This document summarizes a study on surgical outcomes of posterior urethral strictures in children. It describes deficiencies in current knowledge due to lack of pediatric-specific data. The study objectives were to validate a radiographic scoring system ("gapometry index") to predict the type of surgical repair needed based on the size of the urethral defect. The study retrospectively analyzed 38 patients who underwent end-to-end urethral anastomosis. The success rates were over 90% for perineal and transpubic approaches. A higher gapometry index correlated with more complex surgical procedures. The index provided useful information on feasibility of repairs based on urethral gap length and bulbar urethral
This study compared quality of life and functional outcomes between patients receiving a J pouch or side-to-end anastomosis after rectal cancer surgery. The study found that quality of life scores and bowel and sexual function were similar between the two groups at multiple time points post-surgery. While both procedures carried risks of complications, the side-to-end anastomosis may be easier to perform, especially in patients with a narrow pelvis or bulky mesocolon. However, longer follow-up is still needed to determine long-term differences between the procedures.
- Dr. v.veeranath reddy presented on a study comparing outcomes of stapled vs handsewn anastomoses for lower gastrointestinal malignancies.
- 60 patients underwent either stapled (30 patients) or handsewn (30 patients) anastomoses. Mean operating time was shorter for stapled anastomoses.
- Patients who received stapled anastomoses resumed oral feeding 1 day earlier on average. There was no significant difference in hospital stay, infection rates, or leak rates between the two groups. The study concluded stapling devices can reduce operating time and allow for earlier feeding, but do not impact other outcomes compared to handsewn anastomoses.
Limited three slice head CT protocol for monitoring VP shuntsYasser Asiri
This study evaluated a limited three-slice head CT protocol for diagnosing shunt malfunction in patients with hydrocephalus. The study found the three-slice CT protocol had a sensitivity of 91.6% for identifying ventricular abnormalities and 93.5% for identifying catheter tips, comparable to full head CT. While valid, the study was retrospective and limitations included the need for prospective validation. The results suggest the three-slice CT may allow for accurate diagnosis of shunt malfunction with substantially lower radiation exposure compared to standard protocols.
ECIRS versus PCNL for renal stone management. A meta-analysis of 3 studies with over 300 patients found that ECIRS had a shorter mean operative time and higher stone-free rate compared to PCNL, but similar length of hospital stay. A randomized controlled trial assessed 67 patients and found ECIRS had a shorter operative time and higher stone-free rate. Risk of bias was low. The analysis concluded ECIRS is more efficacious than PCNL for renal stones.
Low Ligation of Inferior Mesenteric Artery in Laparoscopic Anterior Resection...King Hussien Cancer Center
This randomized controlled trial compared low ligation versus high ligation of the inferior mesenteric artery during laparoscopic anterior resection for rectal cancer. The primary outcome was genitourinary dysfunction assessed through validated questionnaires and uroflowmetry at 1 and 9 months postoperatively. Results showed that both techniques resulted in impaired genitourinary function, though low ligation led to less worsening of symptoms over time. There were no significant differences in secondary outcomes like complications or oncological adequacy between the groups. In summary, low ligation of the inferior mesenteric artery better preserved genitourinary function after surgery without compromising other outcomes.
This document summarizes findings from a study examining the oncologic safety of nipple-sparing mastectomy (NSM) in patients with a tumor-to-nipple distance (TND) of less than 1 cm. The study retrospectively analyzed 1,369 patients who underwent NSM at a medical center in Seoul, Korea between 2003-2015. The primary endpoint was locoregional recurrence and secondary endpoints included recurrence-free and disease-free survival rates. The study found that a short TND of less than 1 cm did not compromise long-term oncologic safety as long as the nipple-areolar complex was clinically and radiologically negative and retroareolar margins were clear of tumor cells
This document proposes a standardized definition for a successful urethral reconstruction procedure based on both anatomic and functional outcomes. Anatomical success is defined as the ability to traverse the reconstructed urethra during cystoscopy without force. Functional success is defined as improved voiding symptoms and quality of life without new sexual or pain issues, based on patient-reported outcomes. Both should be routinely reported. Follow-up should utilize uroflowmetry and questionnaires to detect recurrence while minimizing invasive testing. This standardized approach allows for more accurate comparison of reconstruction techniques and outcomes.
This document discusses the challenges facing endourologists performing percutaneous nephrolithotomy (PCNL). It outlines several challenges including difficult patient populations, complex kidney stones, congenital kidney anomalies, and technical difficulties. It also describes advances in imaging technologies like multimodal imaging and stone morphometry analyses that help surgical planning. Advances in patient positioning like prone, supine, and flank positions and new instruments for lithotripsy, retrieval, and hemostasis are discussed. The document emphasizes the importance of training and experience to successfully perform the complicated PCNL procedure.
This study compared quality of life and functional outcomes between patients receiving a J pouch or side-to-end anastomosis after rectal cancer surgery. The study found that quality of life scores and bowel and sexual function were similar between the two groups at multiple time points post-surgery. While both procedures carried risks of complications, the side-to-end anastomosis may be easier to perform, especially in patients with a narrow pelvis or bulky mesocolon. However, longer follow-up is still needed to determine long-term differences between the procedures.
- Dr. v.veeranath reddy presented on a study comparing outcomes of stapled vs handsewn anastomoses for lower gastrointestinal malignancies.
- 60 patients underwent either stapled (30 patients) or handsewn (30 patients) anastomoses. Mean operating time was shorter for stapled anastomoses.
- Patients who received stapled anastomoses resumed oral feeding 1 day earlier on average. There was no significant difference in hospital stay, infection rates, or leak rates between the two groups. The study concluded stapling devices can reduce operating time and allow for earlier feeding, but do not impact other outcomes compared to handsewn anastomoses.
Limited three slice head CT protocol for monitoring VP shuntsYasser Asiri
This study evaluated a limited three-slice head CT protocol for diagnosing shunt malfunction in patients with hydrocephalus. The study found the three-slice CT protocol had a sensitivity of 91.6% for identifying ventricular abnormalities and 93.5% for identifying catheter tips, comparable to full head CT. While valid, the study was retrospective and limitations included the need for prospective validation. The results suggest the three-slice CT may allow for accurate diagnosis of shunt malfunction with substantially lower radiation exposure compared to standard protocols.
