Inguinal Dissection Research Articles

Effects of Tissue Flap on Expression of Vascular Endothelial Growth Factor-C (VEGF-C) as a Marker of Improved Inguinal Lymphatic Circulation on Dissected Mice

Background: Radical surgery in cancer patients might result in complications like lymphedema. Tissue transfer procedure and lymphatic reconstruction could be done to manage lymphedema. Few biomarker expressions were identified to be associated with lymphangiogenesis and improved lymphatic system function after dissection. This study aims to evaluate the development of new lymphatic vessels by adding flap tissue after lymphatic dissection, assessed by VEGF-C expression, macrophage infiltration, and fibrotic tissue development. Methods: This is a non-randomized clinical trial at Animal House Skill Laboratory, Faculty of Medicine, Universitas Indonesia, conducted from January to March 2018. Sprague clawley male mice were aged 8-12 weeks were used and divided into control and trial groups. Each mouse underwent inguinal dissection and was randomized to receive additional flap tissue procedures and then evaluated two months after. Methylene blue dye was used to assess the lymphatic flow. Histopathology and immunohistochemistry examination was used to assess the development of fibrotic tissue. Data analysis was done by using SPSS version 20.0 for Windows. Results: 18 mice were included in the analysis and divided into two groups. Eight out of 9 mice (88.9%) in the trial group, which received flap tissue, showed lymphatic flow from the visualization of methylene blue, compared to two mice (22.2%) from the control group (p=0.15) two months after surgery. Histopathology examination showed wider fibrotic tissue of the lymphatic system from the trial group (p=0.05). Immunohistochemistry analysis also showed higher VEGF-C (p=0.01) and CD68 expression in the trial group (p=0.15). Conclusion: The addition of flap tissue might improve lymphatic flow, proven by increased lymphatic circulation and VEGF-C expression.

Role of Sentinel Lymph Node Biopsy in Clinically Node Negative Carcinoma Penis - a Prospective Study.

Nodal metastasis is a strong prognostic indicator in carcinoma penis, with 25% difference in 5-year cancer-specific survival among node negative and node positive patients. This study aims to assess efficacy of SLNB in identifying occult nodal metastasis (seen in 20-25% of cases), thus avoiding morbidity of prophylactic groin dissection in rest. Study was conducted between June 2016 and December 2019 on 42 patients (84 groins). Primary outcomes assessed were sensitivity, specificity, false negative rates, positive predictive value, and negativepredictive value of sentinel lymph node biopsy (SLNB) compared to superficialinguinal node dissection (SIND). Secondary outcomes were to know prevalence of nodal metastasis, sensitivity, specificity, false negative rates, positive predictive value (PPV), negativepredictive value (NPV) of frozen section study, and ultrasonography (USG) compared to histopathologicalexamination (HPE) and to evaluate false negative results of fine needle aspiration cytology (FNAC). Patients with impalpable inguinal nodes were subjected to USG and FNAC of suspicious nodes. Only those with non-suspicious USG/negative FNAC were included. Patients who werenode positive, had prior chemotherapy/radiotherapy/prior groin surgery, or medically unfit for surgery were excluded. Dual-dye technique was used to identify sentinel node. Superficial inguinal dissection was done in all cases and both specimens were subject to frozen section. If ≥ 2 nodes were involved on frozen section, ilioinguinal dissection was done. SLNB had sensitivity, specificity, PPV, NPV, and accuracy of 100%, respectively. There were no false negative results of frozen section study among168 specimens. Ultrasonography hadsensitivity of 50%, specificity of 48.75%, PPV of 4.65%, NPV of 95.12%, and accuracy of 48.81%. We had 2 false negative results of FNAC. Sentinel node biopsy with frozen section study when done in properly selected cases using dual-dye technique in high volume centers by experienced professionals is a very reliable tool in establishing the nodal status, thereby facilitatingneed directedtreatment, thus prevent either over/under treatment.

