Laparoskopinė urachus cistų ir sinuso šalinimo operacija: du klinikiniai atvejai ir literatūros apžvalga

ĮžangaEmbrioninio šlapimo latako (urachus) anomalijos yra retos. Infekcija yra dažniausia jų komplikacija ir simptomų pasireiškimo priežastis. Simptomines urachus anomalijas reikia šalinti. Mes aprašome du klinikinius atvejus, kai sėkmingai pašalinta urachus cista ir sinusas laparoskopinės operacijos būdu. Mūsų turimais duomenimis, Lietuvoje atliktos pirmosios tokio pobūdžio operacijos.Atvejų pristatymasPirmas atvejis yra 55 metų amžiaus moters, kuri paguldyta į ligoninę dėl du mėnesius trunkančio padažnėjusio šlapinimosi. Atlikus pilvo echoskopiją, klaidingai nustatyta dešinės kiaušidės cistadenoma. Urachus cista buvo aptikta atlikus diagnostinę laparoskopiją, pilvo ir dubens kompiuterinę tomografiją. Antras atvejis yra 22 metų moters, kuri paguldyta į ligoninę dėl 10 dienų trunkančio pilvo skausmo ir bambos šlapiavimo. Pilvo echoskopijos metu žemiau bambos po pilvo siena buvo rastos dvi cistos – viena iš jų netoli šlapimo pūslės, kita atsiverianti į bambą. Remiantis atliktais tyrimais diagnozuota urachus cista ir sinusas. Abiem atvejais buvo atliktos laparoskopinės urachus cistų ir sinuso ekscizijos.IšvadosDaugelį metų urachus anomalijos buvo operuojamos atviruoju būdu, tačiau laparoskopinė operacija tapo gera alternatyva atvirosioms dėl silpnesnio pooperacinio skausmo, mažesnių randų, greitesnio sveikimo.Reikšminiai žodžiai: urachus cista, urachus sinusas, ekscizija, laparoskopinė operacija.Laparoscopic excision of urachal cysts and sinus: report of two cases and review of the literature IntroductionUrachal abnormalities are rare. Usually, they are incidental findings and remain asymptomatic unless a complication (most commonly infection) occurs. A complicated urachal anomaly needs to be removed. We introduce two successful case reports, according to our data the first laparoscopic urachal remnant excision in Lithuania.Cases presentationIn the first case, 55-year-old female patient presented with a two-month history of dysuria. Abdominal ultrasonography misdiagnosed the right ovarian cyst. Diagnostic laparoscopy and pelvic computer tomography showed an urachal cyst. In the second case, a 22-year-old female patient presented with a ten-day history of abdominal pain and umbilical discharge. Abdominal ultrasonography showed two cysts (the first cyst was found near the urinary bladder and the second cyst was connected with the umbilicus) under the anterior abdominal wall. According to clinical symptoms and ultrasound findings, urachus sinus and cyst were diagnosed. Laparoscopic urachal anomaly excision operations were performed to both patients.ConclusionsLaparoscopy is an effective and safe minimally invasive technique in the management of urachal anomalies. Open surgical excision has been the treatment of choice for many years, but the laparoscopic approach has become an attractive alternative because of less postoperative pain, better cosmetics, and rapid convalescence.Key words: urachal cyst, urachal sinus, excision, laparoscopic surgery

