Efficacy of Mitomycin C Combined with Direct Vision Internal Urethrotomy for Urethral Strictures: A Systematic Review and Meta-Analysis

BACKGROUND

The high recurrence of a urethral stricture after direct vision internal urethrotomy (DVIU) has been a problem for years. Mitomycin C (MMC) is an excellent antifibrosis antigen that has been used in many fields, but its effect on a urethral stricture remains controversial. The purpose of this review was to investigate the effectiveness of MMC in reducing the recurrence rate of a urethral stricture after the first urethrotomy.

METHODS

Common databases were searched for publications prior to November 30, 2020. Randomized controlled and cohort trials were all included. Recurrence and success rates after the first urethrotomy of the posterior urethra were the main outcomes. Revman 5.3 was used for statistical analysis. Two evaluation systems, the Cochrane risk of bias tool and the Newcastle Ottawa Scale, were used to examine the risk of bias for RCTs and all studies. The quality of evidence was assessed by the Grading of Recommendations, Assessment, Development, and Evaluation standard.

RESULTS

Sixteen trials were included, the reporting quality of which was generally poor, and the evidence level was very low to moderate. The addition of MMC could significantly reduce the recurrence rate of urethral strictures (risk ratio [RR] = 0.42; 95% confidence interval [CI]: 0.26, 0.67; p = 0.0002; 9 trials; 550 participants). The results of the subgroup analysis suggested that the effect of MMC combined with DVIU was significant in short (≤2 cm) anterior urethral strictures (RR = 0.39; 95% CI: 0.20, 0.78; p = 0.008), >12-month follow-up (RR = 0.45; 95% CI: 0.26, 0.76; p = 0.003). It also increased the success rate of the first urethrotomy procedure for posterior urethral contracture (RR = 0.74; 95% CI: 0.65, 0.84; p < 0.00001; 7 trials; 342 participants). Low-dose local injection of MMC was the most commonly used method.

CONCLUSION

MMC combined with DVIU is a promising way to reduce the long-term recurrence rate of a short-segment anterior urethral stricture. It also increases the success rate of the first urethrotomy of the posterior urethra. However, more high-quality randomized controlled trials are needed.

The effectiveness of spatially cross-linked polymer in the postoperative epidural fibrosis prevention: an experimental study

Introduction. Epidural fibrosis is an urgent problem in modern spinal surgery and orthopedics. The formation of connective tissue in the epidural space after performing surgical interventions on the spinal column inevitably leads to adhesion of the latter to the dura mater and compression of neural structures, followed by the formation of clinical and neurological symptoms. The  search for literary sources in domestic and foreign scientific databases has demonstrated the presence of several works studying the effectiveness of barrier methods for preventing the development of epidural fibrosis. It should be noted that the results of these studies are ambiguous and largely contradictory.

The purpose was to study the effectiveness of using a spatially cross-linked polymer in the postoperative lumbar epidural fibrosis prevention in an experiment.

Materials and methods. The study included 26 male Wistar rats (average body weight 338.5±9.07 g), which were divided into two groups: Group I (control, n = 12): animals underwent laminectomy at the level of vertebral bodies LVII – SI  without application of spatially crosslinked polymer; Group II (experimental, n = 14): animals underwent laminectomy at the level of vertebral bodies LVII – SI  followed by application of a spatially cross-linked polymer to the dura mater. The morphological and instrumental parameters were studied.

Results. Significant differences were noted in the severity of epidural fibrosis (χ2 = 14.846, p = 0.003), the number of newly formed vessels (F = 14.371, p<0.001), the number of fibroblasts (F = 11.158, p<0.001), as well as in the severity of vertebral stenosis channe l according to multislice computed tomography (χ2 = 17.207, p=0.002) between the control and experimental groups of animals.

Conclusion. Application of a spatially cross-linked polymer to the dura mater is an effective way to prevent the development of postoperative epidural fibrosis.

