Disease and toxicity outcomes for a modern cohort of patients with squamous cell carcinoma of cutaneous origin involving the parotid gland: Comparison of volumetric modulated arc therapy and pencil beam scanning proton therapy

OBJECTIVES

We sought to describe outcomes for locally advanced cutaneous squamous cell carcinoma (SCC) involving the parotid treated with volumetric modulated arc therapy (VMAT) versus pencil beam scanning proton beam therapy (PBT).

MATERIALS AND METHODS

Patients were gathered from 2016 to 2022 from 5 sites of a large academic RT department; included patients were treated with RT and had parotid involvement by: direct extension of a cutaneous primary, parotid regional spread from a previously or contemporaneously resected but geographically separate cutaneous primary, or else primary parotid SCC (with a cutaneous primary ostensibly occult). Acute toxicities were provider-reported (CTCAE v5.0) and graded at each on treatment visit. Statistical analyses were conducted.

RESULTS

Median follow-up was 12.9 months (1.3 - 72.8); 67 patients were included. Positive margins/extranodal extension were present in 34 cases; gross disease in 17. RT types: 39 (58.2 %) VMAT and 28 (41.8 %) PBT. Concurrent systemic therapy was delivered in 10 (14.9 %) patients. There were 17 treatment failures (25.4 %), median time of 168 days. Pathologically positive neck nodes were associated with locoregional recurrence (p = 0.015). Oral cavity, pharyngeal constrictor, and contralateral parotid doses were all significantly lower for PBT. Median weight change was -3.8 kg (-14.1 - 5.1) for VMAT and -3 kg (-16.8 - 3) for PBT (p = 0.013). Lower rates of ≥ grade 1 xerostomia (p = 0.002) and ≥ grade 1 dysguesia (p < 0.001) were demonstrated with PBT.

CONCLUSIONS

Cutaneous SCC involving the parotid can be an aggressive clinical entity despite modern multimodal therapy. PBT offers significantly lower dose to organs at risk compared to VMAT, which seemingly yields diminished acute toxicities.

Gross tumor volume margin and local control in p16-positive oropharynx cancer patients treated with intensity modulated proton therapy

BACKGROUND

To determine if the extent of high-dose gross tumor volume (GTV) to clinical target volume (CTV) expansion is associated with local control in patients with p16-positive oropharynx cancer (p16+ OPC) treated with definitive intensity modulated proton therapy (IMPT).

METHODS

We performed a retrospective analysis of patients with p16+ OPC treated with IMPT at a single institution between 2016 and 2021. Patients with a pre-treatment PET-CT and restaging PET-CT within 4 months following completion of IMPT were analyzed.

RESULTS

Sixty patients were included for analysis with a median follow-up of 17 months. The median GTV to CTV expansion was 5 mm (IQR: 2 mm). Thirty-three percent of patients (20 of 60) did not have a GTV to CTV expansion. There was one local failure within the expansion group (3%).

CONCLUSION

Excellent local control was achieved using IMPT for p16+ OPC independent of GTV expansion. IMPT with minimal target expansions represent a potential harm-minimization technique for p16-positive oropharynx cancer.

Regionalization of Head and Neck Oncology Tumor Boards: Perspectives of Collaborating Physicians

Objectives

To survey academic and community physician preferences regarding the virtual multidisciplinary tumor board (MTB) for further improvement and expansion.

Study Design

This anonymous 14-question survey was sent to individuals that participated in the head and neck virtual MTBs. The survey was sent via email beginning August 3, 2021, through October 5, 2021.

Setting

The University of Maryland Medical Center and regional practices in the state of Maryland.

Methods

Survey responses were recorded and presented as percentages. Subset analysis was performed to obtain frequency distributions by facility and provider type.

Results

There were 50 survey responses obtained with a response rate of 56%. Survey participants included 11 surgeons (22%), 19 radiation oncologists (38%), and 8 medical oncologists (16%), amongst others. More than 96% of participants found the virtual MTB to be useful when discussing complex cases and impactful to future patient care. A majority of respondents perceived a reduction in time to adjuvant care (64%). Community and academic physician responses strongly agreed that the virtual MTB improved communication (82% vs 73%), provided patient-specific information for cancer care (82% vs 73%), and improved access to other specialties (66% vs 64%). Academic physicians, more so than community physicians, strongly agreed that the virtual MTB improves access to clinical trial enrollment (64% vs 29%) and can be useful in obtaining CME (64% vs 55%).

Conclusion

Academic and community physicians view the virtual MTB favorably. This platform can be adapted regionally and further expanded to improve communication between physicians and improve multidisciplinary care for patients.

Human Papillomavirus Impact on Temporal Treatment Trends in Oropharyngeal Carcinoma: 2010-2016

INTRODUCTION

The study objective was to identify practice patterns in oropharyngeal cancer management from 2010 to 2016 among human papillomavirus (HPV)-associated and non-HPV-associated oropharyngeal squamous-cell carcinoma (OPSCC) patients.

METHODS

The National Cancer Database was utilized to identify OPSCC patients from 2010 to 2016. Frequency distributions and multivariable analyses were generated to identify practice patterns and predictors of treatment modality.

RESULTS

A total of 35,956 patients with nonmetastatic OPSCC were included. HPV status was not associated with a treatment modality preference. At academic centers, the proportion of HPV-associated OPSCC patients versus non-HPV-associated OPSCC patients undergoing surgical management was similar (35.7%; 35.9%). Community cancer programs treated patients less often surgically but with no significant treatment preference based on HPV status. Within each facility type, HPV status was not a predictor of surgical or nonsurgical management.

CONCLUSION

HPV association does not appear to significantly influence treatment modality preference among OPSCC patients. The proportion of OPSCC patients undergoing surgical treatment declined from 2010 to 2016.

New Medical Device and Therapeutic Approvals in Otolaryngology: State of the Art Review 2020

Objectives

To evaluate new drugs and devices relevant to otolaryngology–head and neck surgery that were approved by the US Food and Drug Administration (FDA) in 2020.

Data Sources

Publicly available device and therapeutic approvals from ENT (ear, nose, and throat), anesthesia, neurology (neurosurgery), and plastic and general surgery FDA committees.

Review Methods

Members of the American Academy of Otolaryngology–Head and Neck Surgery’s Medical Devices and Drugs Committee reviewed new therapeutics and medical devices from a query of the FDA’s device and therapeutic approvals. Two independent reviewers assessed the drug’s or device’s relevance to otolaryngology, classified to subspecialty field, with a critical review of available scientific literature.

Conclusions

The Medical Devices and Drugs Committee reviewed 53 new therapeutics and 1094 devices (89 ENT, 140 anesthesia, 511 plastic and general surgery, and 354 neurology) approved in 2020. Ten drugs and 17 devices were considered relevant to the otolaryngology community. Rhinology saw significant improvements around image guidance systems; indications for cochlear implantation expanded; several new monoclonal therapeutics were added to head and neck oncology’s armamentarium; and several new approvals appeared for facial plastics surgery, pediatric otolaryngology, and comprehensive otolaryngology.

Implications for Practice

New technologies and pharmaceuticals offer the promise of improving how we care for otolaryngology patients. However, judicious introduction of innovations into practice requires a nuanced understanding of safety, advantages, and limitations. Working knowledge of new drugs and medical devices approved for the market helps clinicians tailor patient care accordingly.

