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• Associate Professor of Medicine
• Member in the Duke Clinical Research Institute

https://medicine.duke.edu/faculty/j-matthew-brennan-md

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Dt of paticntll will in the end require reoperation to revise the Miami pouch (Penalver, 1998). At this point, the ultimate choice to proceed with creation of a Miami pouch is made. Within the mesentery, the underlying vasculanue is reviewed to ensure enough conduit blood provide. At this level, inteninal continuity is re�mablished by a func:donal cnd-~d stapled ileotransvc. The colon phase is folded in half and 4 dclayedahsorhable keep sutures are plar. A 14F purple rubber catheter is inserted via the termi- 9 nal Ueum section illto the pouch. Of this bowd section, the whole c:"Olonic portion is opened with an decaosurgical blade along the tenia of the:uitimescntcric border to �dctubula. Both ureters are additional mobiliud from their retroperitoneal attachmenu and brought into place under the ascending mesoc:olon utilizing a 4-0 gauge delayed-abmrhablc keep suture at the tip. Manipulation with this suture avoids crush harm by forceps and subsequent necrosis. A hemost:at is poked via the bowel wall, grasps the ureteral stay suture, and thereby pulls 2 cm of each. A massive Malccot c:atheter is introduced into the pouch through an incision made away &om the ileocecal valve. Absorbable suture is used for this purse string, as the Malec:ot catheter shall be removed only 2 to 3 weeks postoperatively. Continenc:c may be tested by wetting a purple rubber c:atheter via the plicated Uewn, filling the pouch with 250 to 300 mL of sall. Additional pune-string sutures could also be plaa:d on the ileocccal valve if incontinence is demonstrated. The pouch Is stabilized by Surgeries for Gynecologic Malignancies in the conduit dw housed these tubes will heal secondarily. The interval between c:atheterizations is progressively increased over wc:da to attain 6 hours in the course of the day and span sleep hours at night. Moreover, reconstruction may significantly prolong an already prolonged operation and lead to additioaal pcriopcradvc morbidity (Mirlwhcmi. However, proponcntB recommend that filling the large pelvic dc:fca and bringing in a nc:w 10urcc of blood supply might aaually stop poatopcrative 6stula or abscess formation (Goldberg, 2006; Juqdo, 2000). Hawcvcr, these require that a lot of the native subananeous tissue has been retained on the neovagina website and require months of stenting with a vaginal mould to stop stricture Kusiak, 1996). Regudlcss of reconstruction method, sczual operate is often significantly impaired in ladies after pdvic aentcration (Hockd, 2008: Ratliff, 1996). Some ladies could have unrealistic cxpeaatlons diat are essential to addras preoperativcly. Thigh Fasciocuaneous Consent the potential morbidity of the neongioa is determined by the sort of recoll8t. Flap necrosis, prolapse, wound separation, or different complicatio111 might require reoperadon and/or result in an un. Patient Preparation the preceding ezenterative surgical procedure typically dictates wanted preoperative preparation. Blood provide derives from every posterior labial amry, which is a branch of the intmial pu. From a pcrincal strategy, the pknoed incWons arc marked alongside the skin from the non-hair-bearing areas ju. Notably, In skinny patiena, a skinny, poody vasc:ularized, attcnuaaxl omcntum may be inadeqwn: to form a considerable cylinder and cover the mildew. Only three quarters of the omentum is divided, so as to protect the left pstroeplplolc ancry fur blood supply. Each of the remaining smaller perineal 0 Spllt-Thlckness Skin Graft with Omental J. Modific:alion of the omen� tal flap, which is often wed to close off the pelvic inlet after ae. From a perincal strategy, a reference line is drawn on the medial thigh &om the pubic tubercle to the mc:di. The gracilis mtl$de is totally mobilized with blunt and s1wp dissection &om distal to proximal. Through the opcrarlvc website on the thigh, a subfuclal tum1d is bluntly developed medially to the open perincal defi:ct. Beginning at the distal tip, the tubular gracilis neovagina is constructed by sunuin. Each of the remaining smaller perincal defects, now above and below the neovagina. This Sap uses the one stomach of the rectus abdominis muscle and its overlying skin and subcutaneous tissue to fuhion the vaginal tube. For this flap, a pores and skin and muscle island may be harvested &om any location on the belly wall as lengthy as the base of its form is at the umbiliC1$. I opening, the pores and skin, subcutaneous tissue, and aiiterior rectus sheath are incised. One belly of the rec:nu abdominis muscle is freed with blunt dissection &om its poste� rior sheath. The stomach is split proximally, - and its anastomotic vasels connecting to the superior epigut:ric system are ligated. The remaining bordeno of the skin island are incised deeply to the anterior rectus sheath and distally to the arcuate line. The subcuta� noous fats is mobilized along the lateral and medial margins of the rectus muscle stomach. At the distal portion of the pores and skin island, the rectus muscle is then bluntly dissected inferiody &om the anterior sheath to its insertion onto the pubic bone. The flap comists of skin, subcutanc-ous tissue, anterior sheath, rec:tus bdly, and blood provide &om the infi:rior cpigastric: vessels. The open end of the ncovagina is introduced out underneath the symphysis pubis to the perineum. Each of the remaining smaller perineal defects, now ahove and below the ncovagina, Is closed in the midline with internipted stitches of 3-0 gauge ddayed-absorbable sunue. Flap lou Is slgnific:antly extra frequent if rect01igrnoid anastomosis is carried out c. Residual scarring on the legs is a frequent, albeit comparatively minor, grievance postoperatively. Ideally, they fill pdvic lifeless rpac:e, reduce the risk offistulas, and provide satilfactory sexual activity Goldberg, 2006).

