Inguinal Recurrence Research Articles

The Quality of Life of Inguinal Hernia Patient in India: The Application of Hernia- Specific Quality of Life Assessment

Background: In inguinal hernia patient post-operative recurrence rate has been decrease due to advancement in prosthetic mesh. The hernia outcome study should concentrate on hernia post-operative quality of life and various complications.
 Objectives:
 
 To study the application of HERQL INSTRUMENT in surgical practice.
 To study the quality of life pre-operatively & post-operatively.
 To utilise as HERQL INSTRUMENT in clinical management as a prognostic indicator to improve upon the healthcare system.
 
 Methodology: All the patients of inguinal hernia presenting to Acharya Vinoba Bhave Rural Hospital, Sawangi (Meghe), Wardha as an elective/emergency case will be included in the study after obtaining consent. Patient has to go through the HERQL questionnaire pre-operatively and post-operatively or post-operatively only. These patients will be enrolled in the study.
 Results: We expect a causal relationship between formative symptomatic subscale and the reflective functional status demonstrated by HERQL. The assessment of summative pain in preoperative and immediate postoperative patient shows changes in summative pain and 3 month follow up suggestive of clinical response of HERQL.
 Conclusion: This study will help to know quality of life in “post-operative” hernia patient with the help of “HERQL instrument”.

Comparison of Open Repair and Laparoscopic Percutaneous Internal Ring Suturing Method in Repairing Inguinal Hernia in Children.

IntroductionAn inguinal indirect hernia is one of the most frequent surgical conditions in children. In this study the experience with laparoscopic percutaneous internal ring suturing (PIRS) and open inguinal hernia surgery and their relations evaluated.MethodsAll children over 90 days of age and without having prior inguinal region surgery with a diagnosis of indirect inguinal hernia underwent surgical repair with open or laparoscopic PIRS technique. Patients' gender, age at surgery, inguinal hernias side, surgery duration, recurrence, complications, and follow-ups were collected.ResultsA total of 488 inguinal hernias of 405 patients were repaired. The diagnoses were unilateral inguinal hernia in 360 (88.9%) and it was bilateral in 33 (8.1%) patients. The operative technique was laparoscopic PIRS for 227 and open inguinal hernia surgery for 178 patients. In the PIRS group, a contralateral hernia was found in 48 of 205 children (23.4%). The surgery times were 23.3 (PIRS) and 33.7 (open) min for unilateral and 28 (PIRS) and 53.1 (open) min on average for bilateral inguinal hernia surgery. Mean follow-up was 30.4 months for PIRS and 24.4 months for open technique. Recurrence was observed in seven (3%) patients in PIRS and one (0.5%) in the open group and postoperative complications in three (1.3%) in PIRS and four (2.2%) in the open group.ConclusionPIRS method has the advantage to evaluate contralateral hernia at the same session, minimal scar related to surgery, and preserve the spermatic cord from manipulation. PIRS is an alternative feasible method and easy to perform to repair the inguinal hernia with/without communicating hydrocele in children.

Elective Inguinal Node Irradiation Is Not Necessary in Cervical Cancer Invading Lower Third of Vagina

To explore the necessity of prophylactic inguinal irradiation in cervical cancer invading lower vagina. We retrospectively analyzed the patients with stage III to IV cervical cancer invading lower vagina in our institution between 2010 January and 2017 August. From 2010 January to 2017 August, 165 cervical cancer patients with lower third vaginal involvement received radiotherapy or chemo-radiotherapy in our institution. Of 159 patients having negative inguinal nodes and omitting the prophylactic inguinal irradiation, 54 patients had regional or distance recurrences after 2 to 53 months. The median time to recurrence was 12 months. Fifteen patients recurred in lung, 5 in liver, 9 in bones, 5 in mediastinal or cervical lymph nodes, 1 in brain, 1 in spleen, 10 in reginal lymph nodes, 14 in cervix or vagina, 2 in inguinal recurrence. Of the two patients had inguinal recurrence, one had multiple recurrences including cervical, mediastinal, reginal and inguinal lymph nodes five months after diagnosis then had four cycles of chemotherapy. Only one patient had isolated inguinal recurrence. This patient diagnosed stage IIIB cervical cancer in 2017 March, and had inguinal recurrence in 2017 July, then received curative local treatments. Until the 2020 February, this patient is alive with no evidence of other recurrences. Of 6 patients who had inguinal area involvement at the time of diagnosis and had bilateral inguinal irradiation, five patients developed recurrences after 7 to 14 months. The median time to recurrence was 12 months. Three patients had distance recurrences in liver, mediastinal lymph nodes or bones and 2 had local recurrences in cervix or vulva, none of them had inguinal failure. The isolated inguinal node recurrence is rare (1/159) in cervical cancer patients with lower third vaginal involvement when prophylactic inguinal irradiation was omitted. Considering the low recurrence rate and curative salvage treatments of isolated inguinal node recurrence, the routine elective inguinal irradiation is not necessary.

