The impact of FDG-PET/CT in the management of patients with vulvar and vaginal cancer.

OBJECTIVES: To evaluate the changes in prognostic impression and patient management following PET/CT in patients with vulvar and vaginal carcinoma; and to compare PET/CT findings with those of conventional imaging modalities. METHODS: We summarized prospectively and retrospectively collected data for 50 consecutive patients from our institution that enrolled in the National Oncologic PET Registry and underwent FDG-PET/CT for a suspected or known primary or recurrent vulvar/vaginal cancer. RESULTS: 54/83 (65%) studies included had a diagnosis of vulvar cancer, and the remaining 29/83 (35%), a diagnosis of vaginal cancer. Following FDG-PET/CT, the physician's prognostic impression changed in 51% of cases. A change in patient management, defined as a change to/from a non-interventional strategy (observation or additional imaging), to/from an interventional strategy (biopsy or treatment), was documented in 36% of studies. The electronic records demonstrated that 95% of the management strategies recorded in the physician questionnaires were implemented as planned. MRI and/or CT were performed within one month of the FDG-PET/CT in 20/83 (24%) and 28/83 (34%) cases, respectively. FDG-PET/CT detected nodes suspicious for metastases on 29/83 (35%) studies performed. MRI and CT detected positive nodes on 6 and 11 studies respectively. Distant metastases were identified in 10 cases imaged with FDG-PET and 5 cases that had additional conventional CT imaging. All suspicious lesions seen on CT were positively identified on PET/CT. In 4 cases, an abnormality identified on PET/CT, was not seen on diagnostic CT. CONCLUSIONS: FDG-PET/CT may play an important role in the management of vulvar and vaginal carcinoma.

Volume-based quantitative FDG PET/CT metrics and their association with optimal debulking and progression-free survival in patients with recurrent ovarian cancer undergoing secondary cytoreductive surgery.

OBJECTIVE: Our aim was to evaluate the associations between quantitative (18)F-fluorodeoxyglucose positron-emission tomography (FDG-PET) uptake metrics, optimal debulking (OD) and progression-free survival (PFS) in patients with recurrent ovarian cancer undergoing secondary cytoreductive surgery. METHODS: Fifty-five patients with recurrent ovarian cancer underwent FDG-PET/CT within 90 days prior to surgery. Standardized uptake values (SUVmax), metabolically active tumour volumes (MTV), and total lesion glycolysis (TLG) were measured on PET. Exact logistic regression, Kaplan-Meier curves and the log-rank test were used to assess associations between imaging metrics, OD and PFS. RESULTS: MTV (p = 0.0025) and TLG (p = 0.0043) were associated with OD; however, there was no significant association between SUVmax and debulking status (p = 0.83). Patients with an MTV above 7.52 mL and/or a TLG above 35.94 g had significantly shorter PFS (p = 0.0191 for MTV and p = 0.0069 for TLG). SUVmax was not significantly related to PFS (p = 0.10). PFS estimates at 3.5 years after surgery were 0.42 for patients with an MTV ≤ 7.52 mL and 0.19 for patients with an MTV > 7.52 mL; 0.46 for patients with a TLG ≤ 35.94 g and 0.15 for patients with a TLG > 35.94 g. CONCLUSION: FDG-PET metrics that reflect metabolic tumour burden are associated with optimal secondary cytoreductive surgery and progression-free survival in patients with recurrent ovarian cancer. KEY POINTS: • Both TLG and MTV were associated with optimal tumour debulking. • There was no significant association between SUVmax and tumour debulking status. • Patients with higher MTV and/or TLG had significantly shorter PFS. • SUVmax was not significantly related to PFS.

Relation of plasma renin to end organ damage and to protection of K+ feeding in stroke-prone hypertensive rats.

We studied the effects of regular diet (0.35% NaCl/1.1% potassium), high sodium diet (4% NaCl/0.75% potassium), or high sodium and high potassium diet (4% NaCl/2.11% potassium) on blood pressure, plasma renin activity, renal and cerebrovascular lesions, and incidence of stroke and mortality in male stroke-prone spontaneously hypertensive rats (SHRSP). In the first 4 weeks, the rise in blood pressure was higher in high NaCl than in high NaCl/high potassium or regular diet groups. However, by 8 and 12 weeks, the blood pressure in all three groups was similar. After 4 weeks of diet, plasma renin activity was similar in the three groups (3.4 +/- 0.8, 4.1 +/- 0.9, and 5.2 +/- 1.6 ng/ml/hr, in high NaCl, high NaCl/high potassium, and regular diet groups, respectively) and were not related to sodium excretion. After 8 weeks, plasma renin activity was significantly increased only in the high NaCl group (13.7 +/- 3.7 ng/ml/hr), and by 12 weeks plasma renin activity was significantly higher in the high NaCl group (25.3 +/- 3.6 ng/ml/hr) than in the high NaCl/high potassium (11.1 +/- 2.9 ng/ml/hr) or in the regular diet (7.8 +/- 4.6 ng/ml/hr) groups. Moderate to severe renal vascular lesions were first detected in the high NaCl group by 8 weeks of diet. At 12 weeks, renal vascular damage index (RVDI), estimated histologically, was significantly higher in the high NaCl group (RVDI = 79 +/- 14) than in the high NaCl/high potassium (RVDI = 40 +/- 11) and regular diet (RVDI = 7.8 +/- 4.6) groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Excision of ellipses of tunica albuginea for primary correction of penile curvature.