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Prolonged fasting longer than 12 hours could lower liver glycogen levels, which might impair glucose metabolism and lift insulin resistance (Kehlet, 1997). The American Society of Anesthesiologists (2017) recommends perioperative feeds but high-fut meals are halted 8 hours before surgical procedure. Light meals could additionally be taken up to 6 hours before, and clear liquid taken as a lot as 2 hours previous to surgical procedure. Ingestion of a complex-carbohydrate drink in nondiabetics decreases affected person thirst, anxiousness, and insulin resistance (Noblett, 2006). Medications such as acetaminophen and gabapentin can assist with preoperative analgesia (Alayed, 2014; Moon, 2011). The American College of Obstetricians and Gynecologists (2018a) describes the oral trio of celecoxib, four hundred mg; acetaminophen, a thousand mg; and gabapentin, 600 mg. Hypothermia is related to greater rates of perioperative complications, notably with wound therapeutic (Sessler, 2016). Its purported profit was prevention of bowel anastomotic leaks from passage of hard feces and reduction of fecal and bacterial loads to decrease wound an infection charges (Barker, 1971; Nichols, 1971). Multiple studies evaluating colorectal surgical procedure present contradictory findings (Duncan, 2009; Giienaga, 2011; Ohman, 2017; Scarborough, 2015). Although routine use ideally is restricted, mechanical bowel preparation may be elected for sure superior laparoscopic surgeries or for female pelvic reconstructive procedures involving the posterior vaginal wall and anal sphincter. In these cases, rectal stool evacuation supplies further working area and undistorted anatomy. It also permits proctosigmoidoscopy if needed to interrogate potential rectosigmoid laceration. Moreover, following sphincteroplasty, preoperative evacuation sometimes delays stooling and permits preliminary therapeutic. The Caprini score is a software validated using a big sample of common, vascular, and urologic surgery sufferers (Table 39-9) (Gould, 2012). Despite not being validated in gynecologic surgical procedure, the patient populations are sufficiently just like permit extrapolation. Caprini scores of 0-1 points categorize a affected person as "very low risk," 2 factors replicate "low threat," 3-4 points confer "moderate risk," and ~5 factors place sufferers at "high risk. Thrombin converts fibrinogen to an lively type that assembles into fibrin for clot formation. When thrombin is bound to thrombomodulin on intact endothelium, its procoagulant activities are neutralized. Activated protein C resistance (Factor V Leiden mutation is essentially the most prevalent thrombophilia and is attributable to a single mutation within the issue V gene. The unimpeded abnormal issue V protein retains its procoagulant activity and predisposes to thrombosis. The position of thrombophilia testing is advanced, becawe the testing may be expensive and harmful if inaccurate. Guidelines to direct thrombophilia testing are missing within the United States, and people of other international teams are incongruow (Connors, 2017; De Stefano, 2013). TheAmerican Society ofHematology recommends in opposition to thrombophilia testing in adults with VfE arising in a major transient setting similar to surgery, trauma, or extended immobility (Hicks, 2013). Moreover, testing results not often have an effect on clinical choices relating to VfE therapy. They also suggest against screening asymptomatic first-degree relations of a recognized thrombophilia affected person who skilled a VfE. If used in conjunction with other strategies of prophylaxis, further profit is achieved (Amaragiri, 2000). It seems to be efficient in moderate- and high-risk patients, if initiated previous to the induction of anesthesia and continued until patients are totally ambulating (Clarke-Pearson, 1993; Gould, 2012). Table 39-10 summarizes applicable remedy strategies based mostly on risk (Gould, 2012). Chest 141(2 Suppl):c44S, 2012 Agostini P, Cieslik H, Rathinam S, et al: Postoperative pulmonary complications following thoracic surgical procedure: arc there any modifiable threat factors Accessed July 19, 2019 American Society of Ancsthesiologists: Practice guiddincs for preoperative fasting and the utilization of pharmacologic brokers to cut back the chance of pulmonary aspiration: software to wholesome patients present process elective procedures: an up to date report by the American Society of Anesthes. Am J Prcv Med 38(4 Suppl):S495, 2010 Blcssberger H, Kammler J, Domanovits H, er al: Perioperarive bcca-bloclrers fur preventing surgery-related mortality and morbidity. N Engl J Mcd 377(12):1177, 2017 Coulter A, Ellins J: Effectiveness of strategics for informing, educating, and involving patients. New York, McGraw-Hill, 2014, p 1030 De Stefano V, Rossi E: Testing for inherited thrombophilia and penalties for antithrombotic prophylaxis in patients with venous thrombocmbolism and their family members. Clin Colon Rectal Surg 22(1):14, 2009 Eichenberger A, Proictti S, Wicky S, et al: Morbid weight problems and postoperative pulmonary atdcctasls: an underestimated problem. Endocr Pract 10:seventy seven, 2004 Goldman L, Lee T, Rudd P: Ten Commandments for efficient consultations. Arch Intern Med 143:1753, 1983 Goldwasser P, Fddman J: Association of scrum albumin and mortality threat. Clin J Med 73(Suppl 1):S95, 2006 Iorio A, Kcaron C, Filippucci E, et al: Risk of recurrence after a primary episode of symptomatic venous thromboembolism provoked by a traruient risk issue: a systematic evaluation. Obstct Gynecol 111(5):1183, 2008 Kachalia A, Berg A, Fagcrlin A, et al: Overuse of testing in preoperative analysis and syncope: a survey ofhospitalists. Eur Heart J eight:23, 1987 Kcaron C, Hirsh J: Management of anticoagulation earlier than and after dective surgery. J Med 336:1506, 1997 Kchlct H: Multimodal method to management postoperative pathophysiology and rehabilitation. N Engl J Med 335: 1713, 1996 Mansour A, Watson W, Shayani V, et al: Abdominal operations in patients with cirrhosis: still a significant surgical challenge. Int J Gynaccol Obstet 120(1):10, 2013 Nakagawa M, Tanaka H, Tsukuma H, et al: Rdationship between the length of the preoperative smoke-free interval and the incidence of postoperative pulmonary complications after pulmonary surgical procedure. Snow V, Fittcrman N, et al: Risk evaluation for and strategics to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery: a guideline from the American College of Physicians. Yang D, et al: Rdationship between intraoperative hypotension, ddined by either discount from baseline or absolute thresholds, and acute kidney and myocardial damage after noncardiac surgical procedure: a retrospective cohort evaluation. Auerbach M: Can intravenous iron remedy meet the unmet wants created by the new restrictions on erythropoietic stimulating agcntli Gupta N, Ramaltrishna H, et al: Perioperative main opposed cardiovascular and ccrcbrovascular occasions associated with noncardiac surgical procedure. Clinical Assessment of the Rdiability of the Examination-Chronic Obstructive Airways Disease. Hematol Oncol Clin North Am 24(4):683, 2010 Vessey M, Mant D, Smith A, et al: Oral contraceptives and venous thromboembolism: findings in a big potential study. Ancsthesiology 85:460, 1996 W ckslcr N, Klein M, Szcndro G, et al: the dilemma of instant preoperative hypertension: to deal with and function or to postpone surgery

