Transperineal retropubic approach in total pelvic exenteration for advanced and recurrent colorectal and anal cancer involving the penile base: technique and outcomes.

BACKGROUND: Complete pathological resection of locally advanced and recurrent anorectal cancer is considered the most important determinant of survival outcome. Involvement of the retropubic space with cancer threatening or involving the penile base poses specific challenges due to the potential for margin involvement and blood loss from the dorsal venous plexus. In the present study we evaluate a new transperineal surgical approach to excision of anterior compartment organs involved or threatened by cancer which facilitates exposure and visualisation of the bulbar urethra and the deep vein of the penis caudal to the retropubic space and penile base. METHODS: A retrospective study was performed on male patients with tumour extension into the penile base treated at our institution using the transperineal surgical approach. Descriptive data for patient demographics, radiology, operative details, postoperative histology, complications and outcomes were collated. RESULTS: Ten male patients with tumour extension into the penile base were identified. Two patients had recurrent anal cancer, 6 had locally advanced primary rectal cancer and 2 had recurrent rectal cancer. All patients had exenterative surgery with excision of the penile base utilising the transperineal approach. All patients had R0 resection. No local recurrence developed after a median follow up period of 15 months. CONCLUSIONS: The transperineal approach to the penile base and retropubic space allows for high rates of R0 resection margin status with direct visualisation of the dorsal venous plexus, thereby minimising blood loss. In our experience, this technique is the preferred approach to excision of cancers threatening and involving the penile base and also for most male patients requiring total pelvic exenteration.

High subcortical sacrectomy: a novel approach to facilitate complete resection of locally advanced and recurrent rectal cancer with high (S1-S2) sacral extension.

AIM: R0 resection of locally advanced or recurrent rectal cancer is the key determinant of outcome. Disease extension high on the sacrum has been considered a contraindication to surgery because of associated morbidity and difficulty in achieving complete pathological resection. Total sacrectomy has a high morbidity with poor function. METHOD: We describe a novel technique of high subcortical sacrectomy (HiSS) to facilitate complete resection of disease extending to the upper sacrum at S1 and S2 to avoid high or total sacrectomy or a nonoperative approach to management. Details of patient demographics, radiology, operative details, postoperative histology, length of hospital stay and complications were entered into a prospectively maintained electronic patient database. All patients had had preoperative chemoradiotherapy. RESULTS: During 2013-2014, five patients, including three with advanced primary cancer and two with recurrent rectal cancer, underwent excision using this approach. All patients had an R0 resection. Four patients had a minor postoperative complication (Clavien-Dindo Grades I and II) and one had a major complication (Clavien-Dindo Grade IIIb). There was no mortality at 90 days, and four patients were disease free at a median of 18 months. CONCLUSION: Patients with locally advanced and recurrent rectal cancer involving the upper sacrum may be rendered suitable for potentially curative radical resection with a modified approach to sacral resection. This pilot series suggests that this novel technique results in a high rate of complete pathological resection with acceptable morbidity in patients for whom the alternatives would have been an incomplete resection, a total sacrectomy or nonoperative management.

Extended lateral pelvic sidewall excision (ELSiE): an approach to optimize complete resection rates in locally advanced or recurrent anorectal cancer involving the pelvic sidewall.

BACKGROUND: Complete pathological resection of locally advanced or recurrent rectal and anal cancer is regarded as one of the most important determinants of oncological outcome. Disease in the lateral pelvic sidewall has been considered a contraindication for pelvic exenteration surgery owing to the significant likelihood of incomplete resection. METHODS: We describe a novel technique (ELSiE) to resect disease involving the lateral pelvic sidewall. Patient demographics, post-operative histology, length of hospital stay and complications were collected from prospectively maintained electronic patient database. RESULTS: During 2011-2013, six patients underwent pelvic exenteration surgery with the ELSiE approach. All patients had R0 resection. Three patients required sciatic nerve excision. Four patients developed post-operative complications although no major complications occurred. CONCLUSIONS: Patients with locally advanced and recurrent cancer involving the lateral pelvic sidewall may be rendered suitable for potentially curative radical resection with a modification in the approach to the lateral pelvic sidewall. Our pilot series seems to indicate that our novel technique (ELSiE) is feasible, safe and yields high rates of complete pathological resection.

