Common Iliac Vessels Research Articles

Is there any clinical significance of compression of left common iliac vein?

Deep venous thrombosis (DVT) has been noted to occur as much as 60% more frequently in the left lower extremity than in the right extremity [1]. Virchow first suggested this disparity in 1851 when he observed that iliofemoral vein thrombosis was five times more likely to occur in the left leg than in the right leg [2]. In 1957, May and Thurner [3] pathologic changes at the points where the right common iliac artery crosses over the left common iliac artery. They found that the right iliac artery compressed the left iliac vein against the fifth lumbar vertebra in 22% of 430 cadavers. A recent large number of study using computed tomography showed that mean percentage of compression was 36.6%: 29.7% (66/222) of greater than 50% compression and 7.2% (16/222) of greater than 70% compression [4]. They concluded that increasing levels of percentage compression were not associated with left-sided DVT up to 70%; however, greater than 70% compression might be associated with left DVT. The results of this study are consistent with those of previous smaller studies on iliac vein compression [5,6]. However, Kibbe et al. [7] reported that hemodynamically significant left common iliac vein compression is a frequent anatomic variant in asymptomatic individuals. Hence, they concluded that compression of the left iliac vein might represent a normal anatomic pattern that has thus far been thought as a pathologic condition. Several studies have demonstrated that therapeutic roles of lymphadenectomy in endometrial cancer and cervical cancer [8-10]. Moreover, extended systematic lymph node dissection resulted in high regional tumor control and high metastatic lymph node rate in cervical cancer [11,12]. To perform the extended systematic lymphadenectomy, it is important to know the exact anatomy of major retroperitoneal vascular structure. Kose et al. [13] demonstrated that prevalence of major retroperitoneal vascular structure anomalies was 17% and common iliac artery and/or vein anomalies was 1.8%. Presence of these anomalies may lead to devastating complications resulting in organ loss or death. However, a few data on anomalies of common iliac vessels are available. Cancer patients are at increased risk of venous thromboembolism and pulmonary embolism. For prediction of venous thromboembolism, several biomarkers were introduced including blood count analysis (elevated leukocyte and platelet count and decreased hemoglobin), D-dimer, prothrombin fragment, soluble P-selectin, and clotting factor VII [14]. Furthermore, risk assessment models were developed that include clinical and laboratory markers. From a clinical perspective, it would be helpful to have biomarkers that enable early identification of cancer patients at risk of venous thromboembolism and to target anticoagulation for primary prevention of venous thormboembolism based on risk stratification. In summary, severe compression of the common iliac vein may be associated with left-sided DVT. We should be concerned about the degree of compression to the common iliac vein during systematic para-aortic and pelvic lymphadenectomy for the treatment of gynecologic cancer patients. To prevent life threatening bleeding during systematic lymphadenectomy, it is important to know the exact anatomy of major retroperitoneal vascular structure including common iliac vessels [15]. Thromboprophylaxis is considered to reduce venous thromoembolism using several biomarkers and clinical parameters.

719A Rare Variant of Lemierre's Syndrome – Fusobacterium necrophorum Sepsis from Gynecological Origin

History: 19 year-old female presented with abdominal pain, nausea, vomiting and fever. Initially the patient denied any sexually transmitted diseases or recent pregnancy. Physical examination: Negative except severe pallor (+) Laboratory Values: Hemoglobin 2.9 g/dl, white blood cell count was normal 8000/microliter. Peripheral blood smear: no evidence of hemolysis, but severe microcytic anemia and thrombocytosis. Imaging: Abdominal and chest computerized tomography showed pelvic thrombophlebitis with extensive clot burden extending from common femoral vein to common iliac vessels with fluid in adenexa as well as segmental/sub-segmental pulmonary emboli. Other tests: Admission blood cultures grew Fusobacterium necrophorum on day 3. Hospital course: Detailed sexual history was taken again by a female medical resident and the patient revealed she had an abortion (not done by a medical professional). Diagnosis and Management: Keeping in mind . Lemierre’s syndrome is a rare, potentially severe disorder consisting of septic emboli from an internal jugular vein thrombus after oropharyngeal infection. There a few reports illustrating a variant of Lemierre’s syndrome with the female genital tract being the source. Case Report Background

Transperitoneal 3D laparoendoscopic single-site (LESS) nephrectomy: the first clinical case in China