Tiesiosios žarnos iškritimo chirurginis gydymas – vieno centro patirtis

BackgroundNo consensus on the optimal procedure for repair of rectal prolapse (RP) exist. We present the results of our 10 year experience of Vilnius University Hospital Santariskiu Klinikos.Patients and methodsRetrospective review was performed of the patients, operated on for rectal prolapse between 2005 and 2016. Patients were divided into two groups – internal recal prolapse (IRP) and complete rectal prolapse (CRP). Perioperative data between two groups were analysed. Statistical data analysis was carried out using the SPSS 20.0 software. To assess the difference between rectal prolapse groups of statistical methods the χ2 test was used. Data were considered statistically significant at p < 0.05.Results89 patients between 2005 and 2016 underwent surgical treatment for rectal prolapse at our department. IRP group included 52 (58,4%), CRP – 37 (41,6%) patients. The male/female ratio was 1/6,4, the mean age was 58,3±15,2 years. Defecography was performed for 29 (32,6%)patients in IRP group and for 12 (13,5%) – in CRP group (p<0,001). 7 (7,9%) patients in CRP group had previous surgical procedure for RP while in IRP group there were none (p=0,02). The most common management of IRP included 6 strategies (n=25, 67,5% of group); of CRP – 3 different procedures (n=38, 73,1% of group) (p=0,003). Mean hospital stay in IRP group was significantly (p=0,014) longer (9,78±4,6 days) than in CRP group (7,58±3,7 days). Mortality rate was 0 %. Mean follow-up (14 patients) was 20,93±17,21 months.ConclusionThere is no evidence-based consensus regarding treatment of rectal prolapse. Management of IRP covered a more diverse range of surgical options, including of open approach. Thus, hospital stay was longer, but no mortality occurred. Further follow-up for evaluation of long-term outcome is necessary.ĮvadasDėl vienos tiesiosios žarnos iškritimo gydymo strategijos nesutariama. Mes apžvelgėme tiesiosios žarnos iškritimo gydymą Vilniaus universiteto ligoninėje Santariškių klinikose.Pacientai ir metodaiRetrospektyviai tirti pacientai, operuoti dėl tiesiosios žarnos iškritimo 2005–2016 metais. Pacientai suskirstyti į dvi grupes – viso storio iškritimo (CRP) ir vidinio iškritimo (IRP). Buvo palyginti perioperaciniai grupių duomenys. Duomenys apdoroti statistinio duomenų paketo SPSS 20.0 versija. Skirtumas tarp grupių lygintas remiantis chi kvadrato testu, vertintas kaip reikšmingas,jei p vertė buvo < 0,05.RezultataiMinėtu laikotarpiu operuoti 89 pacientai. Dėl vidinio iškritimo – 52 (58,4 %), dėl viso storio iškritimo – 37 (41,6 %). Vyrų ir moterų santykis buvo 1/6,4, vidutinis amžius – 58,3 ± 15,2 metų. Defekografija atlikta 29 (32,6 %) IRP grupės ir 12 (13,5 %) – CRP grupės pacientams (p < 0,001). Septyni (7,9 %) CRP grupės pacientai praeityje buvo operuoti dėl tiesiosios žarnos iškritmo, o IRP grupėje anksčiau operuotų pacientų nebuvo (p=0,02). IRP grupės pacientai buvo operuoti šešiais būdais, o CRP – trimis būdais (p = 0,003). Vidutinė IRP grupės pacientų hospitalizacijos trukmė buvo ilgesnė (p = 0,014) (9,78 ± 4,6 dienos) negu CRP grupės (7,58 ± 3,7 dienos). Mirštamumas buvo 0 %. Vidutinė 14 pacientų stebėjimo trukmė buvo 20,93±17,21 mėnesio.IšvadaIki šiol nesutariama dėl to, kuri operacija tinkamiausia sergantiesiems tiesiosios žarnos iškritimu. Laparoskopinė ventralinė rektopeksija tinkleliu šiuo metu yra populiariausia operacija šiai ligai gydyti