ECIRS versus PCNL for renal stone management. A meta-analysis of 3 studies with over 300 patients found that ECIRS had a shorter mean operative time and higher stone-free rate compared to PCNL, but similar length of hospital stay. A randomized controlled trial assessed 67 patients and found ECIRS had a shorter operative time and higher stone-free rate. Risk of bias was low. The analysis concluded ECIRS is more efficacious than PCNL for renal stones.
Low Ligation of Inferior Mesenteric Artery in Laparoscopic Anterior Resection...King Hussien Cancer Center
This randomized controlled trial compared low ligation versus high ligation of the inferior mesenteric artery during laparoscopic anterior resection for rectal cancer. The primary outcome was genitourinary dysfunction assessed through validated questionnaires and uroflowmetry at 1 and 9 months postoperatively. Results showed that both techniques resulted in impaired genitourinary function, though low ligation led to less worsening of symptoms over time. There were no significant differences in secondary outcomes like complications or oncological adequacy between the groups. In summary, low ligation of the inferior mesenteric artery better preserved genitourinary function after surgery without compromising other outcomes.
This document summarizes findings from a study examining the oncologic safety of nipple-sparing mastectomy (NSM) in patients with a tumor-to-nipple distance (TND) of less than 1 cm. The study retrospectively analyzed 1,369 patients who underwent NSM at a medical center in Seoul, Korea between 2003-2015. The primary endpoint was locoregional recurrence and secondary endpoints included recurrence-free and disease-free survival rates. The study found that a short TND of less than 1 cm did not compromise long-term oncologic safety as long as the nipple-areolar complex was clinically and radiologically negative and retroareolar margins were clear of tumor cells
This document proposes a standardized definition for a successful urethral reconstruction procedure based on both anatomic and functional outcomes. Anatomical success is defined as the ability to traverse the reconstructed urethra during cystoscopy without force. Functional success is defined as improved voiding symptoms and quality of life without new sexual or pain issues, based on patient-reported outcomes. Both should be routinely reported. Follow-up should utilize uroflowmetry and questionnaires to detect recurrence while minimizing invasive testing. This standardized approach allows for more accurate comparison of reconstruction techniques and outcomes.
This document discusses the challenges facing endourologists performing percutaneous nephrolithotomy (PCNL). It outlines several challenges including difficult patient populations, complex kidney stones, congenital kidney anomalies, and technical difficulties. It also describes advances in imaging technologies like multimodal imaging and stone morphometry analyses that help surgical planning. Advances in patient positioning like prone, supine, and flank positions and new instruments for lithotripsy, retrieval, and hemostasis are discussed. The document emphasizes the importance of training and experience to successfully perform the complicated PCNL procedure.
1. This document discusses erectile dysfunction following radical prostatectomy. It addresses factors such as who is a candidate for nerve-sparing surgery, why rates of post-surgery erectile dysfunction vary, and how erectile function should be defined.
2. The document focuses on rehabilitation protocols to preserve erectile function after surgery. It examines questions such as where and when rehabilitation should be used, what protocols should be considered, and when rehabilitation efforts should be stopped.
3. The overall goal of the document is to provide guidance to doctors on discussing risks and managing expectations regarding erectile function with patients undergoing prostatectomy surgery.
- Recurrent retroperitoneal sarcoma is common, occurring in 50% of patients within 5 years of primary resection. Late recurrences beyond 5 years are also possible, requiring long-term follow-up.
- Patterns of recurrence vary depending on histological subtype. Well-differentiated liposarcoma often recurs locally, which can sometimes be managed with additional surgery. Leiomyosarcoma commonly spreads to distant sites, with 50% of patients experiencing metastases.
- Complete surgical resection remains the main treatment for recurrent retroperitoneal sarcoma when possible. Management decisions must consider the likelihood and implications of local versus distant failure based on histological factors.
The document discusses the anatomy and clinical presentation of colorectal cancer. It notes that 80% of patients present electively with symptoms like altered bowel habits, bleeding, abdominal pain, or anemia. Physical examination often finds a rectal or abdominal mass. Diagnosis relies on colonoscopy and barium enema imaging. Treatment involves surgical resection with chemotherapy and radiation also playing a role depending on cancer stage. Early detection improves prognosis but 55% of patients still present with late stage or metastatic disease.
This document summarizes the surgical approach and management of oral cavity cancer. It discusses that single modality treatment is preferred for stage I-II cancer, while multimodality treatment is essential for stage III-IV cancer. A multidisciplinary tumor board is important to maximize survival while preserving function. The extent of surgery depends on factors like perineural invasion. Frozen section analysis during surgery helps ensure clear margins, and reconstruction is then performed. Sentinel lymph node biopsy is an alternative to elective neck dissection for early stage cancers.
This document provides preparation instructions for CT, MRI, and contrast administration. It outlines screening requirements like medical history, allergies, medications, and creatinine tests. For CT and MRI, it instructs patients to remove metallic objects and drink water. CT patients may need premedication for contrast allergies. MRI screening identifies absolute contraindications like pacemakers. Gadolinium administration requires creatinine testing in high risk patients due to risks of nephrogenic systemic fibrosis. Pregnant women should only have MRI if absolutely necessary due to risks of intravenous gadolinium.
Laparoscopic gastrectomy is being compared to open gastrectomy for gastric cancer treatment. Several studies show that laparoscopic and open approaches have comparable short-term surgical outcomes in terms of complication rates. Regarding long-term oncologic outcomes, multiple studies found no differences in the number of retrieved lymph nodes or disease-free and overall survival rates between the two approaches. While the laparoscopic approach has a learning curve of around 20 cases, it provides better post-operative quality of life measures like less pain and earlier return of bowel function.
