Intraoperative Bowel Perforation Research Articles

Understanding suprapubic catheter usage in the Canterbury population

Background:Suprapubic catheter (SPC) insertion is a common urological procedure, typically performed for individuals who are unable to drain their bladder via the urethra. While often considered to be safe and straightforward, our experience suggests this procedure may be associated with significant comorbidity, serious adverse events, and a higher length of stay than expected. This study aimed to understand current rates of SPC insertion, demographics, indications, complications, and length of stay. Methods:A retrospective review of all patients having undergone SPC insertion at Christchurch Hospital since the inception of the SPC synoptic note in 2017 was undertaken. Data was collected on demographics, indication, procedural details, in-hospital complications, length of stay and long-term outcomes. Patient groups were identified to determine if there were any predictive factors placing individuals at an increased risk of complications. Results:Data was analysed on 213 SPC insertions performed using the Add-a-Cath trocar technique (29.4% female); the mean age at insertion was 64.2 (range: 8–98). Overall, there were 2 intraoperative bowel perforations, in these patients neither had a previous abdominal incision or difficult to distend bladders and in both cases the bladder was filled with their existing urethral catheter. 47.7% of SPC insertions were associated with at least 1 complication following discharge requiring reattendance to hospital. The mean length of stay for those who presented to the hospital was 3.1 days. Infective factors were the most common complications, accounting for 43.3% of presentations. Long term complications were similar in patients whose bladder was filled via cystoscope (50.4%) versus urethral catheter (44.7%). Eight patients (3.79%) required surgical reinsertion of their SPC.Seven patients underwent open cut-down SPC insertion (42.9% female); of these, there was one intraoperative bowel perforation and 57.1% experienced at least one complication following discharge. The average number of visits relating to SPC complications following discharge was 8. Conclusion:While SPC insertions are commonly perceived to be well tolerated by patients and a simple solution to catheter-related issues, our study highlights a higher than previously understood rate of complications following discharge. This data will facilitate informed decision making between clinician and patient, recognising potential risk factors that increase an individual’s likelihood of experiencing adverse events leading to improved resource allocation.

Transperineal abdominoperineal resection in the prone jackknife position in male patients with low rectal cancer.

In male patients with low rectal cancer undergoing abdominoperineal resection (APR), successful dissection of the anterior anorectum is key to reducing the risk of circumferential resection margin involvement, intraoperative bowel perforation, and local recurrence, but it is challenging. To overcome difficulties dissecting the anterior anorectum, we present a safe and feasible procedure using a transperineal endoscopic approach during APR (TpAPR). The male patient is placed in the prone jackknife position. TpAPR precedes the procedure from an abdominal approach. We use some pelvic tissues as clear anatomical landmarks to dissect the anterior anorectum. The key steps of this procedure are shown in the video. The identification of a clear anatomical dissection plane of the anterior anorectum is difficult because of the complex surgical anatomy of the region. Clear anatomical landmarks for dissection of the anterior anorectum are necessary for safe implementation of this procedure. Therefore, TpAPR in the prone jackknife position can be performed to obtain better visualization of each anatomical landmark at a glance.

A nationwide comparison of short-term outcomes after transanal, open, laparoscopic, and robot-assisted total mesorectal excision.

Laparoscopic rectal cancer surgery has several limitations. Transanal total mesorectal excision (TaTME) can potentially overcome these limitations. The aim of this study was to compare the rates of non-radical surgery and anastomotic leakage after TaTME, open TME (OpTME), laparoscopic TME (LaTME) and robotic TME (RoTME) procedures in a nationwide cohort. We extracted the demographic, perioperative and pathological data of patients who underwent a curative OpTME, LaTME, RoTME or TaTME procedure between January 2014 and December 2018 from the national database of the Danish Colorectal Cancer Group (DCCG). We conducted multiple group-comparisons, uni- and multivariate analyses to determine the factors associated with positive resection margin (+RM) and anastomotic leakage. We included 2393 patients (OpTME = 205, LaTME = 1163, RoTME = 713 and TaTME = 312). The rate of +RM was 5.7% after TaTME. The lowest rate of +RM was achieved after RoTME (8.2%, 4.7%, 2.52%, and 5.7%, after OpTME, LaTME, RoTME and TaTME respectively, p<0.001). In multivariate analysis, having a T4 tumour and intraoperative bowel perforation were associated with the risk of +RM (p<0.001, p<0.001, respectively). The factors associated with anastomotic leakage in multivariate analysis were male gender, high BMI and intraoperative bowel perforation (p<0.001, p=0.049, p=0.002, respectively). TaTME was associated with the highest rate of sphincter-saving procedures (79.8%, p<0.001), the lowest rate of bowel perforation (2.9%, p=0.028) and the lowest rate of conversion to open surgery (1.3%, p<0.001). In a nationwide audit of TME approaches, the rate of +RM was lowest after RoTME. No differences were found between the four approaches regarding the risk of anastomotic leakage. TaTME offered advantages related to sphincter-saving, perforation and conversion.

