Dino Papeš

What Is the Acceptable Rate of Negative Appendectomy? Comment on Prospective Evaluation of the Added Value of Imaging within the Dutch National Diagnostic Appendicitis Guideline - Do We Forget Our Clinical Eye?

ing to Dutch guidelines, such rates may be considered unacceptable. So what is the acceptable NAR? When searching through the literature, one may find reports with considerably low NAR, that is, below 10%. However, there are several factors that apparently decrease NAR. The three largest series on pediatric appendectomy within the last two years are by Bachur that included 55,227 appendectomies (NAR 3.6%), Oyetunji that included 250,783 appendectomies (NAR 6.7%), and Cheong that included 78,625 children from US and 41,492 children from Canada (NAR 6.3 and 4.3%) [2–4] . Large database analyses report only the discharge letter diagnosis or intraoperative appearance of the appendix without analyzing the histology report. This is present in all three previously mentioned reports. Had we used this criterion, the rate of negative appendectomy in our series would be 3% since of 47 negative appendectomies, 32 (68%) were initially during operation diagnosed as inflamed appendicitis and were later on histological examination found to be non-inflamed. Further, even if histology reports are used, the histological definition of appendicitis also differs. Histological definition of inflamed appendix is not described in many reports that have low negative appendecWe read with interest the article of Schok et al. [1] . In 2014 we did an audit of our results on pediatric appendectomy (0– 18 years) in the form of a cross-sectional retrospective study that was conducted using hospital database that reviewed all appendectomies in our department in two twoyear periods (1999–2000 and 2012–2013) to see the changes after introduction of ultrasound and CT scan into practice. There were a total of 380 appendectomies performed: 154 as laparoscopic and 226 as open procedures. Regarding the pathological outcome of the operation, negative appendectomy rate (NAR) was 12% (47 patients) and perforation rate (PR) was 18% (69 patients). In children younger than 5 years of age (26 patients) PR was 30% and NAR 8%. Regarding imaging, 83 patients (22%) received preoperative ultrasound examination, and 2 received a CT scan (0.5%). The NAR and PR among children who received preoperative imaging were 8.4% (7/ 83) and 15.7% (13/83), respectively, which did not differ significantly (p > 0.05) from children who did not receive any imaging. To evaluate our results we searched Pubmed and found that NAR and PR in our series were comparable to other similar reports, including the report from Schok et al. As mentioned by the authors, accordPublished online: March 28, 2015

Detection of sexually transmitted pathogens in patients with chronic prostatitis/chronic pelvic pain: a prospective clinical study:

In <10% of patients with prostatitis syndrome, a causative uropathogenic organism can be detected. It has been shown that certain organisms that cause sexually transmitted infections can also cause chronic bacterial prostatitis, which can be hard to diagnose and treat appropriately because prostatic samples obtained by prostatic massage are not routinely tested to detect them. We conducted a clinical study to determine the prevalence of Chlamydia, mycoplasma, and trichomonas infection in 254 patients that were previously diagnosed and treated for chronic prostatitis/chronic pelvic pain syndrome due to negative urethral swab, urine, and prostate samples. Urethral swabs and standard Meares–Stamey four-glass tests were done. Detailed microbiological analysis was conducted to detect the above organisms. Thirty-five (13.8%) patients had positive expressed prostatic secretions/VB3 samples, of which 22 (10.1%) were sexually transmitted organisms that were not detected on previous tests.

Postoperative Gastric Perforation in a Newborn with Duodenal Atresia

Gastric perforation (GP) in neonates is a rare entity with high mortality. Although the etiology is not completely understood, it mostly occurs in premature neonates on assisted ventilation. Combination of duodenal atresia and gastric perforation is very rare. We present a case duodenal atresia who developed gastric perforation after operetion for duodenal atresia. Analysis of the patient medical record and histology report did not reveal the etiology of the perforation.

Issues in designing a randomized clinical trial for chronic prostatitis/chronic pelvic pain syndrome: Comment on Wang et al. Randomized controlled trial of levofloxacin, terazosin, and combination therapy in patients with category III chronic prostatitis/chronic pelvic pain syndrome. Int Urol Nephrol. 2016;48:13–18

limitations include adding an additional therapeutic regimen in the treatment protocol (prostatic massage and warm baths). However, the main issue is the inclusion of patients. This study included young patients with pelvic pain who were alpha-blocker naive and have, as it is stated, never received antibiotics. The diagnosis of CP/ CPPS was made based on the clinical presence of pain and negative EPS culture. Several problems can be noted with patient population in this study. First, the authors excluded chronic bacterial prostatitis based on the negative EPS culture, but they have not (or did not mention) excluded chronic Chlamydia trachomatis, Ureaplasma, Mycoplasma or Trichomonas infection which are wellrecognized causative agents in chronic prostatitis, especially in young patients [6, 7]. Inclusion of such patients in a RCT on CP/CPPS is unacceptable because it mixes patients with chronic prostatitis and pelvic pain. In clinical practice, young patients with the described symptoms that have never received any treatment would be tested for the previously mentioned pathogens and given antibiotic therapy, and not alpha-blockers initially. Second, there is no mention if the UPOINTS protocol was used to differentiate between various phenotypes of patients. It is now recognized that patients that have a dominant psychosocial, neurologic, or muscle component of pain can significantly distort the measured benefit of pharmacologic therapy that is aimed to reduce urinary tract symptoms [8, 9]. Authors mention in several places in the article that CP/CPPS can be considered an infectious disease, which is incorrect. Although infection is a trigger in most cases, various other factors lead to development of chronic pelvic pain [8]. Regardless of the mentioned limitations, the authors conducted a valuable study, which is a difficult task. To minimize the marked difference between available RCTs Editor,

