High Rate Of Long-term Complications Research Articles

1036 Colonic Erosion of a Laparoscopically Inserted Adjustable Gastric Band

Abstract The popularity of laparoscopic adjustable gastric band surgery has declined over the past decade. This is partly due to concerns about a high rate of long-term complications, including band erosions occurring in over 1% of cases. Erosion into the colon is exceedingly rare, with only three reports in the literature. Our images/video illustrate the case of a 51-year-old female patient presenting in February 2022 with abdominal pain and two chronically discharging sinuses around her port site. She had a gastric band initially fitted in 2010, which was revised in 2018. The port was re-sited in 2021 following port-migration and flipping. On this presentation, a CT scan revealed 16cm of tubing within the lumen of the descending colon. Our procedure began with diagnostic laparoscopy, showing the gastric band tubing entering an inflammatory phlegmon in the left flank involving omentum and descending colon attached to the abdominal wall beneath the port site. The tubing was cut near to the gastric band. The gastric band was freed, divided, and removed. The previous port site incision was extended around the external opening of the fistula, which was excised. The port and tubing were easily removed, though partly covered in faeces. A decision was made, based upon prior discussion with the patient, to leave the colocutaneous fistula in-tact. This avoided the risk of colonic resection and anastomosis in freeing the bowel. Stapling across the phlegmon and tract risked diverting colonic contents into another potential tract headed towards the stomach. Postoperative recovery was uneventful.

Long-term follow-up after surgical treatment of talar fractures

Displaced talus fractures are rare and serious injuries with important outcomes. These fractures compromise motion of the foot and ankle and result in severe disability. Therefore, a satisfactory clinical outcome remains a challenge in the treatment of talus fractures. Displaced talar fractures have a high rate of long-term complications. The aim of our study was to evaluate the long-term outcomes of these fractures after operative treatment. This prospective study was conducted to assess the long-term outcome of all operated talus fractures who presented to emergency department of orthopedics, Govt. Bone and Joints Hospital, Barzillai an associated Hospital of Govt. Medical College, Srinagar from June 2019 to January 2022. Reduction was anatomical in 5 (25%) cases, nearly anatomical reduction in 10 (50%) and poor in 5 (25%). Early complications included 2 (10 %) superficial wound infections, 1 (5 %) deep infection and delayed union in 3 (15 %) patients. 4 (20%) patients presented an osteonecrosis of the talus. 5 (25 %) had undergone secondary surgery. 12 (60%) patients presented post-traumatic osteoarthritis in at least one ankle joint. 8 (47.05 %) patients had a normal hindfoot alignment, in 6 (35.29%) patients there was a varus malunion (from 8° of varus to 3° of valgus) and in 3 (17.65 %) cases there was a valgus malunion (10° and 12° of valgus). The average functional score was 69 points (range 43–92 points). Clinical outcome based on ankle-hind foot scoring was rated as excellent in 1 (5 %), good in 10 (50 %), fair in 5 (25 %), and poor in 4 (20 %). The complication rate for talar fractures was high, mostly osteonecrosis and osteoarthritis. The outcome could be improved by better evaluating these fractures with a CT scan, developing dual surgical approaches to best preserve the bone vascular supply and achieve better reduction, and improving the internal fixation hardware, especially the use of plates for comminuted fractures.

Sleeve Gastrectomy, One-Anastomosis Gastric Bypass (OAGB), and Single Anastomosis Sleeve Ileal (SASI) Bypass in Treatment of Morbid Obesity: a Retrospective Cohort Study.

Bariatric surgery is the most effective treatment for morbid obesity. The present study aimed to assess three bariatric procedures with different mechanisms of actions; sleeve gastrectomy (SG), one-anastomosis gastric bypass (OAGB), and single anastomosis sleeve ileal (SASI) bypass, in terms of efficacy and safety. This was a retrospective cohort study on patients with morbid obesity who underwent SG, OAGB, or SASI bypass. The main outcome measures were weight loss and improvement in comorbidities at 6 and 12months postoperatively, and complications. A total of 264 patients (186 female) with mean preoperative body mass index (BMI) of 43.6 ± 9.9kg/m2were included to the study. Significant weight loss was recorded at 6 and 12months after the three procedures. At 6 and 12months postoperatively, body weight and BMI were significantly lower after SASI bypass than after SG and OAGB. The %total weight loss (%TWL) and %excess weight loss (%EWL) were significantly higher after SASI bypass than after SG and OAGB. SASI bypass was associated with a significantly higher rate of improvement in DM than SG and OAGB (97.7% vs 71.4% vs 86.7%; p = 0.04) whereas improvement in other comorbidities was similar. The short-term complication rate was similar between the three procedures, yet SASI bypass was followed by higher long-term complication rate. Based on retrospective review of data, SASI bypass was associated with more reduction in body weight and BMI, higher %TWL and %EWL, better improvement in T2DM, and more long-term nutritional complications than SG and OAGB.