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These elevated ranges might induce sexual precocity in prepuben:al women or heavy, irregular menmual bleeding in reproductive� aged women (Oliva, 1993). This structure consists of a central capillary surrounded by tumor cells, present within a cystic area that may be lined by flat to cuboldal tumor cells. In any given case, Schiller-Duval our bodies may be few in quantity, absent, or have atypical morphologic features. Involvement of both gonads is uncommon, and the opposite ovary is often involved with metastatic disease solely when different metastases are discovered in the peritoneal cavity. Grossly, these rumors type strong masses that are extra ydlow and friable than dysgerminomas. These characteristically have a single papilla, which is lined by tumor cells and contains a central vessel. Fortunately, greater than half current with stage I disease, which is aasociated with a 5-year general survival. Mixed Genn Cell Tumors Ovarian germ cell turners have a blended sample of cellular dif&rentiation in 25 to 30 percent of circumstances, although the incidence of those turners ha. Other Primitive Genn Cell Tumors the rarest subtypes of nondysgerminomatous twnors are sometimes blended with different more common variants and are wually not present in pure form. Immature teratomas comprise a disorderly combination of mature and immature tissues derived from the three germ cell layers-ectoderm, mesoderm, and endoderm. Here, Immature neuroeplthellal cells arranged In rosettes lle inside a background of mature neural tissue. They are composed of tissues derived from the three germ layers: ectodenn, mesoderm, and endodenn. The presence of immature or embryonal buildings, nevertheless, distinguishes these rumors from the far more widespread and benign mature cystic teratoma (dermoid cyst). Bilateral ovarian involvement is rare, however 10 % have a mature teratoma within the conttalateral ovary. Tumor markers arc typically not elevated unless the immature tcratoma is mingled with different germ cell tumor types. With gross c:xtcrnal inspcccion, these tumors arc giant, rounded or lobulated, delicate or 6rrn plenty. With loc:al invasion, surround� ing adhcsions commonly type and are thought to clarify the decrease charges of torsion with this tumor in contrast with that of its benign mature counterpart (Cass, 2001). Solid components could correspond to the immature elements, cartilage, bone, or a mixture of these. Ofthe immature dcments, ncurocctodermal tissues almost all the time predominate and are organized as primitive tubulcs and sheets of small, spherical, malignant cdis that could be related to glia formation. The prognosis is normally difficult to affirm throughout frozen part evaluation, and most tumors arc confirmed solely on last pathologic evaluate (Pavlak. Tumors arc graded I to three primarily by the quantity of immature ncwal tissue they contain. For example, nearly three quaners of immature terammas are stage I at prognosis and have a 5�year survival rate of ninety eight p.c (Chan, 2008). Unilateral salpingo-oopborcctomy is the usual look after these and other malignant germ cell tumors in reproductive-aged ladies. Beincr and collcagucs (2004), howi::ver, handled eight women with early-stage immature tcratoma with ovarian cym� tomy and adjuvant chemotherapy and famous no recurrences. However, these implants of mature tcratomatous dcments, although benign, are proof against chemotherapy and might enlarge throughout or after chemotherapy. Platinwn~based chemotherapy 762 Gynecologic Oncology twnor diasemination patterns, lymphadenectomy ia most necessary for dysgcrminomas, whereas staging peritoneal and omental biopsies are notably valuable for yolk sac: twnors and immature teratomas (Kleppe, 2014). Cytoreductive sW"gery is beneficial for advanced-stage nondysgenninomatous malignant ovarian germ cell twnors if it can be completed with minimal residual illness (Park, 2017). Neoadjuvant chemotherapy is a reasonable choice for the atypical affected person thought to have unn:sectable illness (Talukdar, 2014). Because ofits minimally inva� sive qualities, laparoscopy is a particularly attractive option for delayed surgical staging fullowing major excision and has been shown to accurately detect those ladies who n:quire chemother� apy (Leblanc, 2004). Surgical staging fullowing main excision, nevertheless, is less essential fur scenarios in which chemotherapy might be administered regardless ofsurgical findings. Examples are clinical stage I yolk sac tumors and high-grade clinical stage I immature tetatomas (Stier, 1996). However, no matter treatment acquired, sufferers with advanced illness do poorly (Gainfurd, 2010). Other uncommon forms of malignant options could embody basal-cell carcinomas, sebaceous tumors, malignant mela� nomas, adenocarcinomas, sarcomas, and neuroectodennal tumors. Moreover, endocrine-~ neoplasms similar to struma ovarii (teratoma composed primarily of thyroid tissue) and c:arci� noid also could additionally be fuund inside mature cystic tcratomas. However, incrcas-ingly, investigators with superior endoscopic expertise have noted laparoscopy to be a protected and cffi:ctivc different fur girls with smaller ovarian lots and obvious stage I disease (Shim, 2013). The ovaries are assessed for size, tumor involvement, capsular rupture, exterior excrescences, and adherence to sur� rounding buildings. In either case, fullowing removing of the alfcctcd ovary, surgical staging by laparotomy or lapa� roscopy proceeds as beforehand described fur epithelial ovarian cancer (Chap. However, incompletely rcsccted imma� twe tcratoma is the one circumstance amongst all forms of ovarian cancer in which patients clearly benefit from second-look surgery and excision of chemorcfractory tumor (Culinc, 1996; Rczk, 2005; Williams, 1994). More advanccd illness and all different histologic types of malignant owrian germ cell tumors have historically been handled with mixture chemotherapy after surgical procedure (Morgan, 2016). However, the feasibility ofsurgery fullowed by close surveillance in pediatric and adolcsc:cnt women is being explored (Billmirc, 2014). Because chemotherapy remains dfcctive when used at the time of relapse, some investigators arc attempting to identify further low� danger, early-stage subgroups which could be noticed postopcrativdy to avoid treatment-related toxicity (Bonazzi, 1994; Cushing, 1999; Dark, 199n. However, earlier than this strategy becomes gen� era1 apply, extra giant srudics are needed. Carboplatin and etoposide, given in three cycles, has shown promise instead for chosen sufferers (Williams, 2004). In addition, none of the reported research has noted a higher rate of start defects or spontaneous abortion in those handled with chemotherapy Tangir, 2003; Zanetta, 2001). In contrast, dysgerminomas account for only 1 to 2 p.c of such neoplasms however nonetheless are the commonest ovarian malignancy throughout being pregnant. Initial surgical management together with surgical staging is identical as for the nonpregnant girl (Horbelt, 1994; Zhao, 2006). Malignant ovarian germ cell tumors have the propensity to develop quickly, and delaying therapy until after supply is probably hazardous. However, for patients with nondysgerminomatous tumors (mainly yolk sac tumors and immature teratomas) and people with incompletely resected illness, chemotherapy throughout pregnancy is strongly thought-about. This transition was prompted primarily by the beautiful sensitivity of those tumors to both modality, but higher likelihood of retained ovarian function using chemotherapy (Solheim, 2015).

