Investigating the role of SPECT/CT in dynamic sentinel lymph node biopsy for penile cancers.

PURPOSE: Currently, most centres use 2-D planar lymphoscintigraphy when performing dynamic sentinel lymph node biopsy in penile cancer patients with clinically impalpable inguinal nodes. This study aimed to investigate the role of SPECT/CT following 2-D planar lymphoscintigraphy (dynamic and static) in the detection and localization of sentinel lymph nodes in the groin. METHODS: A qualitative (visual) review was performed on planar followed by SPECT/CT lymphoscintigraphy in 115 consecutive patients (age 28-86 years) who underwent injection of 99mTc-nanocolloid followed by immediate acquisition of dynamic (20 min) and early static scans (5 min) initially and further delayed static (5 min) images at 120 min followed by SPECT/CT imaging. The lymph nodes detected in each groin on planar lymphoscintigraphy and SPECT/CT were compared. RESULTS: A total of 440 and 467 nodes were identified on planar scintigraphy and SPECT/CT, respectively. Overall, SPECT/CT confirmed the findings of planar imaging in 28/115 cases (24%). In the remaining 87 cases (76%), gross discrepancies were observed between planar and SPECT/CT images. SPECT/CT identified 17 instances of skin contamination (16 patients, 13%) and 36 instances of in-transit lymphatic tract activity (24 patients, 20%) that had been interpreted as tracer-avid lymph nodes on planar imaging. In addition, SPECT/CT identified 53 tracer-avid nodes in 48 patients (42%) that were not visualized on planar imaging and led to reclassification of the drainage basins (pelvic/inguinal) of 27 tracer-avid nodes. CONCLUSIONS: The addition of SPECT/CT improved the rate of detection of true tracer-avid lymph nodes and delineated their precise (3-D) anatomic localization in drainage basins.

Feasibility of performing dynamic sentinel lymph node biopsy as a delayed procedure in penile cancer.

INTRODUCTION: Patients diagnosed with penile cancer and clinically impalpable inguinal lymph nodes (cN0), normally undergo dynamic sentinel lymph node biopsy (DSNB) at the same time as the primary penile surgery. The aim of this study is to investigate the diagnostic accuracy and clinical outcomes of performing DSNB in patients who have already undergone surgery for the primary penile cancer. METHODS: Ninety-two patients with unilateral or bilateral impalpable inguinal lymph nodes (LNs) who had already undergone primary resection of the penile tumour (stage ≥ T1G2) were included in this study. All patients underwent a preoperative USS of the groin(s) with fine needle aspiration cytology (FNAC). Provided that the FNAC was clear, DSNB was performed. Radical inguinal lymphadenectomy was performed if the histological analysis of the SLN confirmed the presence of micrometastatic disease. RESULTS: DSNB was undertaken in 165 groins with a nonvisualisation rate of 4.8 % (8/165 groins). The SLN was positive for micrometastatic disease in nine groins (5.5 %) from a total of eight patients (8.7 %). One patient developed regional recurrence in a prepubic LN after excision of bilateral negative SLN (1.1 %). The three-year disease-specific survival for patients with negative and positive SLN was 98.8 and 87.5 %, respectively (p = 0.042). Using DSNB, occult LN metastases in penile cancer can be detected with a sensitivity of 88.9 % and specificity of 100 %. CONCLUSIONS: We have demonstrated that DSNB is feasible as a delayed procedure to localise the SLN. Surgical resection of the primary penile lesion does not appear to change the lymphatic drainage.

Traumatic Metachronous Penile Fracture to the Contralateral Corpora.

Penile fracture is an uncommon condition in day-to-day urological practice. Though most cases of penile fracture are traumatic in nature, these are typically unilateral. Synchronous bilateral cases have been rarely reported. We present the third case recorded to date, to the best of our knowledge, of a metachronous penile fracture to the contralateral corpora due to trauma related to sexual intercourse. The first presentation demonstrated a significant tear to the left corporal body at surgical exploration that was repaired. There was no postoperative complications or erectile dysfunction on outpatient follow-up. Six months thereafter, the patient had another similar presentation and demonstrated a right corporal body fracture which was repaired surgically on an urgent basis. Prompt diagnosis and low threshold for surgical intervention are essential to reduce morbidity and prevent long-term complications.

Zonal mapping of sentinel lymph nodes in penile cancer patients using fused SPECT/CT imaging and lymphoscintigraphy.

PURPOSE: To define the anatomical location of sentinel lymph nodes (SLN) in penile cancer patients based on Daseler's original zonal description using a combination of single photon emission computed tomography-computed tomography (SPECT-CT), cross sectional imaging and lymphoscintigraphy and characterise the limits of Zone V. MATERIALS AND METHODS: Patients with primary penile cancer ≥T1G2 were included in the study. A total of 113 groins with impalpable inguinal lymph nodes (cN0) underwent planar lymphoscintigraphy and SPECT-CT. The sentinel lymph nodes were mapped on cross sectional imaging according to Daseler's anatomical description. Using measurements from fixed anatomical landmarks, a custom-made software program mapped the SLNs. SLNs were mapped to the previously undefined Zone V using 3 approaches to avoid observational bias: (a) as perceived by the uroradiologist, (b) limiting Zone V to a 5 mm radius from the sapheno-femoral junction or (c) using a 10 mm radius from the sapheno-femoral junction. RESULTS: Using SPECT-CT, drainage to the groins was seen in 109 of the 113 cN0 groins (96.5%). The majority of the SLNs were located in the central and superior quadrants with 38.2% lying within Zone I, 45% in Zone II and 13% in Zone V. More importantly, sentinel lymph nodes were still localised to the inferior zones with 3% located in Zone III and 0.8% in Zone IV. CONCLUSIONS: Using a hybrid of SPECT-CT, cross sectional imaging and lymphoscintigraphy we have demonstrated that SLNs may be located in the inferior zones. We also define the limits of Zone V as an area of 5 mm radius from the sapheno-femoral junction.