Regional Nerve Block Complication Analysis Following Peripheral Nerve Block During Foot and Ankle Surgical Procedures.

BackgroundFoot and ankle surgeries are frequently accompanied by a peripheral nerve block in order to reduce postoperative pain. Higher than expected complication rates with peripheral nerve blocks have led to increased concern among surgeons and patients. To our knowledge, no study conducted by the treating surgeon has identified risk factors that may predispose a patient to complications. Our goal was to attempt to identify those risk factors.MethodsWe reviewed patient charts of those who underwent an orthopedic foot and ankle procedure between 2013 and 2018, as performed by the senior author. This yielded 992 procedures performed across four surgical locations. Of these procedures, 137 procedures were removed because no block was used. The remaining cases were analyzed for nerve complications, defined as sensory or motor deficits along the distribution of a nerve. The patients were divided into those with and without complications and were evaluated for differences. Statistical analysis was performed using the SAS® software (SAS Institute Inc., Cary, North Carolina, USA).ResultsThe overall short-term complication rate was 10.1% and the long-term complication rate was 4.3%, with a total of 855 blocks given. Electromyographies (EMGs) were performed on 24.4% of the patients with a complication. Of the EMGs, 95.2% confirmed nerve complications in the distribution of the blocked nerve. The significant factors associated with complications were age, BMI, location, and smoking status. A regression analysis was performed to determine the odds ratio for individual factors. Those with significantly higher odds ratio were between 40 and 65 years of age, had normal or underweight BMI, underwent surgery at an outpatient surgery center, and were current smokers.ConclusionsOur study suggests that there are significant epidemiological factors in predicting postoperative complications related to a peripheral nerve block. The study also shows a similar short-term complication rate but a higher long-term complication rate than other studies. This data are important because it allows for an informed decision to be made between a surgeon, anesthesiologist, and the patient regarding the safety and necessity of delivering a preoperative peripheral nerve block based on patient risk factors.

Diagnosis and Management of Urolume Urethral Stent Complications Using Ultrasonography and Magnetic Resonance Imaging

The UroLume urethral stent (American Medical Systems) was introduced to the market in 1988 for management of male urethral stricture and benign prostatic hyperplasia.1 However, recent reports in the literature showed long-term complications, including: urethral restenosis, urethral pain, recurrent urinary tract infections, and stent migration. Therefore, UroLume's efficacy in managing bladder outlet obstruction had to be weighed against an alarmingly high rate of long-term complications.2,3 In this report, the role of ultrasonography scan and magnetic resonance in the diagnosis and management of UroLume complications is evaluated.

SYSTEMIC VENOUS BAFFLE OBSTRUCTION AND LEAK INTERVENTION RESOLVES OXYGEN REQUIREMENT AND ASCITES IN TRANSPOSITION OF GREAT ARTERIES PALLIATED WITH MUSTARD PROCEDURE

Mustard procedure for the correction of transposition of the great arteries (TGA) is associated with a high rate of long-term complications including arrhythmia, systemic right ventricular dysfunction, and baffle obstruction. Desaturation is infrequent and ascites is rare. A 45 year old with TGA

Long-term radiographic and clinical-functional outcomes of isolated, displaced, closed talar neck and body fractures treated by ORIF: the timing of surgical management