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For instance, juvenile granulosa cell tumors, Senoli-Leydig cell tumors, and sclerosing stromal tumors are found predominantly in prepubertal girls and women throughout the first three decades of life (Schneider, 2005). However, in a hypothesis-generating case-control study, obesity as a hyperestrogenic state was independently related, whereas parity, smoking, and oral contraceptive use had been protecting (Boyce, 2009). These embrace Ollier disease, which is characterized by multiple benign but disfiguring cartilaginous neoplasms, and Peutz-Jeghers syndrome, characterized by intestinal hamartomatous polyps (Stevens, 2005). Moreover, diagnostic laparoscopy or laparotomy with visual assessment of the adnexal mass alone is insufficient. As a outcome, these young people with endocrinologic symptoms are most likely to be diagnosed at earlier levels. The classic presentation is a postmenopausal lady with rapidly evolving stigmata of androgen extra and a complex adnexal mass. Abdominal pain or a mass palpable by the affected person herself are different telling signs and symptoms (Chan, 2005). In this setting, prior to referral, histologic results should be reviewed and confirmed by an experienced pathologist. Following referral to a gynecologic oncologist, surgical staging could also be indicated. Granulosa and Sertoli cells develop from the intercourse cords and thus from the coelomic epithelium. In contrast, thoca cells, Lcydig cells, and 6broblasts are derived from the mcscnchyme. Therefore, growing nunors could additionally be composed of a male-directed cell type (Senoli or Lcydig cell) or a fcmalc-directed cell sort (granulosa or thca cell). Similarly, tumors that arc predominantly Scrtoli or Scrtoli-Leydig cells might comprise minor granulosa components. There arc two clinically and histologically distinct varieties: the grownup form, which includes 95 percent of cases, and the juve� nile type, accounting for five %. Their elongated nuclei might have a longltJdlnal fold or groove that provides them a �coffee bean. Heavy, im:gular menstrual bleeding and postmenopausal bleeding are common and rdlect extended expo. Related to this esttogen excess, coexisting pathology similar to endometrial hyperplasia or adenocarcinoma has been found in 25 to 30 p.c of patienu with grownup granulosa cell tumor (van Meuts, 2013). Altematlvely, symptoms may stem from the mass of the ovary somewhat than &om hormones produced (Ray. An enlarging and potentially hemonhagic tumor could cause stomach ache and dim:ntion. Acute pelvic ache could recommend adncxal mrsion, or tumor rupture with hemopcritoneum can mimic eaopic pregnancy. During surgery, ifan adult granulosacell nunor is confirmed, tumor markers may be requested. Of these, inhibin B seems to be extra accurate than inhibin A, incessantly being elevated months before medical dete<:tion of recunence (Mom, 2007). The diagnostic worth of these markers, however, is usually hampered by their physiologically broad regular ranges (Schneider, 2005). This is especially true fur the younger patient wishing to protect fertility and having the contralatcral ovary left in siru. For this purpose, extra intensive dissection is typically required than fur epithelial ovarian cancers or malignant germ cell tumors. During excision, inadvertent rupture and intraopcrative bleeding from the tumor itself is frequent. Alternatively, the mus can he cysti~ with quite a few locules 61lcd with scrosanguinous or gelatinous fluid (Colombo, 2007). Microscopic examination exhibits predominately granulosa cdls with pale, grooved, "co1fcc bean" nuclei. Adult granulosa cell tumors are low-grade malignancies that typically show indolent progress. Ninety-five p.c arc unilateral, and 70 to ninety p.c are stage I at prognosis (Tab. The 5-ycar survival fur patients with stage I illness is 90 to 95 p.c (Colombo, 2007; Zhang, 2007). The median time to re<:uttcncc is 5 to 6 years however could also be several decades (Abu-Rustum, 2006; East, 2005). Advantageously, these indolent tumors wually pro~ slowly thereafter, and the median size of survival after relapse is one other 6 years. Poor prognostic fu:tors are superior stage, large tumor measurement, and residual illness (Seagle, 2017). Cellular aiypia and mitotic count may help in determining the prognosis but are troublesome to reproducibly quantify (Miller, 2001). Stage and Survival of Common Ovarian Sex Cord-Stromal Tumors Adult Granulosa Cell Sertoll-Leydlg Cell 97% 2-3% 9o-95% 10-20% St. Juvenile granulosa cdl tumors are generally related to Oilier illness or with Maffucci syndrome, which is characterized by endochondromas and hemangiomas (Young, 1984; Yuan, 2004). In affected females, estrogen, progesterone, and testosterone levels could additionally be elevated and lead to suppression of gonadotropins. These tumors occasionally secrete androgens, hut in such cases they may induce virilization. Despite these endocrinologic indicators, a delayed prognosis of juvenile granulosa cell tumors in pre- and postpuhertal women is common and related to a better risk of peritoneal tumor unfold (Kalfa, 2005). Preoperative rupture with resulting hemoperitoneum could create acute abdominal signs in 5 to 10 % of circumstances (Colombo, 2007). Juvenile granulosa cdl tumors are grossly much like the adulttype tumor and show variable strong and cystic componenn. They can attain important size and have an average diameter of approximately 12 cm. Microscopically, cytologic features that distinguish these tumors from the adult sort are their rounded, hyperchromatic nuclei with out "coffee-bean" grooves. Call-Exner our bodies are rare, but often a theca cdl component is found (Young, 1984). Similar to adult-type tumors, ninety five percent of juvenile granulosa cell tumors are unilateral and stage I at diagnosis (Young, 1984). These strong, generally benign ovarian neoplasms arise from the spindled stromal cells that kind collagen. Perhaps 1 p.c of girls current with Mtigr syndrome, which is a triad of pleural effusion, ascites, and a solid ovarian mass (Siddiqui, 1995). Pleural effusions are often right-sided, and these, as nicely as accompanying ascites, are usually transudative and resolve after tumor resection (Majzlin, 1964). Despite this affiliation of ascitcs with benign fibromas, when ascites and a pelvic mass coexist, evaluation is based on an assumption of malignancy.