The association of active and passive tobacco smoke exposure with chronic rhinosinusitis symptom severity: A cross-sectional study

BACKGROUND

 Chronic rhinosinusitis (CRS) causes a great deal of morbidity. There are a multitude of causal factors, though their precise contribution to symptom severity has yet to be defined.  We hypothesized that exposure to both primary and secondhand tobacco smoke would correlate with more severe symptoms of CRS.

METHODS

This is a prospective cross-sectional study performed at an academic tertiary care medical center from 2010 to 2013. A total of 85 consecutive patients with chronic sinusitis were screened; 70 with medically refractory CRS requiring functional Endoscopic sinus surgery (FESS) were enrolled. Recent tobacco exposure was assessed using serum cotinine levels. Sinonasal mucosa was biopsied to assess ciliary architecture. Demographics, medical history, tobacco and environmental exposures, and computed tomography (CT) imaging were also collected. Two quality of life (QOL) surveys were administered: one disease specific, Sinonasal Outcomes Test-20 (SNOT-20), and one general, Short Form-12 (SF-12). Results were correlated with the aforementioned exposures.

RESULTS

 The 70 patients had an average age of 46 years, and 42% were male.  Variables that correlated with worse SNOT-20 scores included serum cotinine (r = 0.43, p = 0.002), number of cigarettes smoked daily (r = 0.27, p = 0.03), and number of secondhand cigarettes exposed to per day (r = 0.29, p = 0.04). There were no significant correlations between SNOT-20 scores and Lund-MacKay or axonemal ultrastructural abnormalities (AUA)-ciliary scores. The two five-variable models best predicted disease-specific QOL.

CONCLUSIONS

 Increased amounts of serum cotinine and primary and secondhand smoke exposure were associated with worse sinonasal QOL. This study establishes an objective relationship between smoke exposure and patient-perceived severity of CRS, emphasizing the importance of tobacco cessation counseling as part of management.

Impact of the Novel Coronavirus 2019 (COVID-19) Pandemic on Head and Neck Cancer Care

Objective

The study aimed to assess the impact of the coronavirus disease 2019 (COVID-19) pandemic on head and neck oncologic care at a tertiary care facility.

Study Design

This was a cross-sectional study conducted between March 18, 2020, and May 20, 2020. The primary planned outcome was the rate of treatment modifications during the study period. Secondary outcome measures were tumor conference volume, operative volume, and outpatient patient procedure and clinic volumes.

Setting

This single-center study was conducted at a tertiary care academic hospital in a large metropolitan area.

Methods

The study included a consecutive sample of adult subjects who were presented at a head and neck interdepartmental tumor conference during the study period. Patients were compared to historical controls based on review of operative data, outpatient procedures, and clinic volumes.

Results

In total, 117 patients were presented during the review period in 2020, compared to 69 in 2019. There was an 8.4% treatment modification rate among cases presented at the tumor conference. There was a 61.3% (347 from 898) reduction in outpatient clinic visits and a 63.4% (84 from 230) reduction in procedural volume compared to the prior year. Similarly, the operative volume decreased by 27.0% (224 from 307) compared to the previous year.

Conclusion

Restrictions related to the COVID-19 pandemic resulted in limited treatment modifications. Transition to virtual tumor board format observed an increase in case presentations. While there were reductions in operative volume, there was a larger proportion of surgical cases for malignancy, reflecting the prioritization of oncologic care during the pandemic.

Abstract PO-017: Evaluating the impact of the coronavirus (COVID-19) pandemic on treatment paradigms in head and neck cancer at a tertiary care hospital

Objective: The study aimed to assess the impact of the coronavirus (COVID-19) pandemic on head and neck oncologic care at a tertiary care hospital. The pandemic caused by the novel severe acute respiratory syndrome coronavirus (SARS-CoV-2) has led to policies designed to limit its spread. Policies including eliminating routine appointments, statewide stay-at-home orders, and restricting surgical cases to emergent surgeries have limited access to care. Therefore, we hypothesized that treatment modifications would be implemented for patients and cancer consultations would decrease compared to historical data.

Methods: Information regarding treatment modifications was collected prospectively during interdepartmental tumor conferences from March 18, 2020 to May 20, 2020. Information regarding patient demographics, tumor characteristics, and incidence of new cancer consultations was collected via chart review. Treatment modifications were categorized as follows: Elimination of Systemic Therapy, Treatment Delay, Change to Non-Surgical Management, or Alteration in Adjuvant Therapy. Rationales for modification were similarly grouped as follows: Operating Room Limitations, Medical Co-Morbidities, COVID-19 positive, Patient concern, or System limitations. We determined the rate of treatment modifications and the frequencies of rationales and modification types. Demographic and tumor characteristics were compared between this population and a retrospectively collected cohort from 2019.

Results: 117 patients were presented during the review period in 2020. There were 69 patients presented across the same time period in 2019. There were no differences in demographic characteristics between the groups. There was no difference between the tumor or nodal stages of the presented cases year over year. During the 2020 time period there were more total case presentations and new cancer cases compared to the 2019 time period. Of the 117 cases presented during the study period, there were 10/117 (8.4%) treatment modifications. The most common reason for modification was limited PPE supply. The most common modification was treatment delay. The second most common modification was change from primary surgical management to nonsurgical management. Treatment modifications occurred most commonly early in the review period and declined subsequently.

Conclusions: Despite the ongoing pandemic and resulting state and institutional restrictions, there was no appreciable reduction in new cancer consultations for head and neck cancer. There were a small number of treatment modifications, particularly early in the course of our state and institutional response to the virus. However, over the 2-month period examined, patient care for these patients remained largely unaffected. While the restriction in elective surgical care was implemented across the state of Maryland, the oncologic triage and emergency surgery prioritization sustained the volume of oncologic practice.

Citation Format: Joshua A. Thompson, Reju Joy, Joshua E. Lubek, Ranee Mehra, Jason K. Molitoris, Rodney J. Taylor, Jeffrey S. Wolf, Matthew E. Witek, Kyle M. Hatten. Evaluating the impact of the coronavirus (COVID-19) pandemic on treatment paradigms in head and neck cancer at a tertiary care hospital [abstract]. In: Proceedings of the AACR Virtual Meeting: COVID-19 and Cancer; 2020 Jul 20-22. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(18_Suppl):Abstract nr PO-017.

A Novel Device for Placement of a Secondary Tracheoesophageal Voice Prosthesis: A Preliminary Feasibility Study

BACKGROUND

Tracheoesophageal puncture (TEP) for post-laryngectomy speech rehabilitation can be performed at the time of laryngectomy (primary) or at a subsequent time (secondary). Traditionally, the secondary procedure is performed using a rigid esophagoscope. Diseases like esophageal stricture, limited neck extension, and soft-tissue fibrosis can make this procedure technically challenging or impossible. We developed a novel device to perform a secondary tracheoesophageal puncture using a flexible esophagoscope.

OBJECTIVE

To test the feasibility of a novel device used to create a secondary TEP in post-laryngectomy cadavers.

METHODS

In this study, we performed a total laryngectomy on 3 fresh cadavers to establish the feasibility of our prototype. In each cadaver, a flexible esophagoscope was passed into the pharynx with the prototype. The prototype was passed through a working port and deployed to distend the esophagus. The puncture was visualized and a wire was passed via the newly established fistula. The device was activated, securing the wire, and then the esophagoscope and device were removed.

