Search

The aim of this prospective study is to describe the combined technique and results of stapled haemorrhoidopexy and lateral internal sphincterotomy for patients suffering from prolapsing 3rd-degree haemorrhoids and chronic fissure-in-ano. During the period from 1999 to 2004, 26 patients underwent combined surgical treatment for anal fissure and prolapsing symptomatic haemorrhoids. Preoperative and postoperative clinical evaluation and the patient’s degree of satisfaction were recorded. Early complications included faecal urgency (3 patients) and pain (2 patients). Complete continence was restored within 10 weeks in all patients except 1 who had persisting incontinence to flatus. All fissures healed completely within 4 weeks. No haemorrhoidal or fissure recurrence has been observed during follow-up. The combination of stapled haemorrhoidopexy and lateral internal sphincterotomy is a safe and effective procedure for the treatment of prolapsing 3rd-degree haemorrhoids and chronic anal fissures. Copyright © 2005 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Several letters to the editor are presented in response to articles in previous issues including long-term results after transanal stapled excision of rectal internal mucosal prolapse and methylene blue injection which reduces pain after lateral anal sphincterotomy.

Abstract Background Adnexal masses are not uncommon in patients with breast cancer. Breast cancer and ovarian malignancies are known to be associated. In patients with breast cancer and co-existing pleural effusions, ascites and adnexal masses, the probability of disseminated disease is high. Nevertheless, benign ovarian masses can mimic this clinical picture when they are associated with Meigs' syndrome making the work-up and management of these patients challenging. To our knowledge, there are no similar reports in the literature and therefore we present this case to highlight this entity. Case presentation A 56-year old woman presented with a 4 cm, grade 2, invasive ductal carcinoma of her left breast. Pre-treatment staging investigations showed a 13.5 cm mass in her left ovary, a small amount of ascites and a large right pleural effusion. Serum tumour markers showed a raised CA125 supporting the malignant nature of the ovarian mass. The cytology from the pleural effusion was indeterminate but thoracoscopic biopsy failed to show malignancy. The patient was strongly against mastectomy and she was commenced on neo-adjuvant Letrozole 2.5 mg daily with a view to perform breast conserving surgery. After a good response to the hormone manipulation, the patient had breast conserving surgery, axillary sampling and laparoscopic excision of the ovarian mass which was eventually found to be a benign ovarian fibroma. Conclusion Despite the high probability of disseminated malignancy when an ovarian mass associated with ascites if found in a patient with a breast cancer and pleural effusion, clinicians should be aware about rare benign syndromes, like Meigs', which may mimic a similar picture and mislead the diagnosis and management plan.

Abstract Background Although local excision (ampullectomy) was first described by Halsted in 1899, its adequacy as an alternative surgical treatment for the ampullary tumors is still a matter of debate. The aim of this study was to evaluate the results of ampullectomy as a curative treatment for benign and malignant tumors arising from the ampulla, in a 14-year single-institution experience. Methods From 1990 to 2004, a total of 20 patients of adenocarcinoma (12) or adenoma (8) of the ampulla of Vater underwent local excision. Clinical data were collected and morbidity, mortality, as well as long-term survival were evaluated. The usefulness of several pre or intraoperative diagnostic methods was also recorded. Median follow-up was 85 (range 6–180) months. Results The combination of endoscopic preoperative biopsies and intraoperative frozen section examination adequately diagnosed ampullary tumors in all cases. The postoperative morbidity and mortality were 0%, whereas the 3 and 5-year survival rates for the patients with adenocarcinoma was 75 % and 33.3 % respectively. All the patients with adenoma are still alive without any sign of recurrence. Conclusion In our series, local excision was a safe option, associated with satisfactory long-term survival rates in patients with benign lesions and in those with small(

Abstract Background Metastases from hepatocellular carcinoma (HCC) can be found in the lung and adrenal gland. We report case of a patient who presented with adrenal metastasis as the first clinical manifestation of HCC. Case presentation A patient was referred for surgical treatment for a tumor in retro-peritoneal space. The computerized tomography (CT) scan revealed a mass originating from the left adrenal gland. The patient underwent left adrenalectomy and the exploration of abdominal cavity did not reveal any other palpable lesions. Histologically, the resected lesion was a poorly differentiated metastatic tumor from HCC. Seven months later patient was readmitted complaining of cachexia, icterus, and significant weight loss. CT scan revealed hyperdense lesions of the liver Conclusion HCC may have atypical presentations like in present case. Fine needle aspiration/tru-cut® biopsy might be useful in the investigation of an accidentally discovered adrenal mass regardless of the size and can lead to the detection of a primary tumor.

