Urethroplasty among Elderly Men, Surgical Techniques and Outcomes

Introduction: Urethroplasty remains the gold standard for the management of urethral stricture. However, the treatment of stricture disease in the elderly tends to be less invasive due to the presumption that they might not be able to stand long hours of surgery and might have higher rates of recurrence due to poor wound healing from microangiopathy. We present our experience with the outcomes of urethroplasty among elderly men seen at the Komfo Anokye Teaching Hospital from January 2012 to December 2021. Methods: This was a retrospective review of data captured in the urology database on all patients 65 years and above who underwent urethroplasty at the hospital over the study period. Data was obtained on patients’ demographics, stricture characteristics, urethroplasty technique, and outcome. A successful outcome was defined as peak flow rate > 15 mls/s, a patent urethra on retrograde urethrogram, patient satisfaction with urine stream, or restoration of the normal stream of urine with only one attempt at urