Lower Abdominal Midline Incision Research Articles

MP38-01 BIOACTIVE FIBROUS MEMBRANE CONTAINING ENDOGENOUS NERVE GROWTH FACTOR PROMOTES CELLULAR AND FUNCTIONAL RECUPERATION OF IMPAIRED CAVERNOUS NERVE: AN IN VIVO ANIMAL STUDY

You have accessJournal of UrologyCME1 May 2022MP38-01 BIOACTIVE FIBROUS MEMBRANE CONTAINING ENDOGENOUS NERVE GROWTH FACTOR PROMOTES CELLULAR AND FUNCTIONAL RECUPERATION OF IMPAIRED CAVERNOUS NERVE: AN IN VIVO ANIMAL STUDY Paulo Mota, Marta Casanova, Helena Vala, Carmen Nóbrega, Alain Morais, Catarina Silva, Sara Anacleto, Alexandre Barros, Rui Reis, Estêvão Lima, Albino Martins, and Nuno Neves Paulo MotaPaulo Mota More articles by this author , Marta CasanovaMarta Casanova More articles by this author , Helena ValaHelena Vala More articles by this author , Carmen NóbregaCarmen Nóbrega More articles by this author , Alain MoraisAlain Morais More articles by this author , Catarina SilvaCatarina Silva More articles by this author , Sara AnacletoSara Anacleto More articles by this author , Alexandre BarrosAlexandre Barros More articles by this author , Rui ReisRui Reis More articles by this author , Estêvão LimaEstêvão Lima More articles by this author , Albino MartinsAlbino Martins More articles by this author , and Nuno NevesNuno Neves More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002592.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Prostate cancer is a frequent disease and the radical prostatectomy one of the most used treatment when the cancer is localized. This procedure commonly causes erectile dysfunction (ED) by injure the cavernous nerve (CN) during the surgery.With this research we investigate the ability of a bioactive fibrous membrane (FM) to regenerate the damaged CN in a rat model of CN injury. METHODS: Male Sprague–Dawley (SD) rats were distributed by 4 experimental groups: sham (only a lower midline abdominal incision), negative control (lower midline abdominal incision with pelvic dissection and CN crush but no FM implantation), electrospun fibrous membrane [eFM] (with CN crush and FM implantation) and electrospun fibrous membrane biofunctionalized with NGF from rat urine [eFM-uNGF] (with CN crush). Function was evaluated five weeks later after an injection of apomorphine by glans observation (visual scoring) and intracavernous pressure (ICP) measurements. Neurogenic genes expression and Histological and Immunohistochemical analysis of CN and cavernous tissue was performed. RESULTS: in this model of bilateral CN crush the treatment with implanted bioactive fibrous membrane induces CN regeneration and restoration of erectile function (p <0.001) (figure), showing a significant increased number of smooth muscle cells and nNOS and eNOS contents. Additionally, the bioactive fibrous membrane promotes a CN protective effect and increase the nerve regeneration capacity by increasing the number of myelinated axons and nNOS-positive cells, recovering from the CN fibrosis observed in rats not treated. CONCLUSIONS: This personalized regenerative strategy could help better recovery of erectile function after CN injuries, and it may constitute an effective novel option to prostate cancer patients suffering from ED after being subject to radical prostatectomy. Source of Funding: The authors would like to acknowledge the Portuguese Foundation for Science and Technology (FCT) for the PhD grant of M.R.C. (PD/BD/113797/2015) financed by the Doctoral Program on Advanced Therapies for Health (PATH) (FSE/POCH/PD/169/2013), the IF grant of A.M. (IF/00376/2014), the project Cells4_IDs (PTDC/BTM-SAL/28882/2017) and FCT - Portuguese Foundation for Science and Technology, under the project UIDB/04033/2020 © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e618 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Paulo Mota More articles by this author Marta Casanova More articles by this author Helena Vala More articles by this author Carmen Nóbrega More articles by this author Alain Morais More articles by this author Catarina Silva More articles by this author Sara Anacleto More articles by this author Alexandre Barros More articles by this author Rui Reis More articles by this author Estêvão Lima More articles by this author Albino Martins More articles by this author Nuno Neves More articles by this author Expand All Advertisement PDF DownloadLoading ...