Three children and 4 adult patients with penile curvature without hypospadias were successfully operated on by the Nesbit technique or excision of ellipses of the tunica albuginea. There was no impotence, and a satisfactory result was obtained in all 7 cases.

Laparoscopic laser-assisted bladder autoaugmentation.

OBJECTIVES: The purpose of this study is to examine the feasibility of performing a laparoscopic bladder autoaugmentation and to assess the urodynamic characteristics of an autoaugmented bladder. METHODS: Laparoscopic bladder autoaugmentation was performed in 9 female canines (20 to 30 kg). Following laparoscopic access to the peritoneal cavity, a midline bladder seromyotomy was performed using the potassium titanyl phosphate 532 nm laser. This produced a large bladder diverticulum. Changes in bladder volume and compliance were quantified over a 3-month period of follow-up. RESULTS: Urodynamic evaluation demonstrated an increase in bladder capacity 6 weeks postoperatively in 8 of 9 dogs, with an average volume increase of 45%. Bladder compliance improved in 7 of 9 dogs with an average increase in compliance of 67%. Three months postoperatively, bladder capacity remained increased in 5 of 9 dogs, with an average increase in volume of only 5.3%. An improvement in compliance was sustained in 5 of 9 animals with an average increase of 13.9%. Laparoscopic exploration revealed grossly normal bladders with adhesions of omentum to the seromyotomy site in all canines and the anterior abdominal wall in 2 of 9 canines. Histologically, the seromyotomy site was devoid of muscle with an intact urothelium and a proliferation of loose connective tissue. CONCLUSIONS: The technique of laparoscopic bladder autoaugmentation can be performed easily in the canine model. Although results at 6 weeks show significant improvement, the longer term, 3-month results were not statistically significant. This technique has the potential to offer a minimally invasive correction for patients with low-capacity, high-pressure bladders that have failed pharmacologic treatment.

Survey of neuromuscular injuries to the patient and surgeon during urologic laparoscopic surgery.

OBJECTIVES: Laparoscopy may be complicated by neuromuscular injuries, both to the patient and to the surgeon. We used a survey to estimate the incidence of these injuries during urologic laparoscopic surgery, to assess risk factors for these injuries, and to determine preventive measures. METHODS: A survey of neuromuscular injuries associated with laparoscopy submitted to 18 institutions in the United States was completed by 18 attending urologists from 15 institutions. RESULTS: From among a total of 1651 procedures, there were 46 neuromuscular injuries in 45 patients (2.7%), including abdominal wall neuralgia (14), extremity sensory deficit (12), extremity motor deficit (8), clinical rhabdomyolysis (6), shoulder contusion (4), and back spasm (2). Neuromuscular injuries were twice as common with upper retroperitoneal as with pelvic laparoscopy (3. 1% versus 1.5%). Among patients with neuromuscular injuries, those with rhabdomyolysis were heavier (means 91 versus 80 kg) and underwent longer procedures (means 379 versus 300 minutes), and those with motor deficits were older (means 51 versus 42 years of age). Of the surgeons, 28% and 17% reported frequent neck and shoulder pain, respectively. CONCLUSIONS: Although not common, neuromuscular injuries during laparoscopy do contribute to morbidity. Abdominal wall neuralgias, injuries to peripheral nerves, and joint or back injuries likely occur no more frequently than during open surgery, but risk of rhabdomyolysis may be increased. Positioning in a partial rather than full flank position may reduce the incidence of some injuries. Measures to reduce neuromuscular strain on the surgeon during laparoscopy should be considered.

Clinical evaluation of renovascular hypertension and therapeutic decisions.