RESULTS

There was 100% successful deployment of the prototype device, allowing rapid creation of the puncture and security of the guide wire in each cadaver. There was no evidence of collateral mucosal injury or esophageal perforation.

CONCLUSIONS

The prototype device offers an alternative method to safely and efficiently perform a secondary TEP without the requirement of rigid esophagoscopy which can sometimes be technically impossible in this patient population.

Retained crossbow bolt after penetrating facial trauma

We present an unusual case of a retained crossbow bolt in the maxillofacial area of a 31-year-old man. While crossbow injuries are rare, this case is of interest because otolaryngologists are often faced with treating retained foreign objects after penetrating facial trauma. These cases are difficult to manage because of the complexity and variety of injuries that can occur during both the initial trauma and the removal. We focus on the management of the bolt's removal and provide a brief discussion of the relevant literature on crossbow injuries to the head and neck.

The influence of intraoperative frozen section analysis in patients with total or extended maxillectomy

BACKGROUND

Intraoperative frozen sections and final pathology may influence treatment with regards to intraoperative and postoperative treatments, respectively.

STUDY DESIGN

A retrospective study comparing intraoperative frozen section analysis with final pathologic analysis in patients who had total or extended maxillectomies for malignant disease between 2008 and 2013.

RESULTS

Twenty-five patients met the inclusion criteria. The mean age was 67.8 years. The majority of patients (76%) had stage IV disease (American Joint Committee on Cancer [AJCC] staging). Intraoperative frozen sections were positive in 24% (n = 6) compared with 60% (n = 15) on final pathologic analysis. Frozen section analysis had a sensitivity of 40%. Positive margins were resected where possible, unless limited by proximity to vital structures. Patients were statistically more likely to follow a recommendation for adjuvant therapy (P < .05) compared with adjuvant chemotherapy (P > .05).

CONCLUSIONS

Intraoperative frozen section analyses are unreliable in predicting positive margins in patients with late-stage maxillary malignancies. Patients were more likely to accept adjuvant radiation than adjuvant chemotherapy.

Oropharyngeal cancer as a driver of racial outcome disparities in squamous cell carcinoma of the head and neck: 10-year experience at the University of Maryland Greenebaum Cancer Center

BACKGROUND

Racial outcome disparities have been observed in head and neck squamous cell carcinoma (HNSCC) with diminished survival for black patients compared with white patients.

METHODS

We retrospectively analyzed 1318 patients with primary HNSCC treated at the University of Maryland Greenebaum Cancer Center (UMGCC) from 2000 to 2010.

RESULTS

Of all the patients, 65.9% were white, 30.7% were black, and 3.3% were of other races. Black patients were less likely to present with oral cavity cancer, and more likely to present with laryngeal or hypopharyngeal cancers. White patients were more likely to have early stage disease, especially in the oral cavity. Black race was independently associated with worse overall survival (OS) in the entire cohort. Black patients had a significantly worse OS among oral cavity and oropharyngeal cancers, with the largest disparity in oropharyngeal cancer. However, in multivariate analysis, race was only still significant in oropharyngeal cancer.

CONCLUSION

We observed differences by race in distribution of disease site, stage, and OS. Survival disparity in the entire cohort was driven mostly by differences among oropharyngeal cancer.

Quality of life factors and survival after total or extended maxillectomy for sinonasal malignancies

PURPOSE

Total and extended maxillectomy results in significant morbidity that can have an effect on quality of life factors. Modern reconstructive techniques have ameliorated this effect, but they have not been quantified. The purpose of the present study was to evaluate the quality of life factors and survival of patients undergoing total or extended maxillectomy for malignant disease.

MATERIALS AND METHODS

A retrospective study was performed of all patients who had undergone total or extended maxillectomy at a tertiary care cancer center from January 2008 to May 2013. The minimum follow-up period was 6 months. The quality of life factors analyzed included swallowing function and diet consistency, pain control, and postoperative complications.

RESULTS

A total of 25 patients (13 women and 12 men) met the inclusion criteria. Using the American Joint Committee on Cancer staging system, 76% of the patients had stage IV disease. Of the 25 patients, 13 received a free tissue transfer, 11 an obturator flap, and 1 a regional flap. None of the patients with a free tissue transfer experienced failure. The tumor size had no systemic influence on the reconstructive method chosen (P = .32 to P = .98). The median follow-up period was 41 weeks (range 24 to 252). One death was recorded, and 10 patients were lost to follow-up. Eleven patients progressed to a regular diet. Fifteen patients required a tracheostomy, and all were decannulated at a mean of 14 days postoperatively. One patient had dental implants placed. The type of reconstruction did not influence swallowing function (P = .49) or long-term pain (P = .38). The mean pain score was 4.9 ± 2.7. Pain management proved difficult in 7 patients. Also, 6 patients developed a surgical site infection, 3 of whom required a return to the operating room. Seven patients were readmitted to the hospital for complications; however, the reconstructive method did not influence the incidence of complications (P = .64).

CONCLUSIONS

The inevitable morbidity, with respect to quality of life factors, that result from the disfiguring effects of total or extended maxillectomy can be deemed acceptable by patients. We recommend discussing all reconstructive options regarding the management of late-stage maxillary malignancies and the potential effect they can have on patients' quality of life.

Intraorbital erosion of a malar implant resulting in mastication-induced vision changes

Complications of cosmetic malar augmentation are uncommon. We describe the unusual case of a 60-year-old woman who experienced vision disturbances (flashing lights and diplopia) while masticating. Ten years earlier, she had undergone bilateral malar enhancement with silicone implants. Imaging studies revealed that the implant on the right side had become displaced. The prosthesis had entered the orbit in the retrobulbar area and eroded the lateral zygomaticomaxillary buttress and the orbital floor. Both implants were removed, and the patient's symptoms immediately resolved. To the best of our knowledge, no case of vision changes secondary to erosion of the posterior orbit by a silicone malar implant has been previously described in the literature.

Retained Crossbow Bolt after Penetrating Facial Trauma

Objective: 1) Describe a challenging case of removal of a retained crossbow bolt from the maxillofacial region. 2) Review the surgical management techniques. 3) Review of the literature on crossbow injuries to the head and neck.

Method: Case report is of a unique mechanism of penetrating maxillofacial trauma with retained foreign body threatening airway and neurovascular injury. Pertinent literature is reviewed.

Results: A 31-year-old man presented after being shot twice in the head with crossbow bolts. He was stable on clinical evaluation, and CT revealed an 8.5-cm retained crossbow bolt extending from the right infratemporal fossa through the pterygopalatine fossa, traversing the nasopharynx with the tip just medial to the left mandibular ramus. There was no apparent vascular injury on CT angiogram. After awake tracheostomy for airway control, the bolt was removed by mandibular swing approach combined with nasal endoscopic assistance. Postoperative course was uneventful and follow-up showed excellent wound healing without complications.

Conclusion: Otolaryngologists often encounter penetrating injuries and retained foreign bodies to the maxillofacial region. The unique shape of a crossbow bolt, along with threat of airway and neurovascular injury, created a management challenge. Herein we discuss various surgical approaches and review the literature on crossbow injuries to the head and neck.