PD36-01 HYPOGASTRIC AND PELVIC NERVE CRUSH INJURY IMPAIRS VAGINAL MICROVASCULAR PERFUSION IN A RAT MODEL

You have accessJournal of UrologySexual Function/Dysfunction: Female (PD36)1 Apr 2020PD36-01 HYPOGASTRIC AND PELVIC NERVE CRUSH INJURY IMPAIRS VAGINAL MICROVASCULAR PERFUSION IN A RAT MODEL Samuel Sorkhi*, Min Chul Cho, Sung Yong Cho, Hong Chung, Christopher Cano Sanchez, Valmik Bhargava, and M. Raj Rajasekaran Samuel Sorkhi*Samuel Sorkhi* More articles by this author , Min Chul ChoMin Chul Cho More articles by this author , Sung Yong ChoSung Yong Cho More articles by this author , Hong ChungHong Chung More articles by this author , Christopher Cano SanchezChristopher Cano Sanchez More articles by this author , Valmik BhargavaValmik Bhargava More articles by this author , and M. Raj RajasekaranM. Raj Rajasekaran More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000907.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Radical hysterectomy (RH), the most common surgical approach to treat early-stage cervical carcinoma results in damage to the autonomic nerves (AN) that supply female genital organs (pelvic plexus, hypogastric and pelvic nerves), as well as vaginal fibrosis leading to female sexual dysfunction. Even with nerve-sparing techniques, impaired neural control of vasocongestion during sexual arousal may arise due to AN damage that supply the vaginal wall and clitoris. Impact of AN injury (ANI) on vaginal and clitoral hemodynamics is unclear. The objectives of our study are to: (A) evaluate vaginal and clitoral blood perfusion (microvascular perfusion-MVP; using via laser speckle contrast imaging; LSCI) changes and (B) to evaluate the effect of transpelvic magnetic stimulation (TPMS) after ANI in a female rat model. METHODS: We used female rats and created AN crush injury (ANI; Fig A: schematic of rat pelvic neural innervation and AN crush and Fig B photomicrograph showing MPG) that simulates RH related nerve damage in women. The rats were anesthetized, pelvic organs were accessed via a lower-midline abdominal incision, and AN were crushed by applying a microsurgical hemostat for 3 x 30 second intervals. After recovery, the rats were further subjected to TPMS with simultaneous monitoring of vaginal microvascular perfusion (MVP) using laser speckle contrast imaging (LSCI; Fig C) by PeriCam PSI system that quantifies MVP in arbitrary perfusion units (AU). RESULTS: Representative MVP images from control and ANI rats are shown in Fig D. TPMS-induced MVP enhancement was lower (∼70-80%; Fig E) in ANI rats when compared to controls. CONCLUSIONS: ANI female rat model is a viable animal model to test RH related genital hemodynamic impairment and TPMS will facilitate genital MVP improvement and possibly prevent fibrosis. Source of Funding: VA Merit Award © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e723-e723 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Samuel Sorkhi* More articles by this author Min Chul Cho More articles by this author Sung Yong Cho More articles by this author Hong Chung More articles by this author Christopher Cano Sanchez More articles by this author Valmik Bhargava More articles by this author M. Raj Rajasekaran More articles by this author Expand All Advertisement PDF downloadLoading ...

Analysis of Risk Factors for Incisional Hernias and its Management

Introduction: Incisional hernia is a common problem after abdominal surgery. Patients present with pain, swelling and intestinal obstruction. It may be repaired by either anatomical suturing or mesh repair.Methods: It is a prospective observational study conducted in Western Regional Hospital and Fewa City Hospital, Pokhara from 2013 to 2016. A total of consecutive 100 patients admitted in these hospitals during the study period were included.Results: Incisional hernia is more common in females (M : F = 1 : 3.8), and in 30 - 50 years age group (60%). Major risk factors were wound infection (30%), overweight (25%), and postoperative cough (10%). It is found to be more associated with gynecological (65%), than gastrointestinal operations, and more so with lower abdominal midline incision (65%). It is found to occur mostly within one year (60%) of primary surgery than later. Even 24% of the patients had first symptom within six months. Mesh repair (92%) was the preferred standard surgical treatment for incisional hernia.Conclusion: Overweight females of age range between 30 - 50 years with history of gynecological operations by lower abdominal midline incision are more prone to develop incisional hernia. This incidence increases when there is wound infection. Mesh repair is the choice of operation for incisional hernia. J-GMC-N | Volume 11 | Issue 01 | January-June 2018, Page: 16-20

Laparoscopic totally extraperitoneal (TEP) inguinal hernia repair in patients with previous lower abdominal surgery.

