Failure Of Surgical Treatment Research Articles

How to avoid surgical failures

Problems and failures in orthodontic-orthognathic surgical treatment arefrequently discussed among colleagues, but not often written about. This lack of documentation may be attributed to a natural inclination for us to report our successes and hide our failures. More positively, we believe the lack of written material on complications probably relates more to the overwhelming success rate in these procedures than to an inclination to hide failures. In addition, some complications are clearly a result of the orthodontic care before and/or after the surgical procedure. This article concentrates on exploring the many complications in orthognathic surgery that are more a result of the orthodontic phase of care, and how the orthodontist can react to and manage surgical complications to achieve a successful result. The more the orthodontist understands the nature of surgical problems, the more able he/she is to manage them.

Trigger finger in children.

At the Texas Scottish Rite Hospital for Children, 239 trigger digits in 176 children were seen and treated surgically over a 10-year period. Trigger fingers accounted for 33 (14%) of these digits in 18 (10%) of the patients. In 8 of 18 patients (44%) the fingers continued to trigger after A-1 pulley release. In children, trigger fingers are different from trigger thumbs. Trigger fingers in children are uncommon and have variable causes, and an A-1 pulley release alone will not always correct the triggering. Additional treatments, such as resection of one or both limbs of the sublimis tendon or an A-3 pulley release, may be required. An awareness of other contributing factors and readiness to explore the entire flexor mechanism should help prevent failure of surgical treatment.

Quantitative methodologies for selection of patients with recurrent abdominopelvic sarcoma for treatment

Peritoneal sarcomatosis is a major cause of surgical treatment failure in patients with abdominal or pelvic sarcoma. In the past, patients with this condition have had a lethal outcome. In this study, 43 consecutive patients with recurrent sarcomatosis were studied in order to evaluate an aggressive reoperative approach. In all patients, the goal of surgery was to resect all recurrent sarcoma in the abdomen and pelvis. In 30 patients in whom sarcomatosis was demonstrated and in whom a complete cytoreduction could be performed, resection was associated with peri-operative intraperitoneal chemotherapy with doxorubicin or cisplatin plus doxorubicin. Using a standardised and quantitative methodology to assess local-regional recurrence and dissemination on peritoneal surfaces, the clinical features that may affect prognosis were tabulated and analysed statistically. The median survival of these 43 patients was 20 months. Clinical features that had a significant impact on survival were involvement of less than six abdominopelvic regions ( P=0.0009), an increase in the involvement of abdominopelvic regions of less than four regions ( P=0.0007), involvement of less than 10 anatomic sites ( P=0.0002), complete cytoreduction with tumour reduced to nodules <2.5 mm ( P=0.005) and a Peritoneal Cancer Index less than 13 ( P=0.01). Histological type and grade of recurrent sarcoma were not correlated with prognosis. In the multivariate analysis, an increase in abdominopelvic regions by four or more showed a risk ratio of 18.5. The involvement of 10 or more anatomic sites showed a risk ratio of 5.9. These data suggest that selected patients with recurrent sarcoma should be considered for further treatment and that the results of aggressive reoperative surgery and peri-operative intraperitoneal chemotherapy are greatly dependent on the volume and distribution of disease, determined at the initiation of therapy. Because of the great likelihood of local-regional treatment failure, the use of peri-operative intraperitoneal chemotherapy in a randomised study in patients with primary abdominopelvic sarcoma should be considered.