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The empty supine stress check as a predictor ofintrinsic urethral sphincter dysfunction. Obstct Gynccol 111: 152, 2008 Lowenstein L, FitzA, Kenton K, etal: Transabdominal utcrosacral suspension: outcomes and issues. Gastrocntcrology 126:S48, 2004 Maher C, Feiner B, Baessler K, et al: Surgical administration of pelvic organ prolapse in women. Arn J Obstet Gynccol 210(2):ninety nine, 2014 Norton P, Brubaker L: Urinary incontinence in women. Perrotti M, etal: Urctcrocntcric anastomosis in continent urinary diversion: longtmn rcsula and issues of direct versus nonrcfluxing strategies. Ncurourol Urodynam 30:1489, 2011 Pilsgaard K, Mouritsen L: Follow up after restore of vaginal vault prolapse with stomach colposacropay. Int J Urol eight:599, 2001 Zeng S, Zhang Z, Bai Y, et al: Antimicrobial brokers for stopping urinaty tract infections in adults present process c:ystoscopy. World J Ural 35(1):139, 2017 Zullo F, Palomba S, Russo T, et al: Laparoscopic col� posuspension using sutures or Prolcne meshes: a 3-ycar follow-up. Of these, radical hysterectomy differs from simple hysterectomy in that the parametrial, paracervical, and paravaginal tissues and their lymphatics are widdy rcscctcd to achieve negative tumor margins. Most ladies with cervical most cancers are handled with laparotomy and radical hysterectomy. Speculations fur these survival differences embody insertion of a uterine manipulator, tumor handling during paracervical resection, and pneumoperitonc:um throughout colpotomy. Until further work is accomplished to establish the true: trigger for this inferior survival price:, we offer open radical hysterectomy because the prefc:rrc:d modality for surgical administration of cervical cancer. That said, there are limitations on what could be reliably detected preoperatively (Chou, 2006). Additionally, long-term dfects on sexual operate and other physique functions are candidly reviewed and are detailed on page 1165 Qensen, 2004; Serati, 2009). Patient Preparation For this, a blood pattern is typed and crossmatched for potential transfusion. However, it might be useful to empty the colon to restrict fecal spill if extensive pelvic adhesions arc anticipated due to prior an infection, endometriosis, or radiation therapy. Suitable perioperative antibiotic prophylaxis to prevent most surgical web site an infection is found in Table 39-8 (p. Typically, a first-generation cephalosporin is given intravenously at spaced intervals. Compared with simple hysterectomy, the high-volume blood loss throughout radical hysterectomy clears antibiotics more rapidly from the operative site, and longer surgical procedure might extend previous the antibiotic half-life. Also, in transposed ovaries, symptomatic periadnexal cysts are commonplace (Buekers, 2001). Oocyte and ovarian cryopreservation have superior, and the previous is a more widespread possibility (Chap. Consent Women undergoing hysterectomy are specifically endorsed relating to the lack of fertility. The tone of the consenting process ought to reflect the extent of the operation required to hopefully remedy or at least begin remedy of the malignancy. Moreover, a patient must be advised that the process could also be aborted if metastatic disease or pelvic tumor cxtc:nsion is found (Leath, 2004). Radical stomach hysterectomy can lead to significant morbidity from shortand long-term issues. Surgery could also be harder and complication rates greater in ladies with weight problems or with prior pelvic infections, abdominal surgical procedure, or pelvic radiation (Cohn, 2000). Blood loss could attain 500 to one thousand mL, and transfusion rates are variable however excessive (Estape, 2009; Naik, 2010). Subacute postoperative complications could embody vital postoperative bladder or bowel dysfunction from surgical denervation (20 percent), symptomatic lymphocyst formation (3 to 5 percent), and ureterovaginal or vesicovaginal fisrula (1 to 2 percent) (Franchi, 2007; Hazewinkel, 2010; Likic, 2008). With any cancer surgery, danger General anesthesia is obligatory, however transverse abdominis peripheral nerve block or epidural placement may be considered for postoperative pain management (Leon-Casasola, 1996). Bimanual examination is performed within the working room before surgical scrubbing. Hair in the: path of the planned incision is clipped if wanted; a Foley catheter is placed; and belly preparation is completed. Pelvic lymphadenectomy is often completed just before or immediately after radical hysterectomy, and paraaortic lymphadenectomy may also be indicated in some circumstances (p. Ovarian removing must be thought of in ladies with cervical adenocarcinoma for the rationale that rate of metastasis to the ovary is 2 percent in contrast with 0. If ovaries are preserved, salpingectomy alone is considered to probably scale back future risk of some epithelial ovarian cancers (Walker, 2015). Alternatively, Cherney or Maylard incisions offer the postoperative advantages found with transverse incisions and permit entry to the lateral pelvis (p. A Pfannenstiel incision presents limited publicity and is reserved only for selected sufferers (Orr, 1995; Scribner, 2001). Following belly entry, a surgeon first completely explores the stomach for apparent metastatic disease. Confirmation of metastases or pelvic tumor extension leads to a call on whether or not to proceed or abort an operation based mostly on general intraoperative findings and medical state of affairs (Leath, 2004). The round ligament could additionally be divided with an eleccrosurgical blade or could additionally be sutured with 0-gauge delayed-absorbable suture. The mda and center fingers are placed on either facet of the artery, and the areolar connective tissue is bluntly 6ngu dissected towards the pa. This permits direct identific:atlon of the frequent iliac artery bifurcation and origins of the cnernal and intemal iliac arteries. Here, the ureter ccossc:s over the bifurcation or over the proximal portion of the enema! Through this space, clamp suggestions are then passed beneath the ureter to grasp a quarter-inch-wide Penrose drain. The utercovariail lig,ament is then clamped, c:ut, and ligated close to the uterus. Devdoplng this avascular spaa:: can be pcrfunned with blunt dissection utilizing a suction c:athcu:r tip or fingertip. In distinction, the parave&ical space is fashioned by dissection of the areolar tiMue medial and caudal to the exterior iliac ve~ sels in the di. The index aild center finger of the other h:uid then sweep intervening avascular areolar tissue deeply and medially toward the midline. The developed paravc:sical area is bounded by the bladder and superior vc:sical artery e Uterine Artery Ug1llon. It may be grasped with a Babcock clamp or lifted by a nanow Deaver reuac:tor and plated on lateral traction. This traction on the superior vcsical artery prevents its inadvertent ligation and aid.!! Tissues surrounding the uterine artery arc bluntly disseacd, and a right-angle damp is positioned beneath this artery to retrieve a 2-0 gauge silk suture.