BackgroundThe main purpose of this retrospective case series study was to evaluate long-term radiographic and clinical outcomes of a consecutive series of patients diagnosed with isolated, displaced, closed talar neck or body fractures treated by open reduction and internal fixation (ORIF). Secondly, the aim was to verify the influence of the location of talar fractures on the outcomes, the prognostic value of the Hawkins sign, whether operative delays promote avascular necrosis (AVN) and if the fractures require emergent surgical management.MethodsFrom January 2007 to December 2012, at our institution, 31 patients underwent ORIF through the use of screws. On the basis of Inokuchi criteria, the injuries were divided between neck and body fractures, which were classified according to Hawkins and Sneppen, respectively. The patients included were divided into two groups in relation to fracture location and complexity. Radiographic assessment focused on reduction quality, bone healing, the Hawkins sign and post-traumatic arthritis (PTA) development. For the clinical evaluation, clinical-functional scores (AOFAS Ankle-Hindfoot Score; MFS; FFI-17; SF-36) and VAS were determined, and statistical analysis was performed.Results27 patients, 19 males and 8 females, mean age 38.3 years, were included with an average follow-up period of 83.2 months (range 49–119). There were 9 neck and 19 body fractures; their reduction was anatomical or nearly anatomical in 22 cases, and all reached radiographic consolidation after a mean period of 3.4 months (range 1.7–7). The Hawkins sign was observed in 9 cases, in which necrosis did not develop. With a 0–11 day surgical timing interval, more than 60% of the patients obtained good or fair results with different scores, while 18 (66.7%) were completely satisfied (VAS: 9–10). The early complications included malunions (21.4%) and wound problems (25%); the late complications involved AVN (25%) and PTA (78.6%).ConclusionsDespite a high rate of long-term complications, satisfactory clinical results were achieved. Talar fracture location did not influence the outcomes, the Hawkins sign was confirmed as a positive prognostic factor, and operation timing did not influence AVN development. Hence, these injuries do not require emergent surgical management by ORIF.

Twelve-Year Experience with Roux-en-Y Gastric Bypass as a Conversional Procedure for Vertical Banded Gastroplasty: Are We on the Right Track?

Vertical banded gastroplasty (VBG) has high rates of long-term complications. Conversion to Roux-en-Y gastric bypass (RYGB) is considered optimal; however, there are limited data on the late results of these conversions. We aimed to analyze our single-center long-term outcomes of patients requiring conversional RYGB for a failed VBG. The records of patients who underwent RYGB as a conversional procedure after VBG from November 2004 to December 2016 were reviewed. Follow-up data were obtained by direct telephone calls with patients, electronic files, and general practitioner reports. Characteristics, indications of conversion, long-term (> 30days) morbidities, weight records, obesity-related comorbidities, and overall patient satisfaction were analyzed. Overall, 305 VBG patients (82% female) underwent conversional RYGB during the study period. The mean pre-RYGB body mass index (BMI) was 35.6 (23-66)kg/m2. Conversions were indicated in 61% of patients because of simultaneous VBG complications and weight regain. After a median follow-up of 74.3 (5-151)months, 225 (73.8%) patients agreed to participate. The mean BMI and percentage of total weight loss (%TWL) were 28.6 (18-45)kg/m2 and 17.4%, respectively. Nearly all conversion indications were addressed effectively. Surgical reintervention was mandatory in 28 of 225 patients (12.4%) due to complications. Approximately 85% of patients reported complete remission of obesity-related comorbidities, and four-fifths were fully satisfied. RYGB resolves VBG complications, improves quality of life, and results in prolonged stable weight loss. It has a key role in the management of obesity-related comorbidities and in expert hands is the preferred conversional procedure for patients with failed VBG.

AUTHOR REPLY

We appreciated the valuable comments on our recently published article in Urology and agree with them. Peyronie's disease and erectile dysfunction (ED) can occur after trauma, such as penile fracture (PF), especially in patients treated conservatively, with high rates of long-term complications. 1 Gamal W.M. Osman M.M. Hammady A. Aldahshoury M.Z. Hussein M.M. Penile fracture: long-term results of surgical and conservative management. J Trauma. 2011; 71: 491-493 Crossref PubMed Scopus (55) Google Scholar , 2 Zargooshi J. Sexual function and tunica albuginea wound healing following penile fracture: an 18-year follow-up study of 352 patients from Kermanshah, Iran. J Sex Med. 2009; 6: 1141-1150 Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar

Biocompatibility of poly(ethylene glycol) and poly(acrylic acid) interpenetrating network hydrogel by intrastromal implantation in rabbit cornea.