Delayed repair of esophageal perforation due to transoesophageal echocardiography.

Since its introduction into clinical practice in the 1980s, transesophageal echocardiography has become an invaluable tool in cardiac surgery having only a few cases of serious complications reported in the literature. We report a novel case of delayed surgical repair of esophageal perforation due to transesophageal echocardiography in cardiac surgery and reviewed the anecdotal literature.

Searching for the G spot in the urinary bladder: autoerotism and potential complications.

Self-insertion of foreign bodies into the urethra and urinary bladder for autoerotic stimulation is a rather rare urological emergency condition. We present a case of 41-year-old lady who self-inserted a crochet needle into the urethra for sexual pleasure, which was successfully retrieved during examination under general anaesthetic and endoscopic bladder evaluation. Foreign bodies in the urinary bladder are rarely encountered yet represent a urological challenge that requires prompt management in view of possible sequellae if left untreated.

Seminoma presented as testicular rupture: Case report and literature review.

Rupture of the testis as a result of blunt trauma is rarely seen in daily urological practice. We report an unusual case of incidental seminoma diagnosed after surgical exploration and subsequent orchidectomy of a severed testis following testicular injury as a result of trivial blunt trauma. This case highlights the inability of investigative tools, such as a scrotal ultrasound, in distinguishing an underlying tumour in the presence of testicular parenchymal damage. We therefore advocate a high index of clinical suspicion for co-existing pathology in cases of testicular rupture secondary to an insignificant blunt trauma to the scrotum.

Mitral valve repair: beyond the French correction.

INTRODUCTION: We analysed retrospectively patients who underwent mitral valve repair using techniques beyond the "French correction", as popularised by Carpentier. METHODS: From June 1997 to June 2006, 153 patients underwent mitral valve repair. Their mean age was 63.1 +/- 13.5 years (range 19-87). Mean Euroscore was 4.9 +/- 2.1 (2-13). Type II lesions were present in 109 cases. There were 123 degenerative cases. Preoperative mitral regurgitation (MR) was severe in 145 cases. Ninety patients were in NYHA class III/IV. The transseptal approach was employed in 89.5% of the series. Annuloplasty alone was performed in 36 patients, whereas leaflet plication/exclusion was applied in 53 patients. The edge-to-edge technique was used in 79. Mitral valve repair was combined with procedures for ischaemic heart disease in 41 patients. RESULTS: The mean postoperative stay was 8.1 +/- 3.7 days (4-25). There was no mortality in the isolated mitral valve repair group. New onset atrial fibrillation occurred in 17% postoperatively. Mean follow-up was 34.3 +/- 25.1 months (0-105). No or mild MR was present in 139 (91%) patients, while 144 (94%) were in NYHA class I. Four patients underwent redo repair. There was a statistically significant difference in relation to the MR between patients who had Alfieri repair with annuloplasty compared to no annuloplasty (p < 0.001). Furthermore, there was a significant difference between the isolated valve and the combined group in terms of postoperative hospital stay (p = 0.006) and survival (p = 0.033). CONCLUSIONS: Our study demonstrates that the techniques beyond the "French correction" simplify the repair, especially when combined with other cardiac procedures. These techniques were applied with no mortality in the isolated mitral valve repair group.

In patients undergoing cardiac surgery does asymptomatic significant carotid artery stenosis warrant carotid endarterectomy?

A best evidence topic in cardiovascular surgery was written according to a structured protocol. The question addressed was whether asymptomatic significant carotid artery stenosis (ASCAS) warrants carotid endarterectomy (CEA) in patients undergoing cardiac surgery. 128 Papers were found using the reported search, of these 10 presented represent the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that low risk, younger patients with a significant asymptomatic carotid artery stenosis should be considered for carotid endarterectomy at some stage. There is, however, no strong evidence that this must be performed prior to, or during CABG.

Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Cervical spine imaging in children under 9 after trauma.

A short cut review was carried out to establish whether the odontoid peg view is useful to radiologically exclude cervical spine injury in children under 9 years of age. Altogether 156 papers were found using the reported search, of which two presented the best evidence to answer the clinical question. In addition recent guidelines are noted. The author, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.

Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Need for cervical spine imaging for alert children after trauma.

A short cut review was carried out to establish whether clinical examination can be used to exclude cervical spine injury in alert children. Altogether 298 papers were found using the reported search, of which three presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.

Are prophylactic beta-blockers of benefit in reducing the incidence of AF following coronary bypass surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether prophylactic beta-blockers effectively reduces the incidence of atrial fibrillation post-cardiac surgery. Altogether 113 papers were found using the reported search, of which 8 represented the best evidence on this topic. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses were tabulated. We conclude that prophylactic beta-blockers clearly reduce the incidence of AF with a number needed to treat of only seven to prevent one episode of AF. The optimal beta-blocker or the benefits to patients with impaired ejection fraction are less clear.