Incidence and risk factors for umbilical trocar site hernia after laparoscopic TAPP repair. A single high-volume center experience.

Trocar site hernia (TSH) is often underestimated after minimally invasive surgery. Scarce information is available about the incidence of TSH in patients undergoing laparoscopic hernioplasty. We aimed to evaluate the incidence and risk factors of umbilical TSH after laparoscopic TAPP hernioplasty in patients with and without an associated umbilical hernia. A retrospective analysis of a prospectively collected database of all patients who underwent laparoscopic inguinal TAPP repair during 2013-2018 was performed. After TAPP repair, the umbilical fascia was closed either by a figure-of-eight stitch with absorbable suture (G1) or by umbilical hernioplasty if it was present (G2). Multivariate logistic regression analysis was used to determine the TSH risk factors. Comparative evaluation regarding demographics, and operative and postoperative variables was performed. A total of 535 laparoscopic TAPP repairs were included. There were 359 (67.1%) patients in G1 and 176 in G2 (32.9%). Surgical site infection was higher in G2 (G1: 0.6% vs G2: 5.7%, p = 0.001). Overall TSH rate was 3.9% after a mean follow-up of 20 (12-41) months. Performing a concomitant umbilical repair significantly increased the risk of umbilical TSH (G1: 2.2% vs G2: 7.4%, p = 0.004). TSH rates in G2 were similar in patients with simple suture or mesh repairs (p = 0.88). Rectus abdominis diastasis (OR 37.8, 95% CI:8.22-174.0, p < 0.001) and inguinal recurrence (OR 13.5, 95% CI:2.04-89.5, p = 0.007) were independent risk factors for TSH. Although trocar site hernia after laparoscopic TAPP repair has a low incidence, its risk is significantly increased in patients with a concomitant umbilical hernia repair, rectus abdominis diastasis, and/or inguinal recurrence.

Tailoring the radiotherapy approach in patients with anal squamous cell carcinoma based on inguinal sentinel lymph node biopsy.

The aim of our study was to analyze the results of selective inguinal node irradiation in patients with anal cancer, based on the biopsy of the inguinal sentinel lymph node (SLN), in terms of local control and prognosis. Records of patients with anal squamous cell carcinoma from January 2001 to December 2016 were retrospectively reviewed. Tc99 lymphoscintigraphy was performed in all the clinically inguinal negative patients, followed by radio-guided surgical removal of the inguinal SLN. All patients were treated with combined radiochemotherapy. In patients with negative sentinel nodes, the inguinal area was excluded in the radiotherapy field. A total of 123 patients, 76 females (61.8%), mean age 60.1 ± 12.19 years old, underwent intraoperative lymph node retrieval. The histological analysis showed metastasis in the SLN in 28 patients (22.8%). The mean follow-up was 43.44 ± 31.86 months. No inguinal recurrence was observed in patients with negative inguinal sentinel node(s). A statistically significant difference was observed for overall and disease-free survivals in a patient with positive and negative inguinal sentinel nodes. In patients with anal canal cancer, the exclusion of the inguinal regions from the radiotherapy field, in patients with negative SLN, does not compromise locoregional control nor prognosis.

Morphological justification of laparoscopic transabdominal preperitoneal (TAPP) operation for the inguinal hernia recurrence