ACHALASIA CARDIA: ENDOSCOPIC THERAPY (POEM)Dr Amit Dangi
POEM is a highly effective treatment for achalasia, providing long-term symptom relief in over 90% of patients. Studies have shown POEM to have similar efficacy to laparoscopic Heller myotomy with benefits including shorter procedure time, less pain, and shorter hospital stay. POEM allows for a longer myotomy and more complete treatment of achalasia compared to Heller myotomy and has been shown to be particularly effective for type 3 achalasia. While short-term complications are low, concerns remain around POEM's learning curve. Further research is still needed regarding its use in special cases like sigmoid achalasia and treatment failure patients.
This study compared clinical examination to examination under anesthesia (EUA) for staging locally advanced cervical cancer in 62 patients. There was significant variation between the two methods. Upstaging occurred in 14 patients and downstaging in 12 patients after EUA. Staging changed in 26 patients overall. Parametrial assessment showed the highest discordance. EUA is recommended for staging, especially for parametrial assessment, as it reduces bias and variability compared to clinical examination alone. The authors conclude that EUA or other objective staging methods should be considered mandatory for accurate staging of locally advanced cervical cancer in India given its high prevalence.
This study assessed satisfaction in 89 women who underwent concurrent pelvic organ prolapse (POP) repair and midurethral sling placement to treat stress urinary incontinence (SUI). At the 1-year follow-up, 72% of patients had complete cure of both POP and SUI, while 17% and 10% had persistent SUI or POP respectively. Overall, 88% reported being satisfied. Patients who achieved complete cure of both conditions had a 95% satisfaction rate, while 40% were dissatisfied if SUI was not cured and 22% if POP was not cured. The only outcome measure correlated with satisfaction was improvement in vaginal bulge symptoms. The study highlights the complex relationship between surgical outcomes and patient
- Microinvasive breast cancer (MIBC) has a low but measurable risk of lymph node metastasis. Several studies found positive lymph nodes in 3.7-7.5% of MIBC patients who underwent sentinel lymph node biopsy (SLNB).
- Factors like lymphatic invasion and positive estrogen receptor status predict higher risk of lymph node metastases in MIBC. However, routine SLNB is not warranted for all MIBC patients. Careful selection based on risk factors is needed to avoid overtreatment.
- Studies of patients with DCIS found lymph node micrometastases in 21-34% of those undergoing SLNB for high-risk features like palpable mass or suspicious imaging. However, the clinical significance
This document discusses the MDCT approach to evaluating pelvic trauma. It begins with an overview of pelvic anatomy and classifications of pelvic fractures. It then discusses the prevalence of different fracture patterns seen in 234 pelvic fracture patients per year. Severe fractures made up 16% of cases. CT is useful for imaging pelvic fractures and hemorrhage. Pelvic fracture hemorrhage can cause significant morbidity and mortality. The fracture pattern correlates with whether bleeding is intra-peritoneal or extra-peritoneal. A multidisciplinary approach including trauma surgery, orthopedics, and radiology is optimal for management. CT signs of arterial bleeding are highlighted.
This document discusses several tumor nephrometry scoring systems used to assess renal cell carcinoma complexity and predict surgical outcomes of partial nephrectomy. It describes the RENAL, PADUA, Centrality Index (C-Index), and DAP scoring systems, including their components, development, validation studies, limitations, and comparisons. The goal of these systems is to standardize reporting on tumor characteristics, surgical complexity, and allow for better patient counseling and comparisons between studies. Later systems like DAP aimed to improve on earlier ones by integrating and optimizing their individual strengths.
External beam radiotherapy (EBRT) for differentiated thyroid cancer (DTC) is debated due to lack of prospective studies. Surgery and radioactive iodine usually effective for locoregional control. Recent retrospective studies report benefit in select patients. Goal of EBRT is to improve locoregional control while limiting treatment toxicity
The document discusses the overuse of CT scans, particularly in emergency departments. It notes that CT use has increased 11 times faster than the rate of ED visits over the last 10 years. Now around 25% of all CT scans are performed in the ED. However, less than 7% of patients presenting with dizziness or syncope benefited from head CT scans. The overuse of CT scans is due to factors like fear of lawsuits, perception that patients want the test, and pressure to utilize expensive machines. Guidelines recommend reducing unnecessary CT scans by using decision rules and clinical assessments to determine who truly needs a CT scan. The document advocates judicious use of CT scans by only using them for appropriate clinical indications and considering alternative imaging methods
This document discusses the management of appendicular lumps. It notes that appendicular lumps are inflammatory tumors consisting of the inflamed appendix and surrounding tissues. Treatment options include emergency surgery, conservative management followed by interval surgery, or totally conservative management without interval surgery. Conservative treatment is associated with a risk of missing hidden pathologies. Emergency surgery carries a high risk of complications while interval surgery risks appendicular abscess or perforation during the waiting period. Randomized controlled trials have found that conservative treatment without interval surgery appears to be the best approach for appendicular masses and abscesses. The document examines factors to consider in decision making and presents cases studies from a tertiary care center.
The document summarizes key landmark breast cancer trials that helped establish modern standards of care. The NSABP B-04 trial showed that modified radical mastectomy was as effective as radical mastectomy. The NSABP B-06 and Milan trials established breast-conserving surgery plus radiation as an equivalent alternative to mastectomy. The NSABP B-32 trial demonstrated sentinel node biopsy alone had similar outcomes as axillary dissection for node-negative cancer. Subsequent trials like ALMANAC and Z011 found sentinel node biopsy reduced arm morbidity without compromising survival. These trials provided critical evidence supporting less invasive surgical approaches for breast cancer.
This study evaluated the diagnostic utility of combined fine needle aspiration and core biopsy (CFNACB) in patients with prior non-diagnostic thyroid nodule FNAs. CFNACB was performed on 90 thyroid nodules in 82 patients with prior non-diagnostic FNAs. CFNACB yielded a diagnostic result in 87% of nodules, with core biopsy alone diagnostic in 77% of nodules. Core biopsy demonstrated superior diagnostic performance compared to repeat FNA. CFNACB was shown to be a safe procedure with no reported complications.
Rectal prolapse: Do we really have a perfect surgical solution? pptx copyDr Amit Dangi
Ventral rectopexy has gained worldwide acceptance for surgical correction of rectal prolapse and high-grade internal rectal intussusception. The technique is based on correcting the descent of the posterior and middle compartments combined with reinforcement of the vaginal septum and elevation of the pelvic floor. anterior mobilization of the distal rectum and mesh suspension performed during VR can correct full-thickness rectal prolapse, rectoceles, and internal rec- tal prolapse and can be combined with vaginal prolapse procedures, such as sacrocolpopexy, in patients with multicompartment pelvic floor defects.