Objective To summarize our experience on the first clinical case of transperitoneal 3Dlaparoendoscopic single-site(LESS)nephrectomy in mainland China,and to assess its safety and feasibility after obtaining the informed consents. Methods On August 5,2013,we performed a 3DLESS nephrectomy using Karl Storz 3Dendoscope and a multi-channel Quad-Port(OlympusTM)through a 3cm skin incision at our institute.The patient was a 69years old man,with a body mass index(BMI)of 27.7kg/m2 and a preoperative serum creatinine level of 81μmol/L.99mTc DTPA was used to determine the glomerular filtration rate(GFR).The preoperative unilateral renal function was 65mL/min for the left side and 9.5mL/min for the right side.And therefore he was diagnosed as"right kidney severe hydrocephalus"and received right nephrectomy.A 3cm external retus incision was made at the umbilicus level at 1cm site.After dissection of the renal pedicle blood vessels the renal blood vessels,the ureterogonadal packet was left en bloc and transected at the level when crossing the common iliac vessels. The kidney was extracted through the original incision after the skin incision was extended to 4cm.Results The procedure was smoothly completed without any extra skin incision.The operating time was 154min,with an estimated blood loss of 150mL. The gastrointestinal function recovered on the first day after operation.Postoperative serum creatinine level on the first day was 76μmol/L.Donor Visual Analog Pain Scores at postoperative day 1,2and 3were 2/10,1/10and 0/10,respectively.The recovery of the patient was uneventful and he was discharged on the 3rd postoperative day.Conclusion Transperitoneal 3D laparoendoscopic single-site nephrectomy is safe,feasible and effective.It has the clinical benefits of less pain,rapid recovery and small incision.The procedure allows for a strong stereo perception,accurate manipulation,and a decreased demand for hand-eye coordination of hand,with a promising clinical future.But more clinical experience needs to be accumulated through more cases.

Accurate Needle Placement - A Must For a Safe and Effective Bone Marrow Biopsy Procedure: An Anatomical and CT Based Cadaver Study

IntroductionBone marrow examination is an essential and commonly performed bedside procedure in diagnosis and staging of hematological malignancies and benign hematological disorders. Although when performed on the posterior superior iliac spine(PSIS), it is considered a safe procedure with minimal complications, cases of excessive bleeding , hematoma formation, injury to neurovascular structures, retroperitoneal and intraperitoneal hemorrhage, pseudo aneurysm formation and gluteal compartment syndrome have been reported. Cases of retroperitoneal hemorrhage are presumed to occur due to penetration of the needle through the iliac crest indicating that accurate placement and angulation of the biopsy needle is critical to avoid iatrogenic complications. Bone marrow biopsy has been described in various publications and text books. However, standardized technique for positioning the biopsy needle and its penetration orientation are lacking. Various authors have described the correct needle placement and orientation as perpendicular to the bone or pointing towards the anterior superior iliac spine (ASIS) but most of the studies do not specify angulation of the needle. These methods appear to be extrapolated from personal experience and, to date, an evidence based approach for needle angulation has not been described. We present a comparison of different described approaches to perform bone marrow biopsy relative to injury to critical structures should the needle penetrate the inner bone cortex. This study compares the two most commonly used PSIS biopsy approaches that advance the needle towards: 1. The Umbilicus (Medial Approach) 2. Ipsilateral ASIS (Lateral Approach). MethodsThe study was done on cadavers in the dissection laboratory at the Albert Einstein College of Medicine. The procedure was performed by Attendings and Fellows in Hematology Division who are experienced in performing bone marrow biopsy. Manual Jamshidi needles or powered bone marrow device were used. Anatomy professors helped identify the landmarks and performed dissections after biopsy procedures. The Radiology Department assisted with performing and reading the CT scans of the pelvises.The first phase of study involved placing two dissected cadavers with intact pelvises in prone and lateral positions. Bone marrow needle was placed perpendicular to the PSIS and, during penetration, the direction was changed toward the umbilicus for the Medial Approach and towards the ASIS during the Lateral Approach. A bone marrow biopsy was obtained. Subsequently, using the same needle track, the needle was deliberately pushed through the inner ilial cortex to assess the resultant potential for injury. Keeping the needles in situ, metal wire probes were inserted via the needle for better visualization. The cadavers were further dissected to identify injury to neurovascular bundles and adjacent structures.In the second phase, bone marrow biopsy was performed on two intact cadavers. The needles with inserted probes were left in situ to mark different angulations. The cadavers were then scanned and dissected to identify penetrated structures and closely related neurovascular bundles that were at risk had the orientation varied slightly. ResultsDissections and CT scan imaging showed that Lateral Approach was less likely to cause injury to significant neurovascular structures and penetrate the sacroiliac joint in comparison to the Medial Approach. Using the Medial Approach, in the event of penetration of inner cortex, we documented injury to the sacro-iliac joint, femoral nerve, common iliac vessels and mesentery of the sigmoid colon. The needle was observed in close proximity to the iliolumbar vein and artery and the lumbosacral trunk. Using the Lateral Approach, the structures adjacent to the needle were limited to the iliacus muscle and the lateral cutaneous branch of femoral nerve. The lateral approach had the added benefit of more consistent orientation since the relationship of the ASIS to the PSIS is both consistent and palpable whereas the location of the umbilicus may vary.We suggest that the safest way to perform a bone marrow biopsy is to advance the needle in a perpendicular direction to reach the PSIS. Once the needle penetrates the outer cortex of the bone, the direction should be changed pointing towards the ipsilateral ASIS. We believe that this procedure will obviate complications reported in the literature.▪▪ Disclosures:No relevant conflicts of interest to declare.