Variability in Operative Experience Among US Gynecologic Oncology Fellows (030)

<b>Objectives:</b> The Accreditation Council for Graduate Medical Education (ACGME) case log system provides a mechanism to assess the breadth and depth of the clinical experience provided by gynecologic oncology fellowships. Logging has been required since 2017; however, the required minimum number of procedures has not yet been determined. We aimed to evaluate the range of operative experience across gynecologic oncology fellowship programs in relation to proposed procedure-specific minimum numbers. <b>Methods:</b> ACGME surgical case logs of graduating gynecologic oncology fellows from 2019 to 2020 were analyzed for case volume trends. <b>Results:</b> Data were collected from 64 graduating gynecologic oncology fellows enrolled in 50 US programs. The median number of intestinal surgeries performed by graduating fellows was 42 (19 performed by those in the 10^th percentile to 89 performed by those in the 90^th percentile); a minimum of 20 has been proposed by the ACGME. By contrast, ACGME requires general surgery residents to complete a minimum of 25 small and 40 large intestinal surgeries during training. Gynecologic oncology fellows who performed more than ten intestinal procedures in training were more likely to feel prepared to perform these surgeries independently, however, only 58% reported feeling prepared to do so within three years of graduation. The median number of urologic procedures performed by graduating fellows was one (0 to 4); a minimum of 2 has been proposed by the ACGME. However, ACGME requires urology residents to complete a minimum of eight urinary diversion procedures during training, with the stipulation that this minimum "does not signify the achievement of competence." The median number of radical hysterectomies performed by graduating fellows was 17 (8 to 32). A minimum of ten has been proposed by the ACGME. A single-institution study of gynecologic oncology fellow productivity reported 17 radical hysterectomies completed per fellow per year since 2005. The median number of exenterations performed by graduating fellows was three (1 to 8); a minimum of two has been proposed by the ACGME. A single-institution study of exenterations over 20 years showed an average of six procedures per surgeon and no association of operative experience with complications or survival. The median number of inguinal dissections performed by graduating fellows was 11 (4 to 18). As this is considered a rare procedure, no minimum has been proposed by the ACGME. A minimum of ten was proposed to overcome the surgeon learning curve for inclusion in GROINSS-V-I. <b>Conclusions:</b> In the US, gynecologic oncology fellows experience significant variability in their surgical training. Based on our extrapolation of ACGME data, approximately half of the fellows fall below the proposed case minimums for urologic procedures. All but those in the bottom 10^th percentile met proposed minimums for radical hysterectomies, exenterations, and intestinal procedures. However, ACGME-proposed case minimums may be inadequate to achieve competence. Understanding the scope and variability of gynecologic oncology surgical training is needed to continue to improve and address gaps in fellow education.

Two-team-approached free flap reconstruction for plantar malignant melanoma: An observational (STROBE-compliant) trial.

Reconstructive treatments of heel defects usually involve regional flap techniques such as medial plantar flap procedures due to the limited availability of adjacent soft tissues. Although free flaps have advantages in terms of function and aesthetics, they remain challenging due to the longer operation time required than for regional flaps. Thus, we introduce an appropriate 2-team surgical protocol to reconstruct plantar defects after wide excision of malignant melanoma using free flap coverage.From 2015 to 2020, a retrospective study was performed including 21 patients who underwent free flap surgeries to reconstruct defects due to plantar malignant melanoma. Lymphoscintigraphy was performed to localize sentinel lymph nodes, and the procedure was carried out by 2 teams working together, a tumor-ablative team and a reconstructive team. The present study is adhered to the STROBE guidelines for cohort studies.The average operation time was 241.4 minutes and was not significantly different even in cases with inguinal dissection (P value: 0.641). All flaps survived after 2 cases of venous insufficiency and 1 case of hematoma were resolved by immediate revision surgery.The 2-team approach to surgically reconstruct heel defects after wide excision of malignant melanoma using free flap coverage offers favorable results and lower morbidity than regional flap approaches.

ASO Visual Abstract: Oncologic Outcomes of Multi-Institutional Minimally Invasive Inguinal Lymph Node Dissection for Melanoma Compared with Open Inguinal Dissection in MSLT-II

ASO Visual Abstract: Oncologic Outcomes of Multi-Institutional Minimally Invasive Inguinal Lymph Node Dissection for Melanoma Compared with Open Inguinal Dissection in MSLT-II

Oncologic Outcomes of Multi-Institutional Minimally Invasive Inguinal Lymph Node Dissection for Melanoma Compared with Open Inguinal Dissection in the Second Multicenter Selective Lymphadenectomy Trial (MSLT-II).