The effectiveness of Mitomycin C in Otolaryngology procedures: A systematic review

OBJECTIVE

Many studies have evaluated the effectiveness of topical intraoperative mitomycin (MCC) usage in a wide range of Otolaryngologic procedures with variable conclusions on effectiveness. This systematic review aims to provide a qualitative estimation of mitomycin C's treatment effectiveness in maintaining or preventing stenosis after surgical interventions.

DESIGN AND MAIN OUTCOME MEASURES

Following the PRISMA guideline, a comprehensive systematic search of MEDLINE, EMBASE, and CINAHL databases was performed including hand-searching and cross-reference checking. The search was limited to humans, sample size greater than two, and study designs including a comparative arm.

RESULTS

571 unique abstracts and 109 full articles were reviewed. 77 studies were included in the final analysis. The available evidence ranged from case series to randomized control studies. Meta-analysis was deemed inappropriate due to heterogeneity of study design. 38 studies assessed the effective of MCC in dacryocystorhinostomy, which is reported in a separate meta-analysis. All other studies were categorized into otolaryngologic site and pathology including: choanal atresia (n=5), endoscopic sinus surgery (n=12), airway procedures (n=9), esophageal procedures (n=8), and other (n=2).

CONCLUSIONS

The published literature on the effectiveness of MMC was mixed, but suggested topical MMC improved surgical outcomes in many Otolaryngologic procedures compared to controls. This was the first review to assemble literature on MMC usage for different surgical procedures. Comprehensive interpretation of the data was limited due to heterogeneity in primary outcome, procedure type, and study quality. High quality prospective and randomized controlled studies are required to further confirm the positive effect of MMC use on surgical outcomes.

Methodological Quality of Systematic Reviews and Meta-analyses Published in High-Impact Otolaryngology Journals

OBJECTIVE

To assess the methodological quality of intervention-focused systematic reviews (SRs) and meta-analyses (MAs) published in high-impact otolaryngology journals.

DATA SOURCES

Ovid Medline, Embase, and Cochrane Library.

REVIEW METHODS

A comprehensive search was performed for SR and MA citations from 2012 to 2017 in the 10 highest impact factor otolaryngology journals. Abstracts were screened to identify published manuscripts in which the authors indicated clearly that they were performing an SR or MA. Applying a modified typology of reviews, 4 reviewers characterized the review type as SR, MA, or another review type. A simplified version of the AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews 2) tool was used to assess the reporting and methodological quality of the SRs and MAs that were focused on interventions.

RESULTS

Search and abstract screening generated 499 manuscripts that identified themselves as performing an SR or MA. A substantial number (85/499, 17%) were review types other than SRs or MAs, including 34 (7%) that were literature reviews. In total, 236 SRs and MAs focused on interventions. Over 50% of these SRs and MAs had weaknesses in at least 3 of the 16 items in the AMSTAR 2, and over 40% had weaknesses in at least 2 of the 7 critical domains. Ninety-nine percent of SRs and MAs provided critically low confidence in the results of the reviews.

CONCLUSION

Intervention-focused SRs and MAs published in high-impact otolaryngology journals have important methodological limitations that diminish confidence in the results of these reviews.

Evaluation of Recurrent Maxillary Sinusitis due to Middle Meatal Antrostomy Site Stenosis

OBJECTIVE

This study was performed to evaluate the incidence, timing, and factors contributing to recurrent maxillary sinusitis due to middle meatal antrostomy (MMA) site stenosis after endoscopic sinus surgery (ESS).

METHODS

The medical records and endoscopic photographs of 288 patients with chronic rhinosinusitis who underwent ESS were evaluated. Patients visited the clinic with similar schedule after ESS; recurrent maxillary sinusitis due to MMA site stenosis was investigated, including in terms of the incidence and timing. The preoperative computed tomography (CT) scans, intraoperative findings, and possible factors contributing to MMA site stenosis were examined.