Plasmacytoid dendritic cells accumulate and secrete interferon alpha in lymph nodes of HIV-1 patients

Circulating plasmacytoid dendritic cells (pDC) decline during HIV-1 infection, but at the same time they express markedly higher levels of interferon alpha (IFNalpha), which is associated with HIV-1 disease progression. Here we show an accumulation of pDC in lymph nodes (LN) of treatment-naïve HIV-1 patients. This phenomenon was associated with elevated expression of the LN homing marker, CCR7, on pDC in peripheral blood of HIV-1 patients, which conferred increased migratory capacity in response to CCR7 ligands in ex vivo functional assays. LN-homed pDC of HIV-1 patients presented higher CD40 and lower BDCA2 levels, but unchanged CD83 and CD86 expression. In addition, these cells expressed markedly higher amounts of IFNalpha compared to uninfected individuals, and were undergoing faster rates of cell death. These results demonstrate for the first time that in asymptomatic, untreated HIV-1 patients circulating pDC up-regulate CCR7 expression, accumulate in lymph nodes, and express high amounts of IFNalpha before undergoing cell death. Since IFNalpha inhibits cell proliferation and modulates immune responses, chronically high levels of this cytokine in LN of HIV-1 patients may impair differentiation and immune function of bystander CD4(+) T cells, thus playing into the mechanisms of AIDS immunopathogenesis.

FcgammaRIIIa polymorphisms and cetuximab induced cytotoxicity in squamous cell carcinoma of the head and neck

PURPOSE

The interaction of Fc fragments of antibodies with the Fcgamma receptors is an essential checkpoint in antibody-dependent cellular cytotoxicity (ADCC). Specific polymorphisms at position 158 enhance FcgammaRIIIa affinity for IgG1 and are associated with improved clinical outcome in lymphoma patients treated with IgG1 anti-CD20 antibody. The role of ADCC in the therapeutic effects of the alpha-epidermal growth factor receptor (EGFR) mAb, cetuximab, in patients with squamous cell carcinoma of the head and neck (SCCHN) is poorly defined. We employed three SCCHN cell lines to test two hypotheses: (1) SCCHN is susceptible to cetuximab-mediated ADCC, (2) efficacy of ADCC is associated with polymorphisms at position 158 of FcgammaRIIIa.

EXPERIMENTAL DESIGN

FcgammaRIIIa-158 polymorphisms were determined for healthy donors, and their purified NK cells were used as effector cells against three SCCHN cell lines in ADCC assays. Cytotoxicity levels were compared for each polymorphism class. Proliferation and cell cycle assays were done to examine the direct effects of cetuximab.

RESULTS

Our results indicate that SCCHN is susceptible to cetuximab-mediated ADCC in vitro. NK cytotoxic efficiency correlates with donor 158-polymorphisms in FcgammaRIIIa. Overall cytotoxicity was greatest for individuals having a single V allele when compared to homozygous F/F individuals; the cumulative percent cytotoxicity for each polymorphism among the cell lines was 58.2% V/V, 50.6% V/F, and 26.1% F/F (P < 0.001). Additionally, the presence of a V allele correlated with superior natural cytotoxicity against NK sensitive targets.

CONCLUSION

These data have both prognostic and therapeutic relevance and support the design of a prospective trial to determine the influence of FcgammaRIIIa polymorphisms on the clinical outcome of patients with SCCHN treated with alpha-EGFR mAbs.

MRSA with progression from otitis media and sphenoid sinusitis to clival osteomyelitis, pachymeningitis and abducens nerve palsy in an immunocompetent 10-year-old patient

A previously healthy 10-year-old patient with headache, otalgia, and hearing loss was diagnosed with pachymeningitis and methicillin-resistant Staphylococcus aureus otitis media and bacteremia. Despite antimicrobial therapy, intracranial extension progressed, including clival osteomyelitis, sphenoid sinusitis, cavernous sinus inflammation and cranial nerve palsies, until the sphenoid sinus was drained. This case exemplifies an aggressive MRSA intracranial infection that advanced despite antibiotic therapy.

Oral lactoferrin results in T cell-dependent tumor inhibition of head and neck squamous cell carcinoma in vivo

PURPOSE

Human lactoferrin is a naturally occurring glycoprotein that inhibits cancer growth. Our purpose was to evaluate recombinant human lactoferrin as a chemotherapeutic agent against head and neck squamous cell carcinoma.

EXPERIMENTAL DESIGN

Controlled experiments both in vitro and in the murine model evaluating both the effect and mechanism of lactoferrin on cancer growth.

RESULTS

In both human and murine cell lines, lactoferrin induced dose-dependent growth inhibition. Using flow cytometric analysis, lactoferrin was shown to induce G(1)-G(0) growth arrest. This arrest seemed to be modulated by down-regulation of cyclin D1. In the in vitro model, luminex data revealed that lactoferrin inhibited cellular release of proinflammatory and prometastatic cytokines, including interleukin-8, interleukin-6, granulocyte macrophage colony-stimulating factor, and tumor necrosis factor-alpha. Lactoferrin up-regulated the cellular activation of nuclear factor-kappaB within 4 h of cellular exposure. In C3h/HeJ mice implanted with SCCVII tumors, orally delivered lactoferrin inhibited tumor growth by 75% compared with control mice. Immunohistochemical analysis of harvested tumors revealed up to 20-fold increases of lymphocytes within treated animals. When mice were depleted of CD3(+) cells, all lactoferrin-induced tumor inhibition was abrogated.

CONCLUSION

We conclude that human recombinant lactoferrin can inhibit the growth of head and neck squamous cell carcinoma via direct cellular inhibition as well as systemically via immunomodulation. Our data support the study of human lactoferrin as an immunomodulatory compound with therapeutic potential.

Immune reconstitution inflammatory syndrome presenting as sinusitis with inflammatory pseudotumor in an HIV-infected patient: a case report and review of the literature

Immune reconstitution inflammatory syndrome (IRIS) encompasses a variety of conditions that occur among HIV-infected patients in a temporal relationship with increases in CD4 cell count as a result of highly active antiretroviral therapy (HAART). Most conditions associated with IRIS are infectious. Malignancies, such as Kaposi's sarcoma, have also been reported. We report a case of sinusitis with presumptive inflammatory pseudotumor as a manifestation of IRIS that occurred 20 weeks after the initiation of HAART.

Informed Consent in Sinus Surgery: Link between Demographics and Patient Desires

OBJECTIVE

To evaluate and understand differences in expectations according to patient demographics during the informed consent process for functional endoscopic sinus surgery (FESS).

STUDY DESIGN

Multi-institutional, cross-sectional survey design.

METHODS

Anonymous surveys were administered to patients in two tertiary academic centers with a chief complaints relating to "allergy and sinus" problems. Patients completed and eight-item questionnaire that assessed demographics and the nature and level of risks that patients wished to be informed of before FESS. Univariate and multivariate analyses were performed to assess for differences in patient desires related to FESS risks according to demographics.

RESULTS

Three hundred eighty-nine completed surveys were analyzed. Younger patients (P = .049), white patients (P = .0026), and more educated patients (P = .0033) wished to know about complications at the lowest risks levels (lowest incidence), regardless of severity. With regards to specific complications, black patients and patients with less formal education were less interested in being informed about the potential risks of orbital complications, cerebrospinal fluid leak, or possible need for revision surgery. Multivariate analysis confirmed that race, education, age were independently significant factors in determining response.