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Many of those complications are manageable: with supportive care and local measures. A palpable mass with c::ompression of the reaum or rec::tovaginal septum indic::ata the necessity fur low lithotomy with legs (l)mfunably positioned in booted suppon stirrup to prepare for possible low anterior resection and anastomosis. Supine positioning is in any other case appropriate, and for VfE prophylms, lowcrcnrcmity pneumatic compression devices are positioned. Ideally throughout mlcaomy, a surgeon will achi1:V1: meticulous hcmostasis, take away the smallest required length of colon, avoid fcal spill. Pn:opcrativc antibioda and pcriopc:ruM: VfE prophylaxis are warranted, and options are listed in Tables 39-8 and 39-10 (p. A surgeon fim: cxplora the whole abdomen to lysc: adhesiom, to �runn the bawd and consider its appcarana: from duodenum to rectum, to exclude different potential sites of obstruction proximally or distally, and to detc. However, the atcnt of resection will still generally be unclear until the operation ii undcrway. This space is bluntly expanded, and elearosurgical diaecdon is ncn guided a:phala. The two segments must corofon:ably approximate antirocscnteric borders with out pressure. To aa:omplish this, the proximal suplc line is elev:wxl with two Allis damps at its lateral edges. The bowd scg� menu are evenly positioned, and the system is then fired along the antimcsentcric aurfaces and removed. Moreover, sufferers present process multiple bowel rcscaions have greater blood loss and longer hospital stay (Salani, 2007). Anastomotic leaks are probably the most specific com� plication and typic:ally present as an ~ or fistula, or as peritonitis within days or maybe weeks ofsurgery. Pelvic absa:ssa also could rault fiom intraoperative fucal spillage or hematoma superinfection. In addition, symptomatic anastomotic strictutu arc infi:equent and often present aa colonic obstruction. Some raiccures cm be managed with endoscopic ster1t1, however usually they requin: reoperation. On occasion, owrian cancer will contain the complete colon, requiring colc:ctomy with a computer. A miclline venical incision is preferable for most situations by which an ileostomy is taken into account. On occasion, tethering of small bowd by c:arcinomatosis or radiation harm will significantly reduce mobility and can requite a more prm:imal diversion. Consent In general, many of the complkations from this process mirror thwe of colostomy: retraction, stricture, ohltruction, and herniation. Patienu are informed that short-term loop ileostomies could be taken down later and not utilizing a laparotomy. The loop can then be approximated tD the stoma website, which is aeated tD accommodate two Bng-m as dacribal fur an ilea! The Penrose drain is eliminated and changed with both the minimize end of a pink rubbtt cathettt or another system that can be sewn to the pores and skin to elevate the loop. If a rncd ailc:ctnmy is pctfonned or if the bowel is too tethered or the affected person too overweight for a loop to attain the stomach w:all, the distal ilewn may need to be divided in. An try is made to evert the smgle stoma by turning the bowel wall over on itself utilizing Allis clamps. In each quadrant of the stoma, stitches of 3-0 gauge delayed absorbablc suture arc placed via the dermis, the acromuscular layer of the bowel at the skin lc:vcl, and a full-thic:lau:ss chunk on the reduce fringe of the cvcrted bowd (p. Higboutput cfBuent may end in dccttolyte abnormalities that are tough to correct. Peritoneum and adhesions attached to the concerned portion ofsmall bowel are dissected to mobilize the bowel. Trauma is minimized to cut back spillage of intestinal contents by inadvertent c:nterotomy. Idc:ally, hc:althyappc:aring sc:rosa for anastomosis is recognized at websites each proximal and distal to the lesion while preserving a most quantity of intestine. A one-quarter inch Penrose drain is pulled through a mc:sc:nterotomy at the proximal and distal websites to be approximated. Patients with recurrent gync:cologic malignancy, notably those with ovarian cancer, are preope. Nwncro1$ sites of obstruction may be suspected to point out a woman with end-stage disease who could be higher served by placement of a palliative percutaneous draining gastrostomy tube. A midlinc vertical incision is prefuahle for many situations during which a small-bowel resection is considered. Infrequently, an adhesion may be situated and lysed to rapidly relieve an obrnuction, thereby avoiding small bowel resection. More usually, an area is clistovc:ml that warrants (, Consent Dc:pc:ttding on c:ircumstana:s, patiena are counscled rega. The proximal and distal bowel segments are devated with Allis damps and matGhed paralld alongside their antlmesenterlc: bonlm. Massively distended bowd from an obstruction could also be decompressed by inserting a pool suction tip into the proximal bowel encl Allis damps arc replao:d on the bowd on the cxfge of every opening. The mcsentcrjc defect could also be closed nat with running 0-gauge cldayedabsorbablc ruauc to stop intcrnal herniation-that. This is perfonned at the conclusion of any bowel resection, but patticulatly if bowel contents spill during the process. Palpation of the stomach will confum correct plac:ement, or else the anesthesiologist can be direc:tecl to advanc:e or pull again the tube as needed. Fistula formation, anastomotic leakage, and obstruction are extra severe problems which will require reoperation. More than half the small intestine may be eliminated with out impairing dietary absorption as long as the remaining bowel. A second complication, vitamin B12 deficiency, results from inadequate absorption and depletion of available shops. Surgeries for Gynecologic Malignancies illness warrants the risks of this process. In general, progressively greater compli� cation charges and poorer long-term bowel operate fullow anastomoses which are extra disaJ. With consideration to danger �actors that would instead indicate a must divert, anastomotic leaks ought to develop in fewe. Following mcction of the involved n:ctoslgmold section, proximal and distal bowel ends arc usually aiwt1:1mosed.