A NEW TECHNIQUE FOR CORRECTION OF THE HIDDEN PENIS IN CHILDREN AND ADULTS

A phenomenon known as hidden penis has numerous origins, including congenital buried penis and obesity with descent of the escutcheon. No previous report to our knowledge mentions abnormal hypermobility of ventral skin and dartos fascia, which is a major cause of surgical treatment failures. Because the skin and dartos fascia are inadequately attached to Buck's fascia, the corporeal bodies telescope proximally inside the scrotum and pubis. Therefore, the subdermis of the penoscrotal junction must also be tacked to the tunica albuginea ventrally to stabilize the proximal penile skin and prevent the penis from retracting into the scrotum. The surgical technique for correction of the hidden penis in adult and pediatric patients with adequate penile shaft skin is described. Surgery for hidden penis from multiple causes was performed in 6 adults and 7 children. Tacking sutures were taken from the subdermis of the ventral penoscrotal junction to the tunica albuginea in all cases. A combination procedure with either suprapubic dermatolipectomy, tacking of the penopubic subdermis to the rectus fascia, penoscrotal Z plasty, circumcision revision or lateral penile shaft Z plasty also was performed in some patients. Improvement was noted in all cases. One child requires suprapubic lipectomy for optimal improvement and 3 minor wound problems occurred. Surgery for hidden penis achieves marked aesthetic and often functional improvement. Surgical failure can be diminished by placing ventral tacking sutures from the tunica albuginea to the subdermis of the penoscrotal junction.

脳動脈瘤治療の現状と今後の動向について

Recently developed interventional radiologic techniques, such as embolization with platinum coils, may induce change of selection for cerebral aneurysmal therapy. The aim of the present study was to investigate current and future status of the treatment for cerebral aneurysms.We analyzed 159 cases with cerebral aneurysms by choice of treatment, surgery or interventional coil embolization. One hundred cases were ruptured, and 59 with 63 aneurysms were unruptured during the past 3 years. Fundamentally, the ruptured aneurysms were treated better than H & K grade IV.For patients who were older than 70 years, had a H & K grade IV, and/or were difficult to clip surgically, interventional coil embolization was selected. Thirteen cases with ruptured aneurysms were treated with embolization after subarachnoid hemorrhage, and one was embolized after failed surgical treatment. In the case of unruptured aneurysms, aneurysms with surgical difficulty, such as posterior circulation aneurysms or internal carotid (C2-3) aneurysms, coil embolization was selected. Among 63 unruptured aneurysms, 9 were treated with coil embolization.Fourteen percent of ruptured and unruptured aneurysms were treated with coil embolization. The factors by which treatment was decided, such as anesthesia, safety of technique, invasiveness of treatment, patient condition and longstanding effectiveness of each treatment, are important for future choices of treatment of aneurysms.

CENTRAL HYPERTHYROIDISM

Central hyperthyroidism is a rare condition in which thyrotoxicosis results from primary overproduction of TSH by the pituitary gland with subsequent thyroid enlargement and hyperfunction. The two known causes of central hyperthyroidism are TSH-producing pituitary tumors (TSHomas) and the syndrome of PRTH. Both of these entities are characterized by clinical thyrotoxicosis, diffuse goiters, elevated circulating levels of free T4 and T3, and a nonsuppressed serum TSH. It is critical to distinguish central hyperthyroidism from the much more common types of primary hyperthyroidism, all of which have undetectable TSH values. TSHomas and PRTH can usually be differentiated from one another by measuring the serum alpha-subunit and the TSH response to intravenous TRH or exogenous thyroid hormone, and by pituitary imaging studies. TSHomas are usually benign adenomas arising from the monoclonal expansion of neoplastic thyrotropes. Causative oncogenes have not yet been convincingly identified. PRTH is a nonneoplastic disorder caused by inherited mutations in the gene for the thyroid hormone receptor beta; it is a poorly understood variant of GRTH. For unclear reasons, in PRTH, the pituitary gland is resistant to the feedback inhibitory effects of circulating thyroid hormones while peripheral tissues respond normally, causing patients to experience the toxic peripheral effects of thyroid hormone excess. TSHomas are best treated by transphenoidal surgical removal. Radiotherapy is indicated for inoperable or incompletely resected tumors. Octreotide administration is a useful adjunct for preoperatively reducing tumor size and for the medical management of surgical treatment failures. PRTH is ideally treated by chronically suppressing TSH secretion with medications such as D-thyroxine, TRIAC, octreotide, or bromocriptine. If such therapy is ineffective or unavailable, thyroid ablation with radioiodine or surgery may be employed with subsequent close monitoring of both thyroid hormone status and pituitary gland size.

Residual splenic function after laparoscopic splenectomy: a clinical concern.