We have performed laparoscopic totally extraperitoneal (TEP) repair for inguinal hernia repair for the last 20years. We use two balloon dilators (sphere and kidney type) to dissect the preperitoneal space for the TEP repair. It may be difficult to obtain exposure in patients who previously underwent lower abdominal surgery, because of adhesions to the abdominal wall. We reviewed our experience with inguinal hernia repairs to retrospectively analyze factors that limit the laparoscopic TEP approach. From 2006 to 2016, 313 patients (281 men and 32 women) underwent laparoscopic TEP inguinal hernia repair at Yuki Hospital. The medical records of these patients were reviewed, and data for patients who previously underwent lower abdominal surgery were analyzed. Eighty-four patients previously underwent lower abdominal surgery including appendectomy (N = 23), inguinal hernia repair [N = 45; including contralateral TEP repair (N = 26), ipsilateral anterior approach (N = 11)], and laparotomy with a lower abdominal midline incision (N = 22). TEP repair was successfully completed in 75 patients (75/84; 89%) and the procedure changed in nine patients to an anterior approach (N = 5), or transabdominal preperitoneal (TAPP) repair (N = 4). The reasons for changing the procedure included difficulty to develop the operative field (N = 5), violation of the integrity of the peritoneal envelope (N = 2), and intraoperative bleeding (N = 2). Seven patients had a contralateral inguinal hernia after TEP repair. The majority of patients with an inguinal hernia and previous lower abdominal surgery underwent successful laparoscopic TEP repair. There is no need to avoid the laparoscopic TEP approach, even in patients with a history of previous lower abdominal surgery. However, patients after TEP repair of a contralateral inguinal hernia may be at increased risk for peritoneal injury and the approach may need to be changed.

KIDNEY-SPARING SEGMENTAL URETERECTOMY WITH TRANSURETHRAL BLADDER CUFF EXCISION FOR DISTAL URETERAL CARCINOMA

(Introduction and objectives) Radical nephroureterectomy with complete distal ureterectomy is the standard therapy for upper tract urothelial malignancy. Segmental ureterectomy with ueteroneocytostomy is an alternative for distal ureteral carcinoma. We describe extravesical complete distal ureterectomy combined by transurethral bladder cuff excision with frozen-section analysis. (Patient and methods) Since December 2008, 11 patients (median age 77 year old, male 10, female 1, right 10, left 1) with solitary distal ureteral carcinoma who had mild hydronephrosis of ipsilateral kidney remaining renal function on enhanced CT. Under general anesthesia, the patient was placed in lithotomy position, rigid cystoscopy was inserted into the bladder. Cold punch biopsy of 4 sites of bladder mucosa 5 mm away from ureteral orifice (12, 3, 6, 9 o'clock) was carried out and sent to frozen-section analysis. Use resectoscopy with needle-type electrode, incise the bladder mucosa along the biopsy sites circumferentially and incise submucosa tissue around the ureteral orifice deeply enough to detach intramural ureter. Then lower abdominal midline incision was made. After entering the retroperitoneal space, the ureter was dissected and ureteral margin was sent to frozen-section analysis. The distal ureter was dissected until the margin of bladder mucosa incised by transurethrally. After ascertainment of no cancer cell in the frozen-section, close the defect in the bladder. Then the ureter was re-implanted into the bladder by extravesical approach. (Results) Median estimate blood loss was 150 ml (40-350 ml) and median operative time was 258 min (170-317 min.). No patients in our series required a blood transfusion. The mean tumor size was 20+/- 4.4 mm. Pathological T stage was Ta 3, T1 3, T2 2 and T3 3. No positive surgical margin was noted. Mean serum creatinine before and 1 month after surgery was 1.05+/- 0.21 mg/dl and 089+/- 0.13 mg/dl. Mean eGFR before and 1 month after surgery was 54.1+/- 11.4 and 63.4+/- 8.4. Median followup was 35 months (range 4 to 93). Although there were two patients who died from distant metastatic disease, no patients have encountered cancer recurrence in the remained ipsilateral upper urinary tract. (Conclusions) Segmental ureterectomy combined by transurethral bladder cuff excision with frozen-section analysis could perform complete resection of distal ureteral carcinoma and preserve ipsilateral renal function. This technique is feasible for patients with distal ureteral carcinoma as an optional treatment. Better preservation of renal function can lead to increased tolerance of cisplatin-based adjuvant or salvage chemotherapy.

Successful management of primary hepatic pregnancy with selective hepatic artery embolization and intra-arterial methotrexate infusion