Wheelchair basketball met a rapid growth in recent decades and became one of the most popular and spectacular sports for people with disabilities. Researchers' efforts to perform tests evaluating the physiological and technical characteristics of the disable athletes have been based on the adoption of tests, used for healthy athletes (7, 15). In addition, different types of disabilities obligated the International Wheelchair Basketball Federation to establish classification degree for the athletes, ranging from 1 to 4.5, according to their disability. The purpose of this study was to evaluate the Greek elite basketball players' technical skills and to compare their performance, (a) with their classification degree and (b) with recent literature. Fourteen (N=14) Greek wheelchair basketball players, all members of the national team, volunteered to perform six skill tests: (a) 20m sprint, (b) free throws, (c) lay-ups, (d) obstacle dribble, (e) pass for accuracy, and (f) pass for distance. The high classification degree athletes, demonstrated significantly higher performance than those with low classification, only in obstacle dribble test (p <.01), but the trend indicated that athletes with high classification degree demonstrated better performance on tests requiring physical abilities (sprint, lay-ups, obstacle dribble, pass for distance), while those with low classification degree performed better on tests requiring skills and concentration (free throws, pass for accuracy). These results are in accordance with recent literature, although Greek basketball players, demonstrated lower performance compared with those of other countries, where wheelchair basketball is widespread (13). The difference between high and low classification players in obstacle dribble test, caused to the lack of abdominal muscles, while overall performance is affected by the frequency of training and years of involvement with the sport, before the time point of injury (9). [ABSTRACT FROM AUTHOR]

Pre-exercise mangiferin-quercetin may enhance athletic performance. This study investigated the effect of mangiferin-quercetin supplementation on high-level male basketball players during a basketball exercise simulation test (BEST) comprising 24 circuits of 30 s activities with various movement distances. The participants were divided into two groups (EXP = 19 and CON = 19) and given a placebo one hour before the BEST (PRE-condition). The following week, the EXP group received mangiferin-quercetin (84 mg/140 mg), while the CON group received a placebo (POST-condition) before the BEST in a double-blind, cross-over design. The mean heart rate (HR) and circuit and sprint times (CT and ST) during the BEST were measured, along with the capillary blood lactate levels (La - ), the subjective rating of muscle soreness (RPMS), and the perceived exertion (RPE) during a resting state prior to and following the BEST. The results showed significant interactions for the mean CT ( p = 0.013) and RPE ( p = 0.004); a marginal interaction for La - ( p = 0.054); and non-significant interactions for the mean HR, mean ST, and RPMS. Moreover, the EXP group had significantly lower values in the POST condition for the mean CT (18.17 ± 2.08 s) and RPE (12.42 ± 1.02) compared to the PRE condition (20.33 ± 1.96 s and 13.47 ± 1.22, respectively) and the POST condition of the CON group (20.31 ± 2.10 s and 13.32 ± 1.16, respectively) ( p < 0.05). These findings highlight the potential of pre-game mangiferin-quercetin supplementation to enhance intermittent high-intensity efforts in sports such as basketball.

Soccer is a complex sport, and balance appears to play a crucial role in the quality execution of technical skills, which are mostly performed while standing on one foot. Nevertheless, in younger ages, when learning still affects soccer performance, the effect of a balance-training program on the player's balance and technical skills remains unexplored. This research examined the effect of a balance-training program (BTP) on balance and technical skills of adolescent soccer players. Τhe participating volunteers were thirty-two soccer players (12-13 years old with 3.84 ± 0.95 years of practice), randomly separated into two groups: an experimental (EXP, n1 = 17) and a control group (CON, n2 = 15). Both groups were evaluated in static and dynamic balance and in technical skills (dribbling, passing, juggling, and shooting with dominant and non-dominant legs) before (Pre-condition) and after the intervention (Post-condition) which was an eight-week BTP for the EXP group and a placebo-training program for the CON group. Α 2 by 2 (groups×condition) mixed analysis of variance (ANOVA) with repeated measures on the condition factor was used to assess possible differences between groups. A significant groups × condition interaction effect was found in dynamic balance (p = 0.008), static (p = 0.042), and shooting (p = 0.022) with dominant leg performance. The EXP group improved (p = 0.007) its static balance by 37.82% and also significantly improved its dynamic balance and shooting accuracy with dominant leg in Post condition by 24.98% (p = 0.006) and 83.84% (p = 0.006) respectively. No significant improvement of other variables was detected in the EXP group Post condition. Dynamic and static balance, and shooting with dominant leg skills can be improved in adolescent soccer players through a specialized 8-week BTP. Balance-training program may contribute to technical skill improvement in soccer training., (© Journal of Sports Science and Medicine.)

This dataset was created with the primary objective of elucidating the intricate relationship between the incidence of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) re-infections and the pre-illness vaccination profile and types concerning alterations in sports-related physical activity (PA) after SARS-CoV-2 infection among adults. A secondary objective encompassed a comprehensive statistical analysis to explore the influence of three key factors-namely, Vaccination profile, Vaccination types, and Incidence of SARS-CoV-2 re-infections-on changes in PA related to exercise and sports, recorded at two distinct time points: one to two weeks prior to infection and one month after the last SARS-CoV-2 infection. The sample population ( n = 5829), drawn from Hellenic territory, adhered to self-inclusion and exclusion criteria. Data collection spanned from February to March 2023 (a two-month period), involving the utilization of the Active-Q (an online, interactive questionnaire) to automatically assess weekly habitual sports-related PA among adults both before and after their last SARS-CoV-2 infection. The questionnaire also captured participant characteristics, pre-illness vaccination statuses (i.e., unvaccinated, partially vaccinated, fully vaccinated, and vaccine types), and occurrences of SARS-CoV-2 re-infections. The dataset sheds light on two noteworthy phenomena: (i) the intricate interplay between post-acute SARS-CoV-2 infection and a decline in sports-related physical activity (-27.6 ± 0.6%, 95%CI: -26.1 - -29.1), influenced by the pre-illness vaccination profile factor ( p = 0.040); and (ii) the divergence in sports-related physical activity decline between partially vaccinated (-38.2 ± 0.7%, 95%CI: -35.3 - -41.1, p = 0.031) and fully vaccinated respondents (-19.2 ± 0.5%, 95%CI: -17.2 - -21.2). These phenomena underscore the imperative for tailored interventions and further investigation to promote the resumption of physical activity and mitigate long-term repercussions. Furthermore, this dataset enriches our understanding of the dynamics of sports-related physical activity and provides valuable insights for public health initiatives aiming to address the consequences of COVID-19 on sports-related physical activity levels. Consequently, this cross-sectional dataset is amenable to a diverse array of analytical methodologies, including univariate and multivariate analyses, and holds potential relevance for researchers, leaders in the sports and medical sectors, and policymakers, all of whom share a vested interest in fostering initiatives directed at reinstating physical activity and mitigating the enduring ramifications of post-acute SARS-CoV-2 infection., (© 2023 The Author(s).)