The renal arteriogram alone, useful as an anatomic guide for the surgeon or radiologist, is inadequate to predict potential blood pressure reversal by correction of the obstructing lesion. A patient must be identified as having functionally significant renal arterial disease before intervention can be recommended. The authors discuss uncovering functionally significant renal artery stenosis, the pathophysiology of experimental Goldblatt hypertension, and criteria to identify renovascular hypertension, including peripheral plasma renin activity and differential renal-vein renin determinations.

Hand-assisted laparoscopic nephroureterectomy versus open nephroureterectomy for the treatment of transitional-cell carcinoma of the upper urinary tract.

BACKGROUND AND PURPOSE: For patients with upper tract transitional-cell carcinoma (TCC), nephroureterectomy with removal of a bladder cuff is the standard of care. Historically, it has been performed using two incisions or one large incision extending from the lateral flank to the symphysis pubis. We describe an alternative using endoscopic management of the bladder cuff combined with hand-assisted laparoscopic (HAL) nephroureterectomy. We compared our results using these minimally invasive advances with those of a contemporary open nephroureterectomy series. PATIENTS AND METHODS: Between May 1998 and June 1999, we performed 11 HAL nephroureterectomies with endoscopic management of the bladder cuff for the treatment of upper tract TCC. The results were compared with those in a contemporary series of 11 patients undergoing the traditional open operation at our institution. The patient age, male:female ratio, and ASA classification were similar in the two groups. Intraoperative measures considered were operative time, estimated blood loss, need for transfusion, complications, specimen weight and volume, pathologic stage and grade of the tumor, and the status of the surgical margins. Postoperative endpoints were time to sustained fluid intake; epidural, parenteral, and oral narcotic requirements; length of stay; and complications. Follow-up, specifically disease recurrence and overall survival, was recorded. RESULTS: The mean operative time was 291 minutes for HAL v 232 minutes for the open operation (P = NS). The average blood loss was 144 v 311 mL (P = 0.04), the mean specimen weight 368 v 392 g (P = NS), and the mean specimen volume was 630 v 693 cc (P = NS). No patient in the HAL group had a positive surgical margin, but one patient in the open surgery group did. The time to sustained fluid intake postoperatively averaged 1.4 v 2.3 days for the HAL and open groups, respectively (P = NS). The epidural narcotic requirement was 0 v 2.7 days (P < 0.001), the mean parenteral narcotic requirement was 45 v 44 mg of morphine sulfate equivalent (P = NS), and the oral narcotic requirement was 5.8 v 16 tablets (P < 0.04). The average length of stay was 4.6 days for the HAL group v 6.1 days for the open group (P = 0.04). In both groups, 7 of the 11 patients (63%) were without evidence of disease with a mean follow-up of 13 (HAL) and 17 (open) months. CONCLUSIONS: Hand-assisted laparoscopic nephroureterectomy with endoscopic management of the bladder cuff is an efficacious alternative to open surgery. The operative time, specimen weight and size, and risk of recurrence for the two procedures are similar. However, convalescence, as measured by pain medication requirements and length of stay, is significantly better with laparoscopy. Longer follow-up with larger numbers of patients is in progress.

Simple nephrectomy: hand-assisted technique.

Chronic inflammation or prior surgical procedures may complicate the laparoscopic performance of simple nephrectomy. In these difficult cases, hand-assisted laparoscopy may be useful. The position of the hand port depends on the particular situation, but the port must allow flexion of the wrist and access to the entire surgical field. The hand-assisted procedure is similar to standard laparoscopy in analgesic use, time to oral intake, length of stay, and time to full recovery. Hand-assisted laparoscopy allows the inexperienced surgeon to perform laparoscopy with the aid of tactile sensation and three-dimensional spatial orientation. For the experienced surgeon, the technique offers an alternative to open conversion when the laparoscopic procedure fails to progress.

Hand-assisted laparoscopic partial nephrectomy.