To document the existence of residual splenic function after laparoscopic splenectomy in a series of 48 patients. A noncomparative descriptive case series. A tertiary care center. A series of 9 patients without clinical improvement after laparoscopic splenectomy of 48 consecutive patients undergoing laparoscopic splenectomy for several hematologic disorders after a mean follow-up of 16 months (range, 1-40 months). A computed tomographic scan and technetium Tc 99m sodium pertechnetate heat-damaged red blood cell scintigraphy were performed for patients with partial (platelet count <100x10(9)/L) or total (platelet count <50x10(9)/L) failure of improvement. Evidence of residual splenic tissue by image diagnosis. The condition of 9 of the 48 patients failed to improve after laparoscopic splenectomy. Six patients experienced a total failure of improvement and 3 experienced a partial failure of improvement (1 patient had human immunodeficiency virus-related thrombocytopenia and 8 had idiopathic thrombocytopenic purpura). Three patients had residual splenic function, which was revealed by scintigraphy. The results of a computed tomographic scan showed an accessory spleen in one patient and splenic implants in splenic fossa in another patient. Laparoscopic splenectomy has a promising role in the management of hematologic diseases requiring splenectomy, but it requires exquisite care to avoid parenchymal rupture and cell spillage and to avoid leaving accessory spleens, which can lead to the failure of surgical treatment.

Vestibulodynia—A subset of vulvar vestibulitis or a novel syndrome?

OBJECTIVE: Our purpose was to recognize special features of women with both vestibulitis and constant vulvar pain (vestibulodynia) and to determine whether vestibulodynia is a separate disease entity or a subset of vestibulitis. STUDY DESIGN: Ninety-one women with severe vulvar vestibulitis underwent perineoplasty by a single surgeon during 1992 to 1995. Twenty-five (27%) of them who had vestibulodynia were compared with 66 (73%) who had dyspareunia alone. With univariate and then multivariate analysis, the two groups were compared with regard to demographic, social, and medical variables, the presence of human papillomavirus deoxyribonucleic acid, physical findings in the vestibule, and surgical outcome. RESULTS: The vestibulodynia and vestibulitis groups differed in age (30.5 ± 10.6 years vs 24.7 ± 6.2 years respectively), as well as in marital status (married, 44% vs 18%, respectively), nonuse of contraception (20% vs 1%, respectively), presence of human papillomavirus deoxyribonucleic acid in the vestibule (80% vs 48%, respectively), and failure of surgical treatment (incomplete response rate, 64% vs 2%, respectively). With multivariate analysis, patients with human papillomavirus deoxyribonucleic acid present in the vestibule have an odds ratio of 5.44 (95% confidence interval, 1.45 to 20.33) of belonging to the group with vestibulodynia, whereas dysuria and age have odds ratios of 3.70 (95% confidence interval 1.09 to 12.55) and 1.14 (95% confidence interval 1.04 to 1.24), respectively. CONCLUSIONS: Vestibulodynia is a unique syndrome in that it affects women who are older than those who have vestibulitis alone and it is associated with human papillomavirus deoxyribonucleic acid, dysuria, and a higher surgical failure rate than that for vestibulitis.(Am J Obstet Gynecol 1997;177:43)

Salvage surgery for lateral tennis elbow.

We undertook a retrospective analysis of 34 patients (35 elbows) who had prior failed surgical intervention for lateral tennis elbow. Revision surgeries were performed between 1979 and 1994. Each patient's non-operative and operative history was recorded before our salvage revision surgery. At revision surgery, findings included residual tendinosis of the extensor carpi radialis brevis tendon in 34 of 35 elbows. In 27 elbows, the pathologic changes in the extensor carpi radialis brevis tendon had not been previously addressed at all, and in 7 elbows the damaged tissue had not been completely excised. Salvage surgery included excision of pathologic tissue in the extensor carpi radialis brevis tendon origin combined with excision of excessive scar tissue and repair of the extensor aponeurosis when necessary. Based on a 40-point functional rating scale proposed here, 83% of the elbows (29 of 35) had good or excellent results at an average followup of 64 months (range, 17 months to 17 years). To prevent failure of surgical treatment for tennis elbow, the pathologic tissue usually present in the extensor carpi radialis brevis tendon should be resected. Release operations, which weaken the extensor aponeurosis but fail to address the pathoanatomic changes, are not recommended.