Extralevator abdominoperineal excision for low rectal cancer: oncological outcome after five-year follow-up

ABSTRACT BACKGROUND: Extralevator abdominoperineal excision (ELAPE) is a surgical technique that is indicated for low rectal cancer where sphincter preservation is not possible. Compared to conventional abdominoperineal excision major advantages of ELAPE are the risk reduction of intraoperative bowel perforation and positive circumferential margin which lead to a better oncological outcome. The aim of this study was to present our results in ELAPE surgery METHODS: From February 2011 to February 2015, 40 patients underwent surgery for low rectal cancer at the Oncology Institute of Vojvodina. The collected data included sex, age, preoperative staging, neoadjuvant treatment, operative time, rate of intraoperative bowel perforation, rate of positive circumferential resection margins, histopathological analysis, postoperative mortality, tumour, node and metastasis (TNM) classification, local recurrence (LR) rate and presence of distant metastases RESULTS: Positive circumferential margin was found in three (7.5%) patients while eight (20%) patients had intraoperative bowel perforation. LR during follow-up was seen in seven (17.5%) patients, three of them had intraoperative bowel perforation and two patients had positive circumferential margin. The estimated five-year cumulative incidence of LR is 7%. Distant metastases occurred in 18 (45%) patients. The estimated five-year survival rate is 62% CONCLUSION: The study shows satisfactory five-year survival rates of 62% in a highly complex patient group treated by ELAPE procedure Keywords: rectal cancer, extralevator abdominoperineal excision, local recurrence, overall survival

A single institutional experience in laparoscopic colorectal surgery: Clinical and oncological outcomes over 10 years

Introduction: The development of laparoscopic colorectal surgery began in 1991. Today, laparoscopic surgery presents standard approach in the surgical treatment of malignant colon and rectal diseases. Aim: Surgical and oncological outcomes and survival rates of laparoscopic colorectal surgery at the Oncology Institute of Vojvodina. Methods: Data were collected prospectively from 66 patients undergoing laparoscopic colorectal surgery between December 2009 and December 2019. Registered data included sex, age, surgical indication and type for the procedure, indication and reason for conversion to open surgery, operative time, performing temporary or permanent stoma, intraoperative bowel perforation, pathologic TNM grade, number of harvested lymph nodes, inclusion of positive resection margin, number of postoperative days at the hospital, postoperative complications, postoperative mortality, presence of distant metastases and survival rates. Results: Laparoscopic procedures were right hemicolectomy in 11/66 (16.7%), left hemicolectomy in 1/66 (1.5%), sigmoid colectomy in 19/66 (28.8%), high anterior rectal resection in 13/66 (19.7%), low anterior rectal resection in 12/66 (18.2%), abdominoperineal amputation of the rectum in 7/66 (10.6%), colectomy in 2/66 (3%) and proctocolectomy in 1/66 (1.5%) patient. The median follow-up was 37.5 months (range 6 to 128). The total number of surviving patients was 60 (90.9%). Conclusion: This study showed that laparoscopic colorectal surgery has good clinical and oncological outcomes.

Extreme lateral lumbar interbody fusion (XLIF) in the management of degenerative scoliosis: a retrospective case series.