Primary hepatic pregnancy is an extremely rare and lifethreatening condition. Fatal hemorrhage after rupture of an ectopic pregnancy is the most feared complication, and any rupture must be managed with emergency surgery. A 31-year-old patient (G6, P2) presented with amenorrhea of 8 weeks’ duration and acute onset of right upper abdominal pain. The patient was hemodynamically unstable and had diffused abdominal tenderness. Hemoglobin concentration was 6.8 g/dL. Coagulation function was normal. Serum hCG level was 23 824 mIU/mL. Pelvic ultrasonography revealed marked echogenic fluid in the pouch of Douglas, but no gestational sac was identified. The patient underwent emergency exploratory laparotomy through a lower abdominal midline incision. The abdominal cavity contained approximately 1000 mL of blood. The uterus, ovaries, and fallopian tubes were normal. Further exploration of the abdomen revealed that the hemorrhage arose from the hepatic area, and the incision was extended vertically to the upper abdomen with the assistance of a general surgeon. The active bleeding continued from a rupture in a 3.0 x 4.0-cm whitish, villiform nodule on the inferior surface of the liver. The nodule could not be removed completely because of deep implantation into the hepatic parenchyma and hilum. Hemostasis was obtained by plication of the bleeding site using absorbable sutures. Histopathologic examination of the liver nodule revealed normal chorionic villi, consistent with the diagnosis of primary hepatic pregnancy. The patient’s hCG level dropped to 10 355 mIU/mL on postoperative day 1, but rose to 11 230 mIU/mL 2 days later. Given the residual elevated hCG level and associated risk of secondary hemorrhage, transcatheter arterial chemoembolization (TACE) with intra-arterial methotrexate infusion was performed to diminish the local blood supply to the lesion and degenerate residual trophoblasts using methotrexate at the same time. The patient’s liver and renal functions were normal before TACE. A common femoral artery approach was used, and hepatic angiography showed a 2.5 x 3.0-cm mass supplied by the right hepatic artery (Fig. 1A). A mixture of 6 mL of Lipiodol (iodized oil; Guerbet, Roissy, France) and 50 mg (1 mg/kg) of methotrexate was infused via the microcatheter as close as possible to the feeding branch, followed by embolization of the feeding artery with gelatin sponge particles (0.5–1.0 mm).A methotrexate–Lipiodol emulsion was used to localize the methotrexate inside the hepatic lesion and release it slowly [1]. After embolization, X-ray examination was performed to confirm the deposition of Lipiodol inside the lesion (Fig. 1B). The patient’s recovery was uneventful. Serum hCG level decreased steadily and was undetectable 12 days after TACE. Liver and renal function tests were performed every 3 days until the patient’s hCG level normalized and remained within limits. One month later, ultrasound examination of the patient’s liver revealed no trace of the ectopic pregnancy. A previous report described slow hemorrhage from hepatic pregnancy managed by laparoscopy and postoperative administration of methotrexate [2]. In two unruptured cases, local methotrexate injection into the hepatic gestational sac was performed under direct [3] or ultrasound guidance [4]. However, additional methotrexate administration was often required for persistently elevated hCG level after surgery and caused prolonged recovery time. TACE induces an acute ischemic degeneration of trophoblasts and avoids secondary hemorrhage. Moreover, the block of blood flow to the lesion exposes the local trophoblastic mass to a higher concentration of methotrexate than intramuscular administration and prevents severe adverse effects. The combination of these two mechanisms may help accelerate the decrease in serum hCG level and shorten the time to resolution of the trophoblastic mass. TACE with intraInternational Journal of Gynecology and Obstetrics 122 (2013) 78–86

EFFICACY OF ANTI‐TNF‐ALPHA THERAPY IN PREVENTING UTERINE ADHESION FORMATION IN RATS

ObjectivePostoperative adhesion formation is a consequence of wound healing and sometimes can result in severe complications. The aim of this study was to evaluate the effect of TNF‐alpha inhibition on the development of postoperative uterine adhesions.MethodsTwenty one female Wistar‐Albino type rats were used in this study. The rats were divided into three groups as sham‐operated, adhesion and adhesion plus the TNF‐alpha inhibitor etanercept. A lower midline abdominal incision was performed and standard uterine lesion was created by electrocautery. Starting immediately after adhesion induction, the treatment group received daily intraperitoneal injections of 2 mg/kg etanercept for a total of 3 days. At day 7, peritoneal washing fluids of rats were obtained for the determination of TNF‐alpha levels. Then all of the rats were sacrificed and uterine adhesions were staged.ResultsThe total adhesion score and tissue malondialdehyde levels were found to be increased whereas superoxide dismutase and glutathione peroxidase activities decreased significantly in the adhesion control group (P&lt;0.05 ). TNF‐alpha inhibition, significantly reversed these findings (P&lt;0.05).ConclusionsAnti‐TNF‐alpha therapy reduces the prevalence of peritoneal and uterine tube adhesion formation in rats possibly by suppressing TNF‐alpha production as well as limiting oxidative stress.

Lower incidence of inguinal hernia after radical prostatectomy using open gasless endoscopic single-site surgery

Inguinal hernia is one of the long-term complications requiring surgical interventions after retropubic radical prostatectomy (RRP), and its incidence has been reported to range from 12 to 21%. The number of open gasless laparoendoscopic single-site surgery, especially minimum incision endoscopic radical prostatectomy (MIES-RRP) is increasing in Japan. The incidence of post-operative inguinal hernia was compared between conventional RRP and MIES-RRP. The medical records of 333 patients who underwent conventional RRP (n=214) or MIES-RRP (n=119) with pelvic lymphadenectomy at our hospital were retrospectively evaluated. There were no significant differences between the two groups in age, pre-operative PSA levels, or previous major abdominal surgery (cholecystectomy, gastrectomy and colectomy), appendectomy or inguinal hernia repair. MIES-RRP was carried out with a 5-8-cm lower abdominal midline incision. Inguinal hernia developed postoperatively in 41 (19%) of the 214 men undergoing conventional RRP during mean follow-up of 58 months (range: 7-60 months). In contrast, 7 (5.9%) of the 119 men receiving MIES-RRP, developed inguinal hernia during mean follow-up of 21 months (range: 13-31 months). The hernia-free survival was significantly higher after MIES-RRP than after conventional RRP (P=0.037). Our results suggest that MIES-RRP is less associated with post-operative inguinal hernia than conventional RRP.