BACKGROUND AND PURPOSE: The indications for partial nephrectomy are expanding as newer and more complete data come forth. A partial nephrectomy has traditionally required a generous flank incision. We report our experience using hand-assisted laparoscopy (HAL) as a less-invasive approach to partial nephrectomies. PATIENTS AND METHODS: Between October 1999 and May 2000, we performed 11 HAL partial nephrectomies. The average age of the patients was 55.7 years, the average body mass index was 25.6, and the average ASA class was 2.2. The indications for partial nephrectomy were enhancing solid renal lesions (N = 9) and nonfunctioning renal moiety in a duplicated system (N = 2). In the majority of cases, access to the renal pedicle was obtained prior to the partial nephrectomy. However, in no case did the renal artery or vein require occlusion. Several excisional techniques were employed, but all relied heavily on the Harmonic Scalpel in conjunction with the argon beam coagulator. Different hemostatic agents were applied to the renal defect, including Surgicel, Avitene, and fibrin-soaked Gelfoam activated by thrombin. In several instances, pledget reinforced sutures were placed in the renal capsule to aid with hemostasis. RESULTS: The average operative time was 273 minutes, the estimated blood loss 319 mL, and the change in hematocrit 7.3 points. No patient required a transfusion, and there was one conversion to open. Postoperatively patients, required an average of 35.6 mg of morphine sulfate equivalent and 8.2 narcotic tablets, resumed oral intake in 1.7 days, and were discharged home in 3.3 days. There were no major complications and only two minor complications. Postoperatively, five lesions were found to be benign, four lesions were confirmed to be malignant, and two lesions were consistent with a nonfunctioning duplicated renal moiety. Specimen size averaged 180 cc, and the tumor diameter averaged 1.9 cm. There were no positive surgical margins. CONCLUSIONS: Hand-assisted laparoscopic partial nephrectomy is feasible and reproducible. The surgeon's hand in the operative field facilitates dissection, vascular control, hemostasis, and suturing. Further long-term and prospective studies are underway.

Oliguria during laparoscopic surgery: evidence for direct renal parenchymal compression as an etiologic factor.

Abdominal insufflation during laparoscopy has been associated with transient oliguria, which abates after desufflation. Direct renal compression evoking a Page kidney effect was proposed as a mechanism. In an effort to confirm this theory, the left kidney was subjected to 15 mm Hg compression in six anesthetized mongrel dogs. For this, a pressure cuff was placed around the kidney excluding the renal hilar structures. The contralateral kidney was left untouched to serve as a control. After a steady-state period, the pressure cuff was inflated to 15 mm Hg for 2 hours. Cuff desufflation was followed by a 1-hour recovery period. Urine output, glomerular filtration rate (GFR), and effective renal blood flow (ERBF) were measured for both kidneys during each clearance period. For the treated kidneys, the mean urine output decreased 63% (P < 0.05) during compression and increased 109% (P < 0.05) after cuff desufflation. The GFR decreased 21% (P < 0.01) during compression and increased 25% (P < 0.05) during recovery. The ERBF decreased 26% (P < 0.05) during compression, and during the 1-hour recovery period, ERBF did not recover to baseline values. For the control kidneys, there were no significant changes in urine output or GFR during the experimental and recovery periods. These data support the view that direct renal parenchymal compression is an important factor in the development of insufflation-induced oliguria. The clinical implications of insufflation-induced oliguria during laparoscopy deserve further investigation.

Acute and chronic interstitial cryotherapy of the adrenal gland as a treatment modality.

BACKGROUND AND OBJECTIVES: Adrenalectomy is indicated for patients with large adrenal lesions or functional tumors. Cryoablation is currently used as a surgical alternative for the treatment of prostate, lung, brain, pharynx, and liver tumors. The purpose of this study was to determine if cryosurgery could be delivered to small areas in the adrenal gland in a controllable and reproducible manner, so that tissue could heal in a nonpathological way. MATERIALS AND METHODS: Fourteen female mongrel dogs underwent acute (N = 8) or chronic (4 weeks) (N = 6) cryoablation using the Cryounit. In the acute study, using an open transabdominal approach, a 2-mm cryoprobe was placed interstitially into the adrenal tissue, while 0.032-inch thermocouples were cannulated into the ipsilateral adrenal artery and vein. Adrenal parenchymal temperature changes were measured using thermocouples placed at 0.4- and 0.8-cm intervals from the cryoprobe. In the chronic study, cryoablation was achieved by transperitoneal laparoscopic access using standard laparoscopic technique. RESULTS: Interstitial cryoprobe temperatures decreased from 33.1 +/- 1.9 degrees C to -148 +/- 1.2 degrees C following 15 minutes of freezing in the acute study. Cryoablation of adrenal tissue achieved temperatures of -41.8 +/- 5.7 degrees C and -21.8 +/- 1 degrees C at distances of 0.4 and 0.8 cm from the cryoprobe, respectively. There were no significant changes in adrenal artery or vein temperatures during cryoablation. Histologically, there was a clear demarcation between viable and nonviable tissue, the latter being characterized by areas of multifocal hemorrhage and pyknosis. After 4 weeks of healing, there was a well-defined line between necrotic and viable tissue. CONCLUSION: Cryoablation of the adrenal gland can be obtained in an effective, controllable, and reproducible manner. This controllable energy form may provide new modality for tissue destruction where adrenal gland preservation is necessary and can be delivered by the laparoscopic approach. Understanding the effect of adrenal cryoablation may allow us to treat selected patients with small tumors in whom organ preservation is necessary.

