Porcine vesical acellular matrix graft of tunica albuginea for penile reconstruction

Aim： To characterize the feasibility of the surgical replacement of the penile tunica albuginea （TA） and to evaluate the value of a porcine bladder acellular matrix （BAM） graft. Methods： Acellular matrices were constructed from pigs＇ bladders by cell lysis, and then examined by scanning electron microscopy （SEM）. Expression levels of the mRNA of the vascular endothelial growth factor （VEGF） receptor, fibroblast growth factor （FGF）-1 receptor, neuregulin, and brain-derived neurotrophic factor （BDNF） in the acellular matrix and submucosa of the pigs＇ bladders were determined through the reverse transcription-polymerase chain reaction （PCR）. A 5 mm× 5 mm square was excised from the penile TA of nine rabbits. The defective TA was then covered in porcine BAM. Equal numbers of animals were sacrificed and histochemically examined at 2, 4 and 6 months after implantation. Results： SEM of the BAM showed collagen fibers with many pores. VEGF receptor, FGF-1 receptor and neuregulin mRNA were expressed in the porcine BAM; BDNF mRNA was not detected. Two months after implantation, the graft sites exhibited excellent healing without contracture, and the fusion between the graft and the neighboring normal TA appeared to be well established. There were no significant histological differences between the implanted tunica and the normal control tunica at 6 months after implantation. Conclusion： The porcine BAM graft resulted in a structure which was sufficiently like that of the normal TA. This implantation might be considered applicable to the reconstruction of the TA in conditions such as trauma or Peyronie＇s disease.

Adult iatrogenic ureteral injury and strictureeincidence and treatment strategies

Iatrogenic ureteral injuries and strictures are relatively common complication of pelvic surgery and radiation treatment.Left untreated they are associated with severe shortand long-term complications such as urinoma,septic state,renal failure,and loss of a renal unit.Treatment depends on timing of diagnosis,as well as extent of injury,and ranges from simple endoscopic management to complex surgical reconstruction under usage of pedicled grafts.While recent advances in ureteral tissue engineering are promising the topic is still underreported.Historically a domain of open surgery,laparoscopic and robotic-assisted approaches have proven their feasibility in small case series,and are increasingly being utilized as means of reconstructive surgery.This review aims to give an outline of incidence and treatment of ureteral injuries and strictures in light of the latest advances.

Congenital H-type anovestibuler fistula

The congenital H-type fistula between the anorectum and genital tract besides a normal anus is a rare entity in the spectrum of anorectal anomalies. We described a girl with an anovestibuler H-type fistula and left vulvar abscess. A 40-day-old girl presented symptoms after her parents noted the presence of stool at the vestibulum. On the physical examination, anus was in normal location and size, and had normal sphincter tone. A vestibuler opening was seen in the midline just below of the hymen. A fistulous communication was found between the vestibuler opening and the anus, just above the dentate line. There was a vulvar abscess which had a left lateral vulvar drainage opening 15 mm left lateral to the perineum. After the management of local inflammation and abscess, the patient was operated for primary repair of the fistula. A protective colostomy wasn′t performed prior the operation. A profuse diarrhea started after 5 hours of postoperation. After the diarrhea, a recurrent fistula was occurred on the second postoperative day. A divided sigmoid colostomy was performed. 2 months later, and anterior sagital anorectoplasty was reconstructed and colostomy was closed 1 month later. Various surgical techniques with or without protective colostomy have been described for double termination repair. But there is no consensus regarding surgical management of double termination.

