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Sabiston Textbook of Surgery, 19th ed
VGHTC Sabiston Textbook of Surgery, 19th ed Chief Round 報告 : R3 楊哲瑞 Contents 1 urologic anatomy for the general surgeon 2 endoscopic urologic surgery 3 urologic infectious disease 4 5 voiding dysfunction, BOO,BPH, and incontinence male reproductive and sexual dysfunction Department of Surgery VGHTC Contents 6 urolithiasis 7 urologic trauma 8 9 nontraumatic urologic emergencies urologic oncology Department of Surgery VGHTC VGHTC Urologic Anatomy for the general surgeon Department of Surgery VGHTC UROLOGIC ANATOMY Upper Abdomen and Retroperitoneum Department of Surgery VGHTC UROLOGIC ANATOMY the surrounding organs: Right Left Posterior 12th rib psoas muscle 11th~12th rib psoas muscle, Anterior pancreas tail and splenic Liver vessels, hepatorenal ligament (coronary ligament) lesser sac and stomach, jejunum, duodenum, splenorenal ligament hepatic flexure of the colon Department of Surgery VGHTC UROLOGIC ANATOMY Department of Surgery VGHTC UROLOGIC ANATOMY URETER Department of Surgery VGHTC UROLOGIC ANATOMY Ureter • • • • • • • lie on the psoas muscle pass medially to the sacroiliac joints cross the iliac vessels anteriorly swing laterally near the ischial spines pass medially to penetrate the base of the bladder vasa deferentia pass anterior to the ureters uterine arteries are closely related to the lower ureters blood supply • The calyces, pelvis, and upper ureter: renal arteries • The lower ureter: common and internal iliac, internal spermatic, and vesical arteries UROLOGIC ANATOMY Pelvic Anatomy: Bladder, Prostate, and Seminal Vesicles Department of Surgery VGHTC UROLOGIC ANATOMY BLADDER Capacity: ~500 mL Cephalad: urachus, a fibrous remnant of the cloaca Superior: covered by peritoneal reflection Inferior: attached to the pubic bone by puboprostatic ligaments / pubovesical ligaments Artery: • hypogastric a.(internal iliac a.)Æsuperior, middle, and inferior vesical arteries • vaginal and uterine a. Vein: • vesicle plexus Æ internal iliac v. Lymphatics: • The bulk of the lymphatic drainage Æ external iliac LN • Anterior, lateral drainage Æ obturator, internal iliac node • Base, trigone Æ internal, common iliac groups transitional epithelial cell = urothelium = bladder mucosa Æ lamina propria Æ muscularis propria = detrusor muscle UROLOGIC ANATOMY Pelvic Anatomy: Bladder, Prostate, and Seminal Vesicles Department of Surgery VGHTC UROLOGIC ANATOMY PROSTATE Weight:~20 g Anterior: puboprostatic ligament Inferiorly: urogenital diaphragm Posterior: Denonvilliers' fascia x2 layersÆ rectum Zonal anatomy • • • • • • peripheral zone central zone transitional zone anterior segment(anterior fibromuscular stroma) preprostatic sphincteric zone *BPH develops from the median or lateral lobes, posterior lobe is prone to cancerous formation. ejaculatory ductsÆ verumontanum Department of Surgery VGHTC UROLOGIC ANATOMY PROSTATE Artery: • inferior vesical a. • internal pudendal a. • middle rectal (hemorrhoidal) a. Vein: • periprostatic plexus, which has connections with the deep dorsal vein of the penis and the internal iliac (hypogastric) veins neurovascular bundles (NVB): near the posterolateral surface of the urethra and prostate gland Department of Surgery VGHTC UROLOGIC ANATOMY Groin, Genitalia, and Perineum Department of Surgery VGHTC UROLOGIC ANATOMY Male urethra 20 cm four anatomic sections • • • • Prostatic urethra Membranous urethra Bulbous urethra penile urethra. female urethra 4 cm lies below the pubic symphysis anterior to the vagina voluntary external urinary sphincter: lies within the urogenital diaphragm Department of Surgery VGHTC UROLOGIC ANATOMY Spermatic cord, contains: vas deferens internal and external spermatic arteries, artery of the vas spermatic vein Lymphatics Nerves epididymis 1~3 seminiferous tubules Ærete testis in the mediastinum Æ12~ 20 efferent ductules Æhead of the epididymis Æsingle coiled duct of the epididymis testis 4 × 3 × 2.5 cm in diameter Tunica albuginea, connects with the lobules within the testis Ævisceral tunica vaginalis Æ serous tunica vaginalis Department of Surgery VGHTC VGHTC endoscopic urologic surgery Department of Surgery VGHTC Endoscopic urologic surgery Cystoscopy/cystourethroscopy(CUS) rigid or flexible adult • 