Development of a Reliable Model of Total Abdominal Wall Transplantation

Among the most common complications associated with abdominal organ transplantation are issues with abdominal wall closure. This difficulty, along with the recent rise in the use of vascularized composite allotransplantation, has led surgeons to the notion of abdominal wall transplantation. The authors have developed a novel surgical model for a full-thickness total abdominal wall transplant based on a unilateral pedicle between fully major histocompatibility complex-mismatched rat strains. An established cuff technique was used to anastomose the donor's common iliac vessels to the recipient's femoral vessels. Three groups (n = 6 per group) received FK506 monotherapy, 0.25, 0.50, or 0.75 mg/kg per day. The transplants were assessed daily for evidence of rejection by visual inspection. Hematoxylin and eosin skin biopsies and fluorescence-activated cell sorting analysis of the recipients' peripheral blood were performed. No signs of rejection were observed in the animals receiving FK506, 0.50 or 0.75 mg/kg per day. Those receiving 0.25 mg/kg per day, however, displayed a mixed rejection response. Flow cytometric analysis did not show evidence of donor-specific chimerism. A full-thickness abdominal wall graft based on a unilateral pedicle is a technically feasible and reliable small-animal surgical model. The use of greater than or equal to 0.50 mg/kg per day FK506 results in 100 percent graft survival. Future plans are to use this model to investigate the immunologic interaction of a concomitant solid organ and an abdominal wall allograft, as would likely occur in the clinical situation.

Anatomie du système lymphatique pelvien

The lymphatic system of the pelvis collects the lymph of the genital and urinary organs and of the digestive tract. It is formed by lymphatic nodes and vessels situated inside the conjunctive tissue, near the organs (visceral lymphatic nodes) but especially along the external, internal and common iliac vessels (iliac lymphatic nodes). These nodes receive afferent vessels issued from the different pelvic organs. From the iliac lymphnodes arise efferent vessels running towards lymphatic collectors, situated above them, and which end in the lymphatic lombar duct. The lymphatic pathways represent the preferential way of scattering of cancerous cells. Therefore, the knowledge of the anatomy, of the situation and of the draining of the nodes is of the utmost importance in the evaluation of a cancer of a pelvic organ.

Identification of sacral plexus at robot-assisted nerve-sparing radical hysterectomy with extended lymphadenectomy

목적: Demonstrate a new instrument, technique or procedure 방법: We use da Vinci system to demonstrate surgical technique of identification of Sacral plexus in part of Robot assisted nerve sparing radical hysterectomy with extended lymphadenectomy for early cervical cancer. It necessary to understand anatomy of deep sacral plexus to prevent the nerve injury in case of extensive lymphadenectomy in high risk cervical cancer. The sacral plexus is formed by the union of the lumbosacral trunk (from the anterior rami of L4 and L5) and the anterior rami of the first, second, third, and fourth sacral nerves. The nerves forming the sacral plexus converge to the lower part of the greater sciatic foramen and unite to form a flattened band, sciatic nerve. The clinical significant of sacral plexus is that an injury to the sacral plexus, leaves the patient with a deficit in the sensation and/or movement and experience neuropathic pain in the lower limb supplied by the corresponding nerve(s) affected. After extended lymphadenectomy, we could confirm the pelvic anatomy more clearly including superior hypogastric plexus, promontory, lower part of aorta, common iliac vessels, hypogastric nerve communicating with parasympathetic nerves, and vesical branches of inferior hypogastic plexus. And sacral plexus, lumbosacral trunk, S1, S2 and S3. 결과: No intraoperative complications or postoperative nerve injury that required treatment occurred. 결론: It would be expected in sacral plexus identifying extended lymphadenectomy that the more number of lymph nodes, metastatic nodes and therapeutic benefits for improvement of survival. However, it needs to evaluate long term survival benefit and functional benefits about identifying sacral plexus extended lymphadenectomy

Role of lymphadenectomy for invasive bladder cancer.