Sephaneous vein graft for anterior urethral stricutreDr. Manjul Maurya
El-Morsi et al. [10] first used a saphenous vein graft (SVG) in 1972 in 10 patients with promising results and suggested it as an alternative to Johanson staged urethroplasty, which was widely used at that time
1. This document discusses erectile dysfunction following radical prostatectomy. It addresses factors such as who is a candidate for nerve-sparing surgery, why rates of post-surgery erectile dysfunction vary, and how erectile function should be defined.
2. The document focuses on rehabilitation protocols to preserve erectile function after surgery. It examines questions such as where and when rehabilitation should be used, what protocols should be considered, and when rehabilitation efforts should be stopped.
3. The overall goal of the document is to provide guidance to doctors on discussing risks and managing expectations regarding erectile function with patients undergoing prostatectomy surgery.
- Recurrent retroperitoneal sarcoma is common, occurring in 50% of patients within 5 years of primary resection. Late recurrences beyond 5 years are also possible, requiring long-term follow-up.
- Patterns of recurrence vary depending on histological subtype. Well-differentiated liposarcoma often recurs locally, which can sometimes be managed with additional surgery. Leiomyosarcoma commonly spreads to distant sites, with 50% of patients experiencing metastases.
- Complete surgical resection remains the main treatment for recurrent retroperitoneal sarcoma when possible. Management decisions must consider the likelihood and implications of local versus distant failure based on histological factors.
The document discusses the anatomy and clinical presentation of colorectal cancer. It notes that 80% of patients present electively with symptoms like altered bowel habits, bleeding, abdominal pain, or anemia. Physical examination often finds a rectal or abdominal mass. Diagnosis relies on colonoscopy and barium enema imaging. Treatment involves surgical resection with chemotherapy and radiation also playing a role depending on cancer stage. Early detection improves prognosis but 55% of patients still present with late stage or metastatic disease.
This document summarizes the surgical approach and management of oral cavity cancer. It discusses that single modality treatment is preferred for stage I-II cancer, while multimodality treatment is essential for stage III-IV cancer. A multidisciplinary tumor board is important to maximize survival while preserving function. The extent of surgery depends on factors like perineural invasion. Frozen section analysis during surgery helps ensure clear margins, and reconstruction is then performed. Sentinel lymph node biopsy is an alternative to elective neck dissection for early stage cancers.
This document provides preparation instructions for CT, MRI, and contrast administration. It outlines screening requirements like medical history, allergies, medications, and creatinine tests. For CT and MRI, it instructs patients to remove metallic objects and drink water. CT patients may need premedication for contrast allergies. MRI screening identifies absolute contraindications like pacemakers. Gadolinium administration requires creatinine testing in high risk patients due to risks of nephrogenic systemic fibrosis. Pregnant women should only have MRI if absolutely necessary due to risks of intravenous gadolinium.
Laparoscopic gastrectomy is being compared to open gastrectomy for gastric cancer treatment. Several studies show that laparoscopic and open approaches have comparable short-term surgical outcomes in terms of complication rates. Regarding long-term oncologic outcomes, multiple studies found no differences in the number of retrieved lymph nodes or disease-free and overall survival rates between the two approaches. While the laparoscopic approach has a learning curve of around 20 cases, it provides better post-operative quality of life measures like less pain and earlier return of bowel function.
ACHALASIA CARDIA: ENDOSCOPIC THERAPY (POEM)Dr Amit Dangi
POEM is a highly effective treatment for achalasia, providing long-term symptom relief in over 90% of patients. Studies have shown POEM to have similar efficacy to laparoscopic Heller myotomy with benefits including shorter procedure time, less pain, and shorter hospital stay. POEM allows for a longer myotomy and more complete treatment of achalasia compared to Heller myotomy and has been shown to be particularly effective for type 3 achalasia. While short-term complications are low, concerns remain around POEM's learning curve. Further research is still needed regarding its use in special cases like sigmoid achalasia and treatment failure patients.
This study compared clinical examination to examination under anesthesia (EUA) for staging locally advanced cervical cancer in 62 patients. There was significant variation between the two methods. Upstaging occurred in 14 patients and downstaging in 12 patients after EUA. Staging changed in 26 patients overall. Parametrial assessment showed the highest discordance. EUA is recommended for staging, especially for parametrial assessment, as it reduces bias and variability compared to clinical examination alone. The authors conclude that EUA or other objective staging methods should be considered mandatory for accurate staging of locally advanced cervical cancer in India given its high prevalence.
This study assessed satisfaction in 89 women who underwent concurrent pelvic organ prolapse (POP) repair and midurethral sling placement to treat stress urinary incontinence (SUI). At the 1-year follow-up, 72% of patients had complete cure of both POP and SUI, while 17% and 10% had persistent SUI or POP respectively. Overall, 88% reported being satisfied. Patients who achieved complete cure of both conditions had a 95% satisfaction rate, while 40% were dissatisfied if SUI was not cured and 22% if POP was not cured. The only outcome measure correlated with satisfaction was improvement in vaginal bulge symptoms. The study highlights the complex relationship between surgical outcomes and patient
- Microinvasive breast cancer (MIBC) has a low but measurable risk of lymph node metastasis. Several studies found positive lymph nodes in 3.7-7.5% of MIBC patients who underwent sentinel lymph node biopsy (SLNB).
- Factors like lymphatic invasion and positive estrogen receptor status predict higher risk of lymph node metastases in MIBC. However, routine SLNB is not warranted for all MIBC patients. Careful selection based on risk factors is needed to avoid overtreatment.