Minimally invasive inguinal lymphadenectomy (MILND) is safe and feasible, but limited data exist regarding oncologic outcomes. This study performed a multi-institutional retrospective cohort analysis of consecutive MILND performed for melanoma between January 2009 and June 2016. The open ILND (OILND) comparative cohort comprised patients enrolled in the second Multicenter Selective Lymphadenectomy Trial (MSLT-II) between December 2004 and March 2014.The pre-defined primary end point was the same-basin regional nodal recurrence, calculated using properties of binomial distribution. Time to events was calculated using the Kaplan-Meier method. The secondary end points were overall survival, progression-free survival, melanoma-specific survival (MSS), and distant metastasis-free survival (DMFS). For all the patients undergoing MILND, the same-basin regional recurrence rate was 4.4 % (10/228; 95 % confidence interval [CI], 2.1-7.9 %): 8.2 % (4/49) for clinical nodal disease and 3.4 % (6/179) for patients with a positive sentinel lymph node (SLN) as the indication. For the 288 patients enrolled in MSLT-II who underwent OILND for a positive SLN, 17 (5.9 %) had regional node recurrence as their first event. After controlling for ulceration, positive LN count and positive non-SLNs at the time of lymphadenectomy, no difference in OS, PFS, MSS or DMFS was observed for patients with a positive SLN who underwent MILND versus OILND. This large multi-institutional experience supports the oncologic safety of MILND for melanoma. The outcomes in this large multi-institutional experience of MILND compared favorably with those for an OILND population during similar periods, supporting the oncologic safety of MILND for melanoma.

MP46-14 INGUINAL LYMPHADENECTOMY FOR PENILE CANCER USING A FASCIAL SPARING TECHNIQUE - OUTCOMES FROM A SINGLE CENTRE

You have accessJournal of UrologyCME1 May 2022MP46-14 INGUINAL LYMPHADENECTOMY FOR PENILE CANCER USING A FASCIAL SPARING TECHNIQUE - OUTCOMES FROM A SINGLE CENTRE Nicolo' Schifano, Castiglione Fabio, Matthew Rewhorn, Paul Hadway, Rees Rowland, Raj Nigam, Hussain M. Alnajjar, and Asif Muneer Nicolo' SchifanoNicolo' Schifano More articles by this author , Castiglione FabioCastiglione Fabio More articles by this author , Matthew RewhornMatthew Rewhorn More articles by this author , Paul HadwayPaul Hadway More articles by this author , Rees RowlandRees Rowland More articles by this author , Raj NigamRaj Nigam More articles by this author , Hussain M. AlnajjarHussain M. Alnajjar More articles by this author , and Asif MuneerAsif Muneer More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002612.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Radical inguinal lymphadenectomy is performed for penile cancer patients who have pN+ disease in the inguinal lymph nodes. In order to reduce the morbidity, modified approaches have been described to reduce the size of the incision or reduce the number of lymph nodes removed. We describe the technique and report the oncological outcomes and complication rates of a fascial sparing inguinal lymphadenectomy technique. METHODS: Over a 10 year period, 294 fascial sparing inguinal lymphadenectomy procedures were performed in 173 patients. The technique uses a subinguinal incision with an ellipse of skin excised if there are any palpable nodes. Identification and preservation of the Scarpa’s and Camper’s fascia is the first layer preserved. All the superficial inguinal nodes were removed en bloc in the femoral triangle under this fascial layer whilst preserving the subcutaneous veins and fascia lata. The saphenous vein was spared where possible as part of the technique. Kaplan-Meier curves estimated the survival functions after the procedure. Postoperative morbidity was also retrospectively analysed. RESULTS: Median (interquartile range, IQR) follow-up was 28 (14-90) months. A median (IQR) number of 9 (6-12) nodes were removed per groin. The 3-year cancer-specific survival rate was 84% for pN1, and 56% for pN2-3 disease (p<0.001) compared to 91% for pN0 cases (Figure 1). A total of 105 postoperative complications (35.7%) occurred, including 46 conservatively-managed wound infections (15.6%), 13 cases of deep wound dehiscence (4.4%), 41 cases of lymphoedema (13.9%), 3 cases of deep vein thrombosis (1.0%), 1 case of pulmonary embolism (0.3%), and 1 case of postoperative sepsis (0.3%). There were no patients requiring blood transfusion. CONCLUSIONS: Fascial sparing inguinal dissection offers excellent oncological outcomes whilst decreasing the morbidity rates. Preservation of the fascia lata does not affect oncological outcomes. Patients with more advanced nodal-involvement had poorer survival rates which is in keeping with contemporary data. The technique reduces the risk of wound breakdown and bleeding from the structures deep to the fascia lata. Source of Funding: No source of founding to be acknowledged © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e778 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nicolo' Schifano More articles by this author Castiglione Fabio More articles by this author Matthew Rewhorn More articles by this author Paul Hadway More articles by this author Rees Rowland More articles by this author Raj Nigam More articles by this author Hussain M. Alnajjar More articles by this author Asif Muneer More articles by this author Expand All Advertisement PDF DownloadLoading ...

Extent of Groin Dissection in Melanoma: A Mixed-Methods, Population-Based Study of Practice Patterns and Outcomes.

Melanoma metastases to the groin are frequently managed by therapeutic lymph node dissection. Evidence is lacking regarding the extent of dissection required. Thus, we sought to describe practice patterns for the use of inguinal vs. ilioinguinal dissection, as well as the perioperative/oncologic outcomes of each procedure. A mixed-methods approach was employed to evaluate surgical practice patterns. A retrospective review of three multi-site databases was carried out, together with semi-structured interviews of melanoma surgeons. A total of 347 patients who underwent dissection were reviewed. The main indications stated for adding a “deep” ilioinguinal dissection were palpable or radiologically positive disease. There was no significant difference in complications, length of stay or lymphedema between patients having inguinal vs. ilioinguinal dissection, irrespective of method of diagnosis. There was also no significant difference in recurrence, cancer-specific survival or overall survival between groups. In conclusion, ilioinguinal dissection is a safe and well-tolerated procedure, with no significant added morbidity relative to an inguinal dissection. The indications for ilioinguinal dissection currently in use produce an appropriate deep node positivity rate and ilioinguinal dissection should continue to be used selectively. Randomized data are needed to clarify the impact of ilioinguinal dissection on regional control and survival.

CANCERS CUTANES SUR PEAU NOIRE : ASPECTS DIAGNOSTIQUES ET THERAPEUTIQUES AU CHU YALGADO OUEDRAOGO

Summary Objective: To study the clinical, diagnostic and therapeutic aspects of skin cancer at the CHU Yalgado Ouedraogo. Methods: This was a cross-sectional and descriptive study carried out over 9 months, from March 1 to November 30, 2020. The dermatology-venereology, general and digestive surgery departments of CHUYO served as the study framework. All histologically confirmed cases of skin cancer were included. Results: Thirty cases of skin cancer were collected. The mean age of the patients was 48.5 years. The sex ratio was 0.6. The main risk factors were chronic wounds (36.4%) and albinism (27.6%). Housewives and farmers accounted for 73.3% of the patients. The average consultation time was 13.4 months. The average size of the tumor was 9.2 cm. The tumors were ulcerative in 40% of cases. The predominant locations were the lower limbs in 36.7% of cases. Soft tissue ultrasound was performed in 8 patients who presented with swelling. Squamous cell carcinoma was the most common histologic type (40%). An extension assessment was performed in 16 patients. Surgery was the main therapeutic means. It was performed in 22 cases. Resection of the tumor was associated with inguinal dissection in 4 cases. Imatinib 400 mg / day has been used in Darier and Ferrand's dematofibrosarcoma. The dissection was complicated by lymphorrhea in 3 cases. Overall survival was 83%. Conclusion: Skin cancers occur in relatively young patients. Tumor sizes are important. The most common is squamous cell carcinoma. Raising public awareness of skin health problems would reduce diagnostic times and improve prognosis. Keywords: skin cancer, black skin, CHU Yalgado Ouedraogo

Clipping inguinal lymphatics decreases lymphorrhoea after lymphadenectomy following cancer treatment: results from a randomized clinical trial

Background Post-operative lymphorrhea is a well-known complication of inguinal lymph node dissection. However, the interventions to reduce the duration of drain in situ have not been sufficiently elaborated. Objectives We evaluated the potential role of intra-operative mapping of lymphatic leakage with peri-incisional methylene blue injection and clipping of lymphatics after inguinal block dissection in reducing postoperative lymphorrhea. Methods We randomized 39 inguinal dissections done for various malignancies such as for carcinoma penis, urethra, malignant melanoma, rectum into 19 dissections (Interventional group) and 20 dissections (Control group). In the interventional group, after the completion of inguinal dissection, two ml of methylene blue dye was injected 4–8cm from the incision to identify the leaking lymphatics and they were clipped. Results The primary outcome was the decrease in duration of days of drain in situ and was found to have significant reduction of 3.07 days in the interventional arm. (p value-0.02). The secondary outcome was the reduction of 21 ml of mean drain output in the interventional group (p = 0.09). The number of lymphatics clipped was not found to have statistical correlation with the duration of drain in situ and the mean drain output. Conclusion The intraoperative mapping of lymphatic channels using methylene blue after inguinal dissection reduces the number of days of drain in situ.