CONCLUSION

Demographic-related differences exist in patient's desires and expectations in the informed consent process for a sinus procedure. Physicians should be aware of these differences when counseling patients about sinus surgery. More research is needed to elucidate the factors that underlie the observed differences.

Informed consent in endoscopic sinus surgery: the patient perspective

OBJECTIVES

To understand patient expectations during the informed consent process for functional endoscopic sinus surgery (FESS).

STUDY DESIGN

Multi-institutional, cross-sectional survey design.

METHODS

Anonymous surveys were administered to patients in two tertiary academic centers with a chief complaint relating to "allergy and sinus" problems. Patients completed an eight-item questionnaire that assessed both the nature and the level of risks that they wished to be informed of prior to FESS.

RESULTS

Three hundred eighty-nine surveys were returned. Sixty-nine percent of patients wished to be informed of complications that occur as infrequently as 1 in 100 cases, regardless of severity. Ninety percent of patients wanted to know of a risk that occurred as frequently as 1 in 10 cases. Patients also reported whether or not they wished to be told in detail about specific complications during the informed consent process, regardless of their infrequency. Affirmative responses were as follows: 83% for cerebrospinal fluid leak and orbital injury, 81% for infection, 76% for revision surgery, 74% for impairment of smell, 73% for bleeding and myocardial infarction, 72% for cerebrovascular accident, and 58% for scarring.

CONCLUSIONS

Patients wanted to be informed about severe FESS complications at a higher rate than physicians previously surveyed, even if the incidence is low. This study, combined with our previous examination of the physicians' perspective, highlights that there may be a discrepancy between what the physician and the patient believe are priority topics during the informed consent process.

Inflammatory myofibroblastic tumor of the larynx in a 2-year-old male

Inflammatory myofibroblastic tumor (IMT) is an uncommon neoplasm that is usually located in the lung in the pediatric population. These tumors contain a variety of cell types with the myofibroblast being dominant. When located in the upper airway, IMTs tend to be less aggressive, but have the potential for local invasion and recurrence. We present an unusual case of IMT in the pediatric larynx and review the medical literature describing the common locations, diagnosis, etiology, histology, and treatment of this tumor. The mainstay of treatment is complete surgical excision. Careful and frequent follow-up including frequent fiberoptic laryngoscopy and CT scans are recommended to evaluate for recurrence. More aggressive resection may be necessary if multiple recurrences occur.

Oral lactoferrin inhibits growth of established tumors and potentiates conventional chemotherapy

In this work, we investigated the anticancer activity of orally administered recombinant human lactoferrin (rhLF) alone and in combination with chemotherapy in tumor-bearing mice. rhLF inhibited the growth of squamous cell carcinoma (O12) tumors in T cell-immunocompromised nu/nu mice by 80% when administered at 1,000 mg/kg (2.9 g/m2) by oral gavage twice daily for 8 days (p < 0.001). Similar activity was observed in syngeneic, immunocompetent BALB/c mice, where orally administered rhLF (1,000 mg/kg, 2.9 g/m2 once daily) halted the growth of mammary adenocarcinoma TUBO. Oral rhLF (200 mg/kg, 0.57 g/m2) was also used alone and in combination with cis-platinum (5 mg/kg) to treat head-and-neck squamous cell carcinoma in a syngeneic murine model. Monotherapy with oral rhLF or cis-platinum caused 61% or 66% tumor growth inhibition over placebo, respectively. Mice receiving both therapies showed 79% growth inhibition, a statistically significant improvement over each drug alone. We then demonstrated that administration of oral rhLF (300 mg/kg, 0.86 g/m2) to tumor-bearing or naive mice resulted in (i) significantly increased production of IL-18 in the intestinal tract, (ii) systemic NK cell activation and (iii) circulating CD8+ T-cell expansion. These data suggest that oral rhLF is an immunomodulatory agent active against cancer as a single agent and in combination chemotherapy, exerting its systemic effect through stimulation of IL-18 and other cytokines in the gut enterocytes. rhLF has been administered orally to 211 people without a single serious drug-related adverse event. Thus, rhLF shows promise as a safe and well-tolerated novel immunomodulatory anticancer agent.

Lactoferrin Inhibits Growth of Malignant Tumors of the Head and Neck

Lactoferrin, a naturally occurring glycoprotein found in breast milk, has previously been shown to have antimicrobial properties and recently has been demonstrated to inhibit malignant tumor growth, presumably through immunomodulation. We hypothesized that intratumoral injection of human and murine recombinant lactoferrin would decrease the growth of malignant tumors in vivo. Using an orthotopic murine model for both squamous cell carcinoma and fibrosarcoma of the floor of the mouth, we administered lactoferrin directly into the tumors using variable dosing strategies. Additionally, we performed in vitro experiments to assess whether the effects of lactoferrin are due to direct cytotoxicity. Our results revealed growth inhibition of 50% (p=0.03)and 54% (p=0.01) as compared with controls for both human and murine tumor cells in immunodeficient and immunocompetent mice, respectively. There was a more dramatic effect in immunocompetent models which may identify immunomodulation as an important mechanism of action for lactoferrin. Support for immunomodulation as a possible mechanism was the lack of any difference between controls and the experimental groups in vitro. Lactoferrin proved effective in reducing malignant tumor growth in a murine model. These properties offer hope for its use as a primary or adjuvant chemotherapeutic agent. Further investigation focused on mechanism and delivery is needed.

Surface modification to improve in vitro attachment and proliferation of human urinary tract cells

OBJECTIVE

To evaluate the attachment and proliferation of cultured human urinary tract cells to culture plates surface-modified by photochemical immobilization of extracellular matrix (ECM) proteins.

MATERIALS AND METHODS

Human uroepithelial (UEC) and smooth muscle (SMC) cells were harvested from ureter and expanded in culture; 24-well culture plates surface-modified by photochemical covalent immobilization of ECM proteins were then seeded with UEC or SMC. To characterize cellular attachment, cells were incubated on surface-modified plates for 30 and 90 min. For proliferation assays the cells were incubated for 3-12 days. Standard tissue culture plates with no surface modification and sham-modified plates served as controls. Differential attachment and proliferation on the various surfaces were assessed using analysis of variance with Fisher's posthoc test for multiple comparisons.

RESULTS

Attachment at 30 and 90 min of both UEC and SMC on plates surface-modified with ECM proteins was significantly greater than in control plates. Surface-modification with collagen resulted in significantly greater cellular attachment than with either laminin or fibronectin. UEC proliferation was also significantly greater than in control plates by surface-modification with collagen and fibronectin, but not with laminin. SMC proliferation was significantly better after surface modification than on sham- modified plates, but was no better than standard plates.

CONCLUSIONS

Covalent photochemical immobilization of ECM proteins to potential growth surfaces enhances the attachment of cultured UEC and SMC and the proliferation of UEC. This technique might be useful in modifying surface properties of synthetic polymer-based materials in a controlled and defined manner, giving them the capacity to promote and sustain the growth of urinary tract cells. This may lead to development of alternative methods of tissue engineering in the urinary tract.