Introduction. The frequency of the inguinal hernia of the repeated recurrences is up from 9,3 to 12%. In surgical treatment re-fixation of the mesh to the atrophied tissues of the inguinal canal is unreliable. The posterior access can be much more reliable for the patients, in which the mesh will be fixed to the unchanged muscular-aponeurotic tissues of the inguinal area.Aim. To increase the efficiency of recurrent inguinal hernias surgical treatment by justification of using the TAPP surgical technology.Materials and methods. An analysis was made in the clinic Kiev City Clinical Hospital No. 5. about surgical treatment of recurrent inguinal hernias in 105 patients. Surgical operations were also divided. The patients were divided into 2 groups, the first group (52), where the Liechtenstein's operation was repeated, and the second group of the patients (53) were confirmed by TAPP (patent No. 1299.1 from 26.11.18). A biopsy of the inguinal muscle aponeurotic tissues was made during surgery in both groups of the patients. Also morphological examination was made. For a final comparison of the morphological examination of inguinal tissues, a biopsy was performed in 20 patients who had an appendectomy.Results and discussions. In I group to the remote period in 8 (16%) patients there were chronic inguinal pain and recurrence of hernia was observed in 4 (8%) patients. In II group long-term results were as follows, chronic inguinal pain was diagnosed in 2 (4%) patients, recurrence was observed in 1 (2%) patient. After making a morphological comparison of the three groups, it was found that in group I were signs of severe chronic inflammation with the formation of granulation of the tissue, scar tissue, destruction of elastic fibers, both in the tissue of the anterior abdominal wall and in the wall of the vascular component. The morphological picture of the II and III groups are similar, with weakly expressed chronic inflammatory infiltration, with savings of the elastic fibers and less degenerative changes.Conclusion. The morphological reasoning of the use of improved TAPP was the absence of atrophic changes in the muscular-aponeurotic tissues of the inguinal region, while in Liechtenstein's second operation there was atrophy, scarring of inguinal tissues, so fixation of the mesh to such tissues can leads to recurrence.

Utility of Minimally Invasive Technology for Inguinal Lymph Node Dissection in Penile Cancer.

Our aim is to review the benefits as well as techniques, surgical outcomes, and complications of minimally invasive inguinal lymph node dissection (ILND) for penile cancer. The PubMed, Wiley Online Library, and Science Direct databases were reviewed in March 2020 for relevant studies limited to those published in English and within 2000–2020. Thirty-one articles describing minimally invasive ILND were identified for review. ILND has an important role in both staging and treatment of penile cancer. Minimally invasive technologies have been utilized to perform ILND in penile cancer patients with non-palpable inguinal lymph nodes and intermediate to high-risk primary tumors or patients with unilateral palpable non-fixed inguinal lymph nodes measuring less than 4 cm, including videoscopic endoscopic inguinal lymphadenectomy (VEIL) and robotic videoscopic endoscopic inguinal lymphadenectomy (RVEIL). Current data suggest that VEIL and RVEIL are feasible and safe with minimal intra-operative complications. Perhaps the strongest appeal for the use of minimally-invasive approaches is their faster post-operative recovery and less post-operative complications. As a result, patients can tolerate this procedure better and surgeons can offer surgery to patients who otherwise would not be a candidate or personally willing to undergo surgery. When compared to open technique, VEIL and RVEIL have similar dissected nodal count, a surrogate metric for oncological adequacy, and a none-inferior inguinal recurrence rate. Larger randomized studies are encouraged to investigate long-term outcome and survival rates using these minimally-invasive techniques for ILND.

Robotic-assisted single site (RASS) TAPP: an advantageous choice? : Outcomes of single site robotic groin hernia repair.

Laparoscopic transabdominal preperitoneal (TAPP) is a valid option for bilateral primary groin hernia and recurrent cases. Robotic approach for inguinal hernia is still debated. The aim of this study is to investigate the potential role of robotic-assisted single site-TAPP (RASS-TAPP) reporting our experience. We performed 44 RASS TAPP in 32 patients from February 2016 to July 2018. Data on patient demographics, type of hernia, operative time, complications, recurrence rate and hospital stay were retrospectively analyzed. Follow-up was scheduled at 1week, 4months and 1year after surgery. Forty-two hernias were treated in 32 patients (27M). Mean age was 48.6years (range 20-67), mean BMI was 26.49kg/m2 (range 16-34.9). Mean operative time was 54.8min (range 28-150). In two cases (6%) a conversion to laparoscopy was necessary. At 1week, two scrotal hematomas and four seromas were observed and treated conservatively. At 4months follow-up, one patient (3.1%) complained temporary pain. No patient had inguinal recurrence or incisional umbilical hernia and chronic pain at 1-year follow-up. RASS TAPP is feasible and safe with a high patient satisfaction. However, the surgeon experiences a technical discomfort due to the conflict of the instrumentation which influences negatively the choice of this approach, despite the better vision and augmented dexterity provided by the robot.