Vulva and lower limb cancer: Results of inguinal lymph node staging on 81 cases

Background: The objective of this work completed at the Cancer Institute in Dakar is to report the results of inguinal lymph node dissection in cancers of the lower limb and of the lower genital tract. Methods: This is a retrospective study over a 10-year period. The parameters being studied are histological type, lymph node involvement, postoperative morbidity, recurrence, and survival. Results: 81 patients received surgery over a period of 7 years. The average age of our patients was 61. The sex ratio is 0.74 with 34 men and 47 women. There were 70 cases of cancer of the lower limbs (86%) and 11 cases of cancer of the vulva (14%). The most common histological type was squamous cell carcinoma (SCC) with 41 cases (51%). Clinical inguinal involvement was noted in 58 patients (72.5%) with palpable lymph nodes. All vulvar cancer patients developed histologically positive nodes. Melanoma patients were more susceptible to developing positive nodes. In sarcoma there were more matches between clinical and histological positive nodes. No vascular and nerve damage was reported. The average length of hospitalization was 5 days, with 3 days being the shortest stay, and 40 days the longest stay. Local complications consisted of suture releases in 9 cases, and 6 surgical necrosis of the wound. A seroma was found with an average duration of 35 days in 69 patients (85%). Postoperative deaths occurred in 5 cases (6%), 1 after a renal failure, 1 due to thromboembolic disease, 1 due to sepsis, and 2 deaths occurred after patients experienced respiratory distress. Conclusion: After five years of follow-up care, no patient presented chronic sequelae after inguinal dissection, 7 patients (8.75%) had local recurrence, and 4 patients (7.7%) had lymph node metastases. We recorded 33 cancer-related deaths (41%). Chronic complications, including lymphedema are underestimated and require better assessment methods for prevention and treatment.

MP40-17 INGUINAL LYMPHADENECTOMY USING A FASCIAL SPARING TECHNIQUE IN THE MANAGEMENT OF PENILE CANCER – TECHNIQUE AND OUTCOMES FROM A SINGLE CENTRE

You have accessJournal of UrologyPenile & Testicular Cancer I (MP40)1 Sep 2021MP40-17 INGUINAL LYMPHADENECTOMY USING A FASCIAL SPARING TECHNIQUE IN THE MANAGEMENT OF PENILE CANCER – TECHNIQUE AND OUTCOMES FROM A SINGLE CENTRE Nicolo' Schifano, Fabio Castiglione, Matthew Rewhorn, Axel Cayetano-Alcaraz, Paul Hadway, Raj Nigam, Rowland Rees, Hussain M. Alnajjar, and Asif Muneer Nicolo' SchifanoNicolo' Schifano More articles by this author , Fabio CastiglioneFabio Castiglione More articles by this author , Matthew RewhornMatthew Rewhorn More articles by this author , Axel Cayetano-AlcarazAxel Cayetano-Alcaraz More articles by this author , Paul HadwayPaul Hadway More articles by this author , Raj NigamRaj Nigam More articles by this author , Rowland ReesRowland Rees More articles by this author , Hussain M. AlnajjarHussain M. Alnajjar More articles by this author , and Asif MuneerAsif Muneer More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002055.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Radical inguinal lymphadenectomy is performed for penile cancer patients who have pN+ disease in the inguinal lymph nodes. In order to reduce the morbidity, modified approaches have been described to reduce the size of the incision or reduce the number of lymph nodes removed. We describe the technique and report the oncological outcomes and complication rates of a fascial sparing inguinal lymphadenectomy technique. METHODS: Over a 10 year period, 294 fascial sparing inguinal lymphadenectomy procedures were performed in 173 patients. The technique used a subinguinal incision with an ellipse of skin excised over any palpable nodes. Identification and preservation of the Scarpa’s and Camper’s fascia was the first fascial preservation. All superficial inguinal nodes were removed en bloc under this fascial layer whilst preserving the subcutaneous veins and fascia lata. The saphenous vein was spared where possible as part of the standard technique. Kaplan-Meier curves estimated the survival functions after the procedure. Postoperative morbidity was also retrospectively analysed. RESULTS: Median (interquartile range, IQR) follow-up was 28 (14-90) months. A median (IQR) number of 9 (6-12) nodes were removed per groin. The 3-year cancer-specific survival rate was 84% for pN1, and 56% for pN2-3 disease (p<0.001) compared to 91% for pN0 cases (Figure 1). A total of 105 postoperative complications (35.7%) occurred, including 46 conservatively-managed wound infections (15.6%), 13 cases of deep wound dehiscence (4.4%), 41 cases of lymphoedema (13.9%), 3 cases of deep vein thrombosis (1.0%), 1 case of pulmonary embolism (0.3%), and 1 case of postoperative sepsis (0.3%). CONCLUSIONS: Fascial sparing inguinal dissection offers excellent oncological outcomes whilst decreasing the morbidity rates. Patients with more advanced nodal-involvement had poorer survival rates, emphasizing the need to evaluate the possible role of adjuvant chemo-radiotherapy protocols in these settings. Source of Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e721-e721 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nicolo' Schifano More articles by this author Fabio Castiglione More articles by this author Matthew Rewhorn More articles by this author Axel Cayetano-Alcaraz More articles by this author Paul Hadway More articles by this author Raj Nigam More articles by this author Rowland Rees More articles by this author Hussain M. Alnajjar More articles by this author Asif Muneer More articles by this author Expand All Advertisement Loading ...