Kidney tumor radiofrequency ablation progress in Lithuania

Background/Objective. This retrospective study aimed to clarify one of the minimally invasive therapies – Radiofrequency ablation (RFA) – performance, extremeness and 5-year survival in patients with small renal tumors. Patients and methods. 118 patients (77 men (65%), and 41 women (35%) with mean age of 68.72 (± 10.12 ) years) were treated with RFA method in Vilnius University Institute of Oncology Urology Section, and since 2003 September 17 till 2012 December 6 were performed 144 renal tumor RFAs. All renal tumors RFAs were performed percutaneously in the projection of the skin, under local or general anesthesia. Procedures were performed by one or several small (up to 1 cm) incisions, and in the US control electrodes were introduced. Since May 2011, 30 RFAs were performed with three electrodes and US control with CT navigation, just a day before the operation additionally titanium markers were put in around the kidney tumor. Results. Since 2003 till 2007 years our patient’s follow-up method was US examination. However, in case of suspicion of tumor progression, percutaneous renal biopsy and CT were performed. From 2007 year patients were follow-up with CT. The ablation zone, contrast agent accumulation and the ablation of the edge were evaluated. Average tumor size was 2.8 (± 0.9) cm. By histology, mainly there were malignant tumors, much less benign, a minority remained histologically unconfirmed. In our study we found out that the most radical renal tumor RFAs were done in the control of US with CT navigation, when additionally around the renal tumor titanium markers were added. Also we clarified, that procedure is more radical when performed using three electrodes. The most common postoperative complication was paranephric hematoma. Conclusions. After RFA, 2-year survival rate is 90 %, 5 years – 58%. Death risk factors: tumor size, higher ASA class, non-radical surgery, metastases or other oncologic process

Inksto rezekcija gali būti sėkmingas inksto epitelioidinės angiomiolipomos gydymo būdas: atvejo pristatymas ir literatūros apžvalga

Background. Renal epithelioid angiomyolipoma is a rare tumour which involves kidneys in most cases. It is known for its aggressive behaviour as a significant number of cases have been associated with metastatic epithelioid angiomyolipoma. Usually, radical treatment with systemic therapy is recommended. Only a small number of cases of epithelioid angiomyolipomas have been reported with the standard treatment being radical or partial nephrectomy. We present a case report showing that partial nephrectomy can be a successful treatment option for renal epithelioid angiomyolipoma. This is the first case of this nature in Lithuania. Case presentation. In this case, a 40-year-old male with epithelioid angiomyolipoma of the left kidney is presented. In 2012, a cystic left renal mass 40 × 41 mm in size was diagnosed incidentally while performing ultrasound and later confirmed by MRI. Due to the size of the tumour and the possibility of renal cell carcinoma, surgery was scheduled. Left partial nephrectomy was performed successfully. Final pathology report came back with the diagnosis of renal epithelioid angiomyolipoma. The patient had yearly follow-up for six years by CT scan, and neither recurrence nor progression were observed. Conclusion. Early detection and diagnosis are crucial for treatment as the tumour tends to have malignancy potential. With early diagnosis, partial nephrectomy can be performed with yearly follow-up and no systemic treatment required

Cloacal reconstruction after a complex treatment of perineal haemangioma in a variant of PELVIS syndrome

PELVIS is an acronym defining the association of perineal hemangioma, malformations of external genitalia, lipomyelomeningocele, vesicorenal abnormalities, imperforate anus and skin tag. Eleven cases have been reported according to the Orphanet data. Acronyms of LUMBAR and SACRAL syndrome have been used and most probably represent a spectrum of the same entity. Very little is known about the success and timing of cloacal reconstruction after the treatment of hemangioma. We presen

Clinical Significance of ADAMTS19, BMP7, SIM1, and SFRP1 Promoter Methylation in Renal Clear Cell Carcinoma