Informed consent in functional endoscopic sinus surgery

OBJECTIVES

Functional endoscopic sinus surgery (FESS) is one of the more common procedures performed by otolaryngologists. Before performing FESS, surgeons are obligated to discuss the procedure and its risks through the process of informed patient consent. The study identifies current practices in informed consent for FESS and formulates guidelines for informed consent for FESS.

STUDY DESIGN

Survey.

METHODS

Surveys were sent to 1000 American Academy of Otolaryngology-Head and Neck Surgery members in the United States. Surveys inquired about current informed consent practices related to FESS.

RESULTS

Three hundred forty-six surveys were returned. Nearly 60% of respondents thought that 1% incidence of a complication warrants a discussion with patients. The percentage of respondents who discuss specific risks were as follows: bleeding, 96.7%; infection, 84.8%; cerebrospinal fluid leak, 99.1%; orbital injury, 96.7%; smell changes, 40.2%; cerebrovascular accident, 17.9%; myocardial infarction, 81%; and death, 28.0%.

CONCLUSIONS

The study suggests that there is variability in specific informed consent practices for FESS among otolaryngologists. It also suggests that the incidence or severity of a complication does not necessarily correlate with whether or not it is mentioned during the informed consent process. The authors think that practicing otolaryngologists may be able to use this information to improve their consent practices.

Flexible ureteroscopy in conjunction with in situ lithotripsy for lower pole calculi

OBJECTIVES

To demonstrate the efficacy and safety of ureteroscopy as a compromise in treating small and intermediate-size lower pole calculi. The optimal management of lower pole calculi remains controversial. Shock wave lithotripsy is associated with minimal morbidity but with suboptimal stone clearance rates. Conversely, percutaneous nephrostolithotomy has greater morbidity but stone-free rates greater than 90% regardless of size.

METHODS

Seventy-two patients underwent ureteroscopy for lower pole calculi 2 cm or less (mean 8.7 mm) during a 3-year period. To minimize confounding, 11 patients with additional calculi at other ipsilateral renal sites and 1 patient with large (2.4 cm each) bilateral calculi were excluded. Two patients with bilateral lower pole calculi and four who required a second procedure were included in the analysis. Thus, the final cohort consisted of 60 patients who underwent 66 procedures.

RESULTS

Of patients with follow-up longer than 1 month, 79% were stone free after a single procedure, and this improved to 88% after a second procedure in 4 patients. All 7 patients with follow-up less than 1 month had a reduction in stone burden after successful fragmentation. Overall, 8 patients required an auxiliary procedure. No intraoperative complications, and 7 (11%) postoperative complications occurred.

CONCLUSIONS

Ureteroscopy for lower pole calculi is associated with minimal morbidity and stone-free rates comparable to shock wave lithotripsy for smaller stones. The greatest utility of ureteroscopy is in the management of intermediate-size calculi, for which it has substantially higher stone-free rates and lower repeated treatment rates than does shock wave lithotripsy.

A canine model to assess the biochemical stress response to laparoscopic and open surgery

PURPOSE

To develop an animal model to assess the stress response to open and laparoscopic surgery. Such a model would allow objective physiologic assessment of the putative benefits of laparoscopy and provide a framework in which to compare modifications in operative and anesthetic technique that might decrease the stress of surgery.

MATERIALS AND METHODS

Mongrel dogs underwent laparoscopic (N = 12) or open surgical (N = 12) left nephrectomy. In 11 control animals, after induction of anesthesia and line placement, the animal underwent either no intervention (open surgery sham; N = 6) or pneumoperitoneum only (laparoscopic sham; N = 5). Serum glucose and cortisol were measured preoperatively, at skin closure, and at 4, 8, and 24 hours postoperatively. Values at each time point were compared in the laparoscopic and open surgical nephrectomy groups and in each of the two nephrectomy groups and their respective shams.

RESULTS

Compared with baseline, there was a sharp rise in serum cortisol at the time of skin closure, with a gradual decline to baseline values by 24 hours, in all experimental animals. Significantly lower serum cortisol concentrations were seen at 4 and 8 hours postoperatively in the laparoscopic group than in the open surgery group. Cortisol was significantly higher in the open group than in the sham-open group at all time points, whereas cortisol was greater in the laparoscopic group than in the pneumoperitoneum-only group only at the 4-hour time point. No differences were seen in serum glucose between groups.

CONCLUSIONS

The serum cortisol concentration appears to be a good measure of surgical stress in the canine model. The rapid decline in serum cortisol after laparoscopy compared with open surgery may indicate a lesser degree, or quicker resolution, of surgical stress in the former. Furthermore, the similarity in cortisol curves between laparoscopy and pneumoperitoneum only suggests that surgical stress in laparoscopic surgery may be attributable mainly to the effects of pneumoperitoneum.

Prospective randomized trial comparing shock wave lithotripsy and ureteroscopy for management of distal ureteral calculi

PURPOSE

We compared the efficacy of shock wave lithotripsy and ureteroscopy for treatment of distal ureteral calculi.

MATERIALS AND METHODS

A total of 64 patients with solitary, radiopaque distal ureteral calculi 15 mm. or less in largest diameter were randomized to treatment with shock wave lithotripsy (32) using an HM3 lithotriptor (Dornier MedTech, Kennesaw, Georgia) or ureteroscopy (32). Patient and stone characteristics, treatment parameters, clinical outcomes, patient satisfaction and cost were assessed for each group.

RESULTS

The 2 groups were comparable in regard to patient age, sex, body mass index, stone size, degree of hydronephrosis and time to treatment. Procedural and operating room times were statistically significantly shorter for the shock wave lithotripsy compared to the ureteroscopy group (34 and 72 versus 65 and 97 minutes, respectively). In addition, 94% of patients who underwent shock wave lithotripsy versus 75% who underwent ureteroscopy were discharged home the day of procedure. At a mean followup of 21 and 24 days for shock wave lithotripsy and ureteroscopy, respectively, 91% of patients in each group had undergone imaging with a plain abdominal radiograph, and all studies showed resolution of the target stone. Minor complications occurred in 9% and 25% of the shock wave lithotripsy and ureteroscopy groups, respectively (p value was not significant). No ureteral perforation or stricture occurred in the ureteroscopy group. Postoperative flank pain and dysuria were more severe in the ureteroscopy than shock wave lithotripsy group, although the differences were not statistically significant. Patient satisfaction was high, including 94% for shock wave lithotripsy and 87% for ureteroscopy (p value not significant). Cost favored ureteroscopy by $1,255 if outpatient treatment for both modalities was assumed.

CONCLUSIONS

Ureteroscopy and shock wave lithotripsy were associated with high success and low complication rates. However, shock wave lithotripsy required significantly less operating time, was more often performed on an outpatient basis, and showed a trend towards less flank pain and dysuria, fewer complications and quicker convalescence. Patient satisfaction was uniformly high in both groups. Although ureteroscopy and shock wave lithotripsy are highly effective for treatment of distal ureteral stones, we believe that HM3 shock wave lithotripsy, albeit slightly more costly, is preferable to manipulation with ureteroscopy since it is equally efficacious, more efficient and less morbid.