A Case Report of Skip Lesions in Perianal Mucinous Adenocarcinoma

Perianal Mucinous Adenocarcinoma (PMA) is a rare gastrointestinal malignancy, known to occur in patients with a long-standing history of recurrent perirectal abscesses or a chronic fistula. In this case report, we present a unique presentation of perianal mucinous adenocarcinoma, which began as a rectal abscess and progressed to a case of perianal mucinous adenocarcinoma, with a skip lesion present all the way up in the mid-rectal region. To the best of our knowledge, this is the first case in which PMA presented with skip lesions as opposed to a continuous lesion, and presented without a long standing history of fistulas and recurrent abscesses, but instead just a 4-day history of perianal burning, itching and tingling. The use of CT imaging, MRI’s and PET scans as diagnostic modalities for PMA are further elucidated in the report, along with a discussion of NCCN guidelines on using radiation therapy followed by an APR with inguinal node dissection for the management and treatment of PMA. Sharing this unique and atypical presentation of PMA with multimodality speciality groups and tumor boards helps in the development of various diagnostic and therapeutic approaches for PMA, as well as enhances our understanding of this rare malignant entity.

Fast Track Surgery in laparoscopic treatment of inguinal hernias

Background. Minimally invasive surgical techniques for inguinal hernia repair reduce the body’s overall stress response to surgical tissue damage, the risk of complications, the percentage of postoperative acute and chronic pain, recovery time.&#x0D; Objective. To improve short-term (acute inguinal pain in the early postoperative period) and long-term (chronic inguinal pain in the long-term follow-up) results of surgical treatment of patients with acquired inguinal hernia by using the modified (sutureless, without mesh fixation) laparoscopic technique of transabdominal preperitoneal hernioplasty (TAPP) with application of Fast Track Surgery guidelines.&#x0D; Materials and methods. The retrospective clinical study included 124 patients aged 18 to 88 years (mean age – 46±2.1) with primary unilateral inguinal hernias who were operated on the clinical bases of the Department of Surgery and Vascular Surgery of Shupyk National Medical Academy of Postgraduate Education. The observation period was 3 years. Modified TAPP was performed in 78 patients (spinal anesthesia, local anesthesia of trocar wounds, terminal peritoneal anesthesia, preperitoneal infiltration of affected inguinal region dissection by local anesthetics, using of anatomical 3D mesh, sutureless restoration of peritoneal defect by electric welding method) and Lichtenstein technique was performed in 46 patients. The peritoneal defect in the main group after implant placement was restored by spot welding.&#x0D; There was experimental study before proceeding the clinical study. The experimental section of the work included 12 rabbits weighing 1.95-3.75 kg (average weight – 2.30±0.52). Each animal was cut peritoneum in three places on both sides of laparotomy with next reconstruction of the defect on one side by welding, and on the other – by suturing with synthetic suture material.&#x0D; Results and discussion. In biological samples from experimental animals, there was decreasing of number of live mesotheliocytes which did not increase the severity of the inflammatory reaction (p˂0.001). A statistically significant difference was observed in the welded scars with higher intensity of collagen formation than in the ligature scars, which provided greater strength of the tissue connection.&#x0D; There was a reduction in the patient’s length of stay in the hospital in 4.2 times in the group of modified technique. There was a reduction in the period before the ability to perform professional duties in 3.4 times in the group of new surgical method. There was no significant difference in the levels of postoperative complications (p=0.036) and re-operations due to complications (p=0.023). In the group of modified surgical treatment there were significant lower rates in the indicators of pain at rest (p&lt;0.001), pain during exercise (p&lt;0.001), recurrence rates (p&lt;0.001). There was a decrease in the need for analgetics in the main group in the early postoperative period (p˂0.001) and a reduction in the risk of prolonged inguinodynia (p˂0.001).&#x0D; Conclusions. The obtained results demonstrate the effectiveness of the use of modified laparoscopic transabdominal preperitoneal hernia mesh repair for primary unilateral inguinal hernias with using Fast Track Surgery protocols with regard improving quality of life of patients in the early and long postoperative period and reduction of the risk of recurrence.