Background: Clear cell renal cell carcinoma (ccRCC) is the most common subtype of kidney tumors, accounting for the majority of deaths from genitourinary cancers. The currently used nomograms for predicting patient outcomes are based on clinical-pathological characteristics only; however, a significant number of ccRCC survivors with similar radiological and histological features still demonstrate a different clinical course of the disease. This study aimed at the identification of novel DNA methylation biomarkers for the monitoring of patients with ccRCC. Methods: Gene expression profiling by SurePrint G3 Human GE 8×60K Microarrays was performed in 4 ccRCC tissues and adjacent non-cancerous renal tissue (NRT) samples. Four down-regulated genes were selected for further DNA methylation status analysis in 123 ccRCC and 45 NRT samples using methylation-specific PCR (MSP). Results: DNA methylation changes of ADAMTS19, BMP7, SIM1, and SFRP1 were cancer-specific with significantly (P<0.050) higher methylation frequency (37%, 20%, 18%, and 42%, respectively) in tumor tissues. The methylated status of at least one gene was significantly related to various clinical-pathological parameters, including tumor size, Fuhrman and WHO/ISUP grades, intravascular invasion, and necrosis. Moreover, the methylated status of multimarker panel ADAMTS19, BMP7 & SFRP1 was predictive for poorer overall survival (HR, 4.11; 95% CI, 1.22-13.86). Conclusion: In conclusion, DNA methylation of the three-gene panel consisting of ADAMTS19, BMP7 & SFRP1 supposedly predicts the outcome of patients diagnosed with ccRCC and possibly might be used to enrich the current prognostic tools

Piktybinis mišrus epitelinis ir stromos inkstų navikas: klinikinis atvejis ir literatūros apžvalga

Introduction. Mixed epithelial and stromal tumour of the kidney (MEST) is a rare and distinctive neoplasm accounting for 0.2% of all renal cancers. Most of these tumours behave in a benign fashion but 13 cases with malignant transformation have already been reported. We present the first case of an extremely aggressive MEST with rapid recurrence after radical treatment, demonstrating objective response to chemotherapy. Case presentation. A 31-year-old female presented to the hospital complaining of gross hematuria. Computed tomography (CT) revealed an intraparenchymal mass in the left kidney forming a tumour thrombus in the inferior vena cava (IVC). Metastatic disease was ruled out and, under the clinical diagnosis of renal cell carcinoma, left radical nephrectomy with IVC thrombectomy was performed. The histopathological examination confirmed malignant MEST of the kidney. At the follow-up 12 months after surgery, a recurrent tumour in the left paravertebral area and a tumour thrombus in the IVC were detected. A second surgery was recommended and the mass from the paravertebral area was removed, so resection of the IVC with prosthetic replacement was performed. The histopathologic examination confirmed a recurrent malignant MEST. At the follow-up three months after the second surgery disease progression was diagnosed, so chemotherapy with ifosfamide and doxorubicin was initiated. The CT scan performed 14 months after the chemotherapy confirmed a stable process of the disease with no signs of progression. Conclusions. A literature review and our case report confirm the existence of extremely aggressive malignant MEST that shows response to chemotherapy. However, more reports are needed to improve our understanding about the biology of the MEST to develop any recommendations on personalized therapy

Urine molecular biomarkers for detection and follow-up of small renal masses

Active surveillance (AS) is the best strategy for small renal masses (SRMs) management; however, reliable methods for early detection and disease aggressiveness prediction are urgently needed. The aim of the present study was to validate DNA methylation biomarkers for non-invasive SRM detection and prognosis. The levels of methylated genes TFAP2B, TAC1, PCDH8, ZNF677, FLRT2, and FBN2 were evaluated in 165 serial urine samples prospectively collected from 39 patients diagnosed with SRM, specifically renal cell carcinoma (RCC), before and during the AS via quantitative methylation-specific polymerase chain reaction. Voided urine samples from 92 asymptomatic volunteers were used as the control. Significantly higher methylated TFAP2B, TAC1, PCDH8, ZNF677, and FLRT2 levels and/or frequencies were detected in SRM patients’ urine samples as compared to the control. The highest diagnostic power (AUC = 0.74) was observed for the four biomarkers panel with 92% sensitivity and 52% specificity. Methylated PCDH8 level positively correlated with SRM size at diagnosis, while TFAP2B had the opposite effect and was related to SRM progression. To sum up, SRMs contribute significantly to the amount of methylated DNA detectable in urine, which might be used for very early RCC detection. Moreover, PCDH8 and TFAP2B methylation have the potential to be prognostic biomarkers for SRMs