Abstract PD8-05: Single-cell analysis of breast cancer metastasis using patient-derived xenograft model reveals clonal relationship between primary tumor and its metastases

Abstract Introduction Breast cancer is the most common cancer in female and triple-negative breast cancer (TNBC) is the most aggressive subtype of breast cancer which shows high rate of recurrence and metastasis. Malignant cells that comprise primary tumor are heterogeneous and during disease progression selection of tumor cells occur as a mean to adapt and survive. Tumor heterogeneity can be studied by grouping cells as clones which refer to a group of cells related to each other by descent from a unitary origin. Understanding the mechanism of clonal dynamics and selection during cancer evolution is important to develop new therapeutic strategies for cancer metastasis. Moreover, it is imperative to be able to detect rare subclones that are responsible for metastasis. Thus, single-cell analysis is critical to identify cellular heterogeneity of cancer and molecular basis of metastatic phenotype in depth. Measuring genome and transcriptome in single-cell level will enable us to discover clonal dynamics during cancer metastasis and infer molecular determinants of metastasis fitness. Here, we propose to investigate the clonal dynamics, genomic, and transcriptomic profiles of human breast tumor metastasis using TNBC patient-derived xenograft (PDX) model to understand the mechanism of breast cancer progression and metastasis. Methods Tumor cells from previously established PDXs were transplanted into mammary fat pad of mice. Tumors were removed when it reached maximum allowed endpoint size (1,000mm3) and mice were monitored and allowed to grow metastasis. PDXs that developed primary tumor and metastasis were selected for subsequent single cell analysis. Single-cell whole-genome sequencing (scWGS) was performed using direct library preparation (DLP+) method which is preamplification-free single-cell genome sequencing approach. scWGS data was used to call cell-specific copy number events, which allows us to cluster cells and identify clones. Hierarchical clustering was used to identify clonal structure of each sample. Phylogenetic tree was computed using copy number data of samples from each PDX. Results Nine different TNBC PDX lines were tested and 6 PDX lines developed metastasis. We focused on 2 PDX lines of which metastatic tissues were available for single cell sequencing. SA919 developed metastatic mass near cervical or lumbar spine area. SA535 developed metastasis to lung, axillary or inguinal area and tumor recurrence at mammary fat pad site. scWGS for SA919 and SA535 was carried out and we generated libraries from single cells of primary tumor and its metastases. Hierarchical clustering using copy number data revealed clonal structure of primary tumor and metastases. SA919 showed oligoclonal primary tumor and metastasis whereas SA535 showed polyclonal metastasis from polyclonal primary tumor. scWGS data of primary tumor and its metastases in each PDX were merged to compute phylogenetic trees. Phylogenetic analysis revealed that not all clones of primary tumor contributed to metastasis in both PDXs. Different metastatic lesions of SA535 harbored different clones from primary tumor. For example, clones consisting left axillary metastasis and right axillary metastasis in SA535 were different from each other, however they both originated from primary tumor clones. Metastatic lesions from SA919 and SA535 also had newly appearing clones that were not present in primary tumor inferring clonal evolution during metastasis. Conclusion We were able to capture different patterns of metastasis in several PDXs. Phylogenetic analysis using scWGS data revealed clonal relationship between primary tumor and metastases. Further analysis of single cell genomic and transcriptomic profiles will provide deeper understanding of metastasis in breast cancer. Citation Format: Hakwoo Lee, Farhia Kabeer, Ciara O'Flanagan, Jazmine Brimhall, Justina Biele, Biexi Wang, Teresa Ruiz Algara, So Ra Lee, Daniel Lai, Michael Yuen, Simong Song, Patricia Ye, Jenifer Pham, Richard Moore, Andy J Mungall, Sohrab P Shah, Samuel Aparicio. Single-cell analysis of breast cancer metastasis using patient-derived xenograft model reveals clonal relationship between primary tumor and its metastases [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr PD8-05.

Dosimetric comparison of organs at risk using different contouring guidelines for definition of the clinical target volume in anal cancer

BackgroundThere are different contouring guidelines for definition of the clinical target volume (CTV) for intensity-modulated radiation therapy (IMRT) of anal cancer (AC). We conducted a planning comparison study to evaluate and compare the dose to relevant organs at risk (OARs) while using different CTV definitions.MethodsTwelve patients with a primary diagnosis of anal cancer, who were treated with primary chemoradiation (CRT), were selected. We generated four guideline-specific CTVs and subsequently planned target volumes (PTVs) on the planning CT scan of each patient. An IMRT plan for volumetric arc therapy (VMAT) was set up for each PTV. Dose parameters of the planned target volume (PTV) and OARs were evaluated and compared, too.ResultsThe mean volume of the four PTVs ranged from 2138 cc to 2433 cc. The target volumes contoured by the authors based on the recommendations of each group were similar in the pelvis, while they differed significantly in the inguinal region. There were no significant differences between the four target volumes with regard to the dose parameters of the cranially located OARs. Conversely, some dose parameters concerning the genitals and the skin varied significantly among the different guidelines.ConclusionThe four contouring guidelines differ significantly concerning the inguinal region. In order to avoid inguinal recurrence and to protect relevant OARs, further investigations are needed to generate uniform standards for definition of the elective clinical target volume in the inguinal region.

