Laparoscopic management of ureteropelvic junction obstruction by division of anterior crossing vein and cephalad relocation of anterior crossing artery.

PURPOSE: We report our experience with laparoscopic management of ureteropelvic junction (UPJ) obstruction by division of the anterior crossing vein and cephalad relocation of the anterior crossing artery. PATIENTS AND METHODS: We used this laparoscopic approach in four male and six female patients with UPJ obstruction associated with anterior crossing vessels. The mean age of the patients was 31.9 years (range 14-59 years). The obstruction was present on the right side in four and on the left side in six patients. Using a transperitoneal approach, the crossing vein was divided, while the crossing artery was preserved, relocated cephalad, and fixed to the peripelvic tissues with metal clips or sutures. Because a grossly normal appearance of the UPJ and upper ureter together with proper pyeloureteral peristalsis and complete renal pelvic emptying were observed intraoperatively, dismembered pyeloplasty was not performed in any of these patients. Diuretic renography and intravenous urography were performed 3, 6, and 12 months postoperatively. RESULTS: The mean operative duration was 140 minutes (range 100-170 minutes). The mean hospital stay was 2.9 days (range 2-5 days), and the mean follow-up was 9.1 months (range 3-22 months). Diuretic renography revealed absence of obstruction in all patients, and intravenous urography showed considerable improvement of the hydronephrosis. CONCLUSION: Select cases of UPJ obstruction associated with anterior crossing vessels seem to be amenable to laparoscopic management by division of the crossing vein and cephalad relocation of the crossing artery. Laparoscopy as a minimally invasive approach may offer a better opportunity to evaluate the role of anterior crossing vessels in UPJ obstruction.

Automatic detection of glaucomatous visual field progression with neural networks.

OBJECTIVE: To evaluate computerized neural networks to determine visual field progression in patients with glaucoma. METHODS: Two hundred thirty-three series of Octopus G1 visual fields of 181 patients with glaucoma were collected. Each series was composed of 4 or more reliable visual fields from patients who had previously undergone automated perimetry. The visual fields were independently evaluated in a masked fashion by 3 experienced observers (K.N.-M, M.W., and J.C.) and were judged to show progression based on the agreement of 2 observers. The stable and progressed series were matched for mean defect at baseline. The threshold data were submitted to a back propagation neural network that was trained to classify each series as stable or progressed. Two thirds of the data were used for the training and the remaining one third to test the performance of the network. This was repeated 3 times to classify all of the series (changing the training and test series). RESULTS: Fifty-nine series of visual fields showed progression and 151 were judged stable. Neural network sensitivity was 73% and specificity was 88% (threshold for progression = 0.5). The concordance of the neural network with the observers was good (0.50 < or = kappa > or = 0.64). CONCLUSIONS: A neural network can be trained to recognize visual field progression in good concordance with experienced observers. Neural networks may be used to aid the physician in the evaluation of glaucomatous visual field progression.

Early capsular distension syndrome after sulcus implantation of intraocular lenses.

Two cases of early capsular distension syndrome (cds) are presented. the first occurred after sulcus implantation of a 12.0 mm poly(methyl methacrylate) iol (5.0 mm optic, 10 degree anterior angulation). the second case occurred after sulcus implantation of a foldable silicone iol with optic capture (6.0 mm optic, no anterior angulation). both cases resolved after a neodymium:YAG laser anterior capsulotomy. Cataract surgeons should be aware of the possibility of CDS after sulcus implantation of an IOL in the presence of an intact capsulorhexis and posterior capsule. A small capsulorhexis and in-the-bag capture of the IOL optic are major predisposing factors in this setting.

Laparoscopic pyelopyelostomy for retrocaval ureter without excision of the retrocaval segment: first report of 6 cases.

PURPOSE: We report our series of 6 cases of retrocaval ureter that were successfully treated with a laparoscopic approach. MATERIALS AND METHODS: Three men and 3 women with a mean age of 31 years (range 16 to 50) were referred to our department with a diagnosis of retrocaval ureter. One patient had a 12 mm renal pelvic calculus. A transperitoneal laparoscopic approach was used in all cases. The retrocaval segment along with some of the more proximal and distal segments of the ureter was readily mobilized. The distal part of the dilated renal pelvis was transected and the divided distal segment was repositioned to lie anterior to the inferior vena cava. The renal pelvic stone in 1 patient was readily removed at this point. Re-anastomosis was then performed over a Double-J stent placed intraoperatively using 2 rows of running 4-zero polyglactin sutures with intracorporeal knot tying. The stent was removed 4 weeks later. Excretory urography was performed 3 months after the laparoscopic procedure. RESULTS: Mean operative duration was 180 minutes (range 150 to 210). Patients were discharged home at a mean of 4 days (range 3 to 5). Followup excretory urogram 3 months after laparoscopic repair revealed a widely patent anastomosis with considerable improvement in hydronephrosis in all patients. CONCLUSIONS: To our knowledge this is the largest series of laparoscopic repair of retrocaval ureter reported to date. Laparoscopic pyelopyelostomy for retrocaval ureter without excision of the retrocaval segment is associated with an excellent outcome, minimal postoperative morbidity, short hospital stay and highly satisfactory cosmetic results.