Comparison of postoperative pain outcomes after vertical or Pfannenstiel incision for major gynecologic surgery

ABSTRACTObjective: The Pfannenstiel incision is commonly used for gynecologic surgery. It is not known if this incision is associated with less postoperative pain compared to a vertical midline incision. Therefore, as part of a study to evaluate the postoperative analgesic effects and dose response of intravenous adenosine in patients undergoing open abdominal gynecologic surgery, this manuscript compares postoperative pain and analgesic consumption in patients who had a midline vertical incision or a Pfannenstiel incision.Research design and methods: This is a secondary analysis of data from a primary study investigating the dose response of IV adenosine for postoperative analgesia. Women scheduled for elective major gynecologic surgery under general anesthesia were enrolled and randomly assigned to receive one of four doses of intraoperative adenosine infusion (25, 50, 100, or 200 µg/kg/min) or matching placebo (normal saline). The anesthetic technique was standardized and adjusted based on hemodynamic and depth of anesthesia (bispectral index) values. Postoperative analgesia was provided with a standardized morphine patient controlled analgesia protocol which included rescue ketorolac, as needed. Comparative outcome analysis of the midline and Pfannenstiel skin incisions with regards to analgesic consumption and pain scores was performed and presented in this manuscript.Results: A total of 165 patients were identified; 105 women had a Pfannenstiel incision and 60 had the lower midline abdominal incision. There were no differences between the midline and Pfannenstiel groups with respect to intraoperative fentanyl, postoperative pain scores [worst pain scores 0–24 h (mean ± SD) 8.2 ± 2.1 vs. 8.2 ± 1.9), p = 0.352], cumulative opioid consumption [0–24 h morphine equivalents (mean ± SD) 63 ± 27 vs. 72 ± 43 mg, p = 0.496], or need for rescue ketorolac. While the duration of surgery was longer in patients who had a vertical incision (p = 0.02), there was no difference between the groups in the duration of postanesthesia care unit (44 ± 53 vs. 30 ± 45 min, p = 0.093) or hospital stays (74 ± 27 vs. 67 ± 20 h, p = 0.254).Conclusions: There was no significant difference in postoperative pain and opioid consumption in patients undergoing major abdominal gynecologic surgery performed with either a midline or Pfannenstiel incision. However, it is important to note that since this a secondary analysis of data from a primary study investigating the dose response of IV adenosine, the patients were not prospectively randomized into the two incision types.

Laparoscopic radical cystectomy with orthotopic ileal neobladder in the female: report of 14 cases

Bladder carcinoma is the most common malignant urological tumor in China. We present our preliminary experience and results of laparoscopic radical cystectomy (LRC) with orthotopic ileal neobladder in female patients with bladder carcinoma. From February 2003 to February 2008, 14 female patients with bladder carcinoma underwent LRC with orthotopic ileal neobladder. Nine of these patients underwent hysterectomy and ovariectomy, and the other 5 had preservation of the uterus and ovarian appendage. Standard bilateral pelvic lymphadenectomy was followed by radical cystectomy that was completed laparoscopically with hysterectomy and ovariectomy when needed. The tumor was removed by a 4 - 5 cm lower midline abdominal incision, followed by the construction of ileal neobladder and the extracorporeal anastomosis of ureter-neobladder. The neobladder was anastomosed to the urethral stump under a laparoscope. The mean operative time and blood loss in the 14 patients were 350.2 minutes and 349.8 ml, respectively. Postoperative complications included uretero-pouch anastomotic stricture in 1 patient and pouch-vaginal fistula in 1 patient. Follow-up time of all patients ranged from 3 to 60 months, and 12 patients were followed up for more than 6 months and achieved micturition in half a year. One patient had occasional day-time urinary incontinence and 2 had night-time incontinence. Two patients who had undergone hysterectomy and ovariectomy had voiding difficulties after one year, which was treated by intermittent self-catheterization. The mean volume of the neobladder and the residual urine were 333.6 ml and 31.2 ml, respectively. Surgical margins were tumor free for all patients. One patient had bone metastasis and died 11 months after the operation. LRC with orthotopic ileal neobladder in female patients is a technically feasible, safe and mini-invasive procedure with a low morbidity and acceptable neobladder function. Long-term follow-up is required to confirm the neobladder function and oncological outcomes.