Retrograde embolization and causes of failure in the primary treatment of varicocele.

To assess retrograde embolization for the treatment of varicocele and to examine the causes of surgical and radiological treatment failure. Of 154 patients with clinical varicocele associated with subfertility or symptoms who were treated, 100 underwent surgical high ligation, retrograde embolization under fluoroscopic control was attempted in 84 and 30 had both forms of treatment. Venographic findings were defined in those patients for whom embolization proved impossible and in those in whom prior high ligation had failed. Among subfertile patients, 64 had semen analyses before and at least 3 months after the procedure available for comparison. Those patients undergoing both radiological and surgical procedures were sent questionnaires to evaluate their experience. Retrograde embolization was technically successful in 68 (81%) of the 84 patients. Two early failures were associated with venous spasm provoked by technical inexperience, while difficulties in the remainder were caused by anomalous venous anatomy. In patients who had recurrent varicocele after previous ligation, venography showed incomplete ligation of collateral channels; 14 of 18 patients were successfully re-treated by embolization. The sperm concentration improved significantly in 83% of patients undergoing embolization and in 63% of those surgically ligated. Patients who underwent both procedures expressed a strong preference for embolization. In centres where there is a skilled interventional radiologist, embolization is an effective alternative to surgical ligation of varicocele. Carried out under local anaesthesia as an out-patient procedure, it is cost-effective, associated with minimal morbidity and most patients are able to return to normal daily activities immediately.

Ilizarov Technique in the Treatment of Congenital Pseudarthrosis of the Tibia

This study analyzes the risks and benefits of Ilizarov's technique in congenital pseudarthrosis of the tibia (CPT). This was a retrospective review of 14 patients treated between 1985 and 1993 for CPT, by using Ilizarov's technique. In 12 cases, this technique was used after failure of previous surgical treatment. Realignment, end-to-end compression, and leg lengthening were undertaken in all the cases, without excision of the pseudarthrosis site. The mean fixation duration was 7.8 months. Union was achieved with the initial treatment in seven cases. Bone grafting was used in six of the seven remaining cases and achieved bone healing in three of them. Refracture occurred in one case, and ended with nonunion. At 3.5-year average follow-up, the tibia was united in nine cases. We found that the best indications for Ilizarov's technique in CPT were the normotrophic and hypertrophic types of pseudarthrosis (Apoil II), after the age of 5 years. Secondary massive bone grafting is to be considered in some cases. The major disadvantage of this method is the lack of excision of the pseudarthrosis site. Even after healing is achieved, the bone remains dystrophic and fragile and necessitates a permanent protective orthosis, until the end of bone growth.

P-6-703 - Benign cerebellar astrocytomas in children: Analysis of causes of failure in surgical treatment

P-6-703 - Benign cerebellar astrocytomas in children: Analysis of causes of failure in surgical treatment

Gastroesophageal reflux disease (GERD): Back to surgery?