- Studies of patients with DCIS found lymph node micrometastases in 21-34% of those undergoing SLNB for high-risk features like palpable mass or suspicious imaging. However, the clinical significance
This document discusses the MDCT approach to evaluating pelvic trauma. It begins with an overview of pelvic anatomy and classifications of pelvic fractures. It then discusses the prevalence of different fracture patterns seen in 234 pelvic fracture patients per year. Severe fractures made up 16% of cases. CT is useful for imaging pelvic fractures and hemorrhage. Pelvic fracture hemorrhage can cause significant morbidity and mortality. The fracture pattern correlates with whether bleeding is intra-peritoneal or extra-peritoneal. A multidisciplinary approach including trauma surgery, orthopedics, and radiology is optimal for management. CT signs of arterial bleeding are highlighted.
This document discusses several tumor nephrometry scoring systems used to assess renal cell carcinoma complexity and predict surgical outcomes of partial nephrectomy. It describes the RENAL, PADUA, Centrality Index (C-Index), and DAP scoring systems, including their components, development, validation studies, limitations, and comparisons. The goal of these systems is to standardize reporting on tumor characteristics, surgical complexity, and allow for better patient counseling and comparisons between studies. Later systems like DAP aimed to improve on earlier ones by integrating and optimizing their individual strengths.
External beam radiotherapy (EBRT) for differentiated thyroid cancer (DTC) is debated due to lack of prospective studies. Surgery and radioactive iodine usually effective for locoregional control. Recent retrospective studies report benefit in select patients. Goal of EBRT is to improve locoregional control while limiting treatment toxicity
The document discusses the overuse of CT scans, particularly in emergency departments. It notes that CT use has increased 11 times faster than the rate of ED visits over the last 10 years. Now around 25% of all CT scans are performed in the ED. However, less than 7% of patients presenting with dizziness or syncope benefited from head CT scans. The overuse of CT scans is due to factors like fear of lawsuits, perception that patients want the test, and pressure to utilize expensive machines. Guidelines recommend reducing unnecessary CT scans by using decision rules and clinical assessments to determine who truly needs a CT scan. The document advocates judicious use of CT scans by only using them for appropriate clinical indications and considering alternative imaging methods
This document discusses the management of appendicular lumps. It notes that appendicular lumps are inflammatory tumors consisting of the inflamed appendix and surrounding tissues. Treatment options include emergency surgery, conservative management followed by interval surgery, or totally conservative management without interval surgery. Conservative treatment is associated with a risk of missing hidden pathologies. Emergency surgery carries a high risk of complications while interval surgery risks appendicular abscess or perforation during the waiting period. Randomized controlled trials have found that conservative treatment without interval surgery appears to be the best approach for appendicular masses and abscesses. The document examines factors to consider in decision making and presents cases studies from a tertiary care center.
The document summarizes key landmark breast cancer trials that helped establish modern standards of care. The NSABP B-04 trial showed that modified radical mastectomy was as effective as radical mastectomy. The NSABP B-06 and Milan trials established breast-conserving surgery plus radiation as an equivalent alternative to mastectomy. The NSABP B-32 trial demonstrated sentinel node biopsy alone had similar outcomes as axillary dissection for node-negative cancer. Subsequent trials like ALMANAC and Z011 found sentinel node biopsy reduced arm morbidity without compromising survival. These trials provided critical evidence supporting less invasive surgical approaches for breast cancer.
This study evaluated the diagnostic utility of combined fine needle aspiration and core biopsy (CFNACB) in patients with prior non-diagnostic thyroid nodule FNAs. CFNACB was performed on 90 thyroid nodules in 82 patients with prior non-diagnostic FNAs. CFNACB yielded a diagnostic result in 87% of nodules, with core biopsy alone diagnostic in 77% of nodules. Core biopsy demonstrated superior diagnostic performance compared to repeat FNA. CFNACB was shown to be a safe procedure with no reported complications.
Rectal prolapse: Do we really have a perfect surgical solution? pptx copyDr Amit Dangi
Ventral rectopexy has gained worldwide acceptance for surgical correction of rectal prolapse and high-grade internal rectal intussusception. The technique is based on correcting the descent of the posterior and middle compartments combined with reinforcement of the vaginal septum and elevation of the pelvic floor. anterior mobilization of the distal rectum and mesh suspension performed during VR can correct full-thickness rectal prolapse, rectoceles, and internal rec- tal prolapse and can be combined with vaginal prolapse procedures, such as sacrocolpopexy, in patients with multicompartment pelvic floor defects.
Sephaneous vein graft for anterior urethral stricutreDr. Manjul Maurya
El-Morsi et al. [10] first used a saphenous vein graft (SVG) in 1972 in 10 patients with promising results and suggested it as an alternative to Johanson staged urethroplasty, which was widely used at that time
Ureteric stent versus percutaneous nephrostomy for acute ureteral obstruction - clinical outcome and quality of life: a bi-center prospective study
Urology Journal Club
Laparoscopic resections in colorectal malignancies by Dr Harsh Shah (www.gast...Dr Harsh Shah
Laparoscopic resection is as effective as open resection for colorectal cancer based on evidence from randomized trials. While laparoscopic surgery provides short term benefits like earlier recovery and less pain, long term oncologic outcomes are equivalent between the two approaches. However, the evidence shows laparoscopic surgery should only be performed by experienced surgeons, as those without extensive laparoscopic experience may not achieve the same results and patient outcomes are worse if conversion from laparoscopic to open is needed.
Short term endpoints of conventional versus laparoscopic assisted surgerymanjil malla
This randomized controlled trial compared short-term outcomes of laparoscopic versus open surgery for colorectal cancer. It found that laparoscopic surgery was as safe as open surgery based on similar tumor and node status, short-term outcomes, and quality of life. However, laparoscopic rectal resection had higher positive margin rates and more complications, so it cannot yet be routinely recommended for rectal cancer. Overall, the laparoscopic approach provided equivalent cancer resection as open surgery for colon cancer.
This document summarizes the safety of bariatric surgery based on a presentation. It discusses the history and evolution of bariatric procedures, common procedures and their complications. It reviews evidence from large studies like LABS-1 and a 2014 meta-analysis that showed bariatric surgery has low 30-day mortality rates of 0.3-0.8% and major complication rates of 4.3-17%. While gastric bypass has higher weight loss, gastric banding and sleeve gastrectomy have lower mortality and complication risks. The document concludes bariatric surgery is very safe, with gastric bypass having a 30-day mortality risk one-tenth of cardiovascular surgery.