Effects of pyrolytic carbon on postoperative adhesion formation in rats

Peritoneal adhesion is a consequence of wound healing that sometimes causes severe postoperative complications. Despite all the preventive measures and agents, adhesions have still not been eliminated completely. The aim of this study was to evaluate the effects of pyrolytic carbon on the development of postoperative peritoneal and uterine tube adhesions. Twenty female Wistar-Albino type rats were used in this study. The rats were divided into two groups: treatment and control groups. After ketamine anaesthesia (50 mg/kg IM), a lower midline abdominal incision was performed and a standard uterine lesion was created by electrocauterization. In the study group, pyrolytic carbon was applied to the surface of the uterus and no additional procedure was applied in the control group. After 2 weeks, all of the rats were killed and uterine adhesions were staged according to the Leach scoring system. In the control group, the total adhesion score was 8.8 +/- 0.42. In the study group, the total adhesion score was 3.3 +/- 1.49, significantly lower than that in the control group (P < 0.001). Pyrolytic carbon significantly reduces the prevalence of peritoneal and uterine tube adhesion formation in rats. However, further more detailed investigations are needed before this material is used in clinical practice.

Techniques for caesarean section

Rates of caesarean section (CS) have been rising globally. It is important to use the most effective and safe technique. To compare the effects of complete methods of caesarean section; and to summarise the findings of reviews of individual aspects of caesarean section technique. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (August 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 3) and reference lists of identified papers. Randomised controlled trials of intention to perform caesarean section using different techniques. Two review authors independently assessed studies and extracted data. 'Joel-Cohen based' compared with Pfannenstiel CS was associated with: less blood loss, (five trials, 481 women; weighted mean difference (WMD) -64.45 ml; 95% confidence interval (CI) -91.34 to -37.56 ml); shorter operating time (five trials, 581 women; WMD -18.65; 95% CI -24.84 to -12.45 minutes); postoperatively, reduced time to oral intake (five trials, 481 women; WMD -3.92; 95% CI -7.13 to -0.71 hours); less fever (eight trials, 1412 women; relative risk (RR) 0.47; 95% CI 0.28 to 0.81); shorter duration of postoperative pain (two comparisons from one trial, 172 women; WMD -14.18 hours; 95% CI -18.31 to -10.04 hours); fewer analgesic injections (two trials, 151 women; WMD -0.92; 95% CI -1.20 to -0.63); and shorter time from skin incision to birth of the baby (five trials, 575 women; WMD -3.84 minutes; 95% CI -5.41 to -2.27 minutes). Serious complications and blood transfusions were too few for analysis.Misgav-Ladach compared with the traditional method (lower midline abdominal incision) was associated with reduced: blood loss (339 women; WMD -93.00; 95% CI -132.72 to -53.28 ml); operating time (339 women; WMD-7.30; 95% CI -8.32 to -6.28 minutes); time to mobilisation (339 women; WMD -16.06; 95% CI -18.22 to -13.90 hours); and length of postoperative stay for the mother (339 women; WMD -0.82; 95% CI -1.08 to -0.56 days). Misgav-Ladach compared with modified Misgav-Ladach methods was associated with a longer time from skin incision to birth of the baby (116 women; WMD 2.10; 95% CI 1.10 to 3.10 minutes). 'Joel-Cohen based' methods have advantages compared to Pfannenstiel and to traditional (lower midline) CS techniques, which could translate to savings for the health system. However, these trials do not provide information on mortality and serious or long-term morbidity such as morbidly adherent placenta and scar rupture.

Oncologic Assessment of Hand-Assisted Retroperitoneoscopic Nephroureterectomy for Urothelial Tumors of the Upper Tract: Comparison with Conventional Open Nephroureterectomy

To evaluate the oncologic results of our operative technique, hand-assisted retroperitoneoscopic nephroureterectomy (HRNU), for the treatment of upper-tract urothelial cancer, various perioperative parameters and oncologic outcomes were compared for HRNU and conventional open nephroureterectomy (CONU). Thirty-six patients with clinical stage T(1,2)N(0)M(0) renal-pelvic and ureteral tumors underwent HRNU. A retroperitoneoscopic nephrectomy was carried out with hand assistance via a lower-abdominal midline incision. The lower ureter was resected by open surgery through the same incision, and the operative specimen was extracted via the same incision. Thirty-seven cases of CONU were reviewed as historical controls. Various perioperative and parameters and oncologic results were compared for the two procedures. The HRNU was completed in all but one case, which was converted to CONU. The mean operating time (395 minutes) was longer than that for CONU (289 minutes), and the mean estimated blood loss with HRNU (497 g) was greater than that with CONU (296 g). The mean time to oral intake (1.4 days) was shorter than that after CONU (2.3 days), and the mean time to walking was shorter (2.1 days v 2.6 days). There were no statistical differences in the cause-specific survival rate, the disease-free survival rate, or the bladder recurrence-free survival rate between HRNU (median follow-up 23 months) and CONU (median follow-up 56 months). The HRNU, a combination of endoscopic and conventional open surgery, seems to be a reasonable surgical procedure, because the lower-abdominal incision can be utilized, not only as a route for hand assistance, but also as a window for open surgery when resecting the distal ureter as well as for extraction of surgical specimens. The procedure is a safe alternative to conventional open surgery for upper urinary-tract tumors from an oncologic viewpoint.