RESULTS

Recurrent maxillary sinusitis due to MMA site stenosis occurred in 10 patients. Most had unilateral sinusitis and stenosis was observed within 6 months postoperatively. All patients had severe inflammation, pus retention, and thick mucosal hypertrophy in the maxillary sinus on preoperative CT; intraoperative findings confirmed these conditions. In most patients, extensive trimming of the hypertrophied mucosa was performed intraoperatively through canine fossa trephination.

CONCLUSIONS

MMA site stenosis is a rare condition after ESS. We hypothesized that rapid shrinkage and fibrosis of the sinus mucosa after extensive trimming thereof may be the main causes of stenosis. Residual mucosal inflammation, granulation formation, and persistent sinus crust and debris may also be contributing factors. Therefore, conservative trimming, meticulous dressing, and removal of sinus crust and granulation tissue near the MMA site should be performed in patients with MMA site stenosis.

Balloon dilation for the treatment of nasopharyngeal stenosis in seven cats

Objectives

The objective of this study was to evaluate the effectiveness of balloon dilation for the treatment of nasopharyngeal stenosis in cats.

Methods

The medical records of seven cats with nasopharyngeal stenosis treated with balloon dilation were reviewed. The most common presenting clinical signs included upper airway noise, sneezing, nasal and/or ocular discharge. All seven cats were confirmed to have nasopharyngeal stenosis via nasopharyngeal endoscopy and were treated with balloon dilation under endoscopic guidance.

Results

All seven cats had acceptable short-term control (median 14 days) of clinical signs after the procedure. Two of six cats had successful long-term control (median 34 days) of clinical signs after one balloon dilation and an additional 2/6 cats had acceptable long-term control of clinical signs after a second balloon dilation procedure. The most significant complication of balloon dilation was the recurrence of stenosis.

Conclusions and relevance

The findings of this study indicate that balloon dilation is a safe and effective treatment option for the relief of clinical signs associated with nasopharyngeal stenosis in cats. Multiple procedures may be necessary for the best chance of long-term success.

The effect of topical 5-flurouracil application post endoscopic inferior turbinoplasty

RATIONALE AND OBJECTIVES

Adhesions are the most common complication after nasal surgery and revision. 5-Fluorouracil (5-FU) reduces various adhesions and epithelial growth related complications. The aim of this study was to evaluate the effects of 5-flurouracil application in the nasal cavity after a multi-procedure nasal surgery in term of complications frequency.

MATERIALS AND METHODOLOGY

Institutional ethical approval was granted and a double-blinded prospective clinical trial was conducted to study the effect of 5-fu on post-operative complications. At the end of a combined endoscopic inferior turbinoplasty with one or more other nasal surgeries, 5-flurouracil-soaked cottonoid with 1mL of 5-flurouracil (5mg/mL) was applied in one side of nasal cavity and saline-soaked cottonoid was applied contralaterally and left for 5min. Patients were assessed over 2months postoperatively by a blinded observer in terms of adhesions, crustation, discharge, pain, discharge, loss of smell and other complications and nasal symptoms.

RESULTS

On the 1st follow up week postoperatively, adhesions were observed in (24 patients) 35%, bilateral in (6 patients) 9% and unilateral in (18 patients) 26%. Unilateral Adhesions were statistically significantly higher in control sides than those in 5-FU sides (22% vs 4% respectively) (p=0.025). Crustation, continued to statistically significantly diminish over time (p=0.035). On the 8th follow up week, adhesions reduction was still statistical significant at the 5-FU treated side (p=0.01).

CONCLUSION

5-FU is safe and effective in preventing adhesions formation when applied during combined endoscopic inferior turbinoplasty procedure with other nasal procedure surgery.

Preclinical study investigating the potential of low-dose-rate brachytherapy with 32P stents for the prevention of restenosis of paranasal neo-ostia

PURPOSE

Ostial restenosis is a common cause of failures in paranasal sinus surgery. The aim of the current study was to investigate the use of low-dose-rate brachytherapy to prevent neo-ostial restenosis in an animal model.

METHODS AND MATERIALS

In 14 rabbits, maxillary neo-ostia were created and measured. One side each was stented with a regular silicone stent, the other side was either not stented (n = 7) or stented with a phosphorous-32 implanted stent depositing a low-dose radiation of 15 Gy (n = 7) within 1 week, after which all stents were removed. After a period of additional 12 weeks of recovery, the animals were sacrificed, the neo-ostia were again measured, and the areas and histopathologic changes compared in between the groups.

RESULTS

After 15-Gy stenting, the mean ostial areas were even slightly enlarged by 5.1% compared to the area at stent removal, whereas a significant reduction in area, indicating a process of restenosis, by 56.1% or 54.0% was seen in the control groups with no stent and normal stent, respectively. Furthermore, no indication for adverse histopathologic radiation effects was seen in the 15-Gy group.

CONCLUSIONS

Low-dose-rate brachytherapy with phosphorous-32 doped silicone stents showed promising results in the prevention of neo-ostium restenosis in this proof-of-concept study, indicating that further preclinical and clinical testing may be warranted.

Comparison of the effects of Mitomycin-C and sodium hyaluronate/carboxymethylcellulose [NH/CMC] (Seprafilm) on abdominal adhesions

Introduction

Intra-abdominal adhesions (IA) may occur after abdominal surgery and also may lead to complications such as infertility, intestinal obstruction and chronic pain. The aim of this study was to compare the effects of Mitomycin-C (MM-C) and sodium hyaluronate/carboxymethylcellulose [NH/CMC] on abdominal adhesions in a cecal abrasion model and to investigate the toxicity of MM-C on complete blood count (CBC) and bone marrow analyses.

Methods

The study comprised forty rats in four groups (Control, Sham, Cecal abrasion + MM-C, and Cecal abrasion + NH/CMC). On postoperative day 21, all rats except for the control (CBC + femur resection) group, were sacrificed. Macroscopical and histopathological evaluations of abdominal adhesions were performed. In order to elucidate the side effects of MM-C; CBC analyses and femur resections were performed to examine bone marrow cellularity.

Results

CBC analyses and bone marrow cellularity assessment revealed no statistically significant differences between MM-C, NH/CMC and control groups. No significant differences in inflammation scores were observed between the groups. The MM-C group had significantly lower fibrosis scores compared to the NH/CMC and sham groups. Although the adhesion scores were lower in the MM-C group, the differences were not statistically significant.

Conclusion

Despite its potential for systemic toxicity, MM-C may show some anti-fibrosis and anti-adhesive effects. MM-C is a promising agent for the prevention of IAs, and as such, further trials are warranted to study efficacy.

Efficacy of endonasal phototherapy for relieving the symptoms of allergic rhinitis: Meta-analysis

BACKGROUND

Endonasal phototherapy can relieve the symptoms of allergic rhinitis (AR) for the patient. However, there is no consensus on whether or not endonasal phototherapy is effective in reducing the symptoms of AR.

OBJECTIVE

The goal of this meta-analysis was to perform a systematic review of the available literature on the effects of endonasal phototherapy on symptoms of AR.

METHODS

Two authors independently searched medical literature databases from their inception of article collection to July 2014. Studies that scored the nasal symptoms of AR and quality of life related to AR before and after endonasal phototherapy, and that compared the effects of phototherapy (treatment groups) with sham treatment (sham group) or antihistamine administration (antihistamine group) were included in the analysis. The outcomes of interest were total nasal symptom scores, disease-specific quality of life questionnaire assessments, and endoscopic findings (discharge and turbinate hypertrophy). Overall, a total of 13 trials met the inclusion criteria of this study, with a total sample size of 679 patients.

RESULTS

Phototherapy significantly reduced nasal symptoms compared with pretreatment values and improved quality of life. The endoscopic findings also significantly improved after phototherapy. In addition, the symptom score and disease-specific quality of life after treatment were significantly lower in the treatment group versus the sham group, and were similar to those in the antihistamine group.

