Permanent Prostate Brachytherapy in Men with Clinically Localised Prostate Cancer

Permanent prostate brachytherapy techniques are associated with excellent biochemical control for patients with localised prostate cancer. Ten-year data show that permanent prostate brachytherapy is compatible with external beam irradiation or radical prostatectomy. However, treatment protocols and techniques for prostate brachytherapy vary between centres and there is little conformity of treatment protocols. The selection of patients for monotherapy or combined external beam irradiation and brachytherapy is controversial. The role of neoadjuvant androgen deprivation also remains unanswered in patients with localised prostate cancer. In addition, post-implant dosimetry may in fact be more significant for predicting outcome than the addition of adjuvant therapies, and should be a requirement when performing prostate brachytherapy. Data now seem to support specific computed tomography (CT)-based criteria to evaluate implant quality and delivered dose to the prostate. Unfortunately, prostate oedema and poor imaging techniques are limiting factors for evaluating implant dosimetry. Treatment planning techniques that use new treatment planning computers may assist in improving the implant procedure and dosimetry and are now available.

Functional and morphological evaluation of a low-weight, monofilament polypropylene mesh for hernia repair

With more than 1 million implantations per year worldwide, mesh repair has become a standard procedure for the treatment of hernias. Apart from various technical problems, the type of material has been proven to be of considerable importance for the functional and histological outcome, particularly for long-term implantation. Whereas the advantageous application of low-weight, large-pore meshes based on multifilaments can be stated without doubt, it is still open whether similar results can be achieved on the basis of pure monofilaments. In the present study, a low-weight polypropylene mesh (LW) made purely of monofilaments was compared to a common heavy-weight polypropylene mesh (HW) in regard to the functional consequences and the tissue response. After implantation in rats as an inlay for 3--90 days, the abdominal-wall mobility of the implant region was recorded by 3D stereography, and the tensile strength of both the suture zone and the mesh was measured. The morphometry of the histological reaction in regard to the inflammatory infiltrate, the connective tissue, the number of granulocytes, macrophages, and fibroblasts served to reflect the tissue response. As parameters for the remodeling process at the interface the cellular activation was evaluated by TUNEL (DNA-strand breaks or apoptosis, respectively), Ki 67 (cell proliferation), and HSP 70 (cell stress). The measured tensile strength of the LW mesh confirmed a sufficient strength of the material-reduced mesh modification. After implantation the consecutive impairment of the abdominal-wall mobility was reduced compared to the HW mesh, concomitant to the reduced fibrotic level at the interface. At the end of the observation period the foreign-body reaction was significantly lowered for the LW mesh, almost reaching physiological values. In conclusion, these data confirm the improved biocompatibility of material-reduced mesh implants.

Influence of suture material and surgical technique on risk of reoperation after non-mesh open hernia repair

BACKGROUND

Although mesh techniques are used with increasing frequency, sutured repair still has a place in groin hernia surgery. Studies relating suture material to recurrence rate have yielded conflicting results. The aim of the present study was to analyse the influence of suture material and sutured non-mesh technique on the risk of reoperation in open groin hernia repair using data from the Swedish Hernia Register.

METHODS

The relative risk of reoperation after sutured repair using non-absorbable, late absorbable and early absorbable sutures was compared in multivariate analyses, taking into account known confounding factors.

RESULTS

Between 1992 and 2000, 46,745 hernia repairs were recorded in the Swedish Hernia Register. Of these, 18,057 repairs were performed with open non-mesh methods and were included in the analysis. Using non-absorbable suture as reference, the relative risk of reoperation after repair with early absorbable suture and late absorbable suture was 1.50 (95 per cent confidence interval (c.i.) 1.22 to 1.83) and 1.03 (95 per cent c.i. 0.83 to 1.28) respectively. Using the Shouldice repair as reference, other sutured repairs were associated with a significantly higher relative risk of reoperation (1.22, 95 per cent c.i. 1.03 to 1.44).

CONCLUSION

A non-absorbable or a late absorbable suture is recommended for open non-mesh groin hernia repair. The Shouldice technique was found to be superior to other open methods.

Changing the path of inguinal hernia surgery decreased the recurrence rate ten-fold. Report from a county hospital

OBJECTIVE

To audit the effect of changes in treatment of inguinal hernias on recurrence rate.

DESIGN

Retrospective analysis of consecutive patients operated on in 1990 and prospective analysis of consecutive patients operated on in 1996. Follow up with questionnaire followed by selective clinical examination.

SETTING

County hospital, Sweden.

SUBJECTS

144 patients with 147 inguinal hernias operated on in 1990 and 154 patients with 165 inguinal hernias operated 1996. on in

INTERVENTIONS

In 1993, we changed many aspects of the treatment of inguinal hernia. We introduced new techniques such as Shouldice, Lichtenstein, and laparoscopic hernia repair. Non-absorbable polypropylene sutures replaced the braided absorbable sutures previously used. Inguinal herniorrhaphy went from a "low status" operation to a high status operation and became a primary teaching operation for surgical residents.

MAIN OUTCOME MEASURES

Recurrence rate at 5 year follow up.

RESULTS

The 5 year recurrence rate decreased from 28% in 1990 to 3% in 1996 (p < 0.001). The m edian operating time increased from 35 minutes in 1990 to 78 minutes in 1996 (p < 0.001).

CONCLUSION

Changing the strategy of inguinal hernia surgery by introducing uniform operating techniques and new materials dramatically improved the results and allowed us to achieve recurrence rates comparable to those seen in specialised hernia centres.

Prognostic factors and survival in node-positive (N1) prostate cancer-a prospective study based on data from a Swedish population-based cohort

OBJECTIVE

At presentation of prostate cancer, patients with proven lymph node metastasis (N1) are comparatively rare. It is difficult to give prognostic information based on the present literature. The aim of this study was to evaluate the impact of known risk factors in patients with pelvic node involvement and without distant metastasis.