Surgical treatment of adult degenerative scoliosis (DS) always remains a challenge and often necessitates complex multilevel surgery via traditional open approaches. However, the severity of the procedure, in association with the fact that many of these patients are at an advanced age with several comorbidities, results in high rate of complications. Therefore, during the last decade, minimally invasive procedures have gained a place in the treatment of this pathology. Our aim is to determine the safety and efficacy of extra lateral lumbar interbody fusion (XLIF) with or without supplemented instrumentation in the treatment of DS. In a retrospective case series study, we reviewed the files of patients who underwent XLIF in our Hospital between 2008 and 2017. We recorded the patients' demographic characteristics, clinical parameters such as back-pain [visual analogue scale (VAS)] and back-related disability [Oswestry Disability Index (ODI)], as well as radiological parameters including the Cobb angle. Comparison of the before and after results were performed with the t-test and Chi-square test, where appropriate. Twelve patients fulfilled the eligibility criteria of our study. All patients were female, with a mean age of 64.5 years (SD =7.8 years) and 28 months (SD =13 months) follow-up. The XLIF decreased the pain intensity by 4.66 cm (SD =1.23 cm), and improved the back-related disability by 26% (SD =8.35%) in the ODI scale at the 6-month follow-up. Similarly, scoliosis improved by an average of 11.5° (SD =7°) and lordosis changed by an average of 13.5° (SD =10.86°). All changes were statistically significant. There were three complications, two patients presented meralgia paresthetica, which resolved spontaneously in 3 months, and in one patient occurred an intraoperative bowel perforation treated with bowel anastomosis. XLIF is a feasible and efficient alternative in the treatment of DS. It can be the treatment of choice in elderly patients in whom comorbidities increase the perioperative risk of complications.

Low risk of intra-abdominal infections in rectal cancer patients treated with Hartmann\u2019s procedure: a report from a national registry

PurposeTo describe the postoperative surgical complications in patients with rectal cancer undergoing Hartmann’s procedure (HP).MethodsData were retrieved from the Swedish Colorectal Cancer Registry for all patients with rectal cancer undergoing HP in 2007–2014. A retrospective analysis was performed using prospectively recorded data. Characteristics of patients and risk factors for intra-abdominal infection and re-laparotomy were analysed.ResultsOf 10,940 patients resected for rectal cancer, 1452 (13%) underwent HP (median age, 77 years). The American Society of Anesthesiologists (ASA) score was 3–4 in 43% of patients; 15% had distant metastases and 62% underwent a low HP. The intra-abdominal infection rate was 8% and re-laparotomy rate was 10%. Multivariable logistic regression analysis identified preoperative radiotherapy (OR, 1.78; 95% CI, 1.14–2.77), intra-operative bowel perforation (OR, 1.99; 95% CI, 1.08–3.67), T4 tumours (OR, 1.68; 95% CI 1.04–2.69) and female gender (OR, 1.73; 95% CI, 1.15–2.61) as risk factors for intra-abdominal infection. ASA score 3–4 (OR, 1.62; 95% CI, 1.12–2.34), elevated BMI (OR, 1.05; 95% CI, 1.02–1.09) and female gender (OR, 2.06; CI, 1.41–3.00) were risk factors for re-laparotomy after HP. The rate of intra-abdominal infection was not increased after a low HP.ConclusionsDespite older age and co-morbidities including more advanced cancer, patients undergoing Hartmann’s procedure had low rates of serious postoperative complications and re-laparotomy. A low HP was not associated with a higher rate of intra-abdominal infection. HP seems to be appropriate for old and frail patients with rectal cancer.

Successful Treatment of a 90-year-old Patient with Ruptured Abdominal Aortic Aneurysm Complicated by Intraoperative Bowel Necrosis and Perforation

Successful Treatment of a 90-year-old Patient with Ruptured Abdominal Aortic Aneurysm Complicated by Intraoperative Bowel Necrosis and Perforation

Laparoscopic extralevator abdominoperineal excision of the rectal cancer in the elderly