This study investigated changes in physical activity (PA) after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection while considering age, PA level, underlying medical conditions (UMCs), vaccination profiles/types, re-infections, disease severity, and treatment. Data were collected from 5829 respondents by using a validated web-based questionnaire. The findings showed that there was a significant overall decrease in PA (-16.2%), including in daily occupation (-11.9%), transportation (-13.5%), leisure-time (-16.4%), and sporting (-27.6%) activities. Age, PA level, UMCs, vaccination profiles/types, disease severity, and treatment played a role in determining PA in individuals' post-acute SARS-CoV-2 infections. Re-infections did not impact the decline in PA. Unvaccinated individuals experienced a significant decline in PA (-13.7%). Younger (-22.4%) and older adults (-22.5%), those with higher PA levels (-20.6%), those with 2-5 UMCs (-23.1%), those who were vaccinated (-16.9%) or partially vaccinated (-19.1%), those with mRNA-type vaccines only (-17.1%), those with recurrent (-19.4%)-to-persistent (-54.2%) symptoms, and those that required hospital (-51.8%) or intensive care unit (-67.0%) admission during their infections had more pronounced declines in PA. These findings emphasize the complex relationship between post-acute SARS-CoV-2 infection and PA and highlight the need for targeted interventions, further research, and multidisciplinary care to promote PA resumption and mitigate long-term effects on global public health.

Background: Our aims were to investigate the time-course effects of a futsal match on performance, oxidative stress, and muscle damage markers, as well as inflammatory and antioxidant responses during a 6-day post-match period., Methods: Thirty-four female high-level futsal players were assessed on several oxidative stress, inflammation, subjective muscle soreness, subjective rate perceived exertion, and performance tests before a futsal match, immediately after, and 24 h to 144 h after., Results: Counter movement jump, 20 m, and 10 m sprints performance significantly decreased immediately after the match ( p < 0.05) and returned to baseline 72 h post-match ( p > 0.05). Delayed onset muscle soreness peaked 24 h post-match and rate perceived exertion peaked post-match ( p < 0.05) and returned to baseline 96 h post-match ( p > 0.05). Inflammatory biomarkers peaked at 24 h ( p < 0.05) and remained significantly elevated for 72 h after the match ( p < 0.05). Muscle damage biomarkers peaked at 24 h ( p < 0.05) and remained significantly ( p < 0.05) elevated for at least 72 h after the match. Oxidative stress markers peaked at 24 h-48 h ( p < 0.05) and returned to baseline 120 h post-match ( p > 0.05). In respect to antioxidant responses, these peaked at 24 h-48 h post-match ( p < 0.05) and returned to baseline 120 h after the match ( p > 0.05)., Conclusions: A single futsal match induces short/mid-term changes in performance, inflammation, oxidative stress, and muscle damage markers for about 72 h-96 h post-match.

Jumping ability in basketball is usually assessed using standardized vertical jump tests. However, they lack specificity and do not consider the player’s basketball skills. Several studies have suggested performing specific jump tests, which are tailored to the movement patterns and requirements of a basketball game. The pivot step jump test (PSJT) is a novel test designed to evaluate the specific jumping abilities of basketball players by combining a pivot step on one leg with a maximum bilateral vertical jump. This study had two aims: to determine the reliability and validity of the PSJT using typical jump tests as the criterion measure and to demonstrate the PSJT as a practical test to evaluate specific jumping ability in young male and female basketball players. Twenty female (EGA; 14.0 ± 0.7 years, 59.3 ± 7.9 kg, 162.1 ± 5.5 cm) and fifteen male (EGB; 14.0 ± 0.7 years, 58.1 ± 7.7 kg, 170.3 ± 6.4 cm) basketball players participated in the study. The test−retest reliability of the PSJT within sessions (intrasession reliability) and across sessions (intersession reliability) was assessed within EGA. For the evaluation of validity, EGB performed the PSJT and a series of criterion jumping tests. For EGA, no changes (p > 0.05) were found in PSJT performance between test sessions and excellent intra- and intersession reliability was observed (ICCs > 0.75). Correlation coefficients indicated high factorial validity between the jumping tests and PSJT (r = 0.71−0.91, p < 0.001). The PSJT appears to offer a valid assessment of jumping ability in basketball and is a practical test for assessing sport-specific jumping skills in young basketball players.