Cosmetic Results of Lower Midline Abdominal Incision: Donati Stitches versus a Continuous Intracutaneous Suture in a Randomized Clinical Trial

The appearance of a laparotomy scar may be an important legacy of surgery for some patients. This randomized study enrolled 80 patients who required gynecologic surgery through a lower midline vertical incision. It compared 2 approaches: a continuous absorbable intracutaneous suture versus interrupted Donati stitches. A fourth-year resident supervised by a staff gynecologist performed all closures. Three independent observers as well as the patients evaluated the cosmetic outcome after 8 days and 4 to 6 months. They used visual analog scales to score hypertrophy, width, color, and crosshatching; in addition, the patients scored their postoperative pain. Clinical features were similar for the 42 women managed with a continuous intracutaneous suture and the 38 in whom the skin was closed by the Donati technique. Both procedures took approximately 13 to 15 minutes. After 4 to 6 months, wound dehiscence exceeding 1 cm was found in 4 patients in the Donati group and one treated by the single-suture technique. Two wound infections occurred in the Donati group. Observers' scores were lower, signifying a cosmetically superior scar, for the single-suture group at early postoperative assessment, but subsequently, there were no meaningful differences. At 4 to 6 months, there was a slight, insignificant difference in patient scores favoring the intracutaneous suture. The observers' and patients' scores did not differ significantly. At no time were there significant differences in pain scores between the 2 patient groups. The authors recommend using an intracutaneous suture for closing lower midline laparotomy wounds. It is not more time-consuming than using Donati stitches and provides comparable cosmetic results with a somewhat smaller risk of wound dehiscence. Both patients and physicians will appreciate not having to remove stitches. If the risk of wound infection is increased, interrupted Donati stitches may be the best option because removing some of the stitches will facilitate wound drainage, if needed.

Hand-assisted retroperitoneoscopic nephroureterectomy for upper urinary-tract urothelial tumors.

We report our experience with hand-assisted retroperitoneoscopic nephroureterectomy for upper urinary-tract urothelial cancer. Our initial 10 cases of clinical stage T(1)N(0)M(0) renal pelvic and ureteral tumors treated with hand-assisted retroperitoneoscopic nephroureterectomy are included in the present report. Nephrectomy was conducted retroperitoneoscopically with hand assistance via a lower-abdominal midline incision. Resection of the lower ureter together with the bladder cuff was performed as open surgery and the specimen was removed en bloc via the same incision. Hand-assisted retroperitoneoscopic nephroureterectomy was completed successfully in all 10 cases. The mean operating time was 456 +/- 90 minutes, and the mean estimated blood loss was 462 +/- 364 mL. The times to oral intake and walking were 1.5 +/- 0.5 days and 2.3 +/- 0.7 days, respectively. One case of renal vein injury, one case of pulmonary embolism, and three cases of wound infection were the complications. This is the first report of hand-assisted endoscopic nephroureterectomy using the retroperitoneal approach. The surgical technique seems quite reasonable because the lower-abdominal incision can be utilized, not only as a route for hand assistance, but also as a window for open surgery when resecting the distal ureter as well as for extracting the surgical specimen.

RETROVESICAL HEMATOMA SECONDARY TO CLEAN INTERMITTENT SELF-CATHETERIZATION

A 36-year-old man presented with massive hematuria after performing self-catheterization with a 14Fr catheter while intoxicated with alcohol and cocaine. Since early childhood, he had suffered from incomplete spastic paraplegia and neurogenic bladder dysfunction consequent to spinal cord trauma. However, for the last 10 years he had successfully performed intermittent self-catheterization, only recently having had to use force because of an approximately 8 cm. long stricture of the penile and bulbar urethra. On physical examination and abdominal ultrasound the bladder was filled with blood clots and a 7 cm. retrovesical mass, consistent with hematoma, was present. The bladder was evacuated with a 20Fr hematuria catheter and a 3-way irrigation catheter were inserted. Cystography showed perforation of the bladder (fig. 1). After conservative treatment with antibiotics and catheter drainage for 7 days, repeat cystography demonstrated closure of the perforation site. The patient resumed intermittent self-catheterization and was discharged from the hospital. The patient returned to the hospital 8 days later with persistent lower abdominal pain and subfebrile temperatures (37.5C). Computerized tomography demonstrated a 10 cm. retrovesical mass (fig. 2). The abdomen was surgically explored via a lower abdominal midline incision and approximately 500 cc of retrovesical hematoma were evacuated. The patient declined concomitant bladder augmentation with continent vesicostomy. Convalescence was uneventful.