Radical cystectomy with lymph node dissection remains the standard of care in the treatment of muscle-invasive and refractory non-invasive bladder cancer. Over the past decade, the extent of lymphadenectomy has varied to include dissection up to the common iliac vessels and aortic bifurcation proximally (may also extend up to the level of the inferior mesenteric artery), the genitofemoral nerve laterally, the circumflex iliac vein and lymph node of Cloquet distally, and the hypogastric vessels posteriorly (obturator fossa, presciatic nodes bilaterally and the presacral lymph nodes over the sacral promontory). Evidence supports the role of lymphadenectomy as both a therapeutic and prognostic variable in patients with invasive bladder cancer. We review the literature regarding the role and extent of lymphadenectomy, as well as its impact on patient outcomes.

Should all men having a radical prostatectomy have a pelvic lymph node dissection? No

For decades, pelvic lymph node dissection (PLND) has been performed at the time of radical prostatectomy (RP) as a lymph node (LN) staging procedure in prostate cancer (PCa) patients. However, growing evidence suggests that PLND might not be an accurate tool for predicting lymph node invasion (LNI). Recently, Mattei and colleagues examined the primary prostate lymphatic drainage sites in PCa patients.1 In their report, they defined “limited PLND” as the removal of LNs along the external iliac vein and obturator nerve; they reported that this dissection missed up to 62% of the primary LNs. Similarly, the extended PLND area, which also included LNs medial and lateral to the internal iliac vein, missed up to 37% of the primary LNs. The authors suggested a new “super extended” PLND area, which additionally includes the LNs along the common iliac vessels up to the ureteric crossing. However, the authors found that even this “super extended” PLND missed 25% of the primary LNs.1 Consequently, the authors concluded that the removal of all primary LNs is not feasible in all or even most patients because of cost, time, extent of surgery and risk of complications. It is noteworthy that the complication rate after PLND may be up to 51%;2 the complication rate appears to be associated with increasing the extent of the dissection.3,4 These findings question the usefulness of PLND as a staging procedure in PCa patients. Moreover, these findings indicate the need to develop more accurate and, possibly less invasive, staging tools.

Robotic Repair of Post-Cystectomy Ureteroileal Anastomotic Strictures: Techniques for Success

Post-cystectomy ureteroileal anastomotic strictures that fail percutaneous or endourologic management require operative repair. These cases can be challenging, and few reports of robotic repairs exist in the available literature. Here we describe our stepwise approach to robotic surgical repair of ureteroileal strictures. The da Vinci(®) Si Surgical System (Intuitive Surgical, Sunnyvale, CA) was used in all cases. The port configuration is similar to robotic cystectomy, although the ports are placed in a more cephalad location on the abdominal wall. The same port configuration was used for both right- and left-sided procedures. Principal surgical techniques used include dissection of the colonic mesentery, careful peeling of the ureter off of the common iliac vessels, and mobilization of the ureter on either side of the sigmoid colon. Four patients with a mean age of 72 years underwent this procedure at our institution, including 2 with left-sided strictures and 2 with right-sided strictures. Three of the 4 patients had undergone prior abdominal surgery in addition to their cystectomy. All patients failed initial percutaneous and/or endourologic attempts to resolve their stricture. The ureteroileal strictures were successfully repaired robotically in all cases. With mean follow-up of 16 months no major complications were encountered, and all patients remain free of stricture recurrence to date. Robotic ureteroileal anastomotic stricture repair is feasible for both right- and left-sided cases. A similar operative approach can be used regardless of stricture side.