Performing effective actions requires the basketball player to balance factors such as motor variability, error minimalization and a complex sequence of coordination to determine the best action., Purpose: The aim of the study was to differentiate the strength of the muscles of the index and middle fingers when performing a basketball shot., Materials and Methods: Study group consisted of 122 male college basketball league students. The study included psychophysiological tests to determine indices of individual and typological characterictics s of higher nervous activity, proprioceptive sensitivity tests of the fingers of the leading hand and field tests to assess participants' shooting skills. The touch-based finger pressure sensing system measured the different levels of pressure exerted by the participants' main index and middle finger during grasping., Results: For both the middle and index finger, the highest correlation with shot efficiency was found for a 120 g load g (p < 0.01 for 2PS; 2PS40 suc; FT; 3PSO and 3.5 mS). Furthermore, high reproducibility of proprioceptive sensitivity of the index and middle finger of the leading hand was found in basketball players., Conclusions: The research indicates that it is possible to organize compensatory behavior between joints on the basis of proprioception, with the last compensatory movements of the kinematic chain being performed by the fingers of the hand. The demonstrated high proprioceptive sensitivity of the index and middle finger of the leading hand in basketball players at a weekly interval may indicate ability to maintain high repeatability of movements controlled by these fingers.

The purpose of the present study was to define the maximal lactate steady state (MLSS meas ) in high-level male basketball players and to compare it with the lactate turnpoint (LTP) and the respective point derived form a prediction method (MLSS cal ). Twelve high-level basketball players underwent one maximal and several submaximal tests on a treadmill on different days where MLSS and LTP were measured. MLSS meas was observed at 75% of the maximal treadmill speed, at 77% of VO 2max , at 88% of HR max and at [La - ] of 3.7 mmol.l -1 . No differences were observed between MLSS meas and LTP in any of the measured variables. A good agreement was observed between MLSS meas and LTP, as well as between MLSS meas and MLSS cal . Therefore, LTP and MLSS cal are offered as acceptable approaches to predict MLSS, but not all the indices used to define MLSS presents high agreement between the methods used.

Background: Randomized controlled trials (RCTs) inform clinical practice and have provided the evidence base for introducing minimally invasive surgery (MIS) in surgical oncology. Crossover (unplanned intraoperative conversion of MIS to open surgery) may affect clinical outcomes and the effect size generated from RCTs with homogenization of randomized groups., Objectives: Our aims were to identify modifiable factors associated with crossover and assess the impact of crossover on clinical endpoints., Methods: A systematic review was performed to identify all RCTs comparing MIS with open surgery for gastrointestinal cancer (1990-2017). Meta-regression analysis was performed to analyze factors associated with crossover and the influence of crossover on endpoints, including 30-day mortality, anastomotic leak rate, and early complications., Results: Forty RCTs were included, reporting on 11,625 patients from 320 centers. Crossover was shown to affect one in eight patients (mean 12.6%, range 0-45%) and increased with American Society of Anesthesiologists score (β = + 0.895; p = 0.050). Pretrial surgeon volume (β = - 2.344; p = 0.037), composite RCT quality score (β = - 7.594; p = 0.014), and site of tumor (β = - 12.031; p = 0.021, favoring lower over upper gastrointestinal tumors) showed an inverse relationship with crossover. Importantly, multivariate weighted linear regression revealed a statistically significant positive correlation between crossover and 30-day mortality (β = + 0.125; p = 0.033), anastomotic leak rate (β = + 0.550; p = 0.004), and early complications (β = + 1.255; p = 0.001), based on intention-to-treat analysis., Conclusions: Crossover in trials was associated with an increase in 30-day mortality, anastomotic leak rate, and early complications within the MIS group based on intention-to-treat analysis, although our analysis did not assess causation. Credentialing surgeons by procedural volume and excluding high comorbidity patients from initial trials are important in minimizing crossover and optimizing RCT validity.

Stuttering priapism is rare and under-investigated clinical entity. Although it shares similarities with ischaemic priapism, by definition, stuttering priapism has distinct characteristics that advocate for a different management in the clinical setting. Therefore, the management of stuttering priapism aims primarily to prevent recurrence rather than the resolution of spontaneous attacks. A multimodal approach and the individualization of each case are essential because of the diversity of the condition and the plethora of proposed therapeutic strategies. Understanding the underlying pathophysiology and familiarity with contemporary, past and emerging future agents and therapeutic options are required in order to provide an optimal solution for each patient. In addition, patient counselling and the option to combine therapeutic strategies and challenge second-line therapies are essential weapons in the armament of the urologist. Although further clinical trials and studies are mandatory in order to obtain solid data and provide recommendations, all therapeutic options are analysed, with specific interest in the potential advantages and disadvantages. A structured evaluation procedure is also described., Competing Interests: Conflict of interest statement: The authors declare that there is no conflict of interest.