CONCLUSIONS

Phototherapy could provide nasal symptom relief and improve quality of life related to AR. However, when considering the insufficient evaluation of the efficacy of phototherapy according to the treatment methods and the high heterogeneity apparent in some parameters, further clinical trials with robust research methodologies should be conducted to confirm the results of this study.

Results of transnasal transostial sphenoidotomy in 79 cases of chronic sphenoid sinusitis

OBJECTIVE

This study was designed to retrospectively review the postoperative results of transnasal transostial sphenoidotomy in 79 patients with isolated chronic sphenoid sinusitis operated between 1995 and 2013 and evaluate the recurrence rate due to postoperative closure of the sphenoidotomy.

PATIENTS AND METHODS

Seventy-nine patients, 44 women and 35 men (M:F sex ratio: 0.79) aged 10 to 84 years (mean age: 48), were included. The most common presenting symptom was headache in 61% of cases. Visual disturbances were present in three cases. The diagnostic work-up comprised nasal endoscopy, computed tomography (CT) and magnetic resonance imaging (MRI) of the sinuses. The surgical indication was based on failure of antibiotic therapy and/or the nature and severity of sphenoid sinusitis. All patients were operated by endoscopic transnasal transostial sphenoidotomy. Samples were taken for histological, bacteriological and mycological examination.

RESULTS

No intraoperative or immediate postoperative complications were observed. Nature of the lesion: forty-seven patients (59.5%) presented nonspecific inflammatory lesions with negative bacterial or fungal culture and inflammatory mucosal changes, 19 patients (24%) had fungal sinusitis presenting as a fungus ball and 13 patients (16.4%) had documented bacterial sinusitis. Mean postoperative follow-up was 7.4 months (range: 6-48). No recurrence of the sinusitis or symptoms was observed in 71 cases (89.8%). Recurrence: eight cases (10.2%) of postoperative closure of the sphenoidotomy were observed, requiring one (6 cases) or several (2 cases) reoperations with a mean of 16.4 months after the initial procedure. Symptoms of recurrence consisted of varying degrees of headache, with similar symptoms to those of the first episode in 7 cases, and retro-orbital headache in 1 case. Reoperation was performed via a transnasal transostial approach in 6 cases and a transethmoidal approach in 2 cases.

CONCLUSION

The transnasal transostial surgical approach is a safe and effective procedure for the treatment of isolated sphenoid sinusitis. However, the recurrence rate due to postoperative closure of the sphenoidotomy observed in our series raises the question of postoperative maintenance of a patent and functional sphenoidotomy.

Comprehensive review on endonasal endoscopic sinus surgery

Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.

Topical anesthetic preparations for rigid and flexible endoscopy: a meta-analysis

Transnasal endoscopy can cause pain or discomfort for the patient. Topical anesthetic has been used in an attempt to reduce this. However, there is no consensus on whether topical anesthetic is effective in optimizing patient experience during the procedure. The goal of this study was to perform a systematic review with meta-analysis of the efficacy of topical anesthetic on pain and comfort outcomes during endoscopy. Two authors independently searched the databases from inception to September 2013. Studies comparing topical anesthetic with placebo where the outcomes of interest were pain, comfort, or side effect outcomes were included. Sufficient data for meta-analysis were retrieved for ten trials with a total of 837 patients. The evidence suggests that local anesthetic alone or in combination with a vasoconstrictor is beneficial to patients' pain [standardized mean difference (SMD) = -0.21; p = 0.045] and comfort (SMD = -0.51; p < 0.001) outcomes when performing transnasal endoscopy. However, the topical anesthetic caused unpleasant sensation with respect to an unpleasant taste (SMD = 0.77; p < 0.001). In addition, there was no significant difference between a topical anesthetic spray and cotton type in pain and discomfort values. Applying topical anesthetic during transnasal endoscopy could reduce pain and discomfort. The spray and cotton type methods of topical anesthetic preparation showed no significant difference in terms of pain and discomfort during the procedure. However, further trials with good research methodology should be conducted to confirm our results.