Topography of Lymph Node Metastases in Prostate Cancer Patients Undergoing Radical Prostatectomy and Extended Lymphadenectomy: Results of a Combined Molecular and Histopathologic Mapping Study

BackgroundTo determine the anatomic extent of pelvic lymph node dissection (PLND) in prostate cancer (PCa) patients at the time of radical prostatectomy (RP), knowledge about the topography of lymph node (LN) metastases is required. ObjectiveBecause small-volume LN metastases may be missed by standard histopathologic examination, we performed an anatomic mapping study combining molecular and histopathologic LN examination in PCa patients treated with RP and extended PLND (ePLND). Design, setting, and participantsA total of 52 patients with intermediate- (n=15) and high-risk (n=37) PCa underwent RP and ePLND without neoadjuvant treatment. ePLND included dissection of the obturator fossa and the external, internal, and common iliac vessels. Outcome measurements and statistical analysisLNs ≥3mm in diameter were analysed by quantitative reverse transcriptase-polymerase chain reaction (qRT-PCR) for prostate-specific antigen (PSA) expression and by standard histopathology. Topography of positive LNs was determined descriptively. Results and limitationsOf 1469 dissected LNs (median: 27 LNs per patient), 1186 LNs were ≥3mm. Molecular LN analysis was positive in 127 LNs of 27 patients (52%) including 32 LNs of 12 patients (23%) with histopathologic positive LNs. Molecular examination was negative in 3 of 35 histopathologic positive LNs (9%). Combining both molecular and histopathologic findings, positive LNs were located in the standard PLND field defined by obturator fossa and external iliac vessels in 71%, along the internal iliac vessels in 16%, and along the common iliac vessels in 13%. Of LN-positive patients, 63% had LN metastases outside the standard PLND field. The internal iliac field was involved in 48% and the common iliac field in 37% of node-positive patients. Notably, internal and common iliac vessels were the only positive regions in 7% and 11% of node-positive patients, respectively. A limitation is the small number of patients included. ConclusionsThese findings underline the enhanced sensitivity of qRT-PCR in comparison with standard histopathology for detection of small-volume LN metastases in PCa patients. Our results support an ePLND including the common iliac vessels, at least up to the ureteral crossing, to optimise nodal staging and to remove LNs potentially harbouring metastases.

Incidence and location of lymph node metastases in patients undergoing radical cystectomy for clinical non–muscle invasive bladder cancer: Results from a prospective lymph node mapping study

ObjectivesThe objective of this study is to investigate the incidence and location of lymph node metastases (LNMs) in patients undergoing radical cystectomy (RC) and lymph node dissection (LND) for clinical non–muscle invasive bladder cancer (NMIBC). Methods and materialsProspectively collected data of 637 patients who underwent RC and ‘superextended’ LND with intent-to-cure for urothelial carcinoma of the bladder between 2002 and 2008 were examined. Inclusion criteria were (a) clinical stage Ta, Tis-only, or T1, (b) muscle presence at diagnostic transurethral resection in clinical T1 patients, (c) no prior diagnosis of≥T2 disease, (d) no neoadjuvant therapy, and (e) lymphatic tissue sample submitted from all 13 predesignated locations. Lymph node mapping was performed in all patients to determine the location of metastatic lymph nodes. Median follow-up time was 4.7 years. Recurrence-free survival and overall survival were reported. ResultsA total of 114 patients were included of whom 9 patients (7.9%) had LNM. Stratified by clinical stage, LNM was present in 6/67 (9.0%) patients with cT1, 3/25 (12.0%) patients with cTis-only, and none of the 22 patients with cTa. Of the 9 node-positive patients (33.3%), 3 had LNM proximal to the aortic bifurcation. No skip metastases were found. After RC, 27 patients (23.7%) were upstaged to muscle invasive disease; of whom 16.7% had cT1, 2.6% had cTa, and 4.4% had cTis-only. Of the remaining 87 patients with pathologic NMIBC, 1 patient (1.1%) had LNM, limited to the true pelvis. Five-year RFS was 82.3%, 81.5%, and 62.0% in patients with pathologic NMIBC, clinical NMIBC, and pathologic muscle invasive bladder cancer, respectively. ConclusionsRoutine LND is important in patients with cT1 and cTis-only bladder cancer, but may have limited value in patients with cTa. LNM beyond the boundaries of a standard LND occurred in up to one-third of node-positive patients. In the absence of skip metastases, however, performing a standard LND would correctly identify all node-positive patients. Whether removal of LNM proximal to the common iliac vessels provides a survival benefit remains to be evaluated in future prospective studies.