Missed Inguinal Cord Lipoma May Mimic Recurrence Following Endoscopic Repair of Groin Hernias

To investigate the preoperative diagnosis, incidence rate, operation method, and recurrence as a cause of inguinal cord lipomas (ICL) in patients that were treated surgically due to groin hernia. This was a retrospective review of hernia repairs from January 2015 to January 2017 with open and endoscopic technique. Operative notes, pathologic reports, and demographic findings were evaluated in those patients. The same group of general surgeons performed all the procedures. A total of 722 patients were operated with the diagnosis of groin hernia. The patients were classified in two groups according to whether or not evaluation with the preoperative ultrasound (US). In total, 519 patients in group 1 had a preoperative US and underwent open surgery, whereas 203 patients in group 2 underwent endoscopic hernia surgery without a preoperative US examination. An US was performed before re-operation in recurrent cases. In group 1, 29 of 519 patients were identified as having ICL preoperatively through US with an incidence of 5.5%. Pathologic reports were confirmed as ICL in all of them. Six recurrences were seen in group 1 (1.15%) over at least 12 months follow-up period (12–48 months). ICL was not seen in these recurrences. Etiology of recurrence was mesh shrinkage in 5 and mesh migration in 1 patient. In group 2, 203 endoscopic hernia repairs were performed without a preoperative US. During the follow-up, 4 recurrences were diagnosed (1.9%). Although there was no suspicion of ICL left reported during the surgery from the operation notes, ICL was mimicking recurrence in two (0.9%) of them. Etiology of recurrence in the other 2 was mesh migration due to inadequate fixation. ICL could mimic recurrence if not removed or missed during hernia surgery. Preoperative US is a simple, useful, noninvasive, and cheap method in finding the ICL and preventing the re-operations.

Regenerative Surgery in Open Mesh Repair for Inguinal Hernia

Inguinal hernia repair is the most frequently performed operation in General Surgery. Over 20 million hernia repair procedures per year are performed worldwide. Complications such as chronic inguinal pain (12%) and recurrence rate (11%) significantly impact the surgical results. The 4 main impacting factors affecting hernia repair results are: mesh material and design; mesh fixation; tissue healing and regeneration and the surgical technique. These essential components are analysed in this article. This analysis is followed by an explanation of how a new procedure, L-PRF-Open Mesh Repair, can improve both short and long term results.

Long-term outcomes for penile cancer patients presenting with advanced N3 disease requiring a myocutaneous flap reconstruction or primary closure-a retrospective single centre study.

Penile cancer patients with advanced metastatic disease in the inguinal region present a therapeutic challenge. We compared the outcomes for patients with advanced inguinal node disease requiring myocutaneous flap reconstruction (MFR) against primary closure for N3 disease. A retrospective comparative study of a consecutive cohort of advanced penile cancer patients with N3 disease was performed. Patient demographics, presenting symptoms, primary tumour site, stage and grade were recorded. The type of MFR used, patient outcomes and post-operative complications were recorded from an institutional database. Kaplan-Meier (KM) curves were calculated to analyse the cancer-specific survival (CSS) rates for the MFR group and compared with the no-MFR group. P values were calculated by log-rank and Chi square tests for CSS rates and complications respectively. Eighteen patients requiring MFR were identified; mean age 62 years. Ten (55.6%) patients had a first presentation with penile cancer and advanced nodal disease with the remaining 8 (44.4%) presenting with an inguinal recurrence having already undergone surgery. The majority (n=15) underwent a vertical rectus abdominis myocutaneous (VRAM) flap. The average length of stay was 23 days for the MFR group versus 8.5 days for the no-MFR group. The 5-year CSS was 20.9% for the MFR group and 39.8% for the no-MFR group (P<0.01). Aggressive surgical management for patients with extensive nodal disease and flap reconstruction is feasible and aids wound management although the long-term prognosis is still poor.