Objective: The aim of this study was to report surgical and functional outcomes in patients who underwent immediate penile fracture repair following location of the tunical tear with ultrasonography., Methods: Patients' clinical notes from September 2005 to October 2015 were reviewed. The inclusion criteria were the documented presence of an albugineal laceration at the preoperative ultrasonography and during surgical exploration. In total, 76 patients were enrolled in the study. The aetiology, presentation, imaging results, intraoperative findings, functional outcomes and complications of surgical repair were retrospectively extrapolated from the clinical notes. Patients were questioned about their erectile and urinary function 12 months after the traumatic event. Validated questionnaires were administered to enquire about sexual and urinary function. Finally, the accuracy of the ultrasound in detecting the site of the tunical defect was evaluated., Results: The mean age was 39.5 years (range 21-72 years) and the median follow-up was 13 weeks. The aetiology of the fracture was sexual intercourse in 70 patients, the taqaandan manoeuvre in three and trauma while sleeping in three. The intraoperative findings showed a ventral and transverse tear in 93.5% of cases. Urethral injuries were evident in one-quarter of the patients. Ultrasonographic findings were confirmed intraoperatively in all patients. Worsening of the quality of erections was reported by 5% of patients, and 5.2% reported a penile curvature postoperatively., Conclusion: Penile fracture is a rare urological emergency and requires early surgical exploration and repair. Ultrasonography is a cheap and readily available investigation that allows confirmation of the diagnosis, and identification of the location of the tear and the associated urethral injury.

Malignant priapism secondary to penile metastases is a rare condition. This term was originally used by Peacock in 1938 to describe a condition of painful induration and erection of the penis due to metastatic infiltration by a neoplasm. In the current literature there are 512 case reports. The primary tumor sites are bladder, prostate and rectum. The treatment has only palliative intent and consists of local tumor excision, penectomy, radiotherapy and chemotherapy. We present one case of malignant priapism originated from prostate cancer, and two from urothelial carcinoma of the bladder. Different approaches in diagnosis and therapy were performed. The entire three patient reported a relief of the pain following the treatment, with an improvement of their quality of life, even though it was only temporary as a palliative. Malignant priapism is a rare medical emergency. Penile/pelvis magnetic resonance imaging (MRI) scan and corporal biopsies are considered an effective method of diagnosis of the primary organ site.

Objective: Early insertion of a penile prosthesis in prolonged ischaemic priapism is easier to perform than late prosthesis placement, and preserves the penile length. The aim of this study was to assess whether a delayed exchange to an inflatable implant allows upsizing of the cylinders in patients who have undergone early insertion for refractory ischaemic priapism., Materials and Methods: Over a 30 month period, 10 patients with ischaemic priapism underwent an early insertion of a malleable penile prosthesis. The mean age was 41.3 years and the mean duration of priapism was 188 h. Following a median period of 130.5 days, all of these patients underwent exchange of the malleable to an inflatable prosthesis., Results: At the time of penile implant exchange, a median upsize in the length of the cylinders of 1 cm in either one or both corporal bodies (range 0-3 cm) was recorded. Five patients had deliberate downsizing at the initial operation owing to a previous shunt. The mean score on the five-item International Index of Erectile Function (IIEF-5) before insertion of the malleable prosthesis was 24 (range 20-25). Three months after the initial insertion of a malleable penile implant the satisfaction rate according to the IIEF-5 score was 80%. Three months after the exchange, the patient satisfaction rate increased to 90%., Conclusion: Insertion of a malleable penile prosthesis is an acceptable option for patients with refractory ischaemic priapism. Although some patients deliberately have a shorter implant inserted initially owing to a previous distal shunt procedure, following a period of resolution the cylinders can be upsized at a later operation.

Objective: To describe a robot-assisted intracorporeal pyramid neobladder reconstruction technique and report operative and perioperative metrics, postoperative upper tract imaging, neobladder functional outcomes, and oncological outcomes., Patients and Methods: In all, 20 patients (19 male and one female) with a mean (sd; range) age of 57.2 (12.4; 31.0-78.2) years underwent robot-assisted radical cystectomy (RARC). Most cases were ≤pT1 (17 patients) and the remaining three patients had muscle-invasive bladder cancer (MIBC) at RARC histopathology. Although half of the patients (10) actually had MIBC at transurethral resection histopathology. All patients underwent RARC, bilateral pelvic lymphadenectomy, and intracorporeal neobladder formation using a pyramid detubularised folding pouch configuration., Results: The median estimated blood loss was 250 mL and operating time was 5.5 h. The mean (sd) number of lymph nodes removed was 16.5 (7.8) and median hospital stay was 10 days. Early postoperative complications included urinary tract infection (UTI) (four patients), ileus (four), diarrhoea and vomiting (three), postoperative collection (two), and blocked stent (one). Late postoperative complications included UTI (seven patients), neobladder stone (two), voiding Hem-o-Loc (two), neobladder leak (two), diarrhoea and vomiting (one), uretero-ileal stricture (one), vitamin B12 deficiency (one), and port-site hernia (one). There was no evidence of hydronephrosis in 18 patients with a median follow-up of 21.5 months. At 24 months, recurrence-free survival was 86% and overall survival was 100%. In all, 19 patients and 13 patients reported 6-month day time and night time continence, respectively., Conclusions: The pyramid neobladder is technically feasible using a robotic platform and provides satisfactory functional outcomes at median of 21.5 months., (© 2015 The Authors BJU International © 2015 BJU International Published by John Wiley & Sons Ltd.)