溶栓治疗挽救游离皮瓣术后误用血凝酶致静脉血管危象1例

1 临床资料患者,男,48岁,因“右耳闷塞感4个月余,咽痛伴牙痛2个月余”入院。专科查体见I度张口受限,右侧腭舌弓隆起,扁桃体不大,被推挤向对侧,右颈部轻微压痛。颅面部MRI及颈部增强CT提示,右侧口咽部及咽旁颅底间隙囊实性占位伴钙化(图1A,图1B)。纤维鼻咽喉镜示右后鼻孔及鼻咽部肿物,表面黏膜光滑。于2019-09-10行气管切开+右侧颅底肿瘤切除+右侧根治性颈淋巴结清扫+右侧上颌骨次全切+下颌骨部分切除+颈外动脉结扎+游离股前外侧皮瓣切取移植+腭咽成形术。

Robot-assisted laparoscopic pyeloureterostomy for ureteropelvic junction rupture sustained in a traffic accident:A case report

BACKGROUND Ureteral reconstruction is a highly technical type of laparoscopic or open surgery.The incidence of ureteral injury is low;however,ureteral injuries tend to be overtreated.Robotic surgery for urinary reconstructive surgery is growing in popularity,which has made procedures such as pyeloplasty,ureteroureterostomy,and ureteroneocystostomy possible,with minimal damage to the patient.To the best of our knowledge,this is the first report of robot-assisted laparoscopic pyeloureterostomy in Korea,in a 17-year-old female patient with a ureteral injury.CASE SUMMARY The patient,a 17-year-old girl without previous medical history,was presented at the emergency room and complained of abdominal and back pain.Tenderness in the right upper quadrant was observed on physical examination.Hemorrhage in the right perirenal space was observed without abdominal organ injuries on the initial enhanced abdomen computed tomography(CT)scan.Ureteral injury was not suspected at this time.The patient was stabilized via conservative treatment,but complained of right flank pain 3 wk later and revisited the emergency room.An enhanced abdominal CT scan revealed a huge urinoma in the right perirenal space with hydronephrosis of the right kidney.Retrograde and antegrade pyelography were performed.Extravasation and discontinuity of the ureter were found.A rupture of the ureteropelvic junction was diagnosed and reconstructive surgery was performed.After 3 mo,the patient did not complain of any symptoms without any abnormal radiologic findings.CONCLUSION This case report discusses the safety and effectiveness of this minimal invasive procedure as an alternative to conventional open or laparoscopic surgery.

Phalloplasty following penectomy for penile cancer

Objective:Penile reconstruction or phalloplasty following penectomy can be offered where the functional penile length is inadequate for a man to void while standing or to have sexual intercourse.Phalloplasty is usually staged due to the complex surgical techniques required.This narrative review describes the technical concepts and summarises the contemporary outcomes following phalloplasty in this challenging cohort.Methods:A retrospective review of the English literature was performed between January 1946 till November 2021.The data were synthesised and complemented by the expert opinion of the authors with 20 years of experience in this field.The flaps are ideally designed with an integrated urethra or alternatively,a further free flap urethroplasty can be offered.Phallo-plasty is further complicated following penectomy by scarring from the previous surgery and the potential loss of structures that would normally be present at the recipient site.Results:There are limited published data with a total of 19 men recorded in the literature.Only the radial artery forearm free flap and anterolateral thigh flap have been described in this cohort of patients.Functional outcomes including standing micturition,sensation in the neo-phallus,and the ability to orgasm are good.Overall quality of life and satisfaction was also good despite the high risk for long-term complications of the neophallus and donor site.Conclusion:Phalloplasty following penectomy requires microsurgical transfer of a free flap or a pedicled flap to reconstruct a neophallus.An erectile device is inserted at a later stage to facilitate sexual intercourse,if desired.Surgical scarring from penectomy and the potential loss of vasculature that would normally be present at the recipient site may further complicate reconstruction.Surgical and functional outcomes are acceptable based on the limited published experience to date.