We evaluated the biocompatibility of a poly(ethylene glycol) and poly(acrylic acid) (PEG/PAA) interpenetrating network hydrogel designed for artificial cornea in a rabbit model. PEG/PAA hydrogel measuring 6 mm in diameter was implanted in the corneal stroma of twelve rabbits. Stromal flaps were created with a microkeratome. Randomly, six rabbits were assigned to bear the implant for 2 months, two rabbits for 6 months, two rabbits for 9 months, one rabbit for 12 months, and one rabbit for 16 months. Rabbits were evaluated monthly. After the assigned period, eyes were enucleated, and corneas were processed for histology and immunohistochemistry. There were clear corneas in three of six rabbits that had implantation of hydrogel for 2 months. In the six rabbits with implant for 6 months or longer, the corneas remained clear in four. There was a high rate of epithelial defect and corneal thinning in these six rabbits. One planned 9-month rabbit developed extrusion of implant at 4 months. The cornea remained clear in the 16-month rabbit but histology revealed epithelial in-growth. Intrastromal implantation of PEG/PAA resulted in a high rate of long-term complications.

Outcomes of calvarial reconstruction in cancer patients.

Limited data exist on outcomes of calvarial reconstruction in cancer patients, including the relative efficacy of various cranioplasty materials, and risk factors for complications. A retrospective review was performed of cancer patients who underwent calvarial reconstruction over a 12-year period. A total of 269 patients underwent 289 calvarial reconstructions. Materials used for cranioplasty included titanium mesh (49.8 percent), methylmethacrylate (16.3 percent), porous polyethylene (4.8 percent), polyetheretherketone (4.5 percent), calcium phosphate cement (3.8 percent), autologous bone grafts (2.1 percent), or a combination of materials (18.3 percent). Perioperative (≤30 days after surgery) complications occurred in 42 cases (14.5 percent), of which 29 (10.0 percent) were at the recipient site, most commonly infection (2.8 percent) and cerebrospinal fluid leak (2.4 percent). Risk factors for perioperative complications included radiation therapy (p = 0.012), prior surgery (p = 0.003), and prior infection (p = 0.014). Late recipient-site complications (>30 days after surgery) occurred in 20 cases (6.9 percent), including infection (3.8 percent) and wound dehiscence (3.1 percent), and for which radiation therapy was identified as a risk factor (p = 0.011). The use of calcium phosphate cement in combination with titanium mesh was associated with a higher long-term complication rate (p < 0.001). Twenty-five cases (8.7 percent) required cranioplasty removal, with infection and dehiscence being risk factors for implant loss (p < 0.001 for both). Alloplastic cranioplasty is effective in cancer patients with calvarial defects. Commonly used materials have similar complication profiles, with the possible exception of calcium phosphate cement, which is associated with a higher rate of complications when combined with titanium mesh and used to reconstruct larger defects. Risk, III.

The Place of Endovascular Treatment in Abdominal Aortic Aneurysm

The endovascular treatment of abdominal aortic aneurysms has become more common. A careful comparison of this technique with the established treatment by open surgery is needed before it can be more widely adopted. We selectively searched the Medline database for articles on the endovascular treatment of abdominal aortic aneurysms, with special attention to prospective, randomized trials comparing it to open aortic surgery (keywords: "endovascular abdominal aortic repair" and "prospective randomized trial"). Data on 30-day mortality and long-term survival are now available from four randomized multicenter trials. In three of these trials, endovascular treatment was found to lower 30-day mortality by two-thirds (endovascular: 0.2% to 1.7%, open repair: 0.7% to 4.7%), but this difference in survival was no longer present at two years. Compared to open open aortic surgery, endovascular treatment has a higher long-term complication rate. Endoleakage (perigraft leakage) accounted for more than 30% of complications and was the commonest reason for reintervention and unsuccessful intervention; in nearly all cases, it was successfully treated by the endovascular route. The rate of secondary aortic rupture was 0.8%, and migration of the prosthesis occurred in 5% of cases. Follow-up checks of the stent graft are now recommended at 3, 6 and 12 months after implantation, and annually thereafter. Prospective randomized trials have shown that the endovascular technique lowers perioperative mortality. In the long term, however, it has a higher complication rate than open aortic surgery and leads to more frequent reintervention.