Injury to major abdominal vessels during posterior lumbar interbody fusion. A case report and review of the literature

Numerous cases of injury to major abdominal vessels during the excision of a lumbar herniated disc have been reported, but no cases of injury during interbody fusion by a posterior approach have been described. To report on an injury to common iliac vessels during a posterior lumbar interbody fusion (PLIF) and discuss the causes and possible preventive measures. A unique case report and a review of the literature. The hospital chart and autopsy report of a single patient were analyzed. A 52-year-old woman with L4-L5 disc degeneration underwent PLIF. During scraping of the vertebral end plates, there was a sudden increase in blood flow from the disc space, however not copious, with no changes of vital parameters. When the patient was placed supine, severe hypotension and abdominal distension led to strongly suspect a lesion to abdominal vessels. At laparotomy, carried out by a vascular surgeon, a vast retroperitoneal hematoma was evacuated and the vascular lesions were repaired. Postoperatively, the patient continued to lose blood from the abdominal drains and after 4 hours, she was reoperated by another vascular surgeon, who found a diffuse hemorrhage from the small vessels in the surgical field. Soon after the surgery the patient died. The lesions were produced by a shaver used for scraping the vertebral end plates. The absence of abundant bleeding from the disc space was possibly because of the compression of the iliac vessels by the pads of the frame on which the patient was lying. The causes of the lesions and possible prevention of similar injuries are analyzed.

Anatomical Relationships of the Anterior Blood Vessels to the Lower Lumbar Intervertebral Discs

Intra-abdominal vascular injuries are rare during posterior lumbar spinal surgery, but they can result in major morbidity or mortality when they do occur. We are aware of no prior studies that have used prone patient positioning during magnetic resonance imaging for the purpose of characterizing the retroperitoneal iliac vasculature with respect to the intervertebral disc. The purpose of this study was to define the vascular anatomy adjacent to the lower lumbar spine with use of supine and prone magnetic resonance imaging. A prospective observational study included thirty patients without spinal abnormality who underwent supine and prone magnetic resonance imaging without abdominal compression. The spinal levels of the aortic bifurcation and confluence of the common iliac veins were identified. The proximity of the anterior iliac vessels to the anterior and posterior aspects of the anulus fibrosus in sagittal and coronal planes was measured by two observers, and interobserver reliability was calculated. The aortic bifurcation and confluence of the common iliac veins were most commonly at the level of the L4 vertebral body and migrated cranially with prone positioning. The common iliac vessels were closer to the anterior aspect of the intervertebral disc and to the midline at L4-L5 as compared with L5-S1, consistent with the bifurcation at the L4 vertebral body. Prone positioning resulted in greater distances between the disc and iliac vessels at L4-L5 and L5-S1 by an average of 3 mm. The position of the anterior aspect of the anulus with respect to each iliac vessel demonstrated substantial variation between subjects. The intraclass correlation coefficient for measurement of vessel position exceeded 0.9, demonstrating excellent interobserver reliability. This study confirmed the L4 level of the aortic bifurcation and iliac vein coalescence but also demonstrated substantial mobility of the great vessels with positioning. Supine magnetic resonance imaging will underestimate the proximity of the vessels to the intervertebral disc. Large interindividual variation in the location of vasculature was noted, emphasizing the importance of careful study of the location of the retroperitoneal vessels on a case-by-case basis.

Adjuvant Surgery in Testicular Cancer Patients Undergoing Postchemotherapy Retroperitoneal Lymph Node Dissection

To evaluate the clinicopathologic characteristics of patients undergoing adjuvant surgery during postchemotherapy retroperitoneal lymph node dissection (PC-RPLND). From 2004 to 2010, 85 testicular cancer patients underwent PC-RPLND by a single surgeon (S.D.). A bilateral template approach was utilized with nerve-sparing technique whenever feasible. The clinicopathologic and outcome of patients who underwent removal of any organ or structure during PC-RPLND were reviewed. Of 85 patients undergoing PC-RPLND, 28 (33%) required adjuvant procedures. Thirteen (15%) required vascular procedures including cavotomy/caval resection in 6, aortic resection in 8, common iliac vessels resection in 4, and renal vessels resection/reimplant in 2. Twelve patients (14%) required adjuvant nephrectomy (ten of 12 left-sided). There was one ureteral resection with appendiceal substitution, one partial duodenectomy, two cholecystectomy, two thoracotomies, four liver resection/biopsy, and one neck dissection. There were eight early complications (28%), including vocal cord paralysis, brachial plexus injury, lower extremities compartment syndrome, thigh numbness, upper gastrointestinal bleeding, retroperitoneal hematoma, and alcohol withdrawal. No perioperative death was reported. Retroperitoneal pathology revealed mature teratoma in 11 patients (39%), fibrosis in 8 (28%), and viable germ cell tumor (GCT) in 9 (32%). A total of 75, 82, and 66% of patients with fibrosis, teratoma, and viable GCT, respectively, had no evidence of recurrence at a mean follow-up of 18months. Many patients undergoing PC-RPLND require adjuvant surgery, including vascular procedures and nephrectomy. The excellent outcomes associated with low operative morbidity and mortality validates such aggressive surgical approaches performed by experienced surgeons.