Objective To investigate the safety and feasibility of laparoscopic ELAPE for elderly patients with low advanced rectal cancer. Methods Totally 48 cases patients with low advanced rectal cancer surgery aged over 65 years old were analyzed retrospectively, who come from Beijing Hospital between Jan 2012 and Jan 2015.A total of 26 cases underwent Laparoscopic extralevator abdominoperineal excision(L-ELAPE)and 22 cases underwent Laparoscopic abdominoperineal excision(L-APE). Clinical data including general data, operation time, intraoperative blood loss, complications, pathological data, postoperative in hospitalization were retrospectively analyzed in patients. Results The mean operation time between L-ELAPE and APE group was(312±46)min vs.(245±62)min, mean intraoperative blood loss was(170±74)ml vs.(250±109)ml, Operative complications was 26.9% vs.27.3%, harvested lymph node was(16.0±5.8)cm vs.(15.0±7.2)cm, intraoperative bowel perforation(IOP)rate was 0% vs.18.2%, CRM involvement was 3.8% vs.13.6%, mean postoperative hospital stay(days)was(13.1±4.6)d vs.(13.7±6.1)d.The mean operating time of L-ELAPE group was longer and mean intraoperative blood loss was much less than APE group, IOP rate and circumferential resection margin(CRM)involvement were higher in APE group(P<0.05). Conclusions L-ELAPE is a safe and feasibility alternative approach for elder patients with rectal cancer.It is related with less intraoperative blood loss, IOP rate, CRM involvement and longer operating time contrast with L-APE. Key words: Rectal neoplasms; Laparoscopy

Poster

Poster

Necessity of subcutaneous suction drains in ileostomy reversal (DRASTAR)-a randomized, controlled bi-centered trial.

Data regarding length of hospital stay of patients undergoing ileostomy reversal are very heterogeneous. There are many factors that may have an influence on the length of postoperative hospital stay, such as postoperative wound infections. One potential strategy to reduce their incidence and to decrease hospital stay is to insert subcutaneous suction drains. The purpose of this study was to examine the influence of the insertion of subcutaneous suction drains on hospital stay and postoperative wound infections in ileostomy reversal. Risk factors for postoperative wound infection were determined. This is a randomized controlled two-center non-inferiority trial with two parallel groups. The total length of hospital stay as primary endpoint and the occurrence of a surgical site infection, the colonization of the abdominal wall with bacteria, and the occurrence of hematomas/seromas as secondary endpoints were monitored. One hundred eighteen patients with elective ileostomy reversal were included. Fifty-nine patients were randomly assigned to insertion of a subcutaneous suction drain, and 59 patients were randomly assigned to receive no drain. After 3months of follow-up, 50 patients in the group with drain and 53 patients in the group without drain could be analyzed. Median total length of hospital stay was 8days in the SD group and 9days in the group without SD (p = 0.17). Fourteen percent of patients with SD and 17% without SD developed SSI, p = 0.68. Multivariate analysis revealed anemia (p < 0.01), intraoperative bowel perforation (p = 0.02) and resident (p = 0.04) or fellow (p = 0.048) performing the operation as risk factors for SSI. This trial shows that the omission of subcutaneous suction drains is not inferior to the use of subcutaneous suction drains after ileostomy reversal in terms of length of hospital stay, surgical site infections, and hematomas/seromas.

Short-term Outcomes of an Extralevator Abdominoperineal Resection in the Prone Position Compared With a Conventional Abdominoperineal Resection for Advanced Low Rectal Cancer: The Early Experience at a Single Institution.

PurposeThis study compared the perioperative and pathologic outcomes between an extralevator abdominoperineal resection (APR) in the prone position and a conventional APR.MethodsBetween September 2011 and March 2014, an extralevator APR in the prone position was performed on 13 patients with rectal cancer and a conventional APR on 26 such patients. Patients' demographics and perioperative and pathologic outcomes were obtained from the colorectal cancer database and electronic medical charts.ResultsAge and preoperative carcinoembryonic antigen (CEA) level were significantly different between the conventional and the extralevator APR in the prone position (median age, 65 years vs. 55 years [P = 0.001]; median preoperative CEA level, 4.94 ng/mL vs. 1.81 ng/mL [P = 0.011]). For perioperative outcomes, 1 (3.8%) intraoperative bowel perforation occurred in the conventional APR group and 2 (15.3%) in the extralevator APR group. In the conventional and extralevator APR groups, 12 (46.2%) and 6 patients (46.2%) had postoperative complications, and 8 (66.7%) and 2 patients (33.4%) had major complications (Clavien-Dindo III/IV), respectively. The circumferential resection margin involvement rate was higher in the extralevator APR group compared with the conventional APR group (3 of 13 [23.1%] vs. 3 of 26 [11.5%]).ConclusionThe extralevator APR in the prone position for patients with advanced low rectal cancer has no advantages in perioperative and pathologic outcomes over a conventional APR for such patients. However, through early experience with a new surgical technique, we identified various reasons for the lack of favorable outcomes and expect sufficient experience to produce better peri- or postoperative outcomes.