A prospective evaluation of short-term and long-term results from colonic stenting for palliation or as a bridge to elective operation versus immediate surgery for large-bowel obstruction

The efficacy and safety of self-expandable metallic stent (SEMS) placement as a bridge to elective surgery or definitive palliation versus emergency operation to treat colorectal obstruction is debated. This study aimed to evaluate the outcomes of patients with colorectal obstruction treated using different strategies. Subjects admitted to the authors' department with colorectal obstruction (n = 134) were studied prospectively. They underwent endoscopic stenting as a bridge to elective surgery (SEMS group: n = 49) or for definitive palliation (n = 34). A total of 51 patients underwent immediate surgery without stenting (NO-SEMS). Treatment was decided by the senior on-call surgeon. Placement of SEMS was technically successful in 95.3 % and clinically successful in 98.7 % of cases. The short-term complications in the SEMS group were perforation (n = 1, 1.2 %), migration (n = 4, 4.9 %), occlusion (n = 4, 4.9 %), colon bleeding (n = 3, 3.7 %), and abdominal pain (n = 6, 7.4 %). The postoperative complication rate was 32.7 % in the SEMS group versus 60.8 % in the NO-SEMS group (P = 0.005), with a significant reduction in wound infections (26.5 vs 54.9 %; P = 0.004), abdominal abscess (14.3 vs 39.2 %; P = 0.006), respiratory morbidity (10.2 vs 37.3 %; P = 0.002), and intensive care treatment (10.2 vs 33.3 %; P = 0.007). The median postoperative hospital stay was 10 versus 15 days (P = 0.001). The in-hospital mortality rate in both groups was 2 %. Long-term follow-up evaluation showed less incisional hernia (6.3 vs 22.0 %; P = 0.04) and definitive stoma formation (6.3 vs 26.0 %; P = 0.01) in the SEMS group than in the NO-SEMS group, respectively. Kaplan-Meier survival curves showed a benefit for the SEMS group (log-rank test, 0.004). The long-term SEMS-related complication rate for the palliative patients was 43.8 %. The hospital readmission rate for SEMS complications was 34.4 %. Overall clinical success was 81.2 %. In case of colorectal obstruction, endoscopic colon stenting as a bridge to elective operation should be considered as the treatment of choice for resectable patients given the significant advantages for short- and long-term outcomes. Palliative stenting is effective but associated with a high rate of long-term complications.

RETRACTED: Hemiarthroplasty for Proximal Humerus Fractures: Early and Late

Hemiarthroplasty has been the preferred surgical procedure for 3and 4-part proximal humeral fractures. Our retrospective study examined function and radiographic outcomes at 2and 5-year follow-up in patients who received a hemiarthroplasty for 3and 4-part proximal humeral fractures. Forty-seven consecutive patients of a single surgeon treated with a shoulder hemiarthroplasty between 2000 and 2006 were examined. Postoperative radiographs were compared with radiographs at 2 and 5 years along with active range of motion and functional outcomes scores. The mean acromiohumeral distance decreased from 10.3 mm postoperatively to 8.5 mm at 2 years and 6.7 mm at 5 years (P < 0.001). More patients had stem osteolysis and tuberosity reabsorption at 2 and 5 years compared with postoperatively (P 0.16 and P < 0.001, respectively). Multiple measures of functional outcome were obtained and all found to be worse at 5 years than at 2 years. Pain scores increased from 2 to 5-year follow-up (P 0.018). Hemiarthropasty has a high rate of long-term complications, including decreased acromiohumeral distance, stem osteolysis, and tuberosity reabsorption. Pain scores and functional outcomes worsened. No improvement in range of motion was observed. Semin Arthro 22:5-9 © 2011 Elsevier Inc. All rights reserved. TE D

Functional and radiographic long-term outcomes of hemiarthroplasty for proximal humeral fractures