17Fr diagnostic rigid scopes • 24 to 26 Fr operating resectoscopes Cold cup biopsy forcep Cone-tipped / straight ureteral catheter Retrograde pyelography (RP): May be safely performed to patients with a history of contrast allergy To aid in identifying the ureters during surgery Department of Surgery VGHTC Endoscopic urologic surgery Optical urethrotome: urethral stricture incision Electroresectoscope cutting loop Green Light laser Holmium laser bipolar resection system Ellik evacuator Continuous bladder irrigation (CBI) Department of Surgery VGHTC Endoscopic urologic surgery Department of Surgery VGHTC VGHTC Urologic Infectious Disease Department of Surgery VGHTC Urologic infectious disease Emphysematous Infection DM Emphysematous pyelonephritis • fulminant infection involving the renal parenchyma progress to involve the perinephric space • most common causative agent: E.coli • percutaneous drainage • urgent nephrectomy: delay if improving with medical treatment Emphysematous pyelitis • gas within the renal collecting system but not within the parenchyma Department of Surgery VGHTC Urologic infectious disease Department of Surgery VGHTC Urologic infectious disease Emphysematous cystitis • gas-forming infection involving the bladder wall • urinary catheter drainage Acute papillary necrosis • ischemic state involving the renal papillae • sloughed papilla into the collecting system and ureter, causing obstruction • urgent drainage of the obstructed upper tract Gas present in the urinary tract • anaerobic urinary infection, instrumentation or catheterization, colovesical fistula Department of Surgery VGHTC Urologic infectious disease Xanthogranulomatous Pyelonephritis foamy, lipid-laden, macrophage infiltrate in the renal parenchyma chronic bacterial infection, usually in the presence of stones and chronic obstruction poorly functioning kidney fistulization to the flank or adjacent organs drainage often are unproductive, Nephrectomy is usually indicated • “cooling off period” for active infection • risk of iatrogenic adjacent organ injury is high • the renal vessels cannot be individually dissected Department of Surgery VGHTC Urologic infectious disease Epididymitis, Epididymo-Orchitis, Without and With abscess infected through ascending infection from the urinary tract down the vas deferens into the scrotum DDx: • testicular torsion • incarcerated inguinal hernia • testicular tumor with necrosis and inflammation Scrotal ultrasound • abscess: surgical drainage +/- orchiectomy • testicular ischemia: exploration +/- orchiectomy Department of Surgery VGHTC Urologic infectious disease Fournier’s Gangrene Necrotizing soft tissue infections of the genitalia scrotal and genital pain, swelling, discoloration or frank necrosis, crepitus, foul-smelling discharge broad-spectrum antibiotic, supportive care, urgent surgical debridement separate the parietal tunica vaginalis of the testes from the overlying necrotic dartos and skin and preserve the tunical compartment intact If the penile skin is necrotic, it can be débrided down to but not through the Buck’s fascial layer urinary tract source: urethral stricture with perforation Foley meshed STSG for the scrotum and nonmeshed thick STSG for the penile shaft Department of Surgery VGHTC Urologic infectious disease Department of Surgery VGHTC Urologic infectious disease Genitourinary Fungal Infections diabetics, immunocompromised patients extensive nosocomial and antibiotic exposure invasive fungal infections of the bladder or kidneys may be life-threatening antifungal bladder irrigation fungus balls in the renal colleting system:direct irrigation or endoscopic removal Department of Surgery VGHTC Urologic infectious disease Genitourinary Tuberculous Infections Urine cultures from the first morning void Upper urinary tract tuberculosis infection • may cause ureteral strictures, result in silent obstruction and renal loss Tuberculous epididymitis chronic epididymitis results in cutaneous fistula formation test for an immunocompromised state, including HIV Department of Surgery VGHTC VGHTC Voiding Dysfunction, BOO, BPH, and Incontinence Department of Surgery VGHTC Voiding dysfunction Postoperative Acute Urinary Retention Cause: • • • • • Immobility Narcosis anticholinergic side effects of anesthetic agents