Part 1 GERD - mechanisms and diagnosis: pathogenesis a possible role for helicobacter pylori in the pathogenesis of reflux oesophagus epidemiology clinical symptoms and prognosis endoscopic classification of reflux oesophagitis by the MUSE system diagnosis. Part 2 State of the art - lecture: solving the GORDian knot, I.M. Modlin et al. Part 3 GERD - nonoperative treatment: inhibition of acid secretion treatment of motility disorders interventional endoscopic therapy. Part 4 GERD and Barrett's oesophagus: the prognosis of Barrett's oesophagus and its relationship with GERD endoscopic surveillance of Barrett's oesophagus is there regression in Barrett's oesophagus?. Part 5 Surgical treatment of GERD: Nissen fundoplication - the gold standard long-term outcome after open fundoplication complications and late consequences of open fundoplication for GERD laparoscopic fundoplication - history of a trend-setting operation laparoscopic antireflux surgery - principles governing assessment of patients for endoscopic surgery and options for surgical treatment failure and pitfalls of Nissen repair. Part 6 International results of laparoscopic fundoplication: German experience with laparoscopic antireflux surgery laparoscopic Nissen fundoplication in the USA early results in the Swiss experience with laparoscopic fundoplication for GERD laparoscopic antireflux surgery in the United Kingdom and Ireland laparoscopic floppy Nissen fundoplication - the Groote Schuur hospital experience. Part 7 Safe performance of a laparoscopic fundoplication: laparoscopic treatment of gastro-oesophageal reflux - Nissen-Rosseti fundoplication safe performance of a laparoscopic Nissen fundoplication - standard technique II the technique of Nissen fundoplication laparoscopic Toupet partial fundoplication laparoscopic anterior partial fundoplication laparoscopic treatment of paraoesophageal hernia laparoscopic cardiomyotomy for achalasia. Part 8 Conclusion: gastro-oesophageal reflux disease (GERD) - back to surgery?, M.W. Buchler et al.

Effect of intraperitoneal chemotherapy and fibrinolytic therapy on tumor implantation in wound sites.

Failure of surgical treatment for gastrointestinal cancers is often caused by recurrence of the tumor in traumatized peritoneal surfaces. This study examined the effect of intraperitoneal administration of doxorubicin and recombinant tissue plasminogen activator (rt-PA), a fibrinolytic agent, on incidence and volume of postoperative tumor implants in peritoneal wounds. Prior to randomization, a surgical wound was created on the right parietal peritoneum of 110 BDIX rats and 6 x 10(5) DHD/K12 colon cancer cells were inoculated intraperitoneally (ip). The control group was given an intraperitoneal injection of saline. Five groups received 1 mg/kg of ip doxorubicin at different times postoperatively: at the end of surgery (D0), 3 hr after surgery (D + 3), postoperative day 1 (D1), postoperative day 3 (D3), and postoperative day 7 (D7). In a second set of experiments, five groups of rats received, in addition to postoperative doxorubicin, 5 mg/kg of intraoperative ip rt-PA. Incidence and volume of tumor implants in peritoneal wounds were assessed for each group 20 days after the tumor inoculation. All rats of the control group (incidence = 100%) developed tumor implants in peritoneal wounds. Mean (SD) volume was 16.2 (4.7) mm3. When administered at D0, D + 3, and D1 intraperitoneal doxorubicin reduced significantly the incidence and volume of tumor implants in wounds. Postoperative administration of doxorubicin at D3 and D7 did not affect significantly the incidence and the volume of tumor implants in peritoneal wounds. When rt-PA was administered intraoperatively, ip injection of doxorubicin at any postoperative timing decreased significantly the incidence and volume of tumor implants. In conclusion, ip doxorubicin administered before postoperative D3 may act on tumor cell implanted in peritoneal wounds. Delayed (D3, D7) ip administration of doxorubicin does not prevent the development of tumor implants in peritoneal wounds. Intraoperative administration of rt-PA may significantly increase the efficacy of delayed ip chemotherapy.

Peritoneal Carcinomatosis from Adenocarcinoma of the Colon

Peritoneal carcinomatosis is a major cause of surgical treatment failure in patients with colorectal cancer. In the past patients with this condition have had a lethal outcome. In this study, 64 consecutive patients were treated by the cytoreductive approach, which involved surgery to maximally resect all cancer in the abdomen and pelvis, early postoperative intraperitoneal chemotherapy with 5-fluorouracil (5-FU) and mitomycin C, and three cycles of adjuvant intraperitoneal 5-FU with systemic mitomycin C. The clinical features that may affect prognosis were assessed and critically analyzed statistically. Peritoneal implant size of < 5 cm present in the abdomen and pelvis at the time of exploration correlated with a good prognosis (p < 0.0001), as did complete cytoreduction with tumor removed to nodules < 2.5 mm (p < 0.0001). Involvement of only one or two of the five abdominopelvic regions, compared to three or more regions, was a significant determinant of prognosis (p < 0.0001). Finally, a mucinous histologic type correlated adversely with prognosis when compared to intestinal-type adenocarcinomas (p < 0.001). These data suggest that patients with small-volume peritoneal seeding from colon cancer should be treated with cytoreductive surgery and aggressive regional and systemic chemotherapy in an attempt to achieve long-term disease-free survival.