Laparoscopic resection of stage II-III rectal cancer was compared to open resection in a randomized controlled trial. While pathological outcomes initially favored open resection, disease-free survival and local recurrence rates at 2 years were equivalent between the two groups. This suggests that while laparoscopic resection may be more technically challenging, oncologic outcomes are comparable to open when performed by experienced surgeons.
CT urography provides a comprehensive non-invasive evaluation of the urinary tract. It is performed as a multiphase exam, including an unenhanced phase followed by corticomedullary, nephrographic and excretory phases after intravenous contrast administration. The nephrographic phase provides the highest sensitivity for detecting renal masses and abnormalities. Various dose reduction techniques can be used, including lower dose protocols, split-bolus contrast injection, dual-energy CT, and iterative reconstruction. These allow radiation doses to be reduced by up to 80% compared to traditional triple-phase CT urography exams.
This annual progress report summarizes a study on the outcomes of interlaminar endoscopy for lumbar canal stenosis. The study has achieved its targets so far, enrolling 58 patients and conducting clinical evaluations and surgical decompression via interlaminar endoscopy. Preliminary results show improvements in pain and disability scores post-operatively. Upcoming work involves further follow-up assessments and data analysis to determine clinical and radiological predictors of surgical outcomes. The study aims to improve understanding and management of lumbar canal stenosis.
This document discusses rectal prolapse and various surgical treatments. It provides details on:
1) Types of rectal prolapse including full thickness, mucosal, and internal prolapse.
2) Common anatomical abnormalities that can cause rectal prolapse like a deep pouch of Douglas or lax muscles.
3) Investigations used to evaluate rectal prolapse like imaging, sigmoidoscopy, and manometry.
4) Goals of treatment include controlling the prolapse, restoring bowel function and continence, and preventing recurrence.
5) Numerous surgical procedures are described ranging from perineal to abdominal approaches, with recurrence rates varying from 0-38% depending on the
This document discusses stricture urethra and its management. It provides details on the epidemiology, etiology, clinical evaluation and surgical options for urethral strictures. Key points include that bulbar strictures are the most common, iatrogenic causes have increased in prevalence, clinical evaluation involves uroflowmetry, retrograde urethrogram and cystoscopy, and surgical options range from dilation and direct visual internal urethrotomy for short strictures to various types of urethroplasty using grafts or flaps for longer or complex strictures.
This document discusses varicoceles, which are abnormal dilations and tortuosity of the internal spermatic veins. It provides definitions, epidemiology, pathogenesis, diagnosis, associated pathological processes like testicular hypotrophy, and effects on semen quality. Key points include that varicoceles are more common on the left side and prevalence increases with infertility. Causes involve increased venous pressure and valvular incompetence. Diagnosis involves physical exam and ultrasound to assess reflux and testicular size. Associated issues involve hypotrophy, though catch-up growth may occur after repair, and effects on semen quality are unclear in adolescents.
Efficacy of laparoscopically assisted high ligation of patent processus vagin...Hisham Ahmed,M.D,PhD,MRCS
Laparoscopically assisted high ligation of patent processus vaginalis in children was evaluated in this study. 40 patients underwent the procedure, which involved inserting trocars and using laparoscopy to identify and ligate the patent processus with sutures tied externally. The procedure had a low complication rate, short hospital stay, and detected unsuspected contralateral hernias in 28% of cases. At 18-month follow up, there was one recurrence with no other complications, demonstrating this technique is a safe and effective minimally invasive option for treating hernias in children.
This document discusses the history and current state of urinary stress incontinence surgery. It covers the main theories around the pathophysiology of stress incontinence, including the hammock hypothesis and integral theory. A variety of surgical techniques are described that address stress incontinence by supporting the urethra or bladder neck, such as Burch colposuspension, transvaginal tape, and mid-urethral slings. The document also discusses drawbacks of different procedures and outcomes. Future treatments explored include stem cell therapy to regenerate pelvic floor muscles.
This annual progress report summarizes an ongoing 8-year study analyzing clinical and radiological predictors of surgical difficulty in interlaminar endoscopic spine surgery. The study has enrolled 88 patients and conducted evaluations to identify suitable candidates for the procedure. Preliminary results show significant reductions in pain and disability scores post-surgery. Upcoming work includes follow-up assessments and data analysis to identify predictors of surgical outcomes and complications to inform patient selection and improve quality of life. The study is progressing well and has presented initial findings at a recent neurosurgery conference. No additional budget or staff is required to complete the remaining work.
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Surgical outcomes of post traumatic posterior urethral strictures in children
1. SURGICAL OUTCOMES OF POST-
TRAUMATIC POSTERIOR
URETHRAL STRICTURES IN
CHILDREN
DR ARKA BANERJEE
PAEDIATRIC SURGERY, MAMC
MODERATOR: DR S. S. PANDA
2. INTRODUCTION
• Pediatric pelvic # after blunt trauma – 2.4-4.6%
• Of these, posterior urethral inuries are seen in 0.47-4.2%
• Historically, transpubic approach preferred due to technical difficulty with
transperineal route
• Recent reports suggest a similar clinical outcome
3. DEFICIENCIES IN KNOWLEDGE
• Management algorithms are extrapolations from adult literature
• Difficult challenge for pediatric urologists
• Small pelvis
• Small urethral calibre
• Tissue fragility
• Poor spongiosal support
• Unstable posterior urethra
• Small prostate
• Lax pubourethral ligaments
• Small perineal space
• Small pelvis
• No data
• age-related feasibility of end-to-end urethroplasty
• Functional urinary and sexual outcomes
4.