underlying subclinical bladder outlet obstruction, local pain and spasm (typical after hemorrhoid or groin hernia surgery) • transient prostatic swelling following coronary bypass surgery or other procedures requiring cardiopulmonary bypass Treatment: • Catheterization voiding trial second catheterization + indwelling Foley catheter for 1 or more days • alpha blocker • adequate analgesics • urodynamic studies • cystoscopy Department of Surgery VGHTC Voiding dysfunction Urinary Incontinence Urgency incontinence • loss of urine associated with an urge to void • overactive bladder / detrusor instability • anticholinergic / antimuscarinic – SE: dry mouth, constipation, confusion – Contraindication: narrow-angle glaucoma Stress incontinence • loss of urine with movement, straining, or increase in abdominal pressure • multiple vaginal deliveries, psot radical prostatectomy • pelvic floor exercises, sling, artificial urinary sphincter Department of Surgery VGHTC Voiding dysfunction Overflow incontinence • loss of urine when the bladder becomes full and there is an inability to empty volitionally • palpate the full bladder, measurement of postvoid residual by ultrasound or catheter drainage • the cause of the bladder distention: obstructive versus detrusor dysfunction Mixed incontinence Department of Surgery VGHTC Voiding dysfunction Neurourology and Voiding Dysfunction of the Neurologically Impaired cerebral dysfunction: uninhibited detrusor function cervical cord lesions: detrusor-sphincter dyssynergia (DESD) lower lumbar / sacral lesions: bladder flaccidity and impaired emptying Department of Surgery VGHTC Voiding dysfunction Benign Prostatic Hyperplasia and Bladder Outlet and Urethral Obstruction LUTS (lower urinary tract symptoms) little correlation between the measured volume of the prostate and degree of symptomatology that results watchful waiting Department of Surgery VGHTC Voiding dysfunction Department of Surgery VGHTC Voiding dysfunction medical therapy • α-adrenergic blocking agents – orthostatic side effects • 5-alpha-reductase inhibitors – – – – block the conversion of testosterone to dihydrotestosterone reduce the actual volume of the prostate alters the serum PSA level (reduces it ≈50%) maximal effects seen by 6 months minimally invasive standard surgical intervention • laser procedures • TURP • open simple prostatectomy Department of Surgery VGHTC VGHTC male reproductive & sexual dysfunction Department of Surgery VGHTC Male Infertility Infertility affects 15% ~ 20% of couples Male factor: 50% of these cases. Hx: • potential gonadotoxic exposure • urologic and sexually transmitted infections • trauma and prior surgery involving the pelvis, groin, and genitalia • family history of infertility PE: • • • • Masculinization meatal location testicular size presence and normalcy of the epididymis and vas deferens • Varicocele • DRE Department of Surgery VGHTC Male Infertility Semen analysis • • • • • • • • semen volume consistency sperm concentration sperm total count percentage motility quality of sperm movement sperm morphology presence of RBC/WBC/bacteria serum hormone studies • • • • • FSH LH testosterone free testosterone prolactin Department of Surgery VGHTC Male Infertility azoospermia: complete absence of sperm from the semen • lack of sperm production – normal semen volume – elevated serum follicle-stimulating hormone (FSH) level • defects in sperm transport or ejaculation – ductal obstruction » iatrogenic injury (e.g., inguinal hernia repair) – ejaculatory dysfunction. abnormal bulk semen parameters: reduced sperm numbers, motility, or morphology • • • • varicocele antisperm antibodies genital duct infection with pyospermia causing sperm dysfunction gonadotoxic exposure Department of Surgery VGHTC Male Sexual Dysfunction 40% of men at 40y/o and 70% of men at 70y/o erectile dysfunction can be an early indication of significant atherosclerotic vascular disease Department of Surgery VGHTC VGHTC Urolithiasis Department of Surgery VGHTC Urolithiasis Risk factors 20~50y/o, males, Caucasians and Asians family history of stone disease Low fluid intake (<1200ml/day) High animal protein intake Low activity levels Chronic UTI primary hyperparathyroidism Sarcoidosis Familial renal tubular acidosis hyperoxaluria cystinuria inflammatory