Lior Heller

Salvage surgery for locally recurrent prostate cancer after radiation therapy: Tricks of the trade

Biochemical recurrence after either radical prostatectomy or radiation therapy of prostate cancer will develop in an estimated 50,000 U.S. men. Salvage therapy has the potential of curing an isolated local recurrence of prostate cancer, however, this comes at the cost of potential morbidity. Salvage surgery after primary radiotherapy is technically demanding, and surgical expertise is necessary to optimize treatment outcomes while minimizing the inherent risks of the operation. Over the last decade, we have developed a substantial experience in salvage surgery for locally recurrent prostate cancer, and have developed key technical points and innovations that include primary closure of the bladder neck, bladder augmentation, and catheterizable urinary reconstruction using a Monti or Mitrofanoff procedure as a method of reducing the risks of postoperative urinary incontinence. We hope this review will provide the surgical oncologist and urologist with the important considerations that must be considered in salvage surgery. In addition, we discuss the importance and surgical details of using a well-vascularized rectus flap as a method of reducing perioperative morbidity.

Strategies and options for free TRAM flap breast reconstruction in patients with midline abdominal scars.

Background: Patients who have a midline abdominal scar from previous abdominal surgery often present a challenge when use of a transverse rectus abdominis myocutaneous (TRAM) flap is desired for breast reconstruction. In this study, the authors reviewed their experience with the TRAM flap for breast reconstruction in patients with midline abdominal scars to evaluate the various strategies used to optimize reconstructive outcomes. Methods: Between January of 1994 and December of 2001, 43 patients with a midline abdominal scar underwent unilateral autologous tissue breast reconstruction with a TRAM flap at The University of Texas, M. D. Anderson Cancer Center. Results: The mean age of the midline abdominal scar was 13 years (range, 4 to 45 years). In 26 patients, only free hemi-TRAM flaps were used for breast reconstruction. Free TRAM flaps were used in nine patients in whom zone II across the midline scar had an adequate blood supply and was able to be incorporated into the flap for breast reconstruction. In five patients, blood supplies from both sides of the TRAM flap were used to augment perfusion to the tissue across the midline scar. In three patients with infraumbilical midline scars, a free TRAM flap was designed higher in the abdomen so that the superior half of the flap was scar-free. Conclusions: Various strategies are available for autologous tissue breast reconstruction using a free TRAM flap in patients with a previous midline abdominal surgical scar. In some cases, the TRAM flap tissue across the midline scar can be used reliably for breast reconstruction.

Staged reconstruction for resection wounds in sarcoma patients treated with brachytherapy

Adjuvant brachytherapy reduces local recurrences following wide local excision of large, high-grade sarcomas, but its use with immediate flap reconstruction is associated with a high wound complication rate following previous radiotherapy. To avoid flap irradiation and reduce wound-healing morbidity, a treatment strategy using negative-pressure wound therapy (NPWT) for temporary wound coverage during brachytherapy followed by delayed flap reconstruction was used in 3 previously irradiated sarcoma patients. NPWT was continued after brachytherapy catheter removal to stimulate vascularization, granulation, and wound contraction. Flap reconstructions were performed after the adequacy of the resection margins was pathologically confirmed and the wound bed appeared grossly vascularized. Prior to reconstruction, 2 patients required additional excision of positive or close permanent-section surgical margins. There were no major wound-healing complications during 9–18 months follow-up. Staged closure using this approach may have advantages over immediate flap reconstruction in some sarcoma patients. Potential advantages include avoiding flap irradiation, reducing wound size and magnitude of the reconstructive procedure, and ensuring tumor-free surgical margins before definitive reconstruction.

Cutaneous leukocytoclastic vasculitis in a patient with myelodysplatic syndrome after therapy with the rapamycin analogue everlimus: Case report and review of the literature

Everolimus (RAD001) is an orally bioavailable derivative of rapamycin that has been approved in Europe as an immunosuppressive to prevent rejection in adult cardiac and renal transplant recipients ...

Two-stitch technique for distal shaft hypospadias repair.

The authors present a new technique for distal shaft hypospadias repair using a flip flap fashioned with only two stitches. In raising the flap, the tissues lateral and proximal to the flap are undermined but there is no undermining beneath the flap. The flap is sutured up to the glans with two 4-0 Vicryl sutures. No sutures are placed at the lateral edges of the flap to create the “tube” of the neo-urethra, and no postoperative urinary drainage is used. Thirty-three children with distal shaft hypospadias underwent the “two-stitch” flip flap operation. The complications were one fistula and one case of urinary retention. The technique is an easy method for reconstructing distal penile hypospadias with a very low rate of complications and is suitable for an outpatient surgical setting.