Laparoscopy: new applications of an established technique.

The safety and cost-effectiveness of any new procedure is, of course, brought into question in this era of heightened fiscal concerns. In general, a review of initial results with laparoscopic pelvic lymph node dissection appears to reveal sufficient patient benefits to warrant further work with these less invasive techniques. The principal benefits include the following: Decreased patient morbidity, early and latent; Shorter hospitalization; Faster recovery and return to normal daily functions; Equivalent efficacy to open surgical alternatives; Overall cost-effectiveness Cosmetic effect; minimizes loss of body image; Reproducible results. Perfecting the skills necessary for complicated laparoscopic surgery requires a commitment of time and work on the part of the surgeon. This is not a procedure that will be learned by auditing a few cases. Laparoscopic surgery requires diligence in mentally and physically preparing the skills needed for surgery and caution in the application of these skills. Nurses can help to minimize this learning curve by taking an active interest in the current and future practice of laparoscopic surgery and by sharing their knowledge and enthusiasm.

Between a rock and a hard place with E/M coding: dilemmas of compliance and practice financial viability.

Compliance with HCFA's Evaluation and Management (E/M) documentation guidelines presents a tremendous challenge to physicians and their staffs due to the complexity of the guidelines. All too frequently, physicians and staff undercode the services actually provided to prevent additional scrutiny and fraud and abuse charges. This results in significant lost revenue for the practice. This article provides guidance on how to ensure accurate reimbursement while complying with E/M guidelines. Special direction is provided on when and how to bill for a consultation.

Effect of atrial natriuretic factor on renin secretion, plasma renin and aldosterone in dogs with acute unilateral renal artery constriction.

Atrial natriuretic factor (ANF) decreases renin secretion rate (RSR), plasma renin activity (PRA) and plasma aldosterone (PA) in normal dogs. To clarify further the mechanisms responsible for these effects, the left renal artery was constricted in seven anaesthetized dogs prior to ANF administration. Constriction of the left renal artery decreased (P < 0.05) ipsilateral mean renal perfusion pressure (MRPP, 29 +/- 7%), renal plasma flow (RPF, 42 +/- 11%) and glomerular filtration rate (GFR) and filtered sodium load (FLNa, 21 +/- 8.8%). Ipsilateral RSR and peripheral PRA tended to increase, although not significantly. Atrial natriuretic factor infusion did not alter GFR in the clamped kidney and failed to decrease RSR or PRA. Despite this, PA levels decreased significantly (7.8 +/- 2.4 to 5.6 +/- 1.8 ng%). These results suggest that ANF-induced inhibition of renin secretion is largely consequent on its renal haemodynamic actions and that suppression of aldosterone by ANF in vivo is due, in part, to direct effects on the adrenal cortex.

Effects of altered dietary calcium intake in experimental hypertension: role of intracellular free magnesium.

Blood pressure, ionic and hormonal effects of high (1.8%) versus low (0.2%) dietary calcium intakes were explored in uninephrectomized DOC-NaCl rats, in two-kidney, one clip (2K, 1C) Goldblatt hypertensive rats and their respective controls. High-calcium diets lowered blood pressure (P less than 0.05) in DOC-NaCl and in control uninephrectomized rats drinking 1% NaCl. However, calcium loading in renin-dependent 2K, 1C rats elevated blood pressure (P less than 0.05) but had no effect in sham-operated controls. Plasma renin activity rose in all animals, while serum ionized calcium rose significantly only in dietary salt-loaded animals. Intracellular free magnesium levels were consistently, inversely linked to blood pressure (r = -0.92, P less than 0.001). This linkage was independent of plasma renin activity, serum ionized calcium values and dietary calcium content. These results demonstrate that the same alteration in dietary mineral content can produce opposite blood pressure effects in different pathophysiological subtypes of hypertensive disease. We conclude that intracellular free magnesium levels directly participate in the final common pathway of events regulating blood pressure and vasoconstrictor tone.

Pharmacologic probes to identify patients with renovascular hypertension.

The renin-angiotensin system has been shown to play a significant role in maintaining blood pressure and sodium balance in health and disease states. The development of various pharmacologic probes that inhibit the RAS at different and specific points in the renin-angiotensin cascade has facilitated the elucidation of the role of angiotensin II in renovascular hypertension. In a clinical regard, inhibitors of the RAS have been instrumental in screening patients for renovascular hypertension, and in predicting curability with a high degree of reliability. Moreover, use of these drugs in an out-patient setting has been determined to be safe, practical, and reliable, making the work-up for renin-dependent hypertension cost effective and accurate.