Hemiarthroplasty is the preferred surgical procedure for 3- and 4-part proximal humeral fractures. Our retrospective study examined functional and radiographic outcomes at 2- and 5-year follow-up in patients who received a hemiarthroplasty for 3- and 4-part proximal humeral fractures. Forty-seven consecutive patients of a single surgeon treated with a cemented shoulder hemiarthroplasty between 2000 and 2006 were followed up. Standard surgical technique was used in all cases. Postoperative radiographs were compared with radiographs at 2 and 5 years along with active range of motion and functional outcomes scores. Twenty-five patients were examined at 2 years and twenty-two at 2 and 5 years. The mean age was 61 years. The mean acromiohumeral distance decreased from 10.3 mm postoperatively to 8.5 mm at 2 years and 6.7 mm at 5 years (P ≤ .001). More patients had stem osteolysis and tuberosity reabsorption at 2 and 5 years compared with postoperatively (P = .016 and P ≤ .001, respectively). The University of California, Los Angeles score decreased from 26.0 to 22.3 (P = .045); the Constant score decreased from 61.1 to 50.1 (P = .01); the Simple Shoulder Test 12 score decreased from 7.7 to 6.2 (P = .018); and the American Shoulder and Elbow Surgeons score decreased from 70.4 to 58.8 (P = .015). Pain scores increased from 2- to 5-year follow-up (P = .018). The range-of-motion measures changed little from the 2-to 5-year follow-up. Hemiarthroplasty has a high rate of long-term complications. Increases in acromiohumeral distance, stem osteolysis, and tuberosity reabsorption were observed between 2- and 5-year follow-up. Pain scores and functional outcomes worsened. No improvement in range of motion was observed.

Long-term follow-up after surgical treatment of talar fractures

Displaced talar neck and body fractures are rare and serious injuries with important outcomes. The aim of our study was to evaluate the long-term outcomes of these fractures after operative treatment in our centre between 1993 and 2005. Displaced talar fractures have a high rate of long-term complications. This was a retrospective study concerning 20 patients with an average follow-up of 7.5years. The final follow-up examination included determination of the AHS score (ankle-hindfoot scale) from the American Orthopaedic Foot and Ankle Society (AOFAS), range of motion evaluation and radiological analysis. Mean age at the time of trauma was 38.8years. This study comprised ten talar neck fractures and ten talar body fractures. We always used a single surgical approach and obtained anatomical reduction in 30% of the whole series of both groups. Four early complications were noted in four patients (20%). We noted no skin complications and the rate of consolidation was 100%. Four patients (20%) developed avascular necrosis of the talus, and at final follow-up seven patients (35%) had undergone secondary surgery. Radiographic analysis showed an osteoarthritis rate of 94% and a malunion rate of 59%. The mean AOFAS score was 66.9/100 and range of motion was systematically decreased. Contrary to undisplaced talar fractures, displaced talar fractures are a therapeutic challenge with many early or late complications. The outcome often revealed stiffness and osteoarthritis.

TRITON-X is most effective among three decellularization agents for ACL tissue engineering.

Ruptures of the anterior cruciate ligament (ACL) are still associated with high rates of long-term complications, even in patients undergoing modern, state-of-the-art replacement. Tissue-engineering approaches have been shown to be of value in improving treatment of ACL ruptures. However, the success of tissue-engineering procedures depends on the choice of an appropriate biomaterial. Decellularized ACL tissue potentially combines the structural composition of the targeted tissue with a reduced risk of graft rejection or disease transmission. In this study, we tested the effectiveness of currently available decellularization methods based on TRITON-X, sodium dodecyl sulfate (SDS), and trypsin. After identifying the most effective decellularization method, the capacity for reseeding with ACL fibroblasts was studied. All decellularization protocols reduced DNA content, with TRITON-X treatment having the greatest effect. Concurrently, decellularization did not affect tissue collagen or total protein content, but did decrease glycosaminoglycan content. TRITON-X also resulted the least glycosaminoglycan depletion. Porcine ACL tissue after decellularization with TRITON-X could be successfully reseeded with human ACL fibroblasts as demonstrated by steady DNA content and increasing pro-collagen expression.

V5

Despite the great success and popularity of adjustable gastric banding (AGB) in Europe, some concerns exist about the high rate of long-term complications. The most frequent of these complications is gastric pouch dilatation. Patients who don’t feel a sense of fullness may fill the proximal gastric pouch with a large amount of food causing an enlargement of the stomach above the band. The onset can be chronic or acute and in many cases requires reoperation.

Staged based directed surveillance of invasive bladder cancer following radical cystectomy: valuable and effective?