METHODS

From the population-based, prospective prostate cancer tumour registry of the South-East Region in Sweden, we collected data on all 181 patients with N1, M0 prostate cancer diagnosed from January 1987 to October 2000 with a follow-up to December 2001. Mean follow-up was 62 months. Pre-operative risk factors as age, T-category, serum PSA, tumour grade and also primary treatment given was correlated to the outcome.

RESULTS

Median age at diagnosis was 65 years. Cancer-specific survival was highly variable with 5-year survival of 72%, a median of 8 years and the projected 13-year figure was 31%. T-category, age, PSA or treatment did not affect the outcome while poorly differentiated tumours had a tendency towards lower cancer-specific survival (p=0.0523) when compared to well and moderately differentiated tumours.

CONCLUSIONS

This population-based cohort of prostate cancer patients with pelvic node involvement treated principally with non-curative intent had a median cancer-specific survival of 8 years. Preoperatively known risk factors seem to have but a modest impact on the prognosis for patients in this stage of the disease.

Randomized clinical trial comparing laparoscopic totally extraperitoneal approach with open mesh repair in inguinal hernia

The aim of this study was to compare laparoscopic totally extraperitoneal approach (TEP) repair with tension-free open mesh repair in inguinal hernia. One hundred thirty-four patients were allocated randomly to undergo TEP repair (n = 67) or open mesh repair (n = 67). Operative and postoperative outcomes were determined. The mean of operating time (49.67 +/- 14.11 vs. 56.64 +/- 12.32; P = 0.001), visual analog scale score (2.73 +/- 1.69 vs. 4.61 +/- 1.77; P = 0.001), hospital stay (1.8 +/- 0.7 vs. 2.7 +/- 1.6; P = 0.001), and duration of recovery (10.8 +/- 7.4 vs. 15.2 +/- 8.5; P = 0.001) was significantly less for TEP repair when compared with open mesh repair. The incidence of complications (13.4% vs. 16.4%; P = 0.631) and recurrence (2.9% vs. 5.9%; P = 0.407) was approximately equal in each group. Our results showed that laparoscopic TEP repair is superior to open mesh repair.

Local or general anesthesia for open hernia repair: a randomized trial

OBJECTIVE

To compare patient outcome following repair of a primary groin hernia under local (LA) or general anesthesia (GA) in a randomized clinical trial.

SUMMARY BACKGROUND DATA

LA hernia repair is thought to be safer for patients, causes less postoperative pain, cost less, and is associated with a more rapid recovery when compared with the same operation performed under GA.

METHODS

All patients presenting to three surgeons during the study period with a primary groin hernia were considered eligible. Outcome parameters measured including tests of vigilance, divided attention, sustained attention, memory, cognitive function, pain, return to normal activity, and costs.

RESULTS

Two hundred seventy-nine patients were randomized to LA or GA hernia repair; 276 of these had an operation, with 138 participants in each group. At 6, 24, and 72 hours postoperatively there were no differences in vigilance or divided attention between the groups. Similarly, memory, sustained attention, and cognitive function were not impaired in either group. Although physical activity was significantly impaired at 24 hours, this and return to usual social activities were similar in both groups. While patients in the LA group had significantly less pain on moving, at 6 hours they were less likely to recommend the same operation to someone else. GA hernia repair cost 4% more than the same operation under LA.

CONCLUSIONS

There are no major differences in patient recovery after LA or GA hernia repair. Patients should be offered a choice of anesthesia, LA or GA, for repair of their groin hernia.

Quality assurance in surgical oncology. Colorectal cancer as an example

Quality assurance in surgical oncology is a field of growing importance. National, regional and local systems have been built up in many countries. Often the quality assurance projects are linked to different registers. The advantage of such a link is the possibility of obtaining population-based data from unselected health care institutions. Few discussions of results from such projects have been published. Quality assurance of colorectal cancer surgery implies the development and use of systems for improvement all the way from detection of the cancer to the outcome as survival and patient satisfaction. To achieve this we must know what methods are being used and the outcome of our treatments. Designing processes for improvement necessitates careful planning, including decisions about end-points. Some crucial issues are discussed step-by-step in the present paper. In addition to auditing and providing collegial feedback, quality assurance is a tool for closing the gap between clinical practice and evidence based medicine and for creating new evidences as well as monitoring the introduction of new techniques and their effects.

[Modified Rives technic in the treatment of recurrent inguinal hernia]

After the introduction of prosthetic material in hernia surgery the fundamental changes in operative strategy occurred. This is because the coverage of myopectineal orifitium with non-absorbable prosthesis decreases the incidence of recurrences. Because of the appearance of lateral re-recurrences after the classical Rives procedure, we modified the operative technique. The modified Rives technique consists of the following: always polypropilen mesh 15x10 cm; creation of the new internal inguinal ring between Poupart's ligament and mesh; no lateral notching the mesh and anchoring mesh 2-3 cm from the medial, inferior, lateral and superior edge. During the period January 2001-December 2003, 34 cases of recurrent hernias were operated on 7th dept. of I Surgical Clinic of CCS. The recurrences were managed by classical (10/34) or modified Rives technique through direct inguinal approach (22/34), less frequently Lichtenstein procedure (1/34) and McVay (1/34) technique. Among 10 patients with recurrent inguinal hernias managed by classical Rives technique 2 re-recurrences appeared (indirect and interstitial) and 2 cases of infection (immediately after the operation or 7 months after the operation), and in the group of 22 cases with recurrent inguinal hernias managed by modified Rives technique the aim complications didn't appear. Using the modified Rives technique we managed the primary hernias in 56 cases without recurrences and infections. The modified Rives technique, because of the way of mesh fixation (all around), no lateral notching of mesh and remaining hem in all directions secures abdominal wall protection 2-3 cm from the line of fixation and prevents any movement of the mesh. This procedure enables management of all inguinal hernias regardless to their size and full protection of the medial, femoral and lateral inguinal triangle. The modified Rives technique is the technique of choice for big multiple defects (giant inguino-scrotal and re-recurrences), especially among patients with increased intra-abdominal pressure when other techniques may be insufficient because of mesh protrusion.