The PRIMETEST trial: Interim analysis of a phase II trial for primary retroperitoneal lymph node dissection (RPLND) in stage II A/B seminoma patients without adjuvant treatment.

507 Background: We thought to evaluate progression-free survival of stage II A/B seminoma patients (pts) undergoing primary retroperitoneal lymph node dissection (RPLND) without adjuvant treatment. Aim is to present interim data of a feasibility study and a phase II trial. Methods: Prior to the phase II study, 9 patients have been treated within a pilot feasibility study. After IRB approval, additional 12 patients from 3/2016 to 9/2018 within the prospective phase II trial were accrued. All patients received primary retroperitoneal lymph node dissection (open or daVinci assisted) for stage IIA/B seminoma without adjuvant treatment. The data was analyzed for peri- and postoperative outcome including recurrence free survival. The trial will have to accrue 30 pts and was designed to exclude a &gt; 30% recurrence to standard treatment. Results: Since 5.2014 twenty-two patients with seminomateous germ cell tumor have been included in both studies, including one patient with an atypical inguinal recurrence and one patient with a 6 cm marker negative recurrence (clinical stage IIC). Primary RPLND was performed in 4 patients with initial CSIIA. 14 and 4 patients experiences a recurrence under surveillance and after carboplatin adjuvant treatment, respectively. Mean tumor size was 2.6 cm with a mean OR time of 134 min and a mean blood loss of 70 cc. One patient after DaVinci RPLND developed a ureteral stricture requiring ileal ureter substitute. The mean follow-up is 24 month (range 1-51 months), 17/22 patients (77%) are free of recurrence. 5/22 (23%) developed a recurrence (4x outside field and 1x inside field) with a mean time to recurrence of 4.5 months. All patients received salvage treatment (4x CTX and 1x radiotherapy) and are currently recurrence free. Conclusions: Primary RPLND in stage IIA/B seminoma patients is an experimental treatment approach in order to reduce long term toxicity and secondary malignancies. Interim results of this strategy justifies continuation of the study. This kind of surgery should only be performed within clinical trials in high volume referral centers. Clinical trial information: NCT 2015053664.

Superficially invasive stage IA vulvar squamous cell carcinoma-therapy and prognosis.

Superficially invasive stage IA squamous vulvar cancer (VSCC) is defined as a single lesion measuring ≤2 cm with a depth of invasion of ≤1.0 mm (FIGO stage IA). This article examines the natural course and prognosis of superficially invasive VSCC. This is a retrospective case series of 46 patients (median age 58 years) with superficially invasive stage IA VSCC receiving wide local excision between January 1996 and November 2014 in the University Medical Center Hamburg-Eppendorf. Median tumor size was 4 mm. In 39/46 (84.8%) patients peri-tumoral high-grade intraepithelial neoplasia (HSIL) and/or lichen sclerosus (LS) of the vulva were histologically detected: 34 (74.0%) usual type high-grade vulvar intraepithelial neoplasia (uVIN, HSIL), 4 (8.7%) LS with simultaneous VIN (3 uVIN, 1 differentiated VIN (dVIN)), 1 (2.2%) with LS only. 37/46 (80.4%) patients had a R0 resection; in 2 (4.3%) a high-grade VIN was detected in the margin and in 7 (15.2%) the resection status was unknown. The mean follow-up was 58 (range 10-185) months. Four patients (8.7%) suffered from an invasive recurrence after 4, 17, 40, and 54 months, three in the vulva and one in the groin. All local recurrences occurred in women with LS in a combination with high-grade VIN (3 uVIN, 1 dVIN). Two were treated surgically again including inguino-femoral lymphadenectomy (ifLAE) (no regional lymph node metastasis histologically) as invasion depth exceeded 1 mm. The third patient refused treatment. Inguinal recurrence was treated with a bilateral ifLAE, revealing one positive lymph node, followed by adjuvant radiotherapy (groins, pelvis). None of these patients had experienced further recurrences at last follow-up. Superficially invasive VSCC is characterized by having a very good prognosis. Sole surgical therapy is highly effective. Patients with LS might benefit additionally from intensified surveillance and adequate maintenance therapy in specialized centers.