SUBMUSCULAR TRANSPOSITION OF THE ULNAR NERVE

Anterior submuscular transposition by the Learmonth technique is more demanding technically than other procedures described to treat cubital tunnel syndrome. I generally reserve submuscular transposition for patients who have failed previous anterior subcutaneous transposition and those who are very thin, in which case the nerve may be prominent immediately beneath the skin, resulting in an area of uncomfortable sensitivity. In patients who are candidates for reoperation following failed anterior submuscular transposition, it is common to find an area of compression that was not released during the initial operation. Most importantly, failure to release the arcade of Struthers, the arcuate ligament, and the flexor carpi ulnaris muscle fascia; excise the medial intermuscular septum; or provide ample room for the ulnar nerve beneath the flexor-pronator muscles will result in failure of surgical treatment. Range-of-motion exercises and hand strengthening facilitate early return of function.

Late Failure of Surgical Treatment for Bioprosthetic Valve Endocarditis Due to Candida tropicalis

Late treatment failures may occur after surgical treatment of endocarditis due to Candida species [1,2] and Pseudomonas spe­ cies [3]; this finding suggests that cure should not be assumed until long-term follow-up has been completed. Failures occurring from 9 months [1] to 7 years [2] after surgical treatment have been reported for intravenous drug users, and such failures have occurred after 6 months in patients who did not use intravenous drugs [1]. We report a case of Candida tropicalis endocarditis in a patient who was not an intravenous drug user; this patient had a probable relapse 44 months after surgery. A 50-year-old man with chronic rheumatic valvular disease un­ derwent aortic valvuloplasty and mitral valve replacement with a bovine pericardial bioprosthesis. Routine culture of the implanted prosthesis was sterile. After the operation, mild aortic insufficiency was noted; fever, pericardial and pleural friction rubs, and atrial fibrillation ensued. The diagnosis ofpostpericardiotomy syndrome was made, and treatment with indomethacin (150 mg daily) was initiated. The patient defervesced and was discharged. The fever relapsed after therapy with indomethacin was discon­ tinued, and the patient was readmitted to the hospital 73 days after discharge (81 days after surgery). On physical examination, aortic insufficiency and splenomegaly were observed. Findings on an echocardiogram were suggestive of vegetations on the prosthesis. After blood for cultures was drawn, therapy with penicillin and streptomycin was started; however, seven of eight sets of blood cultures later yielded C. tropicalis. Antibiotic therapy was changed to that with amphotericin B, and the patient underwent surgery 2 days later. At surgery, rupture of the bioprosthesis and vegetations on the atrial surface of the leaflets were detected; however, there was no involvement ofthe mitral annulus, and aortic valve insuffi­ ciency without endocarditis was noted. The bioprosthesis and the valve were replaced with two bovine pericardial prostheses. Cul­ ture of the excised prosthesis yielded Candida species, although culture of the aortic valve was sterile. Histologic examination of sections of the prosthesis revealed numerous hyphae and spores compatible with a Candida species. A total dose of 2.1 g ofampho­ tericin B (50 mg/d) was administered over 6 weeks. The patient was discharged on the 59th postoperative day, and no evidence of metastatic infection was detected on follow-up.