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The vagina i1 widdy aeparated from the bladder m permit omentum or peritoneal flap placement ab. Seoond, the bladder wall at the: 6swla excision website: is clwed in one or two layen utilizing a working sew of2-0 gauge del. Next, the bladder mucosa is reapproximated with a singlelayer working sew of two. Last, the entry bladder dome incision is closed equally, c:rcept the bladder mucosa is reappramnatcd first and fullowed by blad- der wall closUlC in layers. This covers the incision line to provide an intervening tissue layer between vagina and bladder. Either transurcthral or suprapubic catheter placement will ensure adequate drainage in the quick postoperative interval. Removal of stitches that kink the ureter or administration of a light crush injury is feasible for most gynecologisrs. However, complicated accidents that include transection, severe crush, or thermal trauma profit from the expen help of a urogynecologist, gynccologic oncologist, or urologist. With analysis delayed by quite so much of days, surgical correction often is deferred for six to eight weeks for inflammation and tissue edema to subside. Imponantly, if delayed correction is deliberate, renal perform can be preserved by sufficient drainage by way of retrograde stenting or percutaneous nephrostomy drainage with or without antegrade stenting. Instead, urctcral ligation or small partial transection requires prolonged ureteral stenting. Last, full transection or extensive crwhing or thermal harm warrants either ureter reanastomosis or reimplantation. Specifically, proximal or midlength injuries usually arc managed with ureteroureterostomy (end-to-end reanastomosis). For injuries in the lower-third, ureteroneocystostomy (ureter rcimplantation) sometimes is most well-liked for several reasons. First, reimplantation requires less ureterolysis than reanastomosis and thus can protect the ncurovascular integrity in this vulnerable ponion of the ureter. Second, the ureter is narrower at the ureterovesical junction, and end-to-end anastomosis right here might enhance stricture dangers. With reimplantation, an extravesical method could additionally be chosen, and the ureter is reintroduced at the external surface of the bladder. In one subtype of this approach, the ureter instantly enters the bladder, and urine docs reflux from the bladder into the distal ureter. In another subtype, the ureter instead is runnded a brief distance inside detrusor fibers before entering the bladder. That stated, neither approach has a dangerous effect on renal operate or will increase ureteral stenosis threat in adults Pantuck, 2000; Stefanovic, 1991). Instead, reimplantation can be performed by an intravesical approach, which requires opening of the bladder to reintroduce the ureter. With all three techniqucs, the ureter is reimplanted on the posterior or anterior dome of the bladder and not on its lateral facet. For delayed repairs, the American College of Obstetricians and Gynccologists (2018b) recommends antibiotic prophylaxis previous to urogynccologic surgery, and acceptable broadspectrum choices mirror these for hysterectomy (Table 39-8, p. Most of those injurics require abdominal inspection, both with laparotomy or laparoscopy. Thus, low lithotomy in booted support stirrups is most well-liked to permit concurrent cystoscopy, and patients arc repositioned as wanted. Instead, if the patient is supine fur stomach hysterectomy, cystotomy might replace cystoscopy for trigone inspection and retrograde urctcral catheter passage. Guided by the preliminary surgical route, extra stomach or vaginal sterile preparation could additionally be accomplished. A Foley catheter is placed or remains to enable retrograde bladder filling at cenain steps. Consent For a given major surgical procedure, patients arc initially counscled regarding the relative risk of urcteral harm. In high-risk circumstances, funher matters may embody stcnting or ureteral repair strategies. With a delayed analysis, surgical reconstruction procedures are weak to anastomotic dehiscence and to ureteral stricture, fistula, or necrosis. Bleeding issues and surgical site infection are additional concerns (Sclzrnan, 1996). Pon placement to maximize instrument manipulation but minimize trocar injury is printed in Chapter forty one (p. Altcrnativdy, laparotomy using a low transverse or rnidline vertical incision is suitable, and steps arc described in Chapter 43 (p. If harm is suspected, the ureter first is identified via meticulous dissection. Specifically, if catheter resistance or dye extravasation is famous approximately 13 cm from the ureteric orifice, the damage likely lies close to the pelvic brim. Resistance at four to 5 cm displays harm during uterine vessels ligation and that at 1 to 2 cm signifies trauma close to the vaginal cuff Uackson, 2019). Injuries, corresponding to ureteral kinking, may be managed by simply eradicating the involved 8 Patient Preparation Immediately previous to primary surgery, intravenous antibiotic and VfE prophylaxis generally arc administered. Thus, if an harm is recognized intraoperativdy, no funher antibiotics arc indicated soldy for ureteral repair. However, antibiotics may be redoscd for instances lasting > 3 hours or those related to > 1500 mL blood loss. To start, the affected ureter is recognized as it crosses either the frequent iliac bifurcation or the external iliac anery (Jackson, 2019). The ureter is circumferentially dissected from its connections to peritoneum and surrounding free connective tissue. Dissection aims to present adequate mobility yet preserve the periadventltial tissue that encircles the ureter and that carries its blood supply. After initial liberating of the ureter, a vessel loop is positioned round it to intermittently apply gentle traction throughout dissection. In whole, dissection usually extends from the pelvic brim to a degree just above the broken phase. Once fully mobi- 8 lized, the ureter is sharply transected above the beforehand recognized injury website. A segment from the distal broken ureter could additionally be resected and sent to pathology for damage affirmation. Ultimately, the passable proximal finish is dropped at the supposed cystotomy website in a bladder that ls empty. With this, one or both obliterated umbilical aneries (medial umbilical ligaments) are transected above the bladder apex fur optimum mobility.