Extralevator abdominoperineal excision for low rectal cancer: a systematic review and meta-analysis of the short-term outcome.

The superiority of extralevator abdominoperineal excision (ELAPE) over conventional abdominoperineal excision (APE) remains controversial, despite the publication of many studies on this issue. The aim of this meta-analysis was to provide a clear, evidence-based comparison of the two procedures. A systematic review and meta-analysis was conducted through a comprehensive search of the PubMed, EMBASE/Medline and Cochrane Central Library databases for all studies comparing ELAPE with conventional APE for low rectal cancer. Pooled data on circumferential resection margin (CRM) positivity, intra-operative bowel perforation, perineal wound complications and local recurrence were analysed. Seven studies, involving a total of 2672 patients, were included. Analysis of the pooled data did not reveal a significant difference between the two operations regarding CRM positivity [risk ratio (RR)=0.79, 95% CI: 0.40-1.57; P=0.50, I(2) =86%] and perineal wound complications (RR=0.91, 95% CI: 0.71-1.16; P=0.44, I(2) =49%), and showed a borderline reduced risk of intra-operative bowel perforation for ELAPE, but still did not reveal a significant difference between the two groups (RR=0.61, 95% CI: 0.37-1.00; P=0.05, I(2) =58%). The current evidence does not indicate a statistically significant superiority of ELAPE over conventional APE in terms of CRM positivity and intra-operative bowel perforation.

肛提肌外腹会阴联合切除术治疗低位直肠癌的研究进展

传统的腹会阴联合直肠切除术(abdominoperineal excision, APE)存在环周切缘阳性率高及术中穿孔率较高而影响预后的缺点。肛提肌外腹会阴联合切除术(exralevator abdominoperineal excision, ELAPE)被报道具有肿瘤学优势，最近应用越来越多。尽管相关报道很多，但是，ELAPE是否比传统APE具有优势仍然有很多争议。本文就ELAPE治疗低位直肠癌的研究进展做一综述。 It has been reported that the conventional abdominoperineal excision has the disadvantages of higher rates of positive circumferential resection margin and intraoperative bowel perforation. Extralevator abdominoperineal excision (ELAPE) has become increasingly used because of some evidence of improved oncological outcome. The superiority of extralevator abdominoperineal excision (ELAPE) over conventional abdominoperineal excision (APE) remains controversial, despite the publication of many studies on this issue. The aim of this paper was to review the research progression of extralevator abdominoperineal excision for low rectal cancer.

Comparison of short- and long-term outcomes after extralevator abdominoperineal excision and standard abdominoperineal excision for rectal cancer: a systematic review and meta-analysis