HuD RNA recognition motifs play distinct roles in the formation of a stable complex with AU-rich RNA.

Human neuron-specific RNA-binding protein HuD belongs to the family of Hu proteins and consists of two N-terminal RNA recognition motifs (RRM1 and -2), a hinge region, and a C-terminal RRM (RRM3). Hu proteins can bind to AU-rich elements in the 3' untranslated regions of unstable mRNAs, causing the stabilization of certain transcripts. We have studied the interaction between HuD and prototype mRNA instability elements of the sequence UU(AUUU)(n)AUU using equilibrium methods and real-time kinetics (surface plasmon resonance using a BIACORE). We show that a single molecule of HuD requires at least three AUUU repeats to bind tightly to the RNA. Deletion of RRM1 reduced the K(d) by 2 orders of magnitude and caused a decrease in the association rate and a strong increase in the dissociation rate of the RNA-protein complex, as expected when a critical RNA-binding domain is removed. In contrast, deletion of either RRM2 or -3, which only moderately reduced the affinity, caused marked increases in the association and dissociation rates. The slower binding and stabilization of the complex observed in the presence of all three RRMs suggest that a change in the tertiary structure occurs during binding. The individual RRMs bind poorly to the RNA (RRM1 binds with micromolar affinity, while the affinities of RRM2 and -3 are in the millimolar range). However, the combination of RRM1 and either RRM2 or RRM3 in the context of the protein allows binding with a nanomolar affinity. Thus, the three RRMs appear to cooperate not only to increase the affinity of the interaction but also to stabilize the formed complex. Kinetic effects, similar to those described here, could play a role in RNA binding by many multi-RRM proteins and may influence the competition between proteins for RNA-binding sites and the ability of RNA-bound proteins to be transported intracellularly.

Comparison of the biochemical, immunologic and allergenic properties of vespid venoms collected in early and late summer.

The biochemical, immunologic and allergenic properties of yellow hornet (Vespula arenaria) and bald-faced hornet (Vespula maculata) venoms collected in early and late summer were compared. The phospholipase A content of both hornet venoms decreased in late summer while protease, hyaluronidase and acid phosphatase contents were unchanged. The antigenic and allergenic properties of the two venoms, as measured by their reaction with rabbit antisera and sera from insect-allergic patients, respectively, were unchanged. These results suggest no changes in venom properties during the summer which influence the allergic response to insect stings.

Psychiatric morbidity in Hobart's dependent aged.

Psychiatric morbidity in the dependent aged was studied in the elderly population of Hobart's nursing homes and long-stay hospitals. Only patients with home addresses in Hobart and who were admitted for the first time aged 70 years or over were included. Three hundred and twelve persons were interviewed with a standard interview, and an informant was interviewed when appropriate. The medical records were searched for diagnoses and drug treatments. Physical disability was rated on an ad hoc scale. Comparisons were made of the prevalence of dementia, depression and anxiety in different types of unit, and between these and two domiciliary samples, one of which received domiciliary nursing services (n = 100) and the other not (n = 100). The differential use of institutions by men and women, and a possible sex difference in the prevalence of dementia is discussed.

Allergenic components of bald-faced hornet (V. maculata) venom.

Bald-faced hornet (V. maculata) venom collected by electrical stimulation was fractionated using molecular exclusion gel-filtration and ion-exchange chromatography. Four fractions were selected for in-depth analysis. These were analyzed for phospholipase, hyaluronidase and protease enzyme activities, antigenicity as measured by reaction with anti-hornet venom rabbit serum, and allergenic activity, as determined by RAST reaction with sera from hornet-sensitive patients. The results of these studies suggest that the fractions containing phospholipase, hyaluronidase and protease possess allergenic activity. In addition, there appear to be other allergenic components in hornet venom. Allergic patients differ in their reactivity to the various allergenic components in hornet venom and may have IgE antibodies to one or more of these components.