Dosimetric comparison of different radiation techniques (IMRT vs. 3-dimensional) of the \u201ctrue\u201d (deep) ano-inguinal lymphatic drainage of anal cancer patients

IntroductionThe ano-inguinal lymphatic drainage (AILD) is located in the subcutaneous adipose tissue of the proximal medial thigh. Currently, there are no recommendations for an inclusion of the ‘true’ AILD in the clinical target volume (CTV) of definitive chemoradiation for anal cancer patients. To estimate the relevance of inguinal recurrence, we compared the incidental dose to the AILD in anal cancer (AC) patients who were treated either with Volumetric Arc Therapy – Intensity Modulated Radiation Therapy (VMAT-IMRT) or conventional 3D-radiation technique.MethodsOne VMAT-IMRT-plans and one 3D-plans were calculated on the same target volumes and identical dose prescription in ten patients. We defined the volume of the AILD on the planning CT-scans based on the information of new fluorescence methods. Furthermore, we defined several anatomical subvolumes of interest inside the AILD. We examined and compared absolute and relative dosimetric parameters of the AILD and different anatomical subunits.ResultsThe Dmean of the AILD was 40 Gy in the 3D-group and 38 Gy in the IMRT-group. Dmean and Dmedian as well as the V30Gy of the AILD and all subvolumes of the caudal AILD were significant higher using 3D-RT compared to IMRT. Even though the absolute differences were small, in the caudal aspect of the ano-inguinal lymphatic drainage the V30Gy could be more than 10% less with VMAT-IMRT.Conclusions3D-RT was slightly superior to IMRT in terms of dose coverage of the AILD. However, the absolute differences were very small. Some relevant caudal parts of the AILD received an insufficient dose for treating potential micrometastases. Particularly in high-risk situations, this may lead to inguinal recurrence and therefore the true deep AILD should be included into the target volume in high risk patients.

Long-term assessment of surgical and quality-of-life outcomes between lightweight and standard (heavyweight) three-dimensional contoured mesh in laparoscopic inguinal hernia repair

Mesh weight is a possible contributor to quality-of-life outcomes after inguinal hernia repair. This study compares lightweight mesh versus heavyweight mesh in laparoscopic inguinal hernia repair. A prospective, single-center, hernia-specific database was queried for all adult laparoscopic inguinal hernia repair with three-dimensional contoured mesh (3-D Max, Bard, Inc, New Providence, NJ) from 1999 to June 2016. Demographics and outcomes were analyzed. Quality of life was evaluated preoperatively and after 2 weeks, 4 weeks, 6 months, 12 months, and 24 months, using the Carolinas Comfort Scale. Univariate analysis and multivariate logistic regression were performed. A total of 1,424 laparoscopic inguinal hernia repair were performed with three-dimensional contoured mesh, with 804 patients receiving lightweight mesh and 620 receiving heavyweight mesh. Patients receiving lightweight mesh were somewhat younger (52.6 ± 14.8 years vs 56.3 ± 13.7 years, P < .0001), with slightly lower body mass indices (26.4 ± 9.9 vs 27.1 ± 4.3, P < .0001). Lightweight mesh was used less often in incarcerated hernias (12.5% vs 16.8%, P = .02). There were a total of 3 surgical site infections. There were no differences in complications between groups except for seroma. Although on univariate analysis, seromas appeared to occur more frequently with heavyweight mesh (21.5% vs 7.9%). On multivariate analysis, heavyweight mesh was not independently associated with seroma formation. Average follow-up was 20 months. Recurrence rates were similar between lightweight mesh and heavyweight mesh (0.7 vs 0.6% P > .05). At all points of follow-up (4 week to 3 years), quality-of-life outcomes of discomfort, mesh sensation, and movement limitation scores were similar between lightweight mesh and heavyweight mesh. Contoured lightweight mesh and heavyweight mesh in laparoscopic inguinal hernia repair yield excellent recurrence rates and no difference in postoperative complications or quality of life. Considering the lack of outcome difference with long-term follow-up, heavyweight mesh may be considered for use in laparoscopic inguinal hernia repair patients.

