Adam Carter

Is a sublay prophylactic mesh a necessary prerequisite to prevent ileal conduit herniation

Both ileostomies and colostomies, whether fashioned as a loop or an ‘end’, are ‘iatrogenic’ herniae created with all good intent. Ileal conduit herniation is a common problem when the trephine is raised through the belly of the rectus muscle, and thus we enjoyed reading the outcome of the Swedish audit by Styrke et al. [1], where a sublay mesh was placed prophylactically to lower its frequency. We note that in 58 patients the clinical incidence of herniation was 14% at 3 years’ follow-up. This is certainly much lower than the traditionally documented rates of 27–48% [2,3]. Indeed, some surgeons have attempted to lower the frequency of this complication but to date they have been thwarted despite some novel ideas [4]. As stated by the authors [1], paracolostomy herniation is also a common problem and with this in mind the lateral rectus abdominis positioned stoma (LRAPS) technique to colostomy formation has been described [5]. The aim of this dissection is to minimize disruption of the layers of the anterior abdominal wall, preserving the complete width of the rectus abdominis muscle. The important steps in the dissection [5] include avoiding cruciate (no vertical) incisions in the rectus sheath and creating the trephine above the ‘arcuate line’ of Douglas that defines the lower edge of the posterior rectus sheath. These steps and bringing the stoma lateral to the rectus muscle (but still within the linea semilunaris) all reduce the theoretical risk of later trephine widening (Figure 1). This approach to ileal conduit formation was used by one urologist (ACC) in 47 consecutive patients undergoing radical cystectomy for malignancy over a 6 year period. There were 37 men, with a mean age of 66 years (range 37– 82 years), and the patients’ mean body mass index was

How safe is it to manage diverticular colovesical fistulation non-operatively?

Aim  Colovesical fistula (CVF) is an uncommon condition. Diagnosis and management varies according to presentation and aetiology. The identification of patients suitable for conservative management and their outcome following this approach has not been well documented.

MP04-08 WHY INVESTIGATE ASYMPTOMATIC MICROHEMATURIA? IMPLICATIONS OF APPLYING UK NATIONAL GUIDANCE

(data set-1:previously reported in IHC of DSC2), which included 39 cases of pure UC and 18 cases of UC with SD. Next, we confirmed the result in the other data set of 77 cases of muscle invasive bladder cancer treated with cystectomy from 2006 to 2015 (data set-2). RESULTS: In dataset-1, the positivity of UPK3, CK5/6 and DSC2 in pure UC was 46%, 21% and 0%, while the positivity in UC with SD was 0%, 83% and 100%, respectively. CK5/6 expression correlated with DSC2 expression, and UPK3 expression was mutually exclusive of both CK5/6 and DSC2 expression. In addition, the positivity of UPK3 and CK5/6 in papillary tumors was 43% and 14%, respectively, and in flat and non-papillary tumors was 28% and 49%, respectively. In normal urothelium, UPK3 expression was observed only in umbrella cells, while CK5/6 expression was detected only in the basal layer. The intermediate layer showed no staining with either marker. UPK3 positive cases had the most favorable cancer specific survival (CSS at 5 years; 83%), while CK5/6 positive cases had the worst prognosis (55%), and cases negative for both markers had an intermediate prognosis (68%). In dataset-2, the expression of UPK3 and CK5/6 in papillary UC was 57% and 4%, respectively, while expression in flat and non-papillary UC was 11% and 39%, respectively. CSS at 5 years was 95% in UPK3 positive, 49% in CK5/6 positive and 59% in marker-negative cases. CONCLUSIONS: While genomic subtyping of UC requires clustering of large datasets derived from an entire cohort of patients, our simple IHC with two markers of luminal and basal differentiation is capable of stratifying prognosis on an individual patient basis. IHC classification of UC lends itself to easy adoption in routine clinical practice.

Preventing or repairing ileal conduit herniation

Dear Editor, Jones et al. [1] highlighted the effectiveness of preoperative determination of lean muscle mass, referred as sarcopenia, as a means to identify those at higher risk of major complications after colorectal resection. Given the limitations of current methodology we find the results of Jones et al. [1] particularly important for testing the hypothesis of their article. Sarcopenia is a generalized process which requires assessment of whole-body muscle mass rather than regional measurements of muscle area [2,3]. In the study by Jones et al. [1], diagnosis of sarcopenia was based on measurement of psoas muscle area (PMA) at the third lumbar region. To the best of our knowledge there is no validation study for the use of PMA alone to predict sarcopenia. Jones et al. [1] reported that the method in their work had previously been used in validation studies by Shen et al. [4] and Mourtzakis et al. [5], but Shen et al. [4] reported the validation analysis of total muscle area at the level of the fourth/fifth lumbar region, not PMA at the third lumbar vertebra. Besides this, the study by Mourtzakis et al. [5] assessed the validity of measuring total muscle area at the third lumbar region, consisting of the psoas, paraspinal muscles (erector spinae, quadratus lumborum) and the abdominal wall muscles (transversus abdominus, external and internal oblique and rectus abdominus). Also, the cut-off points (< 385 mm2/m2 for women and < 545 mm2/m2 for men) currently used to define sarcopenia were generated for measurement of total muscle area in the third lumbar region, not only the PMA [6]. It is therefore hard to conclude that the evaluation of muscle mass in their study is optimal.

Prostate with grief

The first in an occasional series of ‘Surgeons as Patients’, in which our colleagues get a dose of their own medicine.

Antibiotic resistance and transrectal prostate biopsies

We wish to add to the comprehensive review of prostate screening.1 Before considering the management of any potential cancer, a persistently raised prostate specific antigen test result usually demands a tissue sample, most often obtained transrectally. However, such sampling …