锁骨上皮瓣修复头颈缺损9例临床分析

目的 探讨锁骨上皮瓣在头颈肿瘤缺损修复中的应用。方法 回顾性分析2017年1月~2020年12月于扬州大学附属苏北人民医院收治的应用锁骨上皮瓣修复头颈缺损的9例患者临床资料,通过研究其头颈肿瘤缺损的原因、术前放疗史、手术方式、皮瓣尺寸及术后愈合情况等因素,探讨锁骨上皮瓣的制备技巧、应用指征及术后并发症的处理。结果 9例患者均为男性,年龄51~79岁。3例一期修复包括1例下咽癌,1例舌根恶性肿瘤,1例鼻咽癌继发颈部淋巴结转移癌;6例二期修复包括1例下咽癌术后继发颈部淋巴结转移癌,1例喉癌术后继发气管造瘘口癌,1例喉及食管癌术后吻合口瘘,3例下咽癌术后咽瘘。2例咽瘘患者采用锁骨上皮瓣联合胸大肌皮瓣修复缺损,7例患者单独采用锁骨上皮瓣修复。术中所取锁骨上皮瓣宽度为4~8 cm,长度为6~15 cm。8例术后随访皮瓣存活,1例术后皮瓣坏死,清创换药后愈合。1例下咽癌术后患者皮瓣存活,但食管入口肿瘤复发予以放射性粒子植入,局部未控,术后第11个月死亡。结论 锁骨上皮瓣是喉咽及颈部皮肤术后缺损较为理想的修复组织瓣,技术比较成熟,术中应注意皮瓣血管的保护,治疗效果比较可靠。

The Right Decision on the Vaginal Construction in Mayer- Rokitansky-Kiister-Hauser syndrome

Vaginal agenesis is a congenital anomaly that affects the life of one of each four thousand women around the world. There is a trend that patients request immediate surgical correction, instead of passive vaginal dilatation. Therefore a differentiated counselling should be provided. We present a comparative chart, based on published evidence, with aspect to the available techniques, which will facilitate the decision- making process in the clinical practice. From our point of view, the best results are achieved with techniques that combine the advantages of the minimal-invasive surgery with those derived of the use of peritoneum as coveting tissue of the neovagina. Nevertheless there is a lack on interdisciplinary consensus about the best option to restore the physical and sexual quality of life.

Long-term follow-up results of dural reconstruction without bone graft at anterior skull-base defects

OBJECTIVE: To clarify whether it is necessary to reconstruct bone defects at the anterior skull base. METHODS: A long-term follow-up study of 50 patients with anterior skull-base defects in which the dura was reconstructed without bone grafts was conducted. CT and MRI examinations were taken periodically after surgery. RESULTS: The ordinates of the bone defects averaged 3.5 cm (range, 2 - 6 cm), and the abscissas averaged 2.8 cm (range, 2 - 5 cm). The abscissas of the bone defects measured 2 - 3 cm in 38 patients, 3 - 4 cm in 10 patients, and 4 - 5 cm in 2 patients. The follow-up ranged from 3 months to 5 years (average, 2 years). CONCLUSIONS: At normal intracranial pressure, if the dura mater is repaired properly at the skull-base defects and reinforced with a pedicled pericranial flap, encephalomeningocele and cerebrospinal fluid (CSF) leakage can be prevented. It may not be necessary to make free bone grafts when the size of the cranial base bone defect is smaller than 4 cm.

Reconstruction of mandible with fibular flap and dental implant distractor:a new approach

OBJECTIVE: To study the application of dental implant distractor (DID) in mandibular functional reconstruction. METHODS: We designed a new device named DID, which includes the permanent dental implant and the temporary distractor in itself. It is specially designed for fibula wider distraction in mandible reconstruction. Twenty-five sets of DID devices were put into 8 patients (6 men and 2 women) during operation. Two patients suffered from ameloblastoma of the mandible, 2 from odontogenic cyst of the mandible, 1 from fibrous dysplasia, and the other 3 from malignant tumor of the mandible. The age of 8 patients ranged from 19 to 67 (mean 46.8) years. RESULTS: During postoperative 2 - 15 months follow up, 7 patients were found to be successful. The clinical examination and X-ray film showed the normal shape of the mandible and the osteointegration of the implants were solid enough to withstand the denture force. Others had the DID removed because of inflammation. Two of the patients successfully worn the fixed dental prosthesis. The outcomes was satisfying. CONCLUSION: The DID device specially designed for mandibular reconstruction with fibular flap can help to simplify convenient procedures to a single surgery.