Whether the introduction of extralevator abdominoperineal excision (ELAPE) improves survival and safety remains controversial. We conducted a systematic review and meta-analysis of all comparative studies to define the efficacy and safety of ELAPE and standard abdominoperineal excision (APE). A search for all major databases and relevant journals from inception to July 2013 without restriction on languages or regions was performed. Outcome measures were the oncological parameters of circumferential resection margin (CRM) involvement, intraoperative bowel perforation (IOP), and local recurrence, as well as other parameters of blood loss, operative time, length of hospitalization, and postoperative complication. The test of heterogeneity was performed with the Q statistic. A total of 949 patients were included in the meta-analysis. Oncological pooled estimates of intraoperative bowel perforation rate (RR 0.34; 95% CI 0.21-0.54; P<0.00001), CRM involvement (RR 0.44; 95% CI 0.34-0.56; P<0.00001), and local recurrence (RR 0.32; 95% CI 0.14-0.74; P=0.008) all showed outcomes that were significantly lower in ELAPE than in APE. A similar incidence of postoperative complication was attributed to both groups, including overall complication (RR 0.93; 95% CI 0.66-1.32; P=0.69), perineal wound complication (RR 0.72; 95% CI 0.33-1.55; P=0.39), and urinary dysfunction (RR 1.53; 95% CI 0.88-2.67; P=0.13). ELAPE has a lower intraoperative bowel perforation rate, positive CRM rate, and local recurrence rate than APE. There is evidence that in selected low rectal cancer patients, ELAPE is a more efficient and equally safe option to replace APE. Due to the inherent limitations of the present study, future randomized controlled trials will be useful to confirm this conclusion.

A comparison of published rates of resection margin involvement and intra‐operative perforation between standard and ‘cylindrical’ abdominoperineal excision for low rectal cancer

The study aimed to compare recent reports on standard and alternative methods of abdominoperineal excision for low rectal cancer regarding the rates of circumferential resection margin involvement and intra-operative bowel perforation. Data on rates of margin involvement and perforation were obtained from eight recently published reports and also from a prospective registry of resections at Concord Hospital. Rates of these outcomes and their 95% confidence intervals were evaluated. There was no evidence that extralevator abdominoperineal excision yielded significantly lower rates of resection margin involvement or intra-operative bowel perforation compared with standard abdominoperineal excision in six independent hospital- and population-based patient series. Abdominosacral resection of the rectum, on the other hand, did show significantly lower rates of these endpoints, albeit in selected patients. The role of extralevator abdominoperineal excision and abdominosacral resection of the rectum should be investigated further in randomized controlled trials.

Quality of surgical care, local recurrence, and survival in patients with low- and midrectal cancers following multimodal therapy

To assess the quality of surgical care and outcome following multimodal treatment for low- and midrectal cancers, focusing on differences between low anterior and abdominoperineal resections. From 1999 to 2007, 179 patients underwent low anterior resection (LAR), abdominoperineal resection (APR), or proctocolectomy for low- or midrectal cancers. Preoperative (chemo)radiotherapy was given according to local guidelines and adjuvant postoperative chemotherapy in stage III disease. Outcome together with clinical and histopathological data were analyzed in relation to the type of surgery performed. The postoperative mortality was 2.2%; morbidity, 39.6%; reoperation rate, 8.4%; and readmission rate, 16.0%. Involved circumferential resection margin (CRM ≤ 1 mm) rate was 4.5% (APR 9.1% vs. LAR 2.6%, p = 0.046). Intraoperative bowel perforation occurred in 5.5% of APRs. Anastomotic leak rate was 15.3%. The 5-year overall survival of the 179 patients was 68.5 %; disease-specific survival, 82.2%; and local recurrence rate, 6.3%. The overall, disease-specific, and disease-free survival rates in the 162 patients treated for cure were 73.1%, 84.6%, and 78.3%, and local recurrence rate was 4.4% with no significant differences between LAR and APR. CRM was the only independent predictor of local recurrence and CRM, tumor stage, and level independent predictors of disease-free survival. Quality of surgical care was in line with the current international standards. CRM was an independent predictor for local recurrence and CRM, tumor stage, and level independent prognostic factors for disease-free survival. Neither the type of surgery (LAR vs. APR) nor the surgical approach (laparoscopic vs. open) influenced the oncologic outcome.

Circumferential resection margin as a prognostic factor in rectal cancer

This study examined the prognostic impact of the circumferential resection margin (CRM) in patients with rectal cancer treated by total mesorectal excision (TME) with or without radiotherapy. A national population-based rectal cancer registry included 3196 patients with known CRM status between 1993 and 2004. Some 90.5 per cent of the patients had surgery alone and 9.5 per cent had preoperative radiotherapy. Patients who did not have TME, those in whom the CRM was not measured, patients with intraoperative bowel or tumour perforation and those who received postoperative radiotherapy were excluded. Five-year local recurrence, distant metastasis and overall survival rates were 23.7, 43.9 and 44.5 per cent respectively for patients with a CRM of 0-2 mm, compared with 8.9, 21.7 and 66.7 per cent respectively for those with wider margins. A CRM of 2 mm or less had an impact on the prognosis of T2 and T3 tumours located 6-15 cm above the anal verge, but not on lower tumours. CRM also had a prognostic impact on the three endpoints in patients who received preoperative radiotherapy, but with less precision. A CRM of 2 mm or less confers a poorer prognosis and patients should be considered for neoadjuvant treatment.