Comparison of methods to detect visual field progression in glaucoma .

OBJECTIVE: The purpose of the study is to develop alternative statistical approaches for evaluating the trend of visual field series over time and to compare the results to human observers. DESIGN: Retrospective analysis of visual field results. PARTICIPANTS: Eighty-three eyes of 83 patients (phakic or pseudophakic) with open-angle glaucoma and 5 or more eligible fields were included in the study. INTERVENTION: Three experienced observers independently reviewed the field series to determine stability or progression. MAIN OUTCOME MEASURES: The following additional methods to determine progression of visual field loss were used: (1) pointwise univariate regression analysis and a glaucoma change analysis; (2) univariate regression analysis on visual field indices mean deviation, corrected loss variance, and glaucoma pattern index; (3) pointwise multivariate regression analysis with fixed effects on panel data; and (4) clusterwise multivariate regression analysis with fixed effects on panel data. The results of different statistical methods were compared by determining the pairwise agreement (Cohen's weighted kappa) between each technique and three experienced observers. RESULTS: Patients were observed for a mean (+/-standard deviation) of 5.6 (+/-1.4) years. The visual fields of 27 (33%) and 56 (67%) eyes were considered to have progressed or remained stable, respectively, based on agreement of at least 2 of 3 observers. Univariate regression analysis on visual field indices was not useful for detection of visual field progression. Pointwise and clusterwise regression analyses with fixed effects on panel data performed as well as pointwise univariate regression analysis compared with human observers (kappa = 0.52, 0.53, and 0.55, respectively). Both methods showed better agreement with human observers than with glaucoma change analysis (kappa = 0.41). CONCLUSIONS: A new statistical model, multivariate regression analyses with fixed effects on panel data, is an appropriate method to evaluate the course of visual field series over time and shows reasonable agreement with experienced observers and pointwise univariate regression analysis.

Outcomes of trabeculectomy for primary open-angle glaucoma.

PURPOSE: To determine the long-term functional and structural outcomes in patients treated with trabeculectomy for primary open-angle glaucoma. METHODS: Records of 78 consecutive patients (78 eyes) who had their first trabeculectomy were studied retrospectively (duration of follow-up, 25 to 112 months). Serial automated perimetry and stereoscopic optic disc photographs were used to assess the long-term efficacy of trabeculectomy to prevent progressive glaucomatous damage. Stereoscopic optic disc photographs were available for 29 eyes (38%). Criteria for intraocular pressure control were a minimum intraocular pressure reduction of 20% and intraocular pressure at or below 20 mmHg. RESULTS: There was no evidence of progression of glaucomatous damage in 81% and 65% of the eyes after 3 and 6 years, respectively. The visual field deteriorated in 16 eyes (21%) and progressive structural optic nerve damage occurred in 4 eyes (5%) during follow-up. Deterioration of the optic nerve head in the absence of visual field progression was detected in three (4%) of those eyes. In 19 eyes (25%), further glaucoma surgery was performed. The probability of successful intraocular pressure control after a single operation was 48% and 40% at 3 and 5 years, respectively. CONCLUSION: Progressive glaucomatous damage occurs in about one third of eyes with moderate to severe primary open-angle glaucoma over a 6-year follow-up after trabeculectomy.

Pseudoexfoliation syndrome in central Iran: a population-based survey.

PURPOSE: To determine prevalence and clinical characteristics of pseudoexfoliation syndrome (PES) in central Iran in a population-based survey. METHODS: A random sample of people aged 50 years or older from Falavarjan county, central Iran, was examined for signs of PES. RESULTS: Eight hundred-six eyes belonging to 405 cases (210 women and 195 men) were examined. Seventy-seven eyes (9.6%; 95% C.I. = 7.6%-11.6%) of 53 cases (13.1%; 95% C.I. = 9.8%-16.4%) showed pseudoexfoliative deposits. Anterior lens capsule was the most common site for deposition of pseudoexfoliative deposits. Several pigmentary signs were significantly associated with presence of PES (p < 0.001 for all signs). Ten out of 77 eyes (13%) with PES demonstrated increased intraocular pressure or glaucoma. CONCLUSION: Pseudoexfoliation syndrome is a frequent finding in the elderly in central Iran. Most cases can be diagnosed by a careful examination of the anterior lens capsule after pupillary dilation. Glaucoma or ocular hypertension is not common in people with PES in central Iran.

[Epidermoid cyst of the testis. Apropos of a case]. / Kyste épidermoïde du testicule. A propos d'un cas.

The epidermoid cyst of the testis, a rare and benign tumour, continues to create problems. Its definitive diagnosis remains a histopathological one and alters the prognosis and therapy. Based on their case report and a literature review, the authors discuss the different diagnostic, prognostic and therapeutic aspects of this lesion.