bowel disease short gut syndrome medullary sponge kidney Department of Surgery VGHTC Urolithiasis Symptoms acute onset pain, hematuria, and possibly nausea, vomiting, and ileus. Image: KUB: 90% of stones are radio-opacity Ultrasound: hydronephrosis non-contrast CT: the stone and the dilated collecting system proximal to it Department of Surgery VGHTC Urolithiasis Acute episodes: obstruction / infection Hydration Analgesics Decompressed urgently if with infection • retrograde ureteral stent insertion • percutaneous nephrostomy insertion • Ureteroscopic lithotripsy is contraindicated. Department of Surgery VGHTC Urolithiasis Treatment Watchful waiting pilots Extracorporeal lithotripsy (ESWL) Intracorporeal techniques • Ureteroscopic stone manipulation • Flexible ureteroscopy and laser treatment • Percutaneous nephrolithotomy (PCNL) Open/Laparoscopic stone surgery • Pyelolithotomy • Anatrophic (avascular) nephrolithotomy • Nephrectomy Department of Surgery VGHTC VGHTC Urologic Trauma Department of Surgery VGHTC Urologic trauma Urologic injury 10% of penetrating abdominal trauma cases variable percentage of blunt abdominal trauma cases Renal injuries 1.4% to 3.25% of all trauma patients 4% to 8% of penetrating trauma patients Department of Surgery VGHTC Urologic trauma Department of Surgery VGHTC Urologic trauma Renal Injuries Imaging :CT scan • • • • • renal vasculature and of parenchymal lacerations displaced or nonperfused parenchymal fragments urinary extravasation assessing function of the contralateral uninjured kidney one-shot IVP may be obtained 10 minutes after the injection of iodinated contrast Treatment • Grade 1 ~ 3:routinely managed nonoperatively • Grade 4:controversial – hemodynamic – Interventional radiology options • grade 5:operative intervention Department of Surgery VGHTC Urologic trauma Ureteral Injuries 5% to 10% of penetrating abdominal trauma uncommon in blunt trauma gross hematuria may be absent Imaging • Contrast-enhanced CT + delayed excretory phase • retrograde pyelography • IVP Treatment • penetrating injuries / blunt avulsion: best managed by surgical repair • Ureteral contusions: – prophylactic stenting to reduce progressive edema, occlusion, and ischemia and postinjury extravasation • avoid devascularization to prevent ischemic injury • spatulated, tension-free anastomosis Department of Surgery VGHTC Urologic trauma Bladder Injuries Gross hematuria Penetrating injuries with laparotomy planned: • direct inspection of the injury site intraoperatively Blunt trauma • stress cystogram to distinguish intraperitoneal from extraperitoneal injury Extraperitoneal rupture • pelvic fracture Æ tearing and shear forces related to injury to the pelvic ring • catheter drainage alone • repair may be necessary when failure of catheter management Intraperitoneal rupture • sudden compression of the bladder by impact to the lower anterior abdominal wall --> laceration of the bladder dome • exploration and repair Complex bladder injuries • extensive lacerations of the bladder neck in women, or concomitant injury to the lower bladder segment and rectum or vagina • require operative repair Department of Surgery VGHTC Urologic trauma Department of Surgery VGHTC Urologic trauma exploration of the bladder: • • • • • • • • midline anterior cystotomy examine interior of the bladder evacuate blood clot assess critical structures – intramural ureters – ureteral orifices – passing feeding tubes up the ureters – intraoperative retrograde pyelography – bladder neck close defects in the bladder wall in two layers – care should be taken when suturing the bladder near the ureteral orifices or intramural ureter – intraoperative stenting Injuries in continuity with rectal or vaginal injuries – omental flap interposition to prevent fistula diversion with a large-bore Foley catheter (22~24Fr) suprapubic cystostomy tubes Department of Surgery VGHTC Urologic trauma Urethral Injuries suspicion of urethral injury • blood per the urethra or blood at the urethral meatus following blunt trauma – pelvic fracture – straddle injury with perineal impact • penetrating trauma – severe pubic diastasis – marked vertical shear pelvic fracture retrograde urethrography prior to Foley catheter insertion Department of Surgery VGHTC Urologic trauma Treatment • primary