AN ELECTRO-MYOGRAPHIC STUDY OF THE DISTAL PORCINE URETER

The accumulation of urine in the renal pelvis causes depolarisation of non-specific muscular pace-maker cells. The wave of depolarisation spreads distally in the ureteric smooth muscle cells via gap junctions. This wave of excitation causes a coordinated peristaltic contraction which transports the urine bolus distally to the bladder. The EMG activity in the distal porcine ureter was studied and analyzed to establish the characteristics of ureteric excitation. Ten female New Yorkshire pigs (50 to 60 kg.) were studied in two groups under light halothane anesthesia (5% at induction and 1% for maintenance anesthesia). In both groups each pig was studied in two separate sessions at a week's interval. In group I (n = 5), bipolar needle electrodes (o: 0. 09 mm.) were implanted through a lower mid-line abdominal incision in the posterior bladder wall, the trigone and the pelvic ureter at intervals of 3 and 8 cm., respectively, from the ureteric orifice. In group II (n = 5), EMG spike burst activity was studied using a twin bipolar ring-electrode attached to an endoluminal ureteric catheter. EMG complexes were recorded using 0 to 30 Hz filters. The duration of spike burst complexes and their intervals were analyzed using a Nicollet, Pathfinder II(R) machine and a Poly(R) 4.9 digital signal processing program. Two types of spike burst activity could be distinguished between the electrodes: A, the migrating type and B, the non-migrating type. Frequency distribution analysis of spike burst duration revealed two main classes in experimental group II, a short spike burst (96%) which lasted 4.5 +/- 1.8 seconds and a longer one lasting 13.4 +/- 1.5 seconds. The conduction velocity of the migrating spike bursts (n = 177, 42% of total) between the proximal and the distal electrode had an average of 2.3 +/- 1.3 cm./sec. No relationship was found between the duration of the proximal spike burst and the conduction velocity. Data from experimental group I correlated well with data from group II. The results of our EMG study in the distal ureter reveal an approximately 9 cm. long electrically active zone in >/= 90% of EMG activity recordings. The duration of activity was approximately 5 seconds. Such an excited segment of ureter led to a contraction which occluded the ureter and could prevent retrograde leakage of intraluminal contents.

Spontaneous Rupture of the Rectum with Evisceration of Omentum through the Anus: A Case Report and Review of the Literature

Spontaneous Rupture of the Rectum with Evisceration of Omentum through the Anus: A Case Report and Review of the Literature

LAPAROSCOPY-ASSISTED PROCTOCOLECTOMY FOR FAMILIAL ADENOMATOUS POLYPOSIS

We report a case of familial adenomatous polyposis with an advanced cancer of the sigmoid colon which was treated with laparoscopic surgery. A 36-year-old woman was pointed out to have a familial adenomatous polyposis with a signoid colon cancer by a barium contrast study of the colon. an operation was conducted through four 10-mm trocars. the total colon was laparoscopically dissected and mobilized from the abdominal wall and retroperitoneum. the root of the inferior mesenteric artery was exposed. The total colon was extracted through a 9cm lower abdominal midline incision. The gastrocolic ligament and right side of the mesocolon were incised. Lymph node dissection of the inferior mesenteric artery was perfromed through the incision. The lower recutm was dissectd through the incision. the total colon was removed through the incision after transcetion of the rectum and ileum. heal-reservoir (J-pouch9 and anal anastomosis were performed. The operation time was 6 hours and 34 minutes. Postoperative course was uneventful. As three months after the surgery, anal function has been good and the patients has bowel movements 3 or 4 times a day.

MINI‐LAPAROTOMY STAGING PELVIC LYMPH NODE DISSECTION FOR LOCALIZED PROSTATE CANCER

We report our early experience with mini-laparotomy staging pelvic lymph node dissection (PLND) for clinically localized prostate cancer. We have used virtually the same original technique described by Steiner and Marshall. A 5 cm lower midline abdominal incision provides excellent exposure, allowing complete PLND under direct visualization. If radical retropubic prostatectomy is indicated by the state of the pelvic lymph nodes, this can be performed only by extending the same incision. Nine patients with histologically proven prostate cancer underwent mini-laparotomy staging PLND. The average intraoperative time for mini-laparotomy PLND was 33 minutes (range, 25-50 minutes). The intraoperative blood loss was 44 ml (range, 20-90 ml). The mean number of pelvic lymph nodes removed was 6.9 (range, 5-10 nodes) on the right and 10.8 (range, 8-21 nodes) on the left. Eight patients underwent immediate radical retropubic prostatectomy and one had radiation therapy. There were no complications directly related to the mini-laparotomy staging PLND. Mini-laparotomy staging PLND is an attractive alternative to laparoscopic PLND, especially for patients at low risk of lymph node metastasis.