Determining the effect of alpha-blockers in chronic prostatitis/chronic pelvic pain syndrome: systematic review and meta-analysis. Re: Giuseppe Magistro, Florian M.E. Wagenlehner, Magnus Grabe, Wolfgang Weidner, Christian G. Stief, J. Curtis Nickel. Contemporary Management of Chronic Prostatitis/Chronic Pelvic Pain Syndrome. Eur Urol 2016 ; 69:286–97

We read with interest the article by Magistro et al. [1]. As the authors emphasised, based on the published randomised controlled trials (RCTs), no specific agent can be recommended to all patients with chronic pelvic pain syndrome (CPPS). The most commonly prescribed agents (besides analgesics) are a-blockers, but evidence of their efficacy is missing, although they are the most studied agents. This is due to the fact that patients with CPPS are diverse and difficult to diagnose, so available RCTs are often characterised by high heterogeneity of effects. Consequently, positive effects of a-blockers found in recent metaanalyses were lost after adjusting the data for the bias [2,3], but no cause of heterogeneity was determined. Consequently, we decided to do another systematic review and meta-analysis to find the possible cause of such high heterogeneity. We searched Medline, Embase, and the Cochrane Central Register of Controlled Trials until August 2015 for RCTs assessing the difference between CPPS patients treated with an a-blocker or placebo in posttreatment National Institutes of Health Chronic Prostatitis Symptom Index and International Prostate Symptom Score (IPSS) symptom scores. Eight RCTs were found (Supplement 1). Mean symptom scores before and after treatment or mean changes were extracted from each group. Standardised mean difference (SMD) was used as the effect size statistic (random-effects model). Heterogeneity was assessed using Q and I

Re: Tunneled Buccal Mucosa Tube Grafts for Repair of Proximal Hypospadias: R. Fine, E. F. Reda, P. Zelkovic, J. Gitlin, J. Freyle, I. Franco and L. S. Palmer J Urol, suppl., 2015;193:1813-1817.

To the Editor: Fine et al have revisited the concept of 1-stage tubed grafts for hypospadias repair. Although the technique seems to yield good functional results, several issues need to be addressed. An inherent problem with 1-stage full circumference tube repairs is the potential for meatal and proximal anastomotic strictures. Furthermore, with grafts there is unpredictability regarding initial graft take and subsequent behavior during the revascularization and maturation phases, and, therefore, inability to plan the size of the meatus and caliber of the urethra with any accuracy. A staged graft procedure overcomes these problems. Stage 1 optimizes graft take because the graft can be “spread fixed” down to the corpora across its entire width with multiple quilting sutures and further immobilized with a tie-over compression dressing. During the ensuing 6 months the graft strip becomes fully integrated and securely vascularized, and stabilizes to its final dimensions, allowing the caliber of the new urethra and meatus to then be planned with accuracy at the second stage. The same degree of graft fixation is not readily achieved with a tunneled tube, wherein vascular and mechanical support may not be readily provided to all parts of the circumference. Although there is good support dorsally on the corporeal bodies and ventrally from the dartos fascia, there is a relative lack of vascularized bed on the sides of the graft. It is not uncommon to reduce or augment the width of the reconstructed plate during a second stage, depending on how the graft has behaved during the preceding 6 months. With a 1-stage tube the planned dimensions have to be a guesstimate, and anything less than optimal graft survival and behavior will inevitably compromise the quality of the new urethra/meatus. The ability to accurately design the urethra from an already vascular and dimensionally stable plate makes the standard 2-stage approach seem a more logical choice and does not require prolonged postoperative urinary diversion or stenting, as in the procedure described by Fine et al. Having to tolerate a stent sutured into the penis for at least 3 months after completing the repair must be unpleasant, and one might expect perimeatal suture marks from such prolonged stenting. However, this may be the only way to decrease the incidence of anastomotic stenoses and to accommodate the capricious nature of a healing graft tube. Although the authors claim to produce a cosmetically natural slit meatus, this has not been our general experience with 1-stage tube repairs. Often a wide, round meatus is created, such as that seen on the right side of figure 2 the article. It would have been helpful to see longer term photographic evidence supporting this claim. The tunneling procedure means that one cannot design additional layers of soft tissue mechanical support over the urethra, and one imagines that in many cases the ventral aspect of the urethral tube will be stuck directly onto the overlying skin, making any subsequent surgical adjustments difficult. Finally, we would question why the authors were using buccal mucosa so frequently for primary hypospadias. In a conventional 2-stage graft repair one would use the much thinner inner preputial skin whenever practicable, as it is a better behaved graft and introduces far less bulk into the glans channel. The thicker buccal mucosa or, indeed, tubed flaps are likely to create a tighter glans channel, with relative outflow obstruction and the potential for long-term hydraulic distention. Cheek mucosa is usually reserved for salvage cases but if 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114