Non-ischaemic priapism is a rare type of priapism and is associated with penile or perineal trauma. The absence of ischaemia should theoretically prevent smooth muscle necrosis and corporal fibrosis which occurs in ischaemic priapism. The aim of this study was to first report a patient series with non-ischaemic priapism that developed distal corpus cavernosum fibrosis and erectile dysfunction. Over a 5 year period, a cohort of 6 patients diagnosed with non-ischaemic priapism presented to a single centre. The diagnosis was based on a clinical history, penile examination with confirmation using a combination of cavernosal blood gas analysis, colour duplex ultrasonography of the penis and angiography. Patients were followed up in clinic at regular intervals with clinical examination and repeat imaging. Following a median follow up of 4 weeks (range 2-12) the patients reported either the development of erectile dysfunction with distal penile flaccidity. Five patients required the use of PDE-5 inhibitors to achieve full tumescence. The remaining patient eventually underwent insertion of a penile prosthesis due to the failure of pharmacotherapies. Based on these findings we suggest that superselective embolisation of non-ischaemic priapism cases occasionally should be performed after a shorter period of conservative treatment.

The uptake of minimally invasive esophagectomy (MIE) has increased vastly over the last decade, with proven short-term benefits over an open approach. The aim of this pooled analysis was to compare clinical outcomes of Minimally Invasive Esophagectomy (MIE) performed in the prone and lateral decubitus positions. A systematic literature search (2000-2015) was undertaken for publications that compared patients who underwent MIE in the lateral decubitus (LD) or prone (PR) positions. Weighted mean difference (WMD) was calculated for the effect size of LD positioning on continuous variables and Pooled odds ratios (POR) for discrete variables. Ten relevant publications comprising 723 patients who underwent minimally invasive esophagectomy were included; 387 in the LD group and 336 in the PR group. There was no significant difference between the groups in terms of in-hospital mortality, total morbidity, anastomotic leak, chylothorax, laryngeal nerve palsy, average operative time, and length hospital stay. LD MIE was associated with a non-significant increase in pulmonary complications (POR = 1.65; 95% C.I. 0.93 to 2.92; P = 0.09), and significant increases in estimated blood loss (WMD = 36.03; 95% 14.37 to 57.69; P = 0.001) and a reduced average mediastinal lymph node harvest (WMD = -2.17; 95% C.I. -3.82 to -0.52; P = 0.01) when compared to prone MIE. Pooled analysis suggests that prone MIE is superior to lateral decubitus MIE with reduced pulmonary complications, estimated blood loss and increased mediastinal lymph node harvest. Further studies are needed to explain performance-shaping factors and their influence on oncological clearance and short-term outcomes., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Boerhaave's syndrome (BS), also known as "spontaneous rupture of the esophagus", constitutes an emergency that requires early diagnosis if death or serious morbidity are to be prevented. First described in 1724, BS is thought to be more common than once thought. Its true incidence remains unknown. Mortality ranges between 20-40% with timely treatment but this rises to virtually 100% if treatment is delayed by more than 48 hours. This is unfortunately a common occurrence due to delayed diagnosis. The commonest precipitating factor is vomiting but BS can be truly "spontaneous". The classical clinical presentation described consists of vomiting, chest pain, and subcutaneous emphysema. However, and contrary to popular belief, this triad is actually uncommon accounting for the frequently delayed diagnosis. A less recognised presenting feature of BS is with pneumothorax due to associated rupture of the parietal pleura. Pneumothorax has been shown to be present in more than 20% of cases of BS-sometimes with a coexistent pleural effusion (hydropneumothorax). This article aims to raise awareness about pneumothorax as the sole initial presenting feature of BS and alert clinicians to consider BS in the differential diagnosis of any patient with respiratory symptoms and a recent history of vomiting.

Objective: To compare the long-term results of early and delayed insertion of a penile prosthesis (PP) in men with refractory ischaemic priapism (IP)., Patients and Methods: Early insertion of a PP was carried out in 68 men with IP within a median of 7 days from the onset of priapism, while 27 had delayed insertion after a median of 5 months. The results for sexual ability, satisfaction and subjective penile shortening were assessed by questioning at follow-up visits., Results: In the early group, a malleable and an inflatable PP were implanted in 64 and four patients, respectively. After a median follow-up of 17 months, six patients needed revision surgery due to infection and curvature. Patient's satisfaction rate and ability to have sexual intercourse was 96%. In the delayed group, a malleable PP was inserted in 12 patients and an inflatable in the remaining 15. In all, 80% of the patients required a second corporotomy and downsized cylinders due to dense fibrosis. After a median follow-up of 21 months,seven patients required revision surgery due to infection,erosion and mechanical failure. In all, 25 patients were able to engage in sexual intercourse but the satisfaction rate was only 60% mainly due to significant penile shortening., Conclusions: Early PP implantation should be the preferred option inpatients with IP, as the procedure is technically easier, has less complication rates and allows greater preservation of penile length.

Pancreatic cystic lesions are increasingly recognised due to the widespread use of different imaging modalities. Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas represent a common, but also heterogeneous group of cystic tumors with a significant malignant potential. These neoplasms must be differentiated from other cystic tumors and properly classified into their different types, main-duct IPMNs vs branch-duct IPMNs. These types have a different malignant potential and therefore, different treatment strategies need to be implemented. Endoscopic ultrasound (EUS) offers the highest resolution of the pancreas and can aid in the differential diagnosis, classification and differentiation between benign and malignant tumors. The addition of EUS fine-needle aspiration can supply further information by obtaining fluid for cytology, measurement of tumor markers and perhaps DNA analysis. Novel techniques, such as the use of contrast and sophisticated equipment, like intraductal probes can provide information regarding malignant features and extent of these neoplasms. Thus, EUS is a valuable tool in the diagnosis and appropriate management of these tumors.

