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.

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.

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.

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.

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.

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.

Clinical application and histological observation of pedicled buccal fat pad grafting

OBJECTIVE: To introduce the applied anatomy of pedicled buccal fat pad (BFP) graft and a series of histological changes in the healing process of BFP as an uncovered pedicled graft. METHODS: The healing processes of BFP are demonstrated via uncovered pedicled grafts on rabbits in histological examination. Uncovered buccal fat pads were used to repair soft tissue defects in rabbit oral cavities. RESULTS: The uncovered buccal fat pads showed complete epithelialization of their oral surfaces at 6 to 8 weeks after surgery and were slowly replaced by fibrous tissue. CONCLUSIONS: Advantages of the pedicled buccal fat pad graft include an anatomic region that is consistent and easy to excise. The operation can be performed in one incision, affecting neither appearance nor function of the area. Use of the buccal fat pad provides a good reconstruction of soft tissue defects in the mouth.

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.

Applied anatomy of the submental island flap and its clinical application in the repair of defects following hypopharyngeal carcinoma resection

Objective: To explore the feasibility of the submental island flap in the repair of hypopharyngeal defects.Methods: We collected wet specimens of fresh cadaveric heads from the Han Chinese adult population for applied anatomy of the submental island flap, and followed five patients with pyriform sinus carcinoma after reconstruction surgery using submental island flaps.Results: We found that the average length and width of the submental island flaps were (65.20 ± 11.69) mm and (46.70 ± 6.59) mm, respectively.The skin flap in all five patients survived after surgery, and tracheal tubes and gastric tubes were removed 7-36 days after surgery.Patients were followed up for 24-42 months, pharyngeal flaps grew well, and speech and swallowing functions were satisfactory.Conclusion: The submental island flap is a preferred material for the repair of hypopharyngeal defects after hypopharyngeal carcinoma resection, because of good blood supply, easy harvesting, and high survival rate.

Resection and repair of large abdominal wall lesions in gynecologic patients

Background The techniques of resection and repair of large lesions in the abdominal wall are very challenging in the area of gynecology. We explored the techniques of resection and plastic surgical repair of large abdominal wall lesions in gynecologic patients. Methods Twenty-six patients with large lesions in the abdominal wall underwent resection by the gynecologists and repair through abdominal plasty and V-Y plasty with or without fascia patch grafting by the gynecologists or plastic surgeons from March 2003 to October 2010. Results All patients had a history of cesarean section. One patient had an infected sinus tract after cesarean section, one patient had an inflammatory nodule, and the others had lesions of endometriosis, including one cancer. The average largest lesion diameter was （4.79 ± 4.18） cm according to the ultrasonography results. The lesions of all patients were completely resected with pretty abdominal contour. A polypropylene biological mesh was added to the fascia in 20 patients. One patient underwent groin flap repair, and one underwent V-Y advanced skin flap repair on the left of the incision to relieve the suture tension. Conclusions Multi-department cooperation involving the gynecology and plastic surgery departments, and even the general surgery department, is essential for patients with large lesions in the abdominal wall. This cooperative effort enabled surgeons to completely resect large lesions. Abdominal wall plastic surgical repair can ameliorate large wounds of the abdominal wall.

Biocompatibility and degradation comparisons of four biodegradable copolymeric osteosynthesis systems used in maxillofacial surgery: A goat model with four years follow-up

pplying biodegradable osteosyntheses avoids the disadvantages of titanium osteosyntheses. However, foreign-body reactions remain a major concern and evidence of complete resorption is lacking. This study compared the physico-chemical properties, histological response and radiographs of four copolymeric biodegradable osteo-synthesis systems in a goat model with 48-months follow-up. The systems were implanted subperiosteally in both tibia and radius of 12 Dutch White goats. The BioSorb FX [poly(70LLA-co-30DLLA)], Inion CPS [poly([70–78.5] LLA-co-[16–24]DLLA-co-4TMC)], SonicWeld Rx [poly(DLLA)], LactoSorb [poly(82LLA-co-18GA)] systems and a negative control were randomly implanted in each extremity. Samples were assessed at 6-, 12-, 18-, 24-, 36-, and 48-month follow-up. Surface topography was performed using scanning electron microscopy (SEM). Differential scanning calorimetry and gel permeation chromatography were performed on initial and explanted samples. Histological sections were systematically assessed by two blinded researchers using (polarized) light microscopy, SEM and energy-dispersive X-ray analysis. The SonicWeld Rx system was amorphous while the others were semi-crystalline. Foreign-body reactions were not observed during the complete follow-up. The SonicWeld Rx and LactoSorb systems reached bone percentages of negative controls after 18 months while the BioSorb Fx and Inion CPS systems reached these levels after 36 months. The SonicWeld Rx system showed the most predictable degradation profile. All the biodegradable systems were safe to use and well-tolerated (i.e., complete implant replacement by bone, no clinical or histological foreign body reactions, no [sterile] abscess formation, no re-interventions needed), but nanoscale residual polymeric fragments were observed at every system’s assessment.

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.

Induction of hair follicle regeneration in rat ear by mi-croencapsulated human hair dermal papilla cells

Objective: To induce hair follicle regeneration in rat ear by microencapsulated dermal papillae (DP) cells.Methods: Intact dermal papillae were obtained from human scalp follicles which were digested with collagenase I. The human hair DP cells were encapsulated with alginate-polylysine-alginate (APA) by a high-voltage electric field droplet generator. The diameters of the DP cell microcapsules were optimized by regulating the voltage, the distance be-tween the needle head and the solution surface and the injection speed. Then DP cell microencapsulations were xenotransplanted into ears of 20 SD rats with a novel method. One rat was killed every week at the postoperative 2-12 weeks and the implantation sites were biopsied for histo-logical observation.Results: The DP cell microencapsulations were found in a group of round, smooth and transparent microcapsules under a phase-contrast microscope. The optimal combina-tion of parameters to obtain 0.4 mm DP cell microcapsules was voltage 7.0 kV, injection speed 55 mm/h, and distance 10mm. After 4-12 weeks, 18 of 20 DP cell microcapsule implan-tations had produced high-density hair. Histological obser-vation indicated that both large follicles and sebaceous gland structures were formed in the rat ear within 3-12 weeks.Conclusions: These findings show that the DP cell microencapsulation maintain the capacity for initiating the follicle regeneration and can be considered as a substitute for fresh isolated dermal papillae.