Quality of life and associated factors after surgical treatment of vulvar cancer by vulvar field resection (VFR)

PurposeTo investigate patient-reported quality of life (QoL) and associated factors in vulvar cancer patients treated surgically by vulvar field resection (VFR) without adjuvant radiation.MethodsWe retrospectively evaluated patient-reported QoL as part of the prospective monocentric VFR trial using the 30-item European Organization for Research and Treatment of Cancer quality-of-life questionnaire (EORTC QLQ-C30) supplemented by a question assessing sexual activity. All patients had been treated by VFR and no participant had received adjuvant radiotherapy. The gynecologic cancer lymphedema questionnaire (GCLQ) was used to determine the presence of lymphedema. Structured telephone interviews were conducted to assess postoperative sequelae and long-term complications.ResultsForty-three VFR patients (median age 63 years) were available for QoL assessment. Thirty-eight (88%) had received inguinal lymph-node dissection in addition to VFR. Mean global QoL (global health status) rating among all patients was 66.1 (± 25.5) on a scale from 0 to 100 with higher scores indicating better QoL. Higher GCLQ scores were significantly associated with lower global QoL scores (Spearman's rank correlation ρ =− 0.7, p < 0.0001). The presence of preoperative co-morbidities and postoperative wound-healing complications were also linked to reduced QoL (p < 0.01 for both). In a multivariable regression model, there was a significant interaction between preoperative co-morbidities and wound-healing complications with regard to global QoL (p < 0.05).ConclusionOverall, VFR patients exhibit good quality of life postoperatively. The presence of lymphedema, wound-healing complications, and preoperative morbidities were associated with reduced QoL. Prospective longitudinal studies have to confirm our findings in the future.

“PK Band” in Laparoscopic Hernia Repair

Laparoscopic inguinal anatomy detail is different from that is necessary for open hernia surgery. ‘PK Band’ is a condensation of areolar tissue lateral to inferior epigastric vessels on either side. It extends from arcuate line to apex of triangle of doom. It is more condensed and prominent in the upper part. ‘PK Band’ is more prominent in males and tall structured individuals. It is an important land mark during laparoscopic inguinal dissection in both TEP (total extra peritoneal) and TAPP (trans abdominal preperitoneal) methods. Lateral blunt dissection in the preperitoneal plane will definitely be restricted by this band. Forcing the scope laterally will cause tear of the peritoneum at that level. Muscle injury may also be caused by blunt dissection. Division of this band during laparoscopic hernia repair connects the space of Bogros with space of Retzius. This provides sufficient space necessary for proper placement of mesh and hence significantly reduce recurrence.

Skip lesions in perianal mucinous adenocarcinoma

Perianal mucinous adenocarcinoma (PMA) is a rare gastrointestinal malignancy that occurs in patients with a long-standing history of recurrent perirectal abscesses or a chronic fistula. We present a unique case of PMA, which began as a rectal abscess and progressed to PMA with a skip lesion present all the way up in the mid-rectal region. This is the first case in which PMA presented with skip lesions as opposed to a continuous lesion, and presented without fistulas and recurrent abscesses history but just a 4-day history of perianal burning, itching, and tingling. CT imaging, MRIs, and PET scans were done for the diagnosis of PMA. A discussion of the National Comprehensive Cancer Network (NCCN) guidelines on using radiation therapy followed by an abdominoperineal resection with inguinal node dissection for the management and treatment of PMA is reported. Sharing the presentation of PMA with multimodality specialty groups and tumor boards helps develop various diagnostic and therapeutic approaches for PMA, as well as enhances our understanding of this rare malignant entity.

Atrophic vulvar lichen sclerosus evolving to an epidermoid carcinoma: about an uncommon case

Malignant tumors of the vulva are usually budding, ulcerated, or infiltrating. The fear of cancer must always be in mind, in front of any vulvar lesion. Therefore, do not hesitate to make biopsies of any lesion of the vulva to confirm or deny a cancer. We hereby report the uncommon case of a postmenopausal 68-old-patient followed for an atrophic vulvar lichen sclerosus which eventually transformed into an epidermoid carcinoma of the vulva. The indication for right hemivulvectomy with sentinel lymph node procedure was retained. Vulvar cancer takes a variety of aspects. It is therefore necessary to always have it in mind and to make a biopsy before any suspicious lesion. Since the atrophic vulvar lichen sclerosus of the vulva is a pre-cancerous lesion, we believe that its follow-up must be strict and a second biopsy must be performed before any worsening of the lesions. Finally, the procedure of the sentinel lymph node is of great interest when we know the morbidity of the inguinal region dissections but also the slow learning curve of surgical techniques of vulvar cancer.