Abdominal adhesions are associated with increased postoperative complications, cost and workload. We performed a systematic review with statistical pooling to estimate the formation rate, distribution and severity of postoperative adhesions in patients undergoing abdominal surgery. A literature search was carried out for all articles reporting on the incidence, distribution and severity of adhesions between January 1990 and July 2011. Twenty-five articles fulfilled the inclusion criteria. The weighted mean formation rate of adhesions after abdominal surgery was 54 % (95 % confidence interval [CI] 40-68 %), and was 66 % (95 % CI 38-94 %) after gastrointestinal surgery, 51 % (95 % CI 40-63 %) after obstetric and gynaecological surgery and 22 % (95 % CI 7-38 %) after urological surgery. The mean overall severity score was 1.11 ± 0.98 according to the Operative Laparoscopy Study Group classification. Laparoscopic surgery reduced the adhesion formation rate by 25 % and decreased the adhesion severity score (laparoscopic; 0.36 ± 0.69 vs. open; 2.14 ± 0.84) for gastrointestinal surgery. Our results demonstrate that the incidence and severity of abdominal adhesions varies between surgical specialties and procedures. An increased awareness of adhesions can help in identifying the underlying mechanisms of adhesion formation and novel therapeutic approaches, while also improving the surgical consent process.

A best evidence topic was written according to a structured protocol. The question addressed was: In patients undergoing oesophagectomy is stapled anastomosis (STA) superior to hand-sewn anastomosis (HSA) with respect to post-operative outcomes. In total, 82 papers were found suitable using the reported search and 14 of these represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Existing evidence shows that STA is associated with reduced time to anastomotic construction and decreased intra-operative blood loss but increased risk of benign stricture formation compared to HSA. There is no difference between HSA and STA with respect to cardiac or respiratory complications, anastomotic leakage, duration of hospital admission or 30-day mortality. In HSA, increasing surgical experience and intra-operative air leakage testing after anastomotic creation are associated with reduced risk of anastomotic leakage. Further adequately powered studies will enable identification of other local and systemic factors influencing anastomotic healing, which will lead to improved patient and anastomotic technique selection for optimal surgical outcomes., (Copyright © 2013. Published by Elsevier Ltd.)