Tension-free inguinal hernia repair: TEP versus mesh-plug versus Lichtenstein: a prospective randomized controlled trial

OBJECTIVE

To compare laparoscopic hernioplasty with two open tension-free hernia repairs.

SUMMARY BACKGROUND DATA

Laparoscopic hernioplasty is associated with a short rehabilitation, but it is a technically difficult procedure. It is unclear if it has advantages over the technically easier open tension-free herniorrhaphy.

METHODS

Two hundred ninety-nine men 30 to 75 years old were randomized to undergo laparoscopic totally extraperitoneal hernioplasty (TEP), open operation with mesh-plug and patch, or Lichtenstein's operation.

RESULTS

Two hundred ninety-four (98%) patients were followed for 19.8 +/- 8.6 months. Over 90% of the patients in all groups were operated in day surgery; the rest of the patients were all discharged within 24 hours. Postoperative pain (visual analog score) was lower in the patients undergoing TEP than in those undergoing Lichtenstein and mesh-plug procedures. The median sick-leave period was 5 days in the TEP group, 7 days in the mesh-plug group, and 7 days in the Lichtenstein group. The median time to full recovery was significantly shorter in the TEP group compared to the other two groups. There were no major complications. Two recurrences were found in the TEP group and two in the mesh-plug group.

CONCLUSIONS

Laparoscopic hernioplasty is superior to tension-free open herniorrhaphy in terms of postoperative pain and rehabilitation.

Watchful waiting as a treatment option for localized prostate cancer in the PSA era

The incidence rate of early-stage prostate cancer has dramatically increased since the introduction of the widespread use of PSA testing in developed countries, including Japan. With the downward stage migration there has been much interest in the concept of watchful waiting not only for elderly patients with a life expectancy of less than 10 years but also in younger patients with good social and sexual activity. The results of a recent randomized comparison between radical prostatectomy and watchful waiting for localized disease indicated comparable overall survival but superiority of surgery in disease-specific survival. The predictive value of clinico-pathological parameters including biopsy features and serum PSA seems insufficient to predict tumor growth potential. Our ongoing prospective study is aimed at clarifying whether PSA doubling time assessment for 6 months in patients with favorable biopsy features can be a good indicator for further watchful waiting or immediate aggressive treatment without any survival disadvantage.

A population-based study on management of prostate cancer in four regions of France

In France, as in other European countries, management of prostate cancer in the population is rather variable. The objective was to analyse diagnosis and treatment modalities of prostate cancer in patients from French cancer registries.A sample of 803 patients with prostate cancer diagnosed in 1995 was drawn at random from cases recorded in four cancer registries in the geographical regions of Bas-Rhin, Calvados, Isère and Tarn. Diagnosis, clinical staging and treatment were analysed by questionnaire. Multivariate analysis by logistic regression was used to describe medical determinants (age, PSA, clinical staging) of the various treatment choices.The mean age of the patients was 71.6 y (range 46-94 y). Clinical staging showed 60% T(1-2) tumours, 15% T(3-4) and 17% N+or metastases. PSA rate (median 18.2 ng/ml) was assessed in 92.4% of patients. Prostate cancer was diagnosed by prostate biopsy in 63% and by transurethral resection of the prostate (TURP) in 32% of patients. The main treatments were radical prostatectomy 22%, radiotherapy 19.4%, hormonal therapy 33%, TURP alone 17.7% and expectant management 6%. The method of treatment was unknown in 5.7% of cases. Adjuvant radiotherapy or hormonal therapy had been used in 31% of cases. Logistic regression analysis showed that radical prostatectomy was most often performed in patients aged <60 y, three times more frequently for T(2) tumour and for PSA between 4 and 20 ng/ml. Radiotherapy was the most frequently applied treatment for patients aged between 65 and 75 y, especially in T(3) tumours.Approximately 75% of the patients in the study underwent a specific treatment for prostate cancer with a curative intention in 40%. This study provides a baseline to clinicians and public health authorities on the management of prostate cancer in France with recent data. This survey will be useful to compare future descriptive analysis and to provide data regarding changing clinical practice.Prostate Cancer and Prostatic Diseases (2001) 4, 154-160.

Pain from primary inguinal hernia and the effect of repair on pain

Background

No previous study has attempted to quantify pain from a primary inguinal hernia. The aim of this study was to quantify patients' pain from inguinal hernia at rest and on moving, and to assess the effect of hernia repair on the pain.

Methods

Linear analogue pain scores at rest and on moving were recorded before operation and at 1 year after surgery in a consecutive series of patients undergoing elective repair of a primary inguinal hernia.

Results

During the study period 323 patients underwent inguinal hernia repair. Eighty-six patients (26·6 per cent) recorded no pain at rest from the hernia, and 174 (53·9 per cent) had mild pain only (score less than 10). On moving, 53 patients (16·4 per cent) had no pain and 137 (42·4 per cent) had mild pain on moving. Only 1·5 per cent experienced severe pain (score greater than 50) at rest, and 10·2 per cent had severe pain on moving. There was no association between pain and hernia type, direct or indirect, or patient occupation. One year after operation only 24·5 per cent of patients had no pain from the hernia repair site at rest, and 21·6 per cent had no pain from the site on moving. Overall there was a significant reduction in pain score at rest (mean(s.e.m.) decrease from baseline −2·9(1·2), P = 0·019) and on moving (−9·2(1·8), P = 0·001) compared with preoperative values, and this was due mainly to the large effect observed in patients with high preoperative values. Patients who had no pain at rest before operation had significant pain scores at rest at 1 year (P = 0·001).