Adjuvant surgery in patients with testicular cancer undergoing post-chemotherapy retroperitoneal lymph node dissection.

335 Background: Up to 50% of patients who undergo induction chemotherapy for metastatic germ cell cancer have significant residual retroperitoneal disease in whom post chemotherapy RPLND is indicated with intent to cure. Since complete resection is a critical component in PC-RPLND, meticulous dissection of the retroperitoneum with resection of involved organs or structures (adjuvant surgery) should be considered whenever feasible to ensure optimal outcome. Methods: From 2004 to 2010, 85 testicular cancer patients underwent PC-RPLND by a single surgeon (SD). A bilateral template approach was utilized with nerve sparing technique whenever feasible. The clinico-pathologic and outcome of patients who underwent adjuvant surgery during PC-RPLND were reviewed. Results: Of 85 patients undergoing PC-RPLND, 28 (33%) required adjuvant procedures. Thirteen (15%) required vascular procedures including cavotomy/ caval resection in six, aortic resection in eight, common iliac vessels resection in four and renal vessels resection/reimplant in two. Twelve patients (14%) required adjuvant nephrectomy (10/12 left sided). There was 1 ureteral resection with appendiceal substitution, 1 partial duodenectomy, 2 cholecystectomy, 2 thoracotomies, 4 liver resection/ biopsy, and 1 neck dissection. There were 8 early complications (28%) including vocal cord paralysis, brachial plexus injury, lower extremities compartment syndrome, thigh numbness, UGI bleeding, retroperitoneal hematoma and alcohol withdrawal. No peri-operative death was reported. Retroperitoneal pathology revealed mature teratoma in 11 (39%), fibrosis in 8 (28%) and viable germ cell tumor (GCT) in 9 (32%) patients. 75%, 82% and 66% of patients with fibrosis, teratoma and viable GCT had no evidence of recurrence in mean follow up of 18 months. Conclusions: A significant number of patients undergoing PC-RPLND require adjuvant surgery including vascular procedures and nephrectomy. The excellent outcomes associated with low operative morbidity/mortality validate such aggressive surgical approaches performed by experienced surgeons.

Deep Vein Thrombosis /Pulmonary Embolism in a Patient with Retroperitoneal Fibrosis: A Case Report

Introduction: Retroperitoneal Fibrosis (RPF) is a clinicopathological condition characterized by inflammatory fibrotic reaction around infrarenal aorta, iliac vessels and surrounding retroperitoneum with myriad presentations. This case report shows how a Deep Vein Thrombosis (DVT) and subsequent Pulmonary Embolism (PE) can be a potential complication of this disease. A potential temporal association was seen with chronic beta blocker use and retroperitoneal fibrosis. Case presentation: A 62-year-old Caucasian male with history of hypertension on chronic beta-blocker therapy for 2 years (Metoprolol 50 mg twice daily) presented with sub-acute left sided non-radiating lower back pain of 5-day duration. Computerized Tomography (CT) scan with contrast of the abdomen and pelvis revealed large segment of inflammatory stranding involving the periaortic retroperitoneum extending from the level of the kidneys upto the pelvis and incasing the left Iliac veins. CT guided retroperitoneal core biopsy was done which was consistent with retroperitoneal fibrosis. Two months later, patient presented with complain of acute onset shortness of breath and increasing lower extremity edema, on the left side. Electrocardiogram was consistent with a finding of new onset Atrial fibrillation (A fib). Ultra Sono Gram (USG) Doppler study of lower extremities unveiled occlusive left sided DVT of the popliteal vein. A CT Angiography demonstrated segmental and sub-segmental pulmonary emboli of the right lower lobe with no evident pulmonary edema. He was treated with steroids, digoxin and warfarin. On follow up a repeat CT scan three months later of the abdomen and pelvis showed stable retroperitoneal mass with no further progression. Conclusion: Our patient presented with lower extremity edema and imaging revealed extension of RPF to involve common iliac vessels. With beta-blockers as a possible inciting event, RPF causing venous stasis, iliac vein compression and thus DVT/PE is the most plausible explanation This case reports add to the medical literature how DVT/PE can be cause by an underlying disease entity not related to the usual causes and if not worked up patients may be labeled as having unprovoked events. Any relationship between beta blockers and RFP is questionable and has not been proven in any randomized trials, but should be thought of by the physician if such clinical situation is encountered.