Purpose: The current management of ischemic priapism that is refractory to conventional medical therapy is a form of shunt procedure that diverts blood away from the corpus cavernosum. We assessed the outcome of the T-shunt and intracavernous tunneling for the management of ischemic priapism., Materials and Methods: During a 36-month period 45 patients presented with prolonged ischemic priapism. Patients were divided into subgroups according to the duration of priapism. All patients had an unsuccessful primary treatment, and underwent a T-shunt and intracavernous tunneling with cavernous muscle biopsies. All patients completed an IIEF-5 (International Index of Erectile Function-5) questionnaire preoperatively and 6 months postoperatively., Results: Resolution of the priapism using a T-shunt and snake maneuver occurred in all patients with a priapism duration of less than 24 hours and in only 30% of those with priapism lasting more than 48 hours. After a 6-month median followup the IIEF-5 score was significantly reduced from a mean of 24 (range 23 to 25) preoperatively to 7.7 (range 5 to 24), which was related to the duration of the priapism (p <0.0005). All patients with priapism for more than 48 hours had necrotic cavernous smooth muscle on biopsy and had severe erectile dysfunction requiring the insertion of a penile prosthesis. Those patients with moderate and mild erectile dysfunction were treated with phosphodiesterase type 5 inhibitors., Conclusions: The success of the T-shunt with snake tunneling is dependent on the duration of priapism. When it is less than 24 hours the results are favorable, although erectile dysfunction is still present in 50% of patients. In those with a priapism duration greater than 48 hours the technique usually fails to resolve the priapism and all patients end up with erectile dysfunction due to smooth muscle necrosis., (Copyright © 2014 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Routine intra-operative cholangiography (IOC) during laparoscopic cholecystectomy is often not performed because of increased operative time, radiation, and failure rate. Laparoscopic ultrasound (LUS) is a less invasive alternative but studies comparing it to IOC have been of small sample size. This study aims to assess the diagnostic accuracy of LUS in detecting common bile duct (CBD) stones compared to IOC., Methods: This meta-analysis was executed and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) statement. 11 comparative studies (1994-2013) reporting on 12 patient groups were included. A bivariate model for diagnostic meta-analysis was used to attain overall pooled sensitivity and specificity for IOC and LUS, and their relationship assessed using a hierarchical summary receiver operating characteristic model with meta-regression., Results: IOC had a pooled sensitivity of 0.87 (95% CI 0.77-0.93) and a pooled specificity of 0.99 (95% CI 0.98-0.99) with no significant heterogeneity. The diagnostic Odds Ratio (OR) was 442 (95% CI 196-997) and pooled weighted Area Under the Curve (AUC) was 0.99 (95% CI: 0.98-1.0). LUS had a pooled sensitivity of 0.87 (95% CI 0.80-0.92) and a specificity of 1.00 (95% CI 0.99-1.00). Heterogeneity was significant for specificity results. The diagnostic Odds Ratio (OR) was 1171 (95% CI 372-3689) and the pooled, weighted AUC was 1 (95% CI: 0.99-1). Meta-regression did not identify factors that significantly predict diagnostic accuracy., Conclusions: LUS is a potentially useful imaging modality to confirm the absence of CBD stones without needing to cannulate the biliary system., (Copyright © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Energy-based hemostatic devices are increasingly being used in thyroid surgery. However, there are several limitations with regard to the existing evidence and a paucity of guidelines on the subject. The goal of this review is to employ the novel evidence synthesis technique of a network meta-analysis to assess the comparative effectiveness of surgical technologies in thyroid surgery and contribute to enhanced governance in the field of thyroid surgery., Methods: Articles published between January 2000 and June 2012 were identified from Embase, Medline, Cochrane Library, and PubMed databases. Randomized controlled trials of any size comparing the use of ultrasonic coagulation (harmonic scalpel) or Ligasure either head-to-head or against the "clamp-and-tie" technique were included. Two reviewers independently critically appraised and extracted the data from each study. The number of patients who experienced postoperative events was extracted in dichotomous format or continuous outcomes. Odds ratios were calculated by a Bayesian network meta-analysis, and metaregression was used for pair-wise comparisons. Indirect and direct comparisons were performed and inconsistency was assessed., Results: Thirty-five randomized controlled trials with 2856 patients were included. Ultrasonic coagulation ranked first (followed by Ligasure and then clamp-and-tie) with the lowest risk of postoperative hypoparathyroidism (odds ratio 1.43 [95% confidence interval (CI) 0.77-2.67] and 0.70 [CI 0.43-1.13], ultrasonic coagulation vs. Ligasure and ultrasonic coagulation vs. clamp-and-tie, respectively), least blood loss (-0.25 [CI -0.84 to -0.35] and -1.22 [CI -1.85 to -0.59]), and drain output (0.28 [CI -0.35 to -0.91] and -0.36 [CI -0.70 to -0.03]). From a health technology viewpoint, ultrasonic coagulation was associated with the shortest operative time (-0.66 [CI -1.17 to -0.14] and -1.29 [CI -1.59 to -1.00]) and hospital stay (-0.28 [CI -0.78 to 0.22] and -0.56 [CI -1.28 to 0.15]). The only exception occurs with the clinically important complication of recurrent laryngeal nerve paralysis, where the reverse trend applies (1.36 [CI 0.25-7.46] and 1.74 [CI 0.94-3.26])., Conclusions: The comparative effectiveness of ultrasonic coagulation in thyroid surgery outcomes seems superior to other techniques with the exception of recurrent laryngeal nerve injury. This network meta-analysis, one of a handful in a surgical field, offers preliminary and robust evidence to guide clinical decisions and policy makers to adopt safer thyroid operations.

Objective: To investigate the learning curve for performing extended pelvic lymphadenectomy (ePLND) during laparoscopic radical prostatectomy (LRP) in patients with intermediate- and high-risk prostate cancer., Patients and Methods: In all, 500 patients underwent ePLND for intermediate- or high-risk prostate cancer by one surgeon during a 48-month period. A transperitoneal laparoscopic approach was used in all patients to allow adequate access to the internal iliac vessels. The variables chosen as being the most important discriminators of the quality of ePLND were operating time, complication rate and lymph node (LN) yield. The learning curves for ePLND were calculated using the cumulative sum and cumulative average methods and the number of procedures performed until attainment of acceptable failure rates (competence levels) was calculated. LN parameters were compared with the results from the preceding 311 cases where limited PLND was undertaken., Results: The median (range) preoperative PSA level was 8.0(1-62.5) ng/mL and biopsy Gleason score was 7(6-10). In all, 64% of patients had intermediate-risk and 36% had high-risk prostate cancer. There were no intraoperative blood transfusions and no conversions to open surgery. The median (range) blood loss was 200(10-1400) mL and the postoperative transfusion rate was 1.6%. The operating time fell at a steady rate of 2.7% after the 15th case and plateaued after 130 patients. At competence levels of 5% and 10%, the learning curve for all complications ended after 346 and 136 patients, respectively. At a 5% competence level the learning curve for PLND-specific complications was 40 cases and there was no learning curve at a 10% competence level. The overall complication rate was 7.2% of which almost half (47%) were deemed to be PLND-specific. The cumulative average of the LN counts plateaued after 150 procedures. Furthermore, the median LN count after ePLND was more than double that of the authors' historical standard PLND controls (14 vs 6, P < 0.001) and increased with experience up to the end of the series (9 to 20). The likelihood of LN involvement (LNI) correlated with biopsy and pathological Gleason grade, clinical and pathological stage and d'Amico risk group., Conclusions: This study suggests a learning curve of ≈130 cases for operating time, 136 cases for all complications, 40 cases for PLND-specific complications and 150 cases for LN yield. The risk of LNI for patients with intermediate- and high-risk prostate cancer was 8.4% and 19.4%, respectively, which suggests that a significant proportion would benefit from ePLND. It also shows that ePLND can be safely incorporated into LRP, and therefore also into robot-assisted RP, in a high-volume setting., (© 2013 BJU International.)