Radical cystectomy with pelvic lymphadenectomy remains the optimal treatment for muscle invasive bladder cancer curing the majority of patients with organ conWned tumors (stage pT1-2), but only a minority of those with low-volume node positive (N1) disease or with locally advanced (stage pT3b-4), and rarely those with extensive node-positive (N2-3), or metastatic (M+) bladder cancer [1–7]. Approximately 50% of patients will suVer a distant recurrence following surgery, most (80–90%) within 24 months of surgery with the most common sites being lung, liver, and osseous [6–12]. Studies consistently show the risk of both local and distant recurrence increases with advancing pathologic stage and nodal burden of disease, whereas recurrences following chemotherapy for metastatic disease seem to have a predilection for prior sites of disease with the brain serving as a sanctuary site for delayed relapse [6–12]. The risk of urothelial recurrences in the upper tract or remnant urethra are also predictable and related to pretreatment clinical factors such as the presence of multifocal disease, diVuse carcinoma in situ, distal ureteral or intramural tunnel involvement, or prior disease involvement of the upper tracts or prostatic urethra [13–18]. The main goal of surveillance is to monitor for recurrence of the primary disease or secondary malignancies, with the assumption that close monitoring will result in earlier detection and treatment of a disease recurrence thereby improving outcome [19–21]. However, there is little data in muscle invasive bladder cancer that routine imaging/exams at predetermined intervals allows any earlier detection of a local or distant recurrence than performing those exams at the time of the Wrst symptom. Routine surveillance at predetermined intervals, however, may be eVective in detecting early urothelial recurrences in the remnant urethra and upper tract in which early intervention may impact survival. In addition, the documented risks and pattern for long-term surgical complications, metabolic abnormalities, and renal deterioration associated with urinary diversions relative to a patient’s baseline comorbidity’s, are being better characterized in series with ten or more years of follow-up [22, 23]. The high rate of long-term complications indicate a need to incorporate routine monitoring for these diversion related complications into current surveillance strategies. Nevertheless most surveillance protocols are staged based, and built on the recurrence patterns observed in retrospective reviews of radical cystectomy series [19– 21]. Prospective trials demonstrating the eVectiveness of this approach over symptom driven evaluation and intervention in bladder cancer are lacking; however, until prospective studies comparing varying frequencies of surveillance or symptom driven surveillance are performed it would seem prudent to utilize stage-based surveillance strategies employing the known risks and patterns of recurrence in bladder cancer. S. M. Donat (&) Department of Urology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10021, USA e-mail: donats@mskcc.org

Retrograde mastoidectomy with canal wall reconstruction: a follow-up report.

To evaluate long-term results of retrograde mastoidectomy with canal wall reconstruction as a single-stage technique for cholesteatoma removal. Retrospective case review. Tertiary referral center. Forty-six patients, representing 50 ears (20 pediatric and 30 adult), who had undergone surgery for cholesteatoma removal with said technique and had an average follow-up of 7.8 years. Temporary removal of the upper canal wall, in association with a retrograde-type mastoidectomy, for full exposure and extirpation of the disease, followed by reconstruction of the canal defect using cymba cartilage. Preoperative and short- and long-term postoperative audiogram, obtained as four-frequency pure-tone average air-bone gap. Complications, including presence of recurrent or residual cholesteatoma, need for tube insertion, perforation, and poor hearing requiring revision surgery, were also reported and correlated with the patient's tobacco use. The average preoperative, short-term postoperative, and long-term postoperative pure-tone average air-bone gap was 25.6+/-11.2 dB, 11.0+/-5.7 dB, and 12.4+/-6.4 dB, respectively. There were significant differences between the pre- and postoperative values (p < 0.5), but there was no significant difference between short- and long-term hearing results. Recurrent cholesteatomas were seen in eight ears (16%); pressure-equalizing tube insertion was performed postoperatively in nine ears (18%); a perforation was seen in one ear (2%); and two ears (4%) had poor hearing results requiring second-look surgery. The long-term complication rate of smokers was 79% (15 of 19), compared with 16% (5 of 31) for nonsmokers. This single-stage technique for cholesteatoma removal and canal wall reconstruction showed acceptable long-term results, but tobacco use was associated with a higher long-term complication rate.