Comparison of outcomes of ureteroscopy for ureteral calculi located above and below the pelvic brim

OBJECTIVES

To compare the safety and efficacy of ureteroscopy performed for proximal and distal ureteral calculi in a contemporary cohort. Ureteroscopy has been used most often for distal ureteral calculi. However, advances in endoscopic equipment have facilitated access to the proximal urinary tract and have broadened the indications for ureteroscopy.

METHODS

One hundred ninety-one patients underwent rigid and/or flexible ureteroscopy for ureteral calculi at the University of Michigan between January 1, 1997 and September 30, 1999. Only 7 patients with either bilateral calculi or steinstrasse were excluded. The final cohort consisted of 184 patients who underwent ureteroscopy for distal stones (n = 103) or middle/upper ureteral stones (n = 81).

RESULTS

Bivariate analyses of pretreatment and perioperative characteristics were used to assess the sample population. The initial success rate for the distal and proximal ureteral calculi was 96% and 78%, respectively (P = 0.0008). After a "second-look" procedure in 4 and 7 patients with distal and proximal calculi, respectively, the success rate improved to 99% and 88%, respectively (P = 0.004). No differences were noted between groups regarding the intraoperative (P = 0.51) or postoperative (P = 0.85) complication rates. Multivariate logistic regression analysis confirmed that larger stone size (odds ratio 1.2, P = 0.0006) and proximal ureteral location (odds ratio 4.8, P = 0.01) are independent predictors of treatment failure.

CONCLUSIONS

Ureteroscopic management of proximal and distal ureteral calculi is highly successful, and the difference in success rates has narrowed substantially. Currently, no greater risk is conferred to the patient for endoscopy of more proximal ureteral calculi.

IL (interleukin)-1alpha promotes nuclear factor-kappaB and AP-1-induced IL-8 expression, cell survival, and proliferation in head and neck squamous cell carcinomas

Interleukin 1alpha (IL-1alpha) is an important regulatory cytokine, the release of which after an injury can induce activation of transcription factors nuclear factor (NF)kappaB and activator protein (AP-1), which promote expression of genes involved in cell survival, proliferation, and angiogenesis. IL-1alpha is expressed autonomously by head and neck squamous cell carcinomas (HNSCCs) and a variety of other cancers, raising the possibility that IL-1alpha may serve as an autocrine factor that stimulates the activation of prosurvival transcription factors and target genes in cancer. In this study, we examined the role of IL-1alpha in the activation of NFkappaB and AP-1, the expression of proangiogenic cytokine IL-8, and in the survival and proliferation of HNSCC cell lines. HNSCCs were found to secrete and respond to functional IL-1alpha, in that culture supernatant from a high IL-1alpha-secreting line, UM-SCC-11B, could induce secretion of cytokine IL-8 by a low IL-1alpha-secreting line, UM-SCC-9; and the induction of IL-8 secretion could be blocked by the anti-IL-1alpha-neutralizing antibody or the IL-1 receptor antagonist (IL-1RA). Furthermore, IL-1alpha could induce the expression of IL-8 through an autocrine mechanism, in that transfection of UM-SCC-9 cells with a plasmid encoding IL-1alpha resulted in the increased coexpression of IL-1alpha and IL-8; whereas transfection with a plasmid encoding IL-1RA lacking the secretory leader sequence led to the decreased coexpression of IL-1alpha and IL-8. IL-1alpha was found to induce coexpression of IL-8 through the activation of NFkappaB and AP-1, in that mutation of the NFkappaB site within the IL-8 promoter abolished autocrine- and recombinant IL-1alpha-induced IL-8 reporter gene activity, whereas mutation in AP-1 partially decreased IL-8 reporter gene activity in UM-SCC-9 cells. Intracellular expression of IL-1RA decreased NFkappaB reporter gene activity, indicating that endogenously expressed IL-1alpha contributes to constitutive NFkappaB activation in this HNSCC line. Expression of IL-1alpha affected survival of UM-SCC-9, inasmuch as transfection of cells with plasmid encoding IL-1alpha or IL-1RA led to the increased or decreased survival of cells cotransfected with a beta-galactosidase reporter gene, respectively. IL-1alpha was also found to promote the increased growth of UM-SCC-9 cells in vitro. We demonstrate that exogenous and endogenous IL-1alpha contributes to the transcriptional activation of NFkappaB and AP-1, to the expression of IL-8, and to cell survival and the growth of HNSCC in vitro.

Comparison of shockwave lithotripsy outcomes in patients receiving sufentanil or lidocaine spinal anesthesia

PURPOSE

To determine whether the use of intrathecal sufentanil, which allows the patient to move during shockwave lithostripsy (SWL), affects treatment outcomes and operative and recovery times compared with standard lidocaine spinal anesthesia.

PATIENTS AND METHODS

We retrospectively studied a series of 62 SWL procedures performed on an unmodified Dornier HM3 lithotripter. The mean calculus size was 10.7 mm. There were 46 renal calculi, 13 ureteral calculi, and 4 patients with calculi in both locations. Of the 63 procedures, 25 were performed using intrathecal sufentanil alone, and 37 were performed with intrathecal lidocaine with or without additional agents. We compared treatment outcomes, as well as treatment time, fluoroscopy time, postanesthesia care unit (PACU) time, time to voiding, and time to ambulation.

RESULTS

Sufentanil use was associated with a significantly higher rate of successful treatment, defined as residual fragments absent or <4 mm on follow-up imaging, compared with lodocaine: 68% v. 40% (p = 0.0394). There was no significant difference between the groups in treatment time or fluoroscopy time. Use of sufentanil was associated with significantly shorter PACU time, time to ambulation, and time to voiding postoperatively. These differences persisted when men and women were analyzed separately, although the differences were less significant in women.

CONCLUSIONS

The use of intrathecal sufentanil for anesthesia during SWL does not adversely affect treatment outcome; it is, in fact, associated with better outcomes. The advantages of this agent in shortening recovery times and in easing patient transfer into the HM3 gantry argue for increasing its use.

Indications, technique, and results of laparoscopic pelvic lymphadenectomy

Despite considerable clinical research, there is still controversy about the optimal management of the pelvic lymph nodes in men with prostate cancer. This article reviews the creation and application of selection criteria for laparoscopic pelvic lymphadenectomy and describes the various techniques.

Laparascopic partial nephrectomy

The role of laparoscopy in urologic surgery has greatly increased over the past decade as has the popularity of elective nephron-sparing surgery. The emergence of these trends in conjunction with improvements in equipment and expertise has led to the increasing application of laparoscopic partial nephrectomy. Initially, this modality was applied in patients with benign diseases, such as chronic pyelonephritis and calculus disease with associated atrophy. Concerns of tumor spillage and local-regional control precluded the application of the laparoscopic modality to small, indeterminate renal masses. However, increasing experience with the technique and advances in intraoperative imaging have prompted its use in removing small renal masses. Herein, we describe the indications for laparoscopic partial nephrectomy, the two approaches (transperitoneal and extraperitoneal) to gain access to the kidney, current options to assist in controlling intraoperative hemorrhage, a comprehensive assessment of the results for benign and malignant resections, and an examination of the similarities and contrasts between open and laparoscopic techniques.

Routine placement of ureteral stents is unnecessary after ureteroscopy for urinary calculi

OBJECTIVES

To report a matched comparison of patients with and without stenting after ureteroscopy for calculi, including middle or proximal ureteral and renal calculi. The elimination of routine stenting after ureteroscopy would prevent stent pain, minimize the need for re-instrumentation, and reduce costs-as long as efficacy and safety are not diminished.