Conclusion

Clinical trials are required to evaluate hernia repair in patients with an asymptomatic inguinal hernia. Results from such trials should help to determine whether repair is the treatment of choice for these patients.

Prostate-specific antigen for prostate cancer staging in a population-based register

OBJECTIVE

Previous studies have shown a relationship between serum prostate-specific antigen (PSA) level and prostate tumour volume. Reports based on selected case series have also indicated that serum PSA may be used for staging, although a varying prevalence of metastasizing tumours complicates the interpretation of these studies. In order to determine the accuracy of the serum level of PSA in predicting the presence of metastases we performed a prospective cohort study of a geographically defined population of men with prostate cancer.

METHODS

Serum level of PSA and the results of investigations for regional lymph node and distant metastases were recorded for all 8328 men with prostate cancer registered in the Swedish National Prostate Cancer Register 1996-1997.

RESULTS

The prevalence of lymph node metastases among men who had undergone lymph node exploration was 4%, 16% and 33% for well, moderately and poorly differentiated tumours. The corresponding prevalence of distant metastases was 12%, 30% and 48%. With serum PSA <20 ng/ml as a cut-off point the negative likelihood ratios for well and moderately differentiated tumours were found to be 0.47 and 0.45 for lymph node metastases and 0.24 and 0.18 for distant metastases, resulting in post-test probabilities >92% for the exclusion of metastases. In men with poorly differentiated tumours, the negative likelihood ratio would need to be even lower to safely exclude disseminated disease.

CONCLUSION

For well to moderately differentiated tumours, further investigations to assess the presence of metastases may be omitted with no great risk for understaging if serum PSA <20 ng/ml.

Prostate-specific antigen as surrogate for characterizing prostate cancer subgroups

OBJECTIVE

To evaluate how serum prostate-specific antigen (PSA) levels in a population-based cohort of men with prostate cancer vary with age and intensity in the diagnostic activity and to describe the treatment selection processes associated with PSA level.

MATERIAL AND METHODS

All men in the Swedish National Prostate Cancer Register diagnosed during 1996-1997 were included. In 1996 the register included 19 counties, covering 61% of the Swedish male population, and in 1997 21 counties with 79% of the Swedish male population.

RESULTS

A total of 8328 men were registered. PSA levels were missing in 341 cases. With increasing PSA there was a shift towards more advanced and poorly differentiated tumours. PSA at diagnosis increased with age, with the exception of patients younger than 50 years who had higher PSA values. The mean logarithm of PSA correlated negatively with the percentage of localized tumours (p < 0.005) and the age-adjusted incidence (p < 0.05) in each respective county in 1997. PSA was higher in men receiving radiotherapy compared with those treated with radical prostatectomy as well as in the group treated with bilateral orchiectomy compared with those receiving GnRH-analogues.

CONCLUSIONS

If PSA is used as a surrogate measure of extent of tumour volume in a population of prostate cancer patients, our findings indicate that age distribution and differences in incidence (possibly due to variation in diagnostic activity) should be taken into account. In our cohort there was a selection process, probably in part guided by PSA level, when choosing type of curative or palliative treatment.

The Swedish National Cataract Register: A 9-year review

The Swedish National Cataract Register (NCR) has been collecting data on cataract extractions in Sweden since 1992. This unique national database now contains data pertaining to more than 400 000 operations, representing 93.4% of all operations performed nationwide during 1992-2000. Clinic participation in the NCR is voluntary. Tests have shown NCR data to be extremely reliable, while the participation of nearly all providers of cataract surgery in Sweden makes the data highly representative of cataract surgery throughout the country. The NCR collects pre- and per-operative data for every cataract extraction performed at participating clinics. Surgical outcome data and data about patients' self-assessed visual function is collected in approximately 10% of cases. Since 1998, all cases of suspected postoperative endophthalmitis have also been reported to the NCR. The rate of surgery has increased from 4.47 to 7.26 per 1000 inhabitants during the period. Female subjects have constituted about 66% of all operated subjects each year and the mean age of patients has slowly increased from 75.2 to 76.1 years. Average pre-operative visual acuity has improved each year. Second eye surgery has increased from 28.5% to 36.8% of all surgeries. Phacoemulsification has reached 98% as type of surgery (in 2000) and 92.7% of all intraocular lenses are foldable. Surgical outcome has improved by achieving a final refraction closer to the target refraction and less surgically induced astigmatism. The positive impact of cataract surgery in very elderly people has been demonstrated, as has the positive effect of second eye surgery, especially in young subjects. The NCR has served to enhance knowledge about trends and results of cataract surgery in Sweden. This review article describes some of the activities carried out and their results.

Effects of docetaxel on pain due to metastatic androgen-independent prostate cancer

Bone pain commonly plagues patients with metastatic androgen-independent prostate cancer. Studies of mitoxantrone demonstrated that chemotherapy can substantially reduce this debilitating symptom. Two of the available studies examining the use of docetaxel with and without estramustine for treatment of androgen-independent prostate cancer include a detailed prospective analysis of pain and quality of life. One study required patients to have pain at entry and demonstrated significant improvement in pain. The second study enrolled patients with low prevalence and intensity of pain and did not demonstrate pain relief. The available results, although preliminary, suggest that patients with significant bone pain due to androgen-independent prostate cancer can experience substantial pain relief with docetaxel-based therapy. Larger randomized studies targeting patients with sufficient prevalence and intensity of pain are needed to refine our understanding of the contribution of docetaxel to pain control in this patient population.

