Hydroceles of the Canal of Nuck in Adults-Diagnostic, Treatment and Results of a Rare Condition in Females.

Nuck's hydroceles, which develop in a protruding part of the parietal peritoneum into the female inguinal canal, are rare abnormalities and a cause of inguinal swelling, mostly resulting in pain. They appear when this evagination of the parietal peritoneum into the inguinal canal fails to obliterate. Our review of the literature on this topic included several case reports and two case series that presented cases of Nuck hydroceles which underwent surgical therapy. We present six consecutive cases of symptomatic hydroceles of Nuck's canal from September 2016 to January 2020 at the Department of Surgery of Charité Berlin. Several of these patients had a long history of pain and consecutive consultations to outpatient clinics without diagnosis. These patients underwent laparoscopic or conventional excision and if needed simultaneous hernioplasty in our institution. Ultrasonography and/or Magnetic Resonance Imaging were used to display the cystic lesion in the inguinal area, providing the diagnosis of Nuck's hydrocele. This finding was confirmed intraoperatively and by histopathological review. Ultrasound and magnetic resonance imaging (MRI) captures, intraoperative pictures and video of minimal invasive treatment are provided. Nuck's hydroceles should be included in the differential diagnosis of an inguinal swelling. We recommend an open approach to external Type 1 Nuck´s hydroceles and a laparoscopic approach to intra-abdominal Type 2 Nuck hydroceles. Complex hydroceles like Type 3 have to be evaluated individually, as they are challenging and the surgical outcome is dependent on the surgeon's skills. If inguinal channel has been widened by the presence of a Nuck's hydrocele, a mesh plasty, as performed in hernia surgery, should be considered.

Effectiveness of parathyroid-hormone measurement in detecting patients with multiple gland disease causing primary hyperparathyroidism.

BACKGROUND AND AIM: Intraoperative parathyroid hormone measurement (iPTH) has strengthened the successful use of minimal-invasive approaches in surgery of primary hyperparathyroidism (pHPT). The aim of the study was to evaluate the efficacy of iPTH monitoring in treating pHPT resulting from multiple gland disease. MATERIALS AND METHODS: In this retrospective study, 58 patients with pHPT underwent surgery (minimally invasive or open exploration) between January 2003 and July 2005. iPTH levels were routinely measured at the start of anesthesia, in any case before skin incision, and 10 as well as 15 min after removal of abnormal gland(s). A drop in iPTH >50% after 10 min and >60% after 15 min was considered adequate to prove the success of the removal of the abnormal gland(s). The removed tissue was examined histologically by immediate frozen section. RESULTS: A single gland disease was found in 51 (88%) cases, a multiple gland disease (double adenoma or hyperplasia) in 7 (12%) cases. In all cases of single adenoma, an adequate drop of iPTH was seen after removal of the pathologic gland. In contrast, in all cases with a second adenoma, an adequate drop in iPTH was detected only after removal of both adenoma/hyperplasia. Immediate sectioning was only helpful for identification of removed tissue, but was no help in deciding whether to search for an additional gland. The follow-up showed no late disease recurrence. CONCLUSION: The measurement of iPTH is an effective and safe means in treating single gland disease as well as multiple gland disease (adenoma/hyperplasia) causing pHPT and also allows a successful limited dissection via minimally invasive parathyroidectomy.

Current concepts and perspectives of immunosuppression in organ transplantation.

BACKGROUND: While early surgical success made organ transplantation possible in the 1950s and 1960s, the breakthrough in clinical organ transplantation was achieved through the discovery and invention of modern immunosuppressive agents in the early/mid-1980s. Especially during the 1990 s, a large array of immunosuppressants has expanded the armamentarium used to prevent and treat allograft rejection, resulting in an excellent short-term and an acceptable long-term outcome. However, these drugs have potent but still non-specific immunosuppressive properties and frequently show severe acute and chronic side effects, sometimes questioning the overall success. CONCEPTS/TRENDS: As the "Holy-Grail" of the transplant community, the induction of "true donor-specific tolerance" has not been achieved yet; current immunosuppressive strategies, in particular in Europe, include "individually tailored immunosuppressive" protocols, mostly based on specific immunologic and non-immunologic risk factors. These protocols allow for optimal immunosuppressive protocols for each patient group according to their needs by choosing the most suitable, well-tolerated combination of agents and the most effective doses to avoid acute rejection episodes (incidence and severity) and minimise drug-related toxicity to reduce long-term drug-related morbidity and mortality. Nevertheless, transplant recipient are still being forced to take a life-long course of chemical immunosuppressive agents to keep their graft, knowing about the possible life-threatening side effects. SUMMARY: We review current trends of immunosuppressive protocols in liver and kidney transplantation, focusing on calcineurin-inhibitor-sparing protocols, mammalian-target-of-rapamycin (mTOR) inhibitor based-protocols and corticosteroid-avoidance protocols, being aware of the fact, that most of these strategies could be applicable for other transplanted organs, too. Finally, we describe future trends and new developments that are rising on the horizon.