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Insertion to this depth is important to allow the robotic arms the proper fulcrum to perform optimally and to reduce port-site tissue stretch. Of newer modifications, reduced-port robotic surgical procedure uses microtip percutaneous devices to decrease the variety of 8-mm ports. Rather than a quantity of trocar websites, it makes use of a solitary port to deliver multiple operative devices by way of the trocar. Triangulation describes devices converging on a focal point from lateral angles of origin. These angles create opposing forces, that are essential for effective tissue retraction, dissection, and resection. When planning belly entry, key buildings of the anterior stomach wall are thought-about to avert neurovascular issues. Key landmarks include the umbilicus, anterior superior iliac spine, and pubic symphysis. Especially within the overweight patient in whom a big pannus could alter anatomic relationships, bony landmarks are used to plan secure port placement. The umbilicus is generally positioned at the stage of the 13-U vertebrae, although it might lie above or beneath relying on habitus. In most patients, the aorta bifurcates at the union ofL4-L5 vertebrae (Nezhat, 1998). The left frequent iliac vein crosses the midline approximately 3 to 6 cm inferior to the extent of the umbilicus. The newer Xi mannequin has arms that extend off a central column to help complex, multiquadrant procedures. Jn this model, the mattress and robotic arms can transfer concurrently for larger surgical flexibility. The Single Port cannula serves as the only conduit for supply of versatile Instruments and laparoscope into the abdomen. In the pelvic retroperitoneum, laparoscopy usually permits simple direct identification of the ureter and vessels of the pelvic sid. Moreover, the course of the pelvic ureter travding from the pelvic brim, alongside the pelvic sidewall, and to the cervix routinely ought to be appredated with every laparoscopy to guarantee normal peristalsis and caliber. To keep away from harm to the ureter, its course is con6rmed repeatedly during adnaal surgical procedure, hysterectomy, and cases with adhesive diaease. Nearly half of all laparoscopic issues happen throughout stomach entry, and nearly one quarter of those are undete<:tcd till the postoperative period (Bhoyrul, 2001; Chandler, 2001). Each of the methods mentioned beneath could additionally be helpful in numerous conditions, however all have potential risks. Its web site could additionally be moved cephalad relying on the scale of pelvic pathology as illustrated by R,A-R1c� Ri. In the midline, the median umbilical ligament ttaverses from the bladder dome to the umbilicus and is the obliterated urachus. Lateral to this lie the medial umhilical foldt, which cowl the obliterated umbilical arteries. Running laterally to the medial umbilical folds and to the spherical ligaments are the /aural umbilicalfo/Js. These folds are fonned by peritonewn overlying Median umbilical � Umbilical Entry the umbilicus is probably the most frequent entry website. The umbilicus is prefetted for main trocar placement because the subcutaneous and preperitoneal tissue layers are thinnest there. Thus, the transumbilical approach is the shortest distance to the belly cavity, even in overweight patients. Laparoscopic enay could be performed with an open or dosed approach, described subsequent. Some authors advocate an open entry method as a method to lower puncture damage charges. To diminish downward thrust when placing a Vcrcss needle and ttocars, a surgeon adjusts the desk top and makes use of a short stepstool if ncccssaiy. To maximize the gap between the puncturing instrument and these vcssds and avert vascular damage, untimely Trcnddcnburg positioning is prevented, and the affected person ought to lie flat. Minimally Invasive Surgery Fundamentals Palpation over these areas can verify enough decompression. The sacral promontory and aorta are also palpated, and a Vcress needle or trocar with a length adequate to attain the peritoneal cavity is sdected. Finally, once all tools is chcckcd and com:ctly conncctc:d, the surgeon confirms with the ancsthcsiologist that the patient is totally paralp. Once a pneumopcritoneum is created, the fascia and peritoneum arc then secondarily punctured with a trocar. The pneumopcritoncum serves to tense the peritoneum and incrcases the space of the viscera and retroperitoneal constructions from the trocar getting into the abdominal wall. The incision may be both horizontal or vertical, is placed centrally within the umbilicus, and may be made with a no. A research utilizing computed tomography images revealed that up to 8 cm may be added between the incision and retroperitoneum by dcvation with towel dips (Shamiycb, 2009). Abdominal wall elevation also supplies a controlled countcrtcnsion to the downward thrust of the Vcress needle and subsequent trocar during insertion. As soon because the tip enters the stomach cavity, the obturator springs forward to forestall the needle from injuring belly viscera. Prior to insertion, the Veress needle is checked for patency by fiuslting Wine through the needle after which withdrawing the fluid. The patient and operating table arc flat, and the anterior stomach wall is dcvated. Compared with other entry strategies, Vcress needle entry is associated with a higher incidence of failed entry and atraperitoneal insufllation. This gaseous dissection of the peritoneum away &om the anterior abdominal wall hinders the trocar in piercing the peritoneum. Fortunatdy, this drawback can often be overcome by a second attempt with the Vercss needle above the umbilicus or by switching to an open entry method. Prcpcritoncal insertion of the Vcress needle is common and may result in abandonment of the laparoscopic procedure. Thus, affirmation of appropriate needle placement in the peritoneal cavity is essential. For con6rmation, a 10-mL syringe containing 5 ml ofsaline is connected to the hub of the inserted Vercss needle. Ifblood or bowel contents arc aspirated, concern for vascular or 890 Aspects of Gynecologic Surgery of 1. Since the entire quantity required to appropriately inaufllate an abdomen will vary relying on affected person habitus, inttaperitoneal pressure, rather than total volume of gasoline, is used to determine ad. When an inu:aperitoneal stress of20 mm Hg is achieved, the Veresa needle could also be withdrawn, and the pneumoperitoneum can help secure main trocar insertion. This transient elevated intraabdominal strain offers a volumetric countertension for primary trocar insertion.

References

• www.cdc.gov/ncidod/EID/vol3no1/ baseman.htm. Murray PR, Rosenthal KS, Pfaller MA. Medical Microbiology, 5th ed. St. Louis, MO: Mosby, 2005:395n9.
• Fisher RI, Coltman CA, Doroshow JH, et al: Metastatic renal cancer treated with interleukin-2 and lymphokine-activated killer cells, Ann Intern Med 108:518n523, 1988.
• Lim KB, Ho H, Foo KT, et al: Comparison of intravesical prostatic protrusion, prostate volume and serum prostatic-specific antigen in the evaluation of bladder outlet obstruction, Int J Urol 13(12):1509n1513, 2006.
• Mininberg DT, Montoya F, Okada K, et al: Subcellular muscle studies in the prune belly syndrome, J Urol 109:524n526, 1973.