Application of navigation template to fixation of sacral fracture using three-dimensional reconstruction and reverse engineering technique

Objective： To provide a new method in the fixation of sacral fracture by means of three-dimensional reconstruction and reverse engineering technique. Methods： Pelvis image data were obtained from threedimensional CT scan in patients with sacral fracture. The data were transferred into a computer workstation. The threedimensional models of pelvis were reconstructed using Amira 3.1 software and saved in STL format. Then the threedimensional fracture models were imported into Imageware 9.0 software. Different situations of reduction （total reduction, half reduction and non-reduction） were simulated using Imageware 9.0 software. The best direction and location of extract iliosacral lag screws were defined using reverse engineering according to these three situations and navigation templates were designed according to the anatomic features of the postero-iliac part and the channel. The exact navigational template was made by rapid prototyping. Drill guides were sterilized and used intraoperatively to assist in surgical navigation and the placement of iliosacral lag screws. Results： Accurate screw placement was confirmed with postoperative X-ray and CT scanning. The navigation template was found to be highly accurate. Conclusion： The navigation template may be a useful method in minimal-invasive fixation of sacroiliac joint fracture.

Relationship between different skin incisions and the injury of the infrapatellar branch of the saphenous nerve during anterior cruciate ligament reconstruction

Background After anterior cruciate ligament （ACL） reconstruction, some patients suffered from sensory disturbance around the surgical incision of the leg. This research was aimed to investigate the relationship between the different skin incisions and the injury of the infrapatellar branch of the saphenous nerve （IPBSN） post ACL reconstruction.Methods ACL reconstructions were performed with quadruple hamstring tendon for 60 patients. Sensory disturbance around the skin incision was followed up at an average of 14.5±4.7 months post operation. Among the 60 patients, vertical incision for 35 patients and oblique incision for 25 patients were used for graft taking during ACL reconstruction. The lengths of the incisions were measured. The patients were asked to mark the sensory disturbance zone at follow up time, and then the marked area was measured. The IPBSN of 15 cadaver knees were anatomized. The distance between the IPBSN and the upper edge of the pes anserinus tendon at the middle point of the incision was measured. independent-samples t-test, chi-square and Mann-Whitney tests were used for statistical analyses. Results The patients＇ age （P=0.329）, the follow-up time （P=0.661）, and the incision length （P=0.732） between the two groups had no significant difference. Twenty-three patients （65.7%） in the vertical incision group had IPBSN injury compared with 6 patients （24.0%） in oblique incision group （P=0.002）. The average sensory disturbance area in vertical incision group （（48.0±75.3） cm^2） was significantly larger （P=0.004） than that in the oblique group （（8.4±19.4） cm^2）. The anatomy measurement showed the average distance between IPBSN and the upper edge of the pes anserinus tendon was 0.6 cm at the incision. Conclusions Oblique incision with less risk of damage for IPBSN may be better for graft harvesting in ACL reconstruction. As the IPBSN is so near and parallel to the hamstring tendons, damage to the IPBSN is one of the potential complications for graft harvesting, regardless of the incision used. That＇s why even in the oblique incision group, 24% patients also had sensory disturbance complication.

Reconstruction of chronic acromioclavicular joint disruption with artificial ligament prosthesis