5. OBJECTIVE
• Validate a simple preoperative radiographic score to predict the type of surgical
repair for traumatic posterior urethral strictures in children
• No previous study has been done in children to correlate gapometry with
posterior urethral defects
7. MATERIALS AND METHODS
• Calculation of gapometry index [G/U ratio – ]
• VCUG
• RGU
lt of urethral
gapbulbar urethral
length
8. MATERIALS AND METHODS
• Location of PS soft tissue junction noted on xray (corresponds to bulbopendulous
junction of urethra) – transition point between curved bulbar urethra and straight
penile urethra
• Bulbar urethral length – measured from its blind proximal end to the
bulbopendulous junction using a semi-rigid, malleable strip
• Length of the urethral gap – measured as a fraction of bulbar urethral length and
called the index of elastic lengthening or gap/urethral (G/U) index or gapometry index
9. MATERIALS AND METHODS
• End-to-end urethral anastomosis done by single experienced surgeon
• After excision of the intervening scarred segment and circumferential mobilization of the
bulbar urethra down to the penoscrotal junction.
• Gapometry index was analysed for 2 patient groups
• Group 1 – simple perineal approach
• Group 2 – pts requiring a more elaborate procedure (eg. Inferior pubectomy/perineo-
abdominal transpubic approach)
• Subdivisions
• <5 yrs
• 5-15 yrs
10. MATERIALS AND METHODS
• Feasibility of anastomosis analysed from the G/U index
• Follow-up : 22 ± 0.42 months
• Symptomatic worsening of flow
• Success of procedure
• Peak urinary flow > 15 ml/s
• No radiographic evidence of urethral stricture
• No need of urethral instrumentation on follow-up
13. RESULTS
• Success rate
• Perineal – 94.6%
• Transpubic – 92.3%
• G/U index: gradually increased as the complexity of the surgical approach increased
• Reflected by an increasing urethral gap in pts requiring simple perineal repair than those
needing inferior pubectomy
• Abdominoperineal repair: Urethral gap did not significantly correlate with G/U index
• The urethral gap was significantly less in <5 yrs age in both groups
• did not correlate with increasing G/U index with age
14. DISCUSSION
• Current belief
• Posterior urethral gaps <2 cm can be repaired by simple perineal approach
• Elaborate perineal/transpubic approach needed for longer gaps
• Singular variables reported for predicting the feasibility of a tension-free urethroplasty
• Morey and McAninch [1997] – stretched penile length >15 cm is a good indicator of anastomotic repair
• Da Silva and Sampaio [2002] – to bridge each 1cm gap of excised urethra, the remaining normal urethra
would have to be mobilized by 3.2 cm in a 1 yr old to 6.6 cm in a 70 yr old
• Koraitim [2008] – length of anterior urethra is crucial for bridging the urethral gap [variable in different
patients and elongation on stretch is directly proportional to its original length]
15. DISCUSSION
• This study
• urethral gap (mean length 2.1 cm, range 1.4–2.6 cm) could be bridged by a bulbar urethra
with a mean length of 4.8 cm (range 4.5–5.2 cm) – achieved by elastic lengthening of 44%
(36–52%) of the original length of the bulbar urethra
• Transpubic approach bridged a urethral gap of 3.6 cm (range 3.2–4 cm) for a bulbar
urethral length of 4.6 cm (range 4.4–4.8 cm), translating into a urethral lengthening of 0.78
cm (range 0.72–0.82 cm) using the gapometry score
• Koraitim [2009] in the adult population reported a G/U index of 0.33 for a simple
perineal repair, above which an elaborate perineal or transpubic approach is
recommended
16. CONCLUSION
• Surgical approach to posterior urethroplasty is dependent not only on the length
of the bulboprostatic urethral gap, but also on that of the bulbar urethra
• G/U index is a composite reflection of both these parameters and hence it is the
best representation of urethral elastic lengthening
• Urethral gaps shorter than 44% of the bulbar urethral length can be mostly
corrected by a simple perineal approach
• Urethral gaps more than 40% of the length of the bulbar urethra require an
elaborate perineo-abdominal transpubic procedure
17. CONCLUSION
• G/U index showed a steady increase from 0.44 for simple perineal repair to 0.71 for
inferior pubectomy and 0.87 for perineo-abdominal transpubic repair
• Simple perineal repair and inferior pubectomy showed a significant correlation with
the urethral gaps (2.8 and 3.6 cm respectively)
• Significant difference in the stricture length between age groups of <5 yrs and 5–15
yrs for the same surgical approach
• G/U index however remained unaffected by age
• Age-related increase in bulbar length, which attains maximum dimensions by 5 yrs would
theoretically counter the variations in stricture length. This may account for the relatively
standard G/U index values across all ages
18. LIMITATIONS
• Small sample size (owing to the low incidence of pediatric urethral stricture
disease)
• Impact of other factors that can influence the surgical approach for urethroplasty
• pubic arch width
• initial management (suprapubic cystostomy vs. primary repair)
• previous failed urethroplasties
• bladder base fistulae
• degree of scarred tissue (moderate vs. severe)
19.
20. OBJECTIVE
• Investigate long-term functional outcomes and quality of life (QOL) of adults who
previously underwent urethroplasty for blunt urethral injury at a young age
21. MATERIALS AND METHODS
• Retrospective study
• 35 yrs (1978-2013)
• Inclusion criteria
• Pts who sustained blunt urethral injury at ≤18 yrs age and subsequently underwent urethral reconstruction by a single surgeon
• Exclusion criteria
• <18 yrs at the time of survey collection
• Lack of capacity to participate
• Confirmed incarceration
• Non-English speaking
• Lack of contact information
• Deceased
22. MATERIALS AND METHODS
• Pts contacted, informed consent obtained
• Web-based validated questionnaire via RedCap®
• to assess their current urinary, sexual, and quality of life status
• to obtain current demographic information
• Records reviewed
• Demographic data
• Clinical characteristics
• Age
• Trauma
• Mechanism
• Type of urethroplasty
• Any additional interventions before or after definitive repair
23. MATERIALS AND METHODS
• Urinary function outcome: Urethral Stricture Surgery Patient-Reported Outcome
Measurement (USS-PROM) [2011]
• first questionnaire specifically designed for patients with urethral stricture disease
• LUTS domain
• six-item bother questions that generates a total score that varies from 0 (asymptomatic) to
24 (most symptomatic)
• Urinary symptom-specific QOL question (score of 0 – 10)
• Peeling’s voiding picture, an illustration of a man voiding scored between 1 (best) and
4 (worst)
24. MATERIALS AND METHODS
• Sexual health
• Sexual Health Inventory for Men (SHIM) for erectile function
• 5-item questionnaire
• Rate different aspects of their erections from 1 – 5
• Score varies between 5 (worst function) to 25 (perfect erections)
• A score of 21 or lower is considered erectile dysfunction
• Male Sexual Health Questionnaire-Ejaculatory Dysfunction (MSHQ-EjD) Short Form to specifically assess ejaculatory
function
• 4 questions
• Scores from 0-5
• Three questions relate to the properties of ejaculation
• Frequency (from total absence to always present)
• Strength of ejaculation (from total absence to normal strength)
• Volume of ejaculation (from total absence to normal amount)
• Fourth question regards the patients’ concern about their ejaculatory condition (ranging from the condition without any problems
to deep concerns).