immediate goal: provide urinary bladder drainage – suprapubic catheter • early catheter realignment for posterior urethral disruption • delay repair Department of Surgery VGHTC Urologic trauma Genital Injuries Early exploration and repair Penile injuries • • • • remove foreign material cleanse the wound hemostasis repair defects in the tunica albuginea or urethra – Penile fracture: sudden flexion of the erect penis during sexual activity Scrotal and testicular injuries • • • • • scrotal ultrasound: whether the testis is ruptured débridement of devitalized parenchyma closure of the capsule (tunica albuginea of the testis) repair of the scrotum Orchiectomy – thoroughly destroy the blood supply to the testis – no viable parenchyma available to salvage. Department of Surgery VGHTC VGHTC Nontraumatic Urologic Emergencies Department of Surgery VGHTC Testicular Torsion congenital deformity: “bell clapper deformity” →able to rotate freely on its spermatic cord pedicle →progressive edema and venous and arterial occlusion →testicular infarction occurring usually in the pediatric, adolescent, and young adult groups DDx: • trauma, • epididymitis, • incarcerated hernia Doppler ultrasound: absence of arterial flow to the testis. Department of Surgery VGHTC Testicular Torsion Department of Surgery VGHTC Testicular Torsion Best results: detorsion within 4 hours of the onset of pain 8 ~ 12 hours: testicular viability and function decreases significantly Ultrasound: within 1 hour after presentation surgical exploration if high suspicion and ultrasound is not available in a reasonable time frame scrotal incision Æ detorsion Æ orchiopexy Æ orchiopexy on the contralateral side at the same setting Even a late torsion is suspected (e.g., several days of fixed swelling, firmness), urgent exploration is still indicated Department of Surgery VGHTC Gross Hematuria With Clot Retention Surgical Emergency: • with a hazardous degree of blood loss • with urinary clot retention Etiology: • • • • post-OP bleeding after TURP /TURBt radiation cystitis pelvic trauma arteriocalyceal fistula Department of Surgery VGHTC Gross Hematuria With Clot Retention Treatment • large-bore (20 to 26 Fr), three-way Foley catheter for removal of clots from the bladder by catheter irrigation • evacuation of clots under rigid cystoscopy and resectoscope sheath • fulguration Department of Surgery VGHTC Priapism Definition: Prolonged and often painful erection in the absence of a sexual stimulus, lasting > 4~6h may resolve spontaneously but, if it persists longer than 2 to 3 hours, measures should be taken Etiology: sickle cell disease drugs pelvic or genital trauma hematologic malignancy Department of Surgery VGHTC Priapism Low-flow priapism Due to veno-occlusion, typical of sickle cell patients More common than high-flow priapism sludging of blood in the corpora cavernosa results in the accumulation of dark thick material Ischaemic priapism > 4h: emergency intervention Aspiration of blood from corpora:50ml portions using a 18~20 gauge butterfly needle Intracavernosal injection of α1 -adrenergic agonist medical treatment of the sickle crisis : rehydration, oxygenation, analgesia, and haematological input (consider exchange transfusion). Department of Surgery VGHTC Priapism High-flow priapism after penile or perineal trauma fistula develops between a central corporal artery and the vascular space within the corpus cavernosum Aspiration: arterial appearance and arterial blood gas parameters cool bath / icepack embolization of the internal pudendal artery Department of Surgery VGHTC VGHTC Urologic Oncology Department of Surgery VGHTC urologic oncology Renal Tumor Diagnosis • solid renal tumors > 3 cm: 65% ~ 75% represent renal cell carcinomas • Bx prior to surgical extirpation is reserved • DDx: – lymphoma – minimally fat-containing angiomyolipoma, – Sarcoma – pseudotumor Paraneoplastic syndromes: found in 20% of patients with RCC • • • • • • hypercalcemia anemia Stauffer's syndrome(Nonmetastatic hepatic dysfunction) ESR elevation *cytokine *Hepatic function normalizes after nephrectomy: 60% to 70% Cystic renal masses: Bosniak classification Department of Surgery VGHTC urologic oncology Department of Surgery VGHTC urologic oncology Histologic Classification Conventional • Clear cell • Granular • Mixed Chromophilic/papillary • Type1 • Type2 Chromophobic Collecting duct • Medullary cell Unclassified *Sarcomatoid variants of almost all the histologic subtypes Department of Surgery VGHTC urologic oncology Partial nephrectomy • small, well-encapsulated, superficial, exophytic, polar lesion • positive margin and local recurrence rate: acceptable range < 5% Radical nephrectomy • multiple tumors, large central tumor, postoperative hemorrhage, necrosis, or loss of collecting system integrity Open, laparoscopic or robotic technique +/- regional lymph node dissection +/- splenectomy, distal pancreatectomy, wedge resection of the liver, duodenum, partial resection of the colon, resection of flank musculature +/- renal vein or vena caval tumor thrombus resection Department of Surgery VGHTC urologic oncology Urothelial Cancer: Upper and Lower Tract Risk factors: • age • Tobacco smoking • chemical exposures: – – – – aniline dyes aromatic amine compounds rubber, leather, dye and petroleum workers Cyclophosphamide • chronic inflammation: SCC • Schistosomiasis:Schistosoma hematobium: SCC Department of Surgery VGHTC urologic oncology Bladder cancer TCC: 90% • consider upper tract imaging • long-term recurrence rate: 50% SCC: 5% ~ 10% • schistosomal infection • chronic inflammatory • smoking Adenocarcinoma: 1% ~ 2% • urachal in origin, typically seen at the upper bladder dome • history of bladder exstrophy • evaluation of the GI system to ensure that the tumor has not arisen from another organ system Department of Surgery VGHTC urologic oncology Symptoms: • • • • • gross painless hematuria: 75% chronic irritative voiding symptoms pelvic mass flank pain: upper tract obstruction flank mass Dx: • Urine cytology / bladder wash cytology Department of Surgery VGHTC urologic oncology Treatment: • TURBt • BCG intravesical immunotherapy: initial + maintenance • Intravesical Chemotherapy: Mitomycin C – immediately following standard TUR • Radical cystectomy: muscle-invasive bladder cancer – +/- neoadjuvant chemotherapy – male: cystoprostatectomy – female: cystohysterectomy – +/- urethrectomy – urinary diversion » ileal conduit » cutaneous catheterizable reservoirs » orthotopic bladder substitution / neobladder: Studer pouch • Chemotherapy: MVAC or GC Department of Surgery VGHTC urologic oncology Upper tract TCC Treatment: • Surgical resection – +/- neoadjuvant chemotherapy – Nephroureterectomy, including ureteral orifice • distal ureterectomy + ureteral reimplantation • endoscopic ablation Department of Surgery VGHTC urologic oncology Prostate Cancer Adenocarcinomas(95%) Dx: • Asymptomatic • DRE, PSA, discovered incidentally during radical cystectomy or TURP Risk factors: • family history : Y chromosome • advancing age • African American heritage Department of Surgery VGHTC urologic oncology Prostate Cancer Screening for prostate cancer: PSA and DRE • recommended by the American Cancer Society and American Urologic Association • in all men older than 50 years • with elevated risk factors: 40 / 45 years • PSA – normal-range » 50 y/o: 2.5ng/mL » 60 y/o 3.5ng/mL – percentage of free PSA » >25%: <10% risk » <10%: >50% risk – PSA velocity: <0.75 U/year • improve survival, but controversy Department of Surgery VGHTC urologic oncology Prostate Cancer Dx: • TRUS Bx • Gleason score: two highest and most prominent grades observed • CT scan: lymph nodes metastasis • Bone scan: bone metastasis Department of Surgery VGHTC urologic oncology Prostate Cancer Tx: • localized disease – – – – – watchful waiting: low PSA level, low-grade, low-volume tumor brachytherapy cryotherapy radical prostatectomy External beam therapy • advanced disease – androgen ablation therapy » luteinizing hormone-releasing hormone (LHRH) agonists » bilateral simple orchiectomy • Castration-Resistant Prostate Cancer – chemotherapy Department of Surgery VGHTC urologic oncology Penile, Urethral, and Other Genital Malignancies Penile cancer • • • • Uncommon SCC chronic phimosis and local infection: HPV circumcision, distal penectomy, or radical penectomy +/- inguinal lymphadenectomy Urethral cancer • women > men • TCC • partial or total urethrectomy Squamous cell cancers of the scrotum • chimney sweeps: carcinogenic effects of inspissated soot • Local excision Department of Surgery VGHTC VGHTC