Objective： Management of Rockwood type 3 acromioclavicular disruptions is a matter of debate. Should we adopt conservative or operative measures at first presentation？ It is not clear but most of the evidences are in favour of conservative management. We present our expe- rience in managing these patients surgically. Methods： We present a prospective series of eight cases of chronic Rockwood type 3 acromioclavicular joint disruptions treated surgically. Anatomical reconstruction of the coracoclavicular ligament was done by artificial braided polyester ligament prosthesis： Results： All the patients were able to perform daily activities from an average of the 14th postoperative day. All patients felt an improvement in pain, with decrease in ave- rage visual analogue scale from preoperative 6.5 points （range 3-9 points） to 2.0 points （range 0-5 points）, Constant score from 59% to 91% and American Shoulder and Elbow Surgeons shoulder score from 65 to 93 points postoperatively. These results improved or at least remained stationary on midterm follow-up, and no deterioration was recorded at an average follow-up of 46 months. Conclusion： This midterm outcome analysis of the artificial ligament prosthesis is the first such follow-up study with prosthesis. Our results are encouraging and justify the further use and evaluation of this relatively new and easily reproducible technique.

Anterolateral thigh free flap for simultaneous reconstruction of digital extensor tendon and defect of the dorsal hand： A case report

This paper describes a new technique in the repair of the hand defect with digital extensor tendon injury. The anterolateral thigh flap with the thick femoral fascia has been used in the reconstruction of the composite defect of the dorsal hand, especially the defect of tendon. This technique requires short period of treatment and hence causes less damage to the donor site but shows a better recovery of the hand function. A favorable curative effect has been obtained in this patient.

A totally laparoscopic peritoneal free flap for reconstruction of hand

Management of defects on the hand and foot with exposed tendons remains a major challenge for plastic surgeons. Here, we present a case of hand reconstruction with a totally laparoscopic peritoneal flap. The anterior rectus sheath was preserved in situ. The peritoneal free flap supplied by peritoneal branches of the deep inferior epigastric artery was retrieved by laparoscopy to cover the soft tissue defect of the hand. The defect of the dorsal hand was 17 cm × 12 cm. The peritoneal flap measuring 22 cm × 15 cm survived completely without any complications. A following split-thickness skin graft offered the suc- cessful wound closure. Motor and sensory function improved gradually within the first year follow-up. The totally laparoscopic peritoneal free flap is a good choice for reconstruction of the soft tissue de- fects accompanied by exposed tendons on the hand and foot.

Clinical observation of particulate cancellous bone impaction grafting in combination with total hip arthroplasty for acetabular reconstruction

Objective： To investigate the effect of particulate cancellous bone impaction grafting in combination with total hip arthroplasty （THA） for acetabular reconstruction in patients with posttraumatic arthritis and bone loss after acetabular fractures. Methods： Totally 15 consecutive cases with unilateral acetabular fracture were treated with bone impaction grafting in combination with THA in our department. There were 10 males and 5 females with mean age of 48.2 years （ranging from 36 to 73 years）. Eight cases had the fracture at left hips, 7 at right hips. The average age at injury was 28 years （ranging from 18 to 68 years）. The mean follow-up period was 4.3 years （ranging from 2 to 7 years）. Results： Compared with mean 42 points （ranging from 10 to 62） of the preoperative Harris score, the survival cases at the final follow-up had mean 84 points （ranging from 58 to 98）. One patient had mild pain in the hip. No revision of the acetabular or femoral component was undertaken during the follow-up. Normal rotational centre of most hips was recovered except 2 cases in which it was 0.8 mm higher than that in opposite side. All of them had a stable radiographic appearance. Progressive radiolucent lines were observed in Ⅰ,Ⅲ zones in 2 cases. One patient had a nonprogressive radiolucent line in zone Ⅲ. The cup prosthesis was obviously displaced （6 mm） in one patient, but had not been revised. Conclusion： Particulate cancellous bone impaction grafting in combination with THA as a biological solution is an attractive procedure for acetabular reconstruction in patients with posttraumatic arthritis and bone loss after acetabular fracture, which can not only restore acetabular bone stock but also repair normal hip anatomy and its function.

Current concepts in the management of the duplicated thumb

Preaxial polydactyly is a common congenital anomaly of the hand presenting at birth.Surgical treatment is aimed at creating a functional thumb capable of normal grip and pinch strength with acceptable aesthetics.Each case is unique and presents individual challenges to the hand surgeon.The aim of this review is to provide a synopsis of current knowledge and recommended surgical techniques for the duplicated thumb.