25. MATERIALS AND METHODS
• Quality of Life
• EQ-5D-3L
• 5-item validated questionnaire that assesses individual’s global health on 5 different domains
• Mobility
• Self-care
• Usual activities
• Pain/discomfort
• Anxiety/depression
• Respondents select the level of bother from most bothersome to the least on a 3-level scale: no
problems, some problems, extreme problems
• Dichotomized the responses to “no problem” and “any problem” for final analysis
• Visual analog scale for the respondents to rate their self-rated health on a 0 – 10 scale labeled as
‘Best imaginable health state’ (10) and ‘Worst imaginable health state’ (0).
27. RESULTS
• Median age: 17 yrs (Range 4-18 yrs)
• Median follow-up: 19 yrs (Range 8-28 yrs)
• Median interval between injury and repair
• Posterior strictures: 4 (3-14) months
• Anterior strictures: 6 (4-108) months
• Satisfaction
• Very satisfied (80%)
• Satisfied (20%)
• Intervention-free survival – 93%
• 3 patients had seen a urologist in past 1 yr
• 2 for unrelated complaints
• 1 for urinary frequency
28. RESULTS: USS-PROM
• Median LUTS bother domain (0 least, 24 worst) was 10 (range 7 – 16)
• 12/15 (80%) reported that urinary symptoms do not interfere with daily life
• 2/15 reported symptoms interfering “a little”
• 1 reported symptoms interfering “a lot”
• urinary frequency despite strong urine stream and lack of incontinence on other domains
• Median force of stream assessed by Peeling’s voiding strength picture (1 strongest stream, 4 weakest stream) was
reported as 2 (IQR: 1.5-2)
• 4 patients reported stream strength of 1
• 8 reported 2
• 3 reported 3
• No patients reported strength of 4
• None reported urinary incontinence or any history of any anti-incontinence procedures
29. RESULTS: SHIM
• Median SHIM score was 24 (IQR: 22.5-24)
• 1 patient with a SHIM score of <20, who reported not being sexually active despite
perfect erectile function (SHIM score was 10 in this patient)
• 1 patient reported a score of 20
• Remainder scored 21 or more
• No one reported medical or surgical intervention for erectile dysfunction (ED)
30. RESULTS: MSHQ-EJD
• 3 questions for orgasmic function (0 worst function, 15 normal function) and one question assessing bother
• Median ejaculatory function score was 14 (IQR: 13-14.75)
• 12/15 patients (80%) reported “no problem at all” or “not at all bothered” by their ejaculatory function
• Six patients reported having fathered a child and none reported infertility
• Two patients reported history of pain that they attributed to their urethroplasty
• 1 patient with moderate pain in the scrotum and perineum
• 1 with mild pain in perineum
• None reported pain interfering with daily activity or compromising function
• Three patients reported penile curvature after urethroplasty which has persisted to date
• All 3 reported a severity of <30 degrees curvature
• None have required treatments
• Results of the self-assessed QOL in 5 different domains of EQ-5D-3L health questionnaire demonstrated
• overall median quality of life was 8 (IQR:7.5-8)
32. DISCUSSION: OVERALL SUCCESS
• A relatively normal and functional life regarding sexual and voiding function can be expected,
and patients are overall satisfied with their operation with no major residual morbidity
• Similar quality of life score on EQ-5D-3L compared to healthy adults (8 IQR: 7.5 – 8 vs 9 IQR: 7.5
– 9.5 respectively)
• No patients reported erectile dysfunction (SHIM score >21)
• Lack of the need for repeated intervention is a commonly considered successful outcome after
urethroplasty and only 1 patient (6%) in this cohort reported a secondary endoscopic
intervention
• Short-term urethroplasty success rate after anterior and posterior urethroplasty is about 90%
• Urethroplasty outcomes are durable and if the patients have not required an intervention in the
first few years of follow-up, the chance of them needing an additional intervention is low
33. DISCUSSION: ED
• Erectile dysfunction is a dreaded long-term complication after pelvic fracture given severe soft tissue
and vascular injury that can ensue
• The reported rate of de novo ED after pelvic fracture is 34% (25%–45%) in the literature, and
urethroplasty has been reported to harbor an additional 3% risk in the adult population
• In long-term follow-up, patients did not report erectile dysfunction
• This survey did not include a specific question about penile length
• In anterior urethroplasty literature in the adult population, ED has been a matter of debate since
Mundy [1993] reported de novo permanent ED in 5% of patients after anterior anastomotic
urethroplasty and 0.9% after augmented urethroplasty with a graft
• Anterior urethroplasty does not have a deleterious effect on erectile function in pediatric population as
well
34. CONCLUSION
• Urethroplasty after blunt anterior and posterior urethral injury in children is
associated with high surgical success rates, similar to adult population.
• Despite possible transient voiding dysfunction at early postoperative years, these
children seem to be left with minimal voiding and sexual function morbidity in
adulthood
35. LIMITATIONS
• Small sample size
• Urethral reconstruction has undergone significant changes over 35 years
• Although the basic surgical principals have remained constant, follow up protocols and methods
of assessing symptoms have changed
• They did not perform surveillance cystoscopy on any of these patients, which is the routine
current practice in adults within the first year after repair, and therefore these patients might
have anatomic recurrence of stricture
• No preoperative PROM data for comparison and the long interval between survey response and
the injury might affect the participants’ scores
• The data is not equipped to conclusively report the success rate of urethroplasty in children