Risk of femoral hernia after inguinal herniorrhaphy

BACKGROUND

Small case series have suggested an increased risk of femoral hernia after previous inguinal herniorrhaphy, but no large-scale data with complete follow-up are available.

METHODS

Data were extracted from the Danish Hernia Database covering the interval from 1 January 1998 to 1 July 2001, and included 34 849 groin hernia repairs.

RESULTS

Of 1297 femoral hernia repairs, 71 patients had previously had an operation for inguinal hernia within the observation period. These 71 femoral hernias represented 7.9 per cent of all reoperations for groin hernia recorded in the database. The median time to reoperation for a 'recurrent' femoral hernia after previous inguinal herniorrhaphy was 7 months, compared with 10 months for inguinal recurrences. The risk of developing a 'recurrent' femoral hernia after previous inguinal herniorrhaphy was 15 times higher than the rate of femoral hernia repair in the general population.

CONCLUSION

This study of 34 849 groin hernia repairs demonstrated a 15-fold greater incidence of femoral hernia after inguinal herniorrhaphy compared with the spontaneous incidence. These femoral recurrences occurred earlier than inguinal recurrences, suggesting that they were possibly femoral hernias overlooked at the primary operation.

Treatment of patients with clinical T3 prostate cancer

OBJECTIVE

To describe and evaluate treatment alternatives for patients with clinical T3 prostate cancer.

MATERIAL AND METHODS

Literature review with main focus on recent studies in order to include the impact of prostate specific antigen (PSA). The possibility of using neoadjuvant/adjuvant hormonal therapy in combination with surgery or radiation was assessed. Results were related to life expectancy, tumour grade and serum PSA.

RESULTS

M and N-staging is mandatory before treatment with curative intent. Watchful waiting is an option for selected patients but early hormonal therapy seems to offer some survival advantages. Standard 65-70Gy external beam radiation is not sufficient for these patients with extracapsular disease but better results are obtained with dose-escalation (beyond 70Gy) and/or adjuvant hormonal therapy. Radical prostatectomy may be an option for patients with long life expectancy and "early" tumours, neoadjuvant hormonal withdrawal is of no proven value.

CONCLUSIONS

Patients with a long life expectancy should not be denied treatment with curative intent solely based on the finding of extracapsular disease.

Correlation of initial PSA level and biopsy features with PSA-doubling time in early stage prostate cancers in Japanese men

OBJECTIVE

To distinguish good candidates for watchful waiting from those who need immediate treatment in localized prostate cancer.

METHODS

Prostate specific antigen (PSA)-doubling time (DT) was calculated by a log-linear regression model for 78 patients with clinically localized prostate cancer (T1c: 47, T2a: 6, T2b: 21, and T3: 4) under surveillance. Median observation period was 37.5 months. The first 1-year PSA-DT was compared with the overall PSA-DT in 41 patients who had been under surveillance for more than 3 years.

RESULTS

There was significant difference in the PSA-DT distribution between a pooled group of T1c and T2a and a group of T2b and T3 patients (median 58.8 versus 33.3 months, P = 0.0052). A combination of three parameters consisting of initial PSA level less than 10 ng/ml, WHO grade 1, one or two positive core per six to eight systematic biopsy cores with 50% or less cancer involvement significantly correlated with PSA-DT distribution in the T1c plus T2a group (P = 0.0034). The first year assessment of PSA-DT was identical to the overall assessment in 48.8%, 2 years or more in 36.6%, while it was 2 years or less (possibly over-estimated) in 14.6%.

CONCLUSION

PSA-DT can be predictable to some extent with the initial PSA level and biopsy features in early stage prostate cancers. Prospective study is needed to clarify whether temporary observation together with PSA-DT estimation is a safe strategy and is complementary to clinico-pathological parameters at diagnosis.

Randomized trial of Lichtenstein versus Shouldice hernia repair in general surgical practice

BACKGROUND

The aim of the present randomized trial was to compare the Shouldice procedure and the Lichtenstein hernia repair with respect to recurrence rate, technical difficulty, convalescence and chronic pain. A further aim was to determine to what extent general surgeons in routine surgical practice were able to reproduce the excellent results reported from specialist hernia centres.

METHODS

Three hundred patients with primary inguinal hernia were randomized to either a Shouldice repair or to a tension-free Lichtenstein repair. In a pretrial training programme the five participating general surgeons were taught to perform the two techniques in a standard manner. Follow-up was performed after 8 weeks, 1 year and 3 years. The last examination was performed by an independent blinded assessor.

RESULTS

There was a significant difference in operating time in favour of the Lichtenstein technique. After a follow-up of 36-77 months seven recurrences were found in the Shouldice group (95 per cent confidence interval (c.i.) 1.3 to 8.1) and one in the mesh group (95 per cent c.i. 0.0 to 2.0). Chronic groin pain was reported by 4.2 and 5.6 per cent in the Shouldice and Lichtenstein groups respectively. It was characterized as mild or moderate in all except two patients who had the Shouldice operation.

CONCLUSION

Lichtenstein hernia repair was easier to learn, took less time and resulted in fewer recurrences. It was possible to achieve excellent results with this technique in a general surgical unit.

Screening for prostate cancer with prostate-specific antigen: beware the biases

BACKGROUND

The evidence relating to the use of prostate-specific antigen (PSA) as a screening test is a highly controversial, as demonstrated by the lack of agreement among experts. There may be biases associated with various studies.

ISSUES

The main controversy is the relatively high prevalence of prostate cancer (PC) found at autopsy compared with the relatively low death rate from the disease. The lack of modifiable risk factors has led to early detection as a strategy to reduce mortality, as there is evidence for a significant burden of disease. Important issues are the accuracy of current screening tests, some attempts to improve on them, and whether there are good prognostic markers. The consequences of PSA testing (usually further testing including biopsy) and outcomes of treatment are presented in terms of mortality and morbidity; quality of life (QOL) must also be considered. Also important are the benefits from, and the difficulties associated with the "informed choice" approach to PSA screening.