Lymph node ratio as a prognostic factor in melanoma: results from European Organization for Research and Treatment of Cancer 18871, 18952, and 18991 studies.

The aim of this study was to assess the prognostic importance of lymph node ratio (LNR) in stage III melanoma after complete lymph nodal dissections. From European Organization for Research and Treatment of Cancer randomized trials 18871, 18952, and 18991, 2358 patients had full information on positive and examined lymph nodes (LNs) and were included. Cox proportional hazards models stratified by trial were used to assess the prognostic impact of LNR adjusted for confounders on melanoma-specific survival. Optimal cutoff values for LNR were calculated for each LN dissection site (axillary, inguinal, and neck). LNR (≥ vs. <35%: hazard ratio=1.44, 95% confidence interval: 1.23-1.69) and number of positive LNs appeared to be of independent strong prognostic importance. Dissection sites impacted the optimal LNR cutoff: 35% for axillary, 40% for inguinal, and 50% for neck dissections. Combining these into one 'high versus low LNR' resulted in a highly significant multivariately adjusted hazard ratio of 1.48 (95% confidence interval: 1.26-1.74). In subgroup analyses, LNR was only significant in advanced disease (American Joint Committee on Cancer stage N2b, N3; IIIC). LNR was most significant for inguinal dissections, followed by axillary dissections, but seemed less useful in neck dissections. LNR is an independent significant prognostic factor in stage III melanoma patients. Our study showed higher than previously reported cutoffs that differed per dissection site. However, because of conflicting results compared with other studies and apparent limited prognostic impact confined to subgroups, the practical use of LNR seems limited.

HPV/p16 Positivity and Nodal Status are Associated With Locoregional Control in Penile Cancer

Penile cancer (PeCa) is a rare aggressive malignancy that can be associated with the human papillomavirus (HPV). HPV tumor positivity is known to correlate with improved response rates to chemoradiation therapy (CRT) in a number of malignancies. PeCa is often managed by surgical resection and can be treated with adjuvant CRT to improve locoregional control (LRC). Our objective was to identify factors associated with PeCa LRC. We retrospectively identified patients with known HPV status diagnosed with squamous cell carcinoma of the penis that underwent surgical resection between 1999 and 2016. Patients with recurrent or distant metastatic disease were excluded. The relationship between tumor/treatment characteristics and LRC were analyzed with univariate (UVA) and multivariate (MVA) Cox proportional hazard regression analysis. Variables with a trending association with LRC on UVA (p<0.1) were included on MVA. Time to event outcomes were also estimated with Kaplan-Meier and compared via log-rank. There were 51 patients identified with a median follow up of 12 months. Patients were primarily HPV negative (n=28, 55%), pathologic node negative (pN0, 45%), AJCC stage II (43%), treated with partial penectomy (76%), had negative surgical margins (94%), and underwent inguinal dissection (82%). Less commonly, patients were treated with adjuvant CRT (33%) and pelvic dissection (10%). The 1 year LRC rate was 63%. Factors predictive of LRC on UVA included: performance status, tumor stage, nodal stage, HPV status and extent of primary surgery (all p<0.1), but only pathologic nodal status continued to predict for LRC on MVA (p=0.03). While HPV status had no association with LRC on UVA (p=0.076), subgroup analysis showed a significant 1-year LRC benefit for HPV+ patients treated with CRT (HPV+ vs. HPV-: 100% vs. 50%, p=0.04). Patients with pN+ disease had a significantly lower 1-year LRC (47% vs. 89%, p=0.002). In subgroup analysis of pN+ patients (n=28), there was a LRC benefit on MVA associated with the addition of CRT (HR 0.23; 95% CI 0.06-0.84, p=0.03) and in HPV+ disease (HR 0.16; 95% CI 0.03-0.74, p=0.02). Pathologic nodal involvement predicts for worse LRC in penile cancer. In our retrospective series, CRT is associated with improved LRC with HPV + disease or with pathologic nodal involvement. Therefore, we recommend prospective investigation of the benefit of adjuvant CRT in these patients.