Survival and prognosis factors of lymphadenectomy in vulvar carcinoma: A tunisian single center study about 150 cases

ObjectiveLymph node metastases represent the major prognostic factor in squamous cell carcinoma of the vulva. However, the therapeutic value is still controversial. The purpose of our work was to identify histopronostic risk factors for lymph node involvement and assess the impact of lymphadenectomy on overall survival (OS) and recurrence free survival (RFS). MethodThis was a retrospective study about 150 cases of squamous cell carcinoma of the vulva over a period of 21 years (1994–2014). Clinical, anatomaphatological and evolutionary data were reported. OS and RFS curves for different parameters were established. ResultsLymph node invasion was significantly correlated with age <70 years, clitoris involvement, palpation of a pathological lymph node, tumor ulceration, median seat, tumor size >2 cm, TNM T-stage, vascular emboli and perinerval invasion. 5-years OS and RFS was 50.3% and 63.8% respectively. The 5-year OS and RFS rate decreased from 61.8% and 81.8% in the absence of lymph node involvement to 31.3% and 70.7% in cases of lymph node involvement respectively. The OS and the RFS at 5 years went from 53.1% and 63.8% to 18.2% and 42.7% respectively, in case of capsular break-up. Bilateral lymph node involvement caused the decrease of the 5-years OS from 52.5% to 34.1%. The lymph node ratio was inversely proportional to the OS. 5-years OS was 39% in case of a ratio <10% and 13% for a ratio between 20% and 30%. The 5-year RFS, decreased from 46% for a ratio <10%, to 24% for a ratio between 20% and 30%. Superficial inguinal lymph node dissection exposed to a high risk of inguinal recurrence. ConclusionThe lymphadenectomy has an incontestable diagnostic and prognostic value. The aim is to optimize the groin management in order to limit the morbidity of lymph node dissection while guaranteeing a carcinological safety.

Inguinal hernias recurrence: causes and surgical treatment

The current paper reveals the definition and classification of recurrent inguinal hernia, the main causes of relapses are highlighted. According to modern data, the relapse causes are divided into three groups: factors caused by the general condition of the patient, morphological features of the primary hernia, and factors that depend on the attending physician. The dependence of the relapses occurrence on the technical errors of the surgeon has been analyzed. Particular attention is paid at the correctness of the certain hernioplasty technique implementation, the surgeon’s experience, the effective treatment method choice of the primary inguinal hernia. The attention is focused on the recurrence mechanisms after endoscopic methods for primary inguinal hernias, which have been increasingly used in general surgical practice. It presents the evolution of improvement laparoscopic plasty techniques to reduce the complications number and relapse rate: using a larger mesh, reducing the taker amount during fixation or the use of methods without fixation with fibrin glue, the entire mesh plastic without cutting it, which prevents relapses at the site of the mesh section. Approaches to the selection of a reliable hernioplasty technique for reducing the number of relapses have been presented. The data are based on the national Swedish and the Danish registers, recommendations of the EHS, according to which it is required to select an alternative mesh placement method to the previous alloplasty for the treatment of relapsing inguinal hernia, the latter allows to use less modified muscle‑aponeurotic structures in the treatment of recurrent inguinal hernias. In this case, special attention should be paid at the sufficient mesh overlapping of scar and atrophied tissues in the inguinal area. The matter of surgical treatment of recurrent inguinal hernias remains up‑to‑date and addresses further improvement.

Effectiveness of definitive radiotherapy for squamous cell carcinoma of the vulva with gross inguinal lymphadenopathy

ObjectiveTo evaluate the effectiveness and long-term side effects of definitive groin radiotherapy for vulvar cancer with grossly involved inguinal lymph nodes. MethodsThe records of 407 women with vulvar squamous cell carcinoma treated with radiotherapy at one institution during 1992–2014 were reviewed to identify patients who had radiographic or histologic evidence of grossly involved inguinal lymph nodes. Patients with lymphadenectomy before radiotherapy and patients treated for recurrent disease were excluded. Actuarial incidences of vulvar, inguinal, and distant recurrences, the relationship between vulvar recurrence and inguinal recurrence, and overall survival were analyzed using the Kaplan–Meier method. ResultsThirty-three patients were identified. The median age at diagnosis was 64 years. The median long-axis radiographic diameter of the largest inguinal lymph node or lymph node mass was 2.5 cm (range, 1.4–8.7). Sixteen patients (48%) also had evidence of pelvic lymph node metastasis. The median radiation dose delivered to grossly involved nodes was 66.0 Gy (range, 60.0–70.0). The 3-year actuarial incidences of vulvar, groin, and distant recurrences were 24.2%, 17.7%, and 30.3%, respectively. With a median follow-up time of 28 months (range, 2–196), four patients (12%) had groin recurrence, of whom three also had vulvar recurrence. There were few major late adverse effects of regional radiotherapy. The 3-year overall survival rate was 51%. ConclusionsHigh-dose volume-directed radiotherapy achieves a high rate of local control with low risk of serious long-term toxic effects in patients with vulvar squamous cell carcinoma and grossly involved inguinal lymph nodes.