Findings concerning testis, vas deference, and epididymis in adult cases with nonpalpable testes

In this study, we aimed to state the relationship between testis, epididymis and vas deference, in adult cases with nonpalpable testis. Between January 1996 and December 2009, we evaluated 154 adult cases with nonpalpable testes. Mean age was 23 years (20-27 years). Explorations were performed by open inguinal incision, laparoscopy, and by inguinal incision and laparoscopy together on 22, 131 and 1 patient, respectively. Of all the unilateral cases, 32 were accepted as vanishing testis. In five of these cases, vas deference was ending inside the abdomen, and in the others, it was ending inside the scrotum. In the remaining 99 unilateral and 22 bilateral cases, 143 testes were found in total. Testes were found in the inguinal canal as atrophic in one case, at the right renal pedicle level with dysmorphic testis in one case, and anterior to the internal ring between the bladder and the common iliac vessels at a smaller than normal size in 119 cases. One (0.69%) case did not have epididymis. While epididymis was attached to the testis only at the head and tail locations in 88 (61.53%) cases, it was totally attached to the testis in 54 (37.76%) cases. There is an obviously high incidence rate of testis and vas deference anomalies, where epididymis is the most frequent one. In cases with abdominal testes, this rate is highest for high localised abdominal testes.

Arterio-venous fistula following a lumbar disc surgery

Vascular complications during posterior lumbar disc surgery are rare and its presentation with varicose veins is even rarer. A 23 year-old male patient presented with large varicose veins in right lower limb. He underwent a posterior lumbar spine discectomy surgery. He noticed mild swelling of the distal third right lower limb 3 months after index surgery and reported 6 months later when he developed varicose veins. Duplex Doppler confirmed varicose veins of the long saphenous vein and its tributaries with a patent deep venous system. A digital subtraction angiogram demonstrated a large right common iliac artery (CIA) false aneurysm with an arteriovenous fistula between right common iliac vessels. He had a right CIA covered stent insertion with good results. Varicose veins were later managed with sapheno-femoral junction ligation and a below knee long saphenous vein stripping. At six month follow-up the lower limb swelling had completely recovered and duplex ultrasound did not show any recurrence of varicose veins.

Super Extended Versus Extended Pelvic Lymph Node Dissection in Patients Undergoing Radical Cystectomy for Bladder Cancer: A Comparative Study

There is evidence from retrospective studies that radical cystectomy with extended pelvic lymph node dissection provides better staging and outcomes than limited lymph node dissection. However, the optimal limits of extended lymph node dissection remain unclear. We compared oncological outcomes at 2 cystectomy centers where 2 different extended lymph node dissection templates are practiced to determine whether removing lymphatic tissue up to the inferior mesenteric artery confers an additional survival advantage. Patients undergoing radical cystectomy and extended lymph node dissection with curative intent from 1985 to 2005 were included in analysis if they met certain criteria, including clinically organ confined urothelial bladder carcinoma (cN0M0), pathological stage pT2-pT3, negative surgical margins and no neoadjuvant therapy. Survival and recurrence data were analyzed. Demographic data and pathological subgroup distribution (pT2 and pT3) were similar in the 554 University of Southern California and 405 University of Bern patients. University of Southern California patients had higher median number of lymph nodes removed than University of Bern patients (38 vs 22, p <0.0001) and a higher incidence of lymph node metastasis (35% vs 28%, p = 0.02). However, the University of Southern California and University of Bern groups had similar 5-year recurrence-free survival for pT2pN0-2 (57% vs 67%) and pT3pN0-2 (32% vs 34%) disease (p = 0.55 and 0.44, respectively). The overall recurrence rate was equal at the 2 institutions (38%). Meticulous extended lymph node dissection up to the mid-upper third of the common iliac vessels appears to provide survival and recurrence outcomes similar to those of a super extended template up to the inferior mesenteric artery. Complete skeletonization in the extended lymph node dissection template is more important than nodal yield. This does not exclude the possibility that certain patient subgroups with suspicious nodes or after neoadjuvant chemotherapy may benefit from more extensive lymph node dissection.