CONCLUSION

There is evidence to suggest that biases can have a significant impact on the utility of PSA as a screening test for PC.

Decline in bilateral orchiectomy for prostate cancer in Olmsted county, Minnesota, 1956-2000

OBJECTIVE

To assess long-term secular trends in the utilization of bilateral compared with unilateral orchiectomy in the community.

PATIENTS AND METHODS

This population-based descriptive study reviewed medical records of all Olmsted County, Minnesota, men undergoing orchiectomy between 1956 and 2000.

RESULTS

Over the 45-year study period, 381 Olmsted County men had a first unilateral orchiectomy, while 431 underwent bilateral orchiectomy (including 8 with a second unilateral orchiectomy). There was no change over time in the age-adjusted utilization of unilateral orchiectomy, which was performed for a wide range of indications, mostly cryptorchidism and testicular malignancy. Most bilateral procedures, on the other hand, were in elderly men for castration, and trends over time generally paralleled those reported for prostate cancer in this community.

CONCLUSION

The declining incidence of prostate cancer in recent years, combined with a shift to earlier stages and younger ages at diagnosis, and the development of pharmacological approaches to hormonal manipulation have led to a dramatic decline in the utilization of bilateral orchiectomy, while unilateral orchiectomy rates have remained unchanged.

One-thousand consecutive inguinal hernia repairs under unmonitored local anesthesia

To evaluate the feasibility and safety of unmonitored local anesthesia (ULA) for elective open inguinal hernia repair, we made a prospective, consecutive data collection from 1000 operations on primary and recurrent hernias. Follow-up consisted of a questionnaire 1 mo after surgery and retrieval from the electronic patient data management system. In 921 ASA Group I and II and 79 ASA Group III and IV patients, the median age was 60 yr (range, 18-95 yr). ULA was converted to general anesthesia in 5 of 1000 cases, and 961 patients were discharged on the day of surgery after 95 min (median; interquartile range, 75-150); 29 patients had complications requiring surgical intervention. Within the first month, three patients died of causes unrelated to hernia surgery, and six had cardiovascular or respiratory events. The questionnaire was returned by 940 patients; 124 were dissatisfied with local anesthesia, day-case setup, or both, primarily because of intraoperative pain (n = 74; 7.8%). We conclude that open inguinal hernia repair can be conducted under ULA, regardless of comorbidity, with a small rate of deviation from day-case setup and minimal morbidity. It provides a safe alternative to other anesthetic techniques with an acceptable rate of satisfaction, but intraoperative pain relief needs improvement.

IMPLICATIONS

Inguinal hernia repair can be safely performed under unmonitored local anesthesia with infrequent postoperative morbidity and acceptable satisfaction, but intraoperative pain may be a problem.

Quality assessment of 26,304 herniorrhaphies in Denmark: a prospective nationwide study

BACKGROUND

Groin hernia repair is one of the most frequent operations, but there is no consensus about surgical or anaesthetic technique. Furthermore, no nationwide studies have been done. Our aim was to investigate outcome results of groin hernia surgery to improve quality of treatment.

METHODS

We prospectively recorded 26304 groin hernia repairs done in Denmark from Jan 1, 1998, to June 30, 2000, in a nationwide Danish hernia database.

FINDINGS

93% of all groin herniorrhaphies done in Denmark in the 30 months of the study were recorded in the database. Kaplan-Meier estimates of reoperation rates 30 months after anterior mesh repair and laparoscopic repair were significantly lower than after sutured posterior wall repairs in primary inguinal hernia (2.2% and 2.6% vs 4.4%; p<0.0001). Reoperation rates were also lower with anterior mesh repair (6.1%; p<0.0001) and laparoscopic repair (3.4%; p<0.0001) than with sutured posterior wall repair (10.6%) after recurrent hernia. Use of Lichtenstein mesh repair increased from 33% in January, 1998, to 62% in June, 2000, whereas use of laparoscopic repair remained constant at about 5%. Kaplan-Meier estimates of reoperation rates were 2.8% in the first 15 months and 1.6% in the second (p=0.03). For elective repairs, only 59% of patients were treated on an outpatient basis, and only 18% had local anaesthesia.

INTERPRETATION

Mesh repairs have a lower reoperation rate than conventional open repairs. Systematic prospective recording of treatment and outcome variables in a national clinical database improved the overall quality of surgical care. However, there is a large potential for cost savings and more efficient patient care with extended use of mesh techniques, outpatient surgery, and local anaesthesia.

Data reliability and structure in the Swedish National Cataract Register

PURPOSE

A Swedish National Cataract Register was instituted in 1992, monitoring nearly all cataract operations in Sweden, and since its inception comprising about 95% of all operations. Data from a total of approximately 290 000 operations have been collected during 1992-1998. Data quality is an important factor, and we have therefore assessed the various types and frequencies of data entry errors in the material.

METHODS

The medical records for all operations in five selected participating clinics were retrieved for a set month. Each data transfer step from the record to the final data base was monitored for a total of 574 operations. A total of 10 variables were recorded for each operation.

RESULTS

Significant sources of error were absent in most variables. However, possibly important errors appeared in three: "date entering waiting list", "preoperative best corrected visual acuity in the operated eye", or "visual acuity in the fellow eye". There were also noteworthy variations between the five clinics, different for different parameters. Errors were predominantly prone to appear at the very first step of registration. In most cases this was due to deviations from the data collection instructions.

