range 12-143 months). In 5 patients with bulky NSGCT there was no complete response to chemotherapy. Three have undergone limited RPLND. The survival rate is 52% at a median follow-up of 130 months (range 108-152 months). In 5 patients with bulky seminomas, the survival rate is 100% at a median follow-up of 55 months (range 29-92 months). Toxicity has been modest except for 1 patient who died postoperatively in the early part of the study. Four patients have fathered children after treatment. We conclude that primary chemotherapy is the treatment of choice for patients with stage 2 testis cancer.

Radical cystectomy for invasive bladder cancer--a local experience.

OBJECTIVES: The aim of this study of patients undergoing cystectomy for invasive transitional cell carcinoma of the bladder was to compare clinical and pathological staging and to review factors that predict survival. PATIENTS: Sixty-three patients (73% male) underwent radical cystectomy between January 1988 and February 1994. The mean age was 61 years (range 33-77 years). RESULTS: Of the patients 14% had clinical and 24% pathological stage T1 disease; figures for T2 disease were 24% and 6%, respectively, for T3 disease 46% and 45%, and for T4 disease 16% and 25%. For T1 and T4 disease the clinical stage predicted the pathological stage in over 80% of cases, and for patients with T3 disease the predictive value of clinical staging was 68%; in no patient with clinical stage T2 disease was this confirmed at cystectomy. The prevalence of tumour infiltration of the lymph glands on histological examination of the cystectomy specimen correlated more closely with pathological stage than with clinical stage. For clinical and pathological staging, respectively, the prevalences were 0% and 0%, for T1, 27% and 0% for T2, 20% and 29% for T3, and 40% and 38% for T4. The overall survival rate (life-table method) was 33% at a median follow-up of 42 months in the surviving patients. No patient with tumour infiltration of the lymph glands survived. Survival also correlated more closely with pathological than with histological stage. For clinical and pathological stage T1 disease the 5-year survival rates were 73% and 91%, respectively; for T2 the rates were 27% and 75%, for T3 32% and 31%, and for T4 28% and 29%. The operative mortality rate was 2% and the rate of recurrence of local disease 10%. CONCLUSIONS: Survival after cystectomy correlates more closely with pathological than with clinical stage of disease. The accuracy of clinical staging in T2 disease is poor. Cystectomy is the standard against which other treatments for bladder cancer must be measured.

Omentopexy for the difficult perigraft lymphocele after renal transplantation.

Between January 1977 and October 1992, 6 patients who had undergone renal transplantation presented with a symptomatic lymphocele that failed to resolve after conventional therapy and eventually required surgical intervention. This complication developed between 7 and 36 months postoperatively. Patients presented with local discomfort combined with deteriorating graft function caused by ureteric obstruction. The lymphoceles recurred after aspiration or external drainage and resolved after omentopexy. We conclude that omentopexy is a satisfactory procedure for the treatment of lymphoceles which fail to resolve after aspiration or external drainage.