Morphology of the carpal tunnel. Movement studies in patients with constriction symptoms and healthy probands using MR tomography

The morphological correlation of the phenomenon of increased pressure in the carpal tunnel during wrist flexion and extension--as has been proved though measurements using wick-catheters--was studied in healthy subjects (n = 15) and symptomatic patients with carpal tunnel syndrome (n = 15). Our own measurements using magnetic resonance imaging (MRI) showed that there is a significant reproducible decrease in carpal tunnel diameter when the wrist is held in position of either flexion or extension. During flexion the diameter is decreased at the pisiformes and hamate level as well as it is lowered during extension at the pisiformes level. This might explain the rise in carpal tunnel pressure and thus the consecutive negative influence on the median nerve. Proximal swelling, distal flattening and increased signal intensity of the median nerve as well as the palmar bulging of the flexor retinaculum at the level of the hook of the hamate and at the level of the pisiformes were significantly higher in patients with carpal tunnel syndrome than in normal volunteers (from p < 0.05 to p < 0.001). In post-operative follow-up examinations of 13 patients with no clinic symptoms the distal flattening of the median nerve normalized in 94% within 3 months. The increased signal of the median nerve on T2-weighted images decreased postoperatively in 2/3 of the patients, whereas the motor latency of the median nerve recovered only in 39% of our patients who had 100% partial or complete clinical benefit. These findings imply that postoperative imaging may be helpful for evaluating the success or failure of surgical treatment.

Diagnostic values and limitations of conventional urodynamic studies (uroflowmetry.residual urine measurement.cystometry) in benign prostatic hypertrophy

Diagnostic values and limitation of conventional urodynamic study (UDS) were assessed in 380 patients with benign prostatic hypertrophy (BPH), in terms of uroflowmetry, measurement of postvoid residual urine and cystometry. Maximum and average flow rate on uroflowmetry improved with increasing voided volume. Neither maximum nor average flow rate correlated with size of the prostate, subjective symptom (International Prostate Symptom Score) and bothersomeness for prostatism. Pre-TUR maximum flow rate did not predict outcomes on postoperative flow rate and surgical treatment failures. Uroflowmetry did not differentiate between obstruction and weakness of detrusor contraction. The intraindividual variation of postvoid residual urine was great and the volume of residual urine correlated poorly with subjective symptom, size of the prostate, maximum and average flow rate. On filling cystometry, although uninhibited detrusor contraction was much more frequently observed in patients with urge incontinence as compared with continent patients, there was no significant difference in other parameters between the two groups. Every parameter on cystometry did not correlate with nocturnal frequency. Postoperative persistence of urge incontinence did not correlate with the bladder volume at the first desire to void or at the maximum desire to void, an amplitude of uninhibited detrusor contractions, or bladder compliance. In some cases, evaluation of the intravesical pressure on voiding phase and uroflowmetry was diagnostic of apparent obstruction. In diagnosis of BPH, conventional UDS has limitation for certain and some caution showed be taken in interpretation of the data. However, since conventional UDS provides important and objective information on obstruction and detrusor function, which are independent of subjective symptom and prostate size, these should be necessary in diagnosis, determination of treatment options and evaluation of treatment outcomes in BPH.

Peritoneal carcinomatosis from adenocarcinoma of the colon.

Peritoneal carcinomatosis is a major cause of surgical treatment failure in patients with colorectal cancer. Patients with this condition have in the past always had a lethal outcome. We reviewed the results of 56 consecutive patients treated by the cytoreductive approach. This involved surgery to maximally resect all cancer in the abdomen and pelvis in combination with early postoperative intraperitoneal chemotherapy with 5-fluorouracil (5-FU) and mitomycin C. All patients also had three cycles of adjuvant intraperitoneal 5-FU with systemic mitomycin C. An assessment of the clinical features that may affect prognosis was performed and critically analyzed statistically. A significant clinical feature was defined as one with a p value > or = 0.05. Small lesion size of implants present in the abdomen and pelvis at the time of exploration correlated with a good prognosis (p = 0.0025). A complete cytoreduction with tumor removed to < 0.25 cm correlated with a good prognosis (p = 0.0001). A limited involvement of the five abdominal regions was an important determinant of prognosis, with a p value of 0.0739. Finally, a mucinous histologic type correlated adversely with prognosis when compared with adenocarcinomas (p = 0.0434). These data taken together may suggest that patients with small-volume peritoneal seeding should routinely be treated with cytoreductive surgery and aggressive regional and systemic chemotherapy in an attempt to achieve long-term disease-free survival in this group of poor prognosis patients.