CONCLUSIONS

The reliability is good for most values entered into the register, but it is important to ensure that data definitions are exact and adhered to. Repeated information to the involved persons on how to fill in the forms appears to be a requisite for maintaining good input quality.

Is a dissection balloon beneficial in bilateral, totally extraperitoneal, endoscopic hernioplasty? A randomized, prospective, multicenter study

SUMMARY

Laparoscopic hernioplasty has been criticized because of its technical complexity and increased costs. Disposable dissection balloons can be used to gain the initial working space in totally extraperitoneal endoscopic (TEP) hernioplasty, but this increases its cost. Forty-four men with bilateral, primary or recurrent inguinal hernias were randomized to undergo TEP with or without dissection balloon. There were two conversions to transabdominal preperitoneal hernioplasty, or open herniorrhaphy, in the group with balloon and four in the group without balloon. There was no difference in the postoperative morbidity or operation time between the two groups, and there were no major complications in either group. The recurrence rate was 4.3% in the group with the balloon and 7.1% in the group without the balloon. There were no statistically significant differences between the groups. Although our study population is too small to detect small differences between the groups, it seems that the use of a dissection balloon is not beneficial in a bilateral TEP.

What effect does the duration of an inguinal hernia have on patient symptoms?

BACKGROUND

Despite the fact that repair of an inguinal hernia is one of the most common operations performed in general surgery, we have very little information on the natural history of the untreated hernia. The aim of this study was to evaluate the association between hernia symptoms and the duration the patients had their hernias before presentation to a surgical outpatient department for an elective or emergency operation.

STUDY DESIGN

Data were gathered prospectively on a consecutive series of 699 patients admitted to two University Departments of Surgery for scheduled operations for an inguinal hernia.

RESULTS

More than one third (267) of patients had their hernias for 1 year or longer, up to 65 years, before presentation. The most common symptom on presentation was pain or discomfort at the hernia site, which occurred in 457 (66%) patients. The cumulative probability of pain increased with time to almost 90% at 10 years. The hernia had become irreducible in 48 patients (6.9%). The cumulative probability of irreducibility increased from 6.5% (95% confidence interval 4% to 9%) at 12 months to 30% (95% confidence interval 18% to 42%) at 10 years. Leisure activities were affected in 29% of patients although only 13% of patients had to take time off work because of hernia-related symptoms. Only two patients (0.3%) required resection of infarcted bowel or omentum.

CONCLUSIONS

Because many patients with an inguinal hernia are asymptomatic or mildly symptomatic, prospective clinical trials to assess the role of operations for such hernias are required.

Pain and health-related quality of life in a geographically defined population of men with prostate cancer

In order to provide baseline data on pain and health-related quality of life, to explore factors predicting pain and reduced quality of life, and to find potentially undertreated cases in men with prostate cancer, we undertook a population-based questionnaire study. The questionnaire, which included the EuroQo1 instrument, the Brief Pain Inventory form and 8 specially designed questions, was sent to all men with prostate cancer in the county of Ostergötland, Sweden. Of the 1442 men included in the study, 1243 responded to the questionnaire. Altogether 42% had perceived pain during the previous week and 26% stated their quality of life to be 50% or lower on a visual analogue scale. A high rating of health care availability and short time since diagnosis were found to significantly predict lower ratings of pain (P< 0.05). Pain was found to be a significant predictive factor for decreased quality of life together with high age, low rating of health care availability and palliative treatment (P< 0.05). In conclusion, assessment and treatment of pain is essential for a good quality of life in men with prostate cancer. The monitoring of prostate cancer patients should be individualized to fit the demands of the groups with the greatest need for support.

Hernia surgery for the third millennium. Does classical herniorraphy still play a role?

The steadily increasing use of prosthetic grafts in hernia repairs can be said to play down the classical approach for repairing groin hernia. We retrospectively report on 894 patients operated on for groin hernia at our out-patient surgery clinic from June 1992 to May 1998. Herniorraphy was widely performed (96.3%). The recurrence rate was of 1.6% (overall). For patients younger than 45 yr with no systemic concurrent disease, as few as 0.1% relapsed after a 58-month average follow-up. According to our results, ambulatory herniorraphy can provide an excellent degree of efficiency in selected young patients suffering from indirect unilateral primary groin hernia. Likewise, we regard the prosthetic repair as the gold standard technique in those patients with a weakened posterior inguinal wall.

Reoperation after recurrent groin hernia repair

OBJECTIVE

To analyze reoperation rates for recurrent and primary groin hernia repair documented in the Swedish Hernia Register from 1996 to 1998, and to study variables associated with increased or decreased relative risks for reoperation after recurrent hernia.

METHODS

Data were retrieved for all groin hernia repairs prospectively recorded in the Swedish Hernia register from 1996 to 1998. Actuarial analysis adjusted for patients' death was used for calculating the cumulative incidence of reoperation. Relative risk for reoperation was estimated using the Cox proportional hazards model.

RESULTS

From 1996 to 1998, 17,985 groin hernia operations were recorded in the Swedish Hernia Register, 15% for recurrent hernia and 85% for primary hernia. At 24 months the risk for having had a reoperation was 4.6% after recurrent hernia repair and 1.7% after primary hernia repair. The relative risk for reoperation was significantly lower for laparoscopic methods and for anterior tension-free repair than for other techniques. Postoperative complications and direct hernia were associated with an increased relative risk for reoperation. Day-case surgery and local infiltration anesthesia were used less frequently for recurrent hernia than for primary hernia.

CONCLUSIONS

Recurrent groin hernia still constitutes a significant quantitative problem for the surgical community. This study supports the use of mesh by laparoscopy or anterior tension-free repair for recurrent hernia operations.