Surgical outcomes in adults with purpura fulminans:a systematic review and patientlevel meta-synthesis

Background:Cutaneous manifestations of purpura fulminans(PF)present many challenges for clinicians and surgeons.In a state of septic shock complicated by limb ischemia,surgical interventions are necessary to control the pathological cascade and improve patient outcomes.The objective of this article was to report etiologies and surgical outcomes associated with cutaneous manifestations in adults.Methods:This systematic review and meta-analysis compared 190 adult patients with etiologies,signs and symptoms,and surgical outcomes associated with cutaneous manifestations of PF.The PubMed,EMBASE,Cochrane Library,Web of Science,and Scopus databases were systematically and independently searched.Patient and clinical characteristics,surgical interventions,outcomes,and complications were recorded.Results:Seventy-nine studies were eligible for the systematic review,and 77 were eligible for meta-analysis using Preferred Reporting Items for Systematic Reviews and Meta-analysis(PRISMA)and Cochrane guidelines.A total of 71/190(38%)cases reported surgical debridement.Fasciotomies were reported in 12/190(6%)cases and 20 procedures.Amputations were reported in 154/190(81%)cases.Reconstruction was reported in 45 cases.Skin grafts were applied in 31 cases.Flaps were used for reconstruction in 28 cases.Median(IQR)surgical procedures per patient were 4(4,5)procedures.Infectious organisms causing PF were 32%Neisseria meningitidis(n=55)and 32%Streptococcus pneumonia(n=55).Coagulase-negative Staphylococcus(95%confidence interval(CI)(8.2–177.9),p=0.032),Haemophilus influenza(95%CI(7.2–133),p=0.029),Streptococcus pneumonia(95%CI(13.3–75.9),p=0.006),and West Nile Virus(95%CI(8.2–177.9),p=0.032)were associated with significantly more extensive amputations compared to other organisms.Conclusion:This systematic review and patient-level meta-analysis found the most common presentation of PF was septic shock from an infectious organism.Neisseria meningitidis and Streptococcus pneumonia were equally the most common organisms associated with PF.The majority of cases were not treated in a burn center.The most common surgeries were amputations,with below-the-knee-amputations being the most common procedure.Skin grafting was the most commonly performed reconstructive procedure.The most common complications were secondary infections.Organisms with significantly more extensive amputations were coagulase-negative Staphylococcus,Haemophilus influenza,Streptococcus pneumonia,and West Nile Virus.Interpretation of findings should be cautioned due to limited sample data.

Simple flaps for reconstruction of pediatric scalp defects after electrical burn

Objective： To analyze the management of high-voltage electrical burn injury of the scalp in our hospital. Methods： This study involved 10 patients who suf- fered from high-voltage electrical bum injury of the scalp. Scalp reconstruction was done by different modalities ac- cording to the size and location of the defect. Results： Complete flap viability was achieved in all the cases. We had one case of gapped wound which was managed only by dressing. Widening of the scar was found in 2 cases. Conclusion： Rotation, advancement and transposi- tion scalp flaps are used for reconstructing scalp defects caused by electrical bum. The choice of ideal flaps for re- construction depends upon the size and site of scalp defect.

Combined index finger pollicization with an anterolateral thiqh flap for thumb reconstruction

A severe crush injury to the hand is devastating to patients. Under conditions in which the crush force is too great, the digits are not viable candidates for replantation. We present two cases in which the patients suffered from loss of the thumb ray at the first carpometacarpal joint and skin defect at the radial side. The tendons, radial nerve and metacarpal bone of the index finger were injured, and the second metacarpal head was retained. There was a comminuted fracture of the trapezium in both patients. The treatment protocols consisted of the index finger pollicization and the free anterolateral thigh flap transfer. The procedure was performed in a single operation. The new thumb is able to provide a stable post for pinch and grip after six months follow-up. Both patients were satisfied with the function and appearance of the reconstructed thumb.