Laparoscopic Surgery on Upper Urinary Tract in Children Younger Than 1 Year: Technical Aspects and Functional Outcome

Minimally invasive procedures are increasingly important in pediatric urology. However, experience is still limited with minimally invasive operations on the upper urinary tract in infants. We analyzed 3 minimally invasive procedures (pyeloplasty, heminephroureterectomy and nephrectomy) in children younger than 1 year. We analyzed 67 children (mean +/- SD age 5.1 +/- 2.9 months) undergoing minimally invasive pyeloplasty in 26 patients (group 1), heminephroureterectomy in 18 (group 2) or nephrectomy in 23 (group 3) with regard to technical aspects, surgical outcome and complications. Preoperative and postoperative ultrasound and mercaptoacetyltriglycine renal scan were statistically evaluated in groups 1 and 2. Mean +/- SD patient weight was 6.4 +/- 1.8 kg and mean +/- SD operative time was 113.2 +/- 41.6 minutes. Conversion to open surgery was necessary in 1 pyeloplasty. One complication (missed intraoperative bowel perforation) occurred. No blood transfusion was required in any child. After pyeloplasty there were improved tracer clearances (mercaptoacetyltriglycine scan) and improved morphologies of the pyelon (ultrasound) in all patients. In groups 1 and 2 there was no statistical difference between preoperative and postoperative partial function of the affected kidney. Mean +/- SD followup was 32.5 +/- 19.8 months. Minimally invasive procedures on the upper urinary tract in children younger than 1 year are technically challenging, and require expertise of the surgeon and the entire team. Given these assumptions, such procedures can be safely performed with excellent functional outcomes.

Sphincter-preserving R0 total mesorectal excision with resection of internal genitalia combined with pre- or postoperative chemoradiation for T4 rectal cancer in females

To evaluate the impact of chemoradiation admi-nistered pre- or postoperatively on prognosis in females following R0 extended resection with sphincter-preserving total mesorectal excision (TME) for locally advanced rectal cancer and to assess the association between chemoradiation and intra- and postoperative variables. Twenty-one females were treated for locally advanced but preoperatively assessed as primarily resectable rectal cancer involving reproductive organs. Anterior resection with TME and excision of internal genitalia was combined with neo- or adjuvant chemoradiation. Two-year disease-free survival analysis was performed with the Kaplan-Meier method and log-rank test. The association between chemoradiation and other variables was evaluated with the Fisher's exact test and Mann-Whitney test. Survival rate decreased in anaemic females (51.5% vs 57.4%), in patients older than 60 years (41.8% vs 66.7%) with poorly differentiated cancers (50.0% vs 55.6%) and tumors located<or=7 cm from the anal verge (42.9% vs 68.1%) but with the lack of importance. Patients with negative lymph nodes and women chemoradiated preoperatively had significantly favourable prognosis (85.7% vs 35.7%; P=0.03 and 80.0% vs 27.3%; P=0.01, respectively). Preoperative chemoradiation compared to adjuvant radiochemotherapy was not significantly associated with the duration of surgery, incidence of intraoperative bowel perforation and blood loss>or=1 L, rate of postoperative bladder and anorectal dysfunction, and minimal distal resection margin. It significantly influenced minimal radial margin (mean 4.2 mm vs 1.1 mm; P<0.01). Despite involving internal genitalia, long-term disease-free survival and sphincter preservation may be achieved with combined-modality therapy for females with T4 locally advanced rectal carcinoma. Neoadjuvant chemoradiation does not compromise functional results and may significantly improve oncological outcomes probably due to enhanced radial clearance.