Incidence rate and management of prostate carcinoma

The age-standardised incidence of prostate cancer varies more than one hundredfold between the areas with the highest and lowest incidences in the world. In certain areas, in particular the Western countries, the incidence has increased rapidly over the last 20 years. There are several environmental and genetic factors which partly explain these variations, although the incidence probably depends most of all on the extent to which small latent tumours are detected. As the clinical significance of small tumours is uncertain, the value of early diagnosis and early aggressive treatment is controversial. Randomised trials addressing this question have been initiated and will hopefully provide more evidence-based data in a decade from now. Small localised tumours are managed by radical surgery or radiation therapy. In elderly men or men unfit for operation or radiation therapy surveillance is often preferred. For advanced or metastatic prostate cancers androgen deprivation has been the mainstay of treatment since the early 1940s. Recently, several new treatment strategies have evolved but have not yet been introduced into clinical routine.

Is a dissection balloon beneficial in totally extraperitoneal endoscopic hernioplasty (TEP)? A randomized prospective multicenter study

BACKGROUND

Laparoscopic hernioplasty has been criticized because of its technical complexity and increased costs. Disposable dissection balloons can be used to facilitate the creation of the initial working space in totally extraperitoneal endoscopic hernioplasty (TEP), but their use adds to the cost of the operation.

METHODS

A total of 322 men with unilateral, primary, or recurrent inguinal hernias were randomized to undergo TEP with or without a dissection balloon.

RESULTS

In the group with the balloon, three of 161 patients (2.5%) required conversion to transabdominal preperitoneal hernioplasty (TAPP), or open herniorraphy, whereas 17 of 161 patients (10.6%) were converted to TAPP or open herniorraphy in the group without the balloon (p = 0.002). The mean operation time was 55 min in the group with the balloon and 63 min in the group without the balloon (p = 0.004). There was no difference between them in postoperative morbidity, and there were no major complications in either group. The recurrence rate was 3.1% in the group with the balloon and 3.7 % in the group without the balloon (p = 0.8).

CONCLUSION

The use of a dissection balloon in TEP reduces the conversion rate and may be especially beneficial early in the learning curve.

Evolution of an inguinal hernia surgery practice

BACKGROUND

Inguinal hernia surgery has undergone numerous advances in the last few years. This study analysed the changes in the practice of one surgeon in a district general hospital over a seven year interval. The effect of changing from Bassini to Lichtenstein repair in 1994 was evaluated.

METHODS

The study involved two parts: first a search of a computerised database of inguinal hernia procedures, and second, postal audits of men who had an inguinal hernia repair in 1993 and 1994 with outpatient follow up for those with a possible recurrence.

RESULTS

A total of 1037 hernias were repaired over the seven years. There was an increase in the proportion of day cases from 18% to 70% and the number of operations performed under local anaesthetic rose from 1% to 45%. The postal audits had response rates of 79% (1993) and 66% (1994). Some 5/98 (5%) recurrent hernias were identified from the 1993 (Bassini) patients compared with 1/67 (1.5%) from the 1994 (Lichtenstein) cohort.

CONCLUSION

Lichtenstein hernia repair can be performed safely as a day case using local anaesthetic in the majority of patients and appears to have a lower recurrence rate than Bassini repair.

Groin hernia repair in Scotland

BACKGROUND

The use of mesh for groin hernia repair has dramatically changed the way this common operation is performed. The aim of this study was to survey the methods of groin hernia repair in Scotland and to assess patient satisfaction with the operation.

METHODS

Between 1 April 1998 and 31 March 1999 all patients who underwent groin hernia repair in the National Health Service in Scotland were identified. As well as looking at the type of hernia repair performed and postoperative morbidity, patients were sent a Short Form-36 about 3 months after the operation to assess satisfaction and return to normal activity.

RESULTS

Information was obtained on 5506 (97 per cent) of patients who underwent groin hernia repair during the study period. Eighty-five per cent of patients had an open mesh repair and 4 per cent had a laparoscopic repair. Most operations (85 per cent) were performed using general anaesthesia on an inpatient basis (78 per cent), and 8 per cent were for repair of a recurrent hernia. Potentially serious intraoperative complications were rare (seven patients), although they were significantly (P < 0. 001) more likely to be associated with a laparoscopic approach or repair of a femoral hernia: relative risk compared with open inguinal hernia repair 33 (95 per cent confidence interval (c.i.) 6-197) and 22 (95 per cent c.i. 3-152) respectively. Wound complications were common and 10 per cent of patients required a district nurse to attend the wound. Patients expressed a high degree of satisfaction; 94 per cent would recommend the same operation to someone else if required.

CONCLUSION

An open mesh repair using general anaesthesia has become the repair of choice for a groin hernia in Scotland. Despite a high incidence of wound complications, patients are satisfied with this operation.

Detection of groin hernia with physical examination, ultrasound, and MRI compared with laparoscopic findings

OBJECTIVE

To determine the diagnostic accuracy of physical examination, ultrasound, and dynamic MRI in patients with inguinal hernia.

METHODS

In 41 patients with clinically evident herniations, 82 groins were evaluated using a standard ultrasound and MRI protocol, the latter including T1- and T2-weighted sequences as well as two dynamic sequences. All ultrasound examinations and MRI scans were reviewed without knowledge of clinical findings. In all cases, correlation with findings at laparoscopic surgery was made.

RESULTS

At surgery, 55 inguinal herniations were found. Physical examination revealed 42 herniations (one false-positive finding), whereas ultrasound made the diagnosis of a hernia in 56 cases (five false-positive and four false-negative findings). MRI diagnosed 53 herniations (one false-positive and three false-negative findings). Thus, sensitivity and specificity figures were 74.5% and 96.3% for physical examination, 92.7% and 81.5% for ultrasound, and 94.5% and 96.3% for MRI.

CONCLUSIONS

In patients with clinically uncertain herniations, MRI is a valid diagnostic tool with a high positive predictive value.