METHODS

Of 318 patients who underwent ureteroscopy, 81 (25%) did not have a ureteral stent placed. Of those, 51 were suitable for analysis and included patients with distal ureteral (n = 22), middle or proximal ureteral (n = 11), and renal calculi (n = 18). This cohort was matched to a stented group by stone size and location.

RESULTS

The preoperative characteristics of the groups were similar. A stone-free rate of 86% and 94% was achieved in the stented and nonstented groups, respectively (P = 0.32). Complications in the nonstented group were less frequent (flank pain in 3 and postoperative nausea in 1) than in the stented group (hospital visits for flank pain in 12, persistent nausea and vomiting in 1, sepsis in 1, perinephric hematoma in 1, and urinary retention in 1) (total of 4 versus 16, P = 0.025).

CONCLUSIONS

Ureteroscopy for distal ureteral stones without ureteral stent placement has been previously described. Our experience expands to include the elimination of stent placement after ureteroscopy for middle or proximal ureteral (22%) and renal (35%) calculi. Our data suggest that after ureteroscopies with short operative times and minimal ureteral trauma, ureteral stents may not be necessary, even if proximal ureteral or renal ureteroscopy has been performed.

Functional effects of unilateral laser papillectomy in the pig

OBJECTIVES

To evaluate the use of endoscopic laser papillectomy in a multi-papillary animal model to unilaterally impair concentrating ability and increase the urinary flow rate.

METHODS

Domestic pigs underwent unilateral retrograde flexible nephroscopy. With a holmium:yttrium-aluminum-garnet laser, varying numbers of papillae were ablated. Four weeks after the procedure, renal function studies were performed during hydropenia and after hydration, the animals were killed, and the kidneys were examined histologically.

RESULTS

The urine flow rate per 100 mL creatinine clearance was significantly increased in the papillectomized kidney compared with the control kidney during hydropenia (1.50 versus 0.94, P <0.01). The papillectomized kidneys were unable to concentrate the urine as well as the control kidneys during both hydropenia (urine osmolarity 430 versus 534 mOsm/L, P <0.01) and after hydration (329 versus 362 mOsm/L, P = 0.02). The free water reabsorption per 100 mL creatinine clearance was impaired in the papillectomized kidneys compared with the control kidneys (0.48 versus 1.00, P = 0.02) after hydration. A significant correlation existed between the percentage of papillae ablated and the difference in osmolarity between the operated and control kidneys (r(2) = 0.50, P = 0.015). Histologic examination demonstrated transitional re-epithelialization with moderate collecting duct dilation and medullary fibrosis underlying the ablated papillae early in the series; however, the histologic features normalized and the creatinine clearance was less impaired with a more proficient technique later in the series.

CONCLUSIONS

Endoscopic laser papillectomy results in increased urine flow and impaired urinary concentrating ability. This surgical technique should be investigated further for its role in the prevention of nephrolithiasis.

Comparison of 2-octyl cyanoacrylate adhesive, fibrin glue, and suturing for wound closure in the porcine urinary tract

OBJECTIVES

To evaluate 2-octyl cyanoacrylate glue (OCG) for wound closure in the urinary tract and compare the ability of OCG, fibrin glue (FG), and suture to withstand physiologic and supraphysiologic stress, because the use of tissue adhesives such as OCG or FG might simplify laparoscopic surgery.

METHODS

Female domestic pigs (n = 22) underwent a 7.5-cm cystotomy. Of these, 8 had closure with OCG and 8 with FG (6 open and 2 laparoscopic in each group). The controls were closed with suture (n = 4) or not at all (n = 2). Postoperative catheter drainage was not used. At 2 days or 4 weeks postoperatively, the bladders were filled with saline to 200 mm Hg pressure and the cystotomy scars inspected for leakage. The excised scars were also examined histologically.

RESULTS

The 2 OCG and 2 FG pigs tested on postoperative day 2 leaked at less than 200 mm Hg. None of the 6 OCG pigs tested at 4 weeks leaked at less than 200 mm Hg, including the 2 closed laparoscopically. Of the 6 FG pigs intended for study at 4 weeks, 3 (including the 2 closed laparoscopically) died from a massive urine leak, 1 tested at 4 weeks leaked, and 2 did not leak. Thus, 4 of 6 FG pigs leaked by 4 weeks compared with none in the OCG group (P = 0.06). The histologic examination was similar in the two groups.

CONCLUSIONS

Preliminary results suggest that OCG provides enough strength to hold together a large bladder wound. In the same model, FG did not consistently provide adequate closure.

Laparoscopic access with a visualizing trocar

Although useful in most situations, there are several inherent disadvantages of the standard laparoscopic access techniques of Veress needle insertion and Hasson-type cannula placement. Veress needle placement may be hazardous in patients at high risk for intraabdominal adhesions and difficult in patients who are obese. The usual alternative, the Hasson-type cannula, often does not provide a good gas seal. As another option, the use of a visualizing trocar (OPTIVIEW) has proven to be effective in the initial experience at the University of Michigan. The inner trocar of the visualizing trocar is hollow except for a clear plastic conical tip with two external ridges. The trocar-cannula assembly is passed through tissue layers to enter the operative space under direct vision from a 10-mm zero-degree laparoscope placed into the trocar. Results suggest that this technique is an excellent alternative to Veress needle placement when laparoscopic access is likely to be hazardous or difficult.

Hand-assisted laparoscopic nephrectomy: technical considerations

PURPOSE

Laparoscopic nephrectomy can be technically difficult and associated with lengthy operative times because of the limitations imposed by working with long instruments rotating about a fixed site on the abdominal wall, and without direct manual contact with the tissue. Hand-assisted laparoscopy is an option that addresses these problems. Herein we report our initial technique for hand-assisted laparoscopic nephrectomy.

TECHNIQUE

After obtaining pneumoperitoneum and placing a 12-mm cannula lateral to the rectus muscle, a 7- to 8-cm incision is made in the upper midline. A commercially available wound protector and occlusive sleeve are inserted. Once an arm strap has been secured, the surgeon can operate with one hand in the abdomen while maintaining pneumoperitoneum. Using instruments placed through one or two additional laparoscopic ports, the nephrectomy is completed and the specimen is removed through the upper midline incision. Our continued experience with 10 hand-assisted laparoscopic nephrectomies to date has been favorable.

CONCLUSION

Hand-assisted laparoscopic nephrectomy may facilitate the laparoscopic management of demanding pathologies, such as severely inflamed kidneys and larger tumors. It is particularly advantageous when intact specimens are required. Although more experience is required to define the role of hand-assisted urologic laparoscopy, we are encouraged by our initial technique and results.

Fragment of a catheter as a foreign body in the kidney

Foreign bodies in the kidney are unusual. A review of the literature disclosed few reports of renal foreign body from nontraumatic causes. In this article, we report a case of gross hematuria due to iatrogenic foreign body in the kidney from ureteral endoscopy. The catheter fragment eluded diagnosis for 18 months until it was discovered and retrieved by means of a flexible ureteroscope. To our knowledge, this is the first report of this complication and presentation following endoscopic manipulation of the upper ureteral tract.