Abdominal Aortic Thrombosis in a Healthy Neonate

Abdominal aortic thrombosis is a rare entity in neonates and has mostly been associated with umbilical artery or cardiac catheterization. We present a complicated case of an otherwise healthy neonate who developed thrombosis of abdominal aorta with renal failure. Therapy with intravenous heparin was unsuccessful, and thrombolysis was contraindicated because of disseminated intravascular coagulation so we decided to perform open thrombectomy using the left retroperitoneal approach. The following day, thrombosis recurred in the same extent and despite high risk of bleeding Alteplase was eventually given, which resulted in recanalization of the aorta 6 hours later. Renal function recovered, dialysis was discontinued, and further course was uneventful. The treatment of abdominal aortic thrombosis in neonates should be considered on a case-by-case basis because the available data on the condition are limited to case report and series. If open thrombectomy is performed, retroperitoneal approach should be preferred because it allows for easy institution of peritoneal dialysis should the need arise.

Reducing damage to the periosteal capillary network caused by internal fixation plating: An experimental study

BACKGROUND The importance of the periosteum in fracture healing is well-known. Preserving periosteal vascularisation is essential during internal plate fixation of fractures. METHODS This was an experimental randomised, controlled animal study on nine sheep. Standard dynamic compression plate (DCP) and four different newly designed reefed plates, with different plate-bone contact surface areas and different reef directions, were fixated on to the tibia or radius. After two weeks the plates were removed and the underlying periosteum was analysed. Blood vessels were marked by immunohistochemical staining (CD31 and CD34), microphotographs were taken and blood vessels counted to calculate blood vessel density. RESULTS Median blood vessel density beneath the standard plate was significantly lower than in the intact periosteum (18.0 vs 27.7mm(3)/cm(3)). Blood vessel density in the periosteum beneath plates with reefs was significantly increased compared with the intact periosteum, and was highest beneath the plate with the lowest bone-plate contact area and crosswise reefs (51.5mm(3)/cm(3)), followed by plates with transverse, oblique and longitudinal reefs, respectively. The direction of the reefs did not have much influence on the periosteal capillary network. Lower contact surface area seems to be the main factor that increases blood vessel density beneath the plates. CONCLUSIONS The results show that plates with lower contact surface area stimulate angiogenesis in the underlying periosteum, which results in much higher blood vessel density compared with standard DCP. A randomised clinical trial is needed to prove the clinical relevance of these findings.

Two-Stage Repair for Severe Proximal Hypospadias Using Oral Mucosal Grafts: Combination of a Modified Bracka Method and a Modified Byars Flap Method: Should Local Flaps be Used for Urethral Reconstruction in Hypospadias Repair?

To the Editor: I t has been just 6 years since Lim et al performed a radical tumor resection of the scalp, ipsilateral superficial parotidectomy, and reconstruction using a latissimus dorsi free flap. In this article, the authors operated on 8 patients presenting with angiosarcoma solely of the scalp. Their procedure consisted of a radical tumor resection of the scalp with minimal 5-cm safety margins from the most peripheral scattered lesions with a burring of the external table of the cranium, ipsilateral superficial parotidectomy, and ipsilateral upper neck dissection. After a resection of the tumor of the scalp, the defect was covered with the latissimus dorsi free flap. Their outcomes were very encouraging to the readers because complete excisions were obtained and negative surgical margins were achieved in all 8 patients. The 18-month diseasefree survival of the entire operation group was 100% (median follow-up, 24 months). According to a previous article that Lim et al did not cite, Pawlik et al operated on and analyzed 29 patients having angiosarcoma of the scalp and stated that negative surgical margins were achieved in only 21.4% of the patients and the median actuarial survival was 28.4 months. They also wrote that radiation therapy was significantly associated with a decreased chance of death (hazard ratio, 0.16; P = 0.006). Because regional lymph node metastasis has appeared even 5 years after the initial treatment, I would really like to know the long-term follow-up results of the 8 patients operated on by Lim et al. To date, some authors advocate radical excision with regional lymph node clearance, with or without adjuvant radiotherapy, whereas others recommend primary radiation therapy, with surgery held in reserve. Morrison et al reported that the 5-year actuarial incidence of distant metastases for all patients was 63%. Lydiatt et al treated 18 patients, and among them, 12 patients (67%) had died of disease a mean of 25 months after diagnosis. The overall 5-year survival was 33%, but only 20% of the patients were disease-free. Mark et al stated a 5-year disease-free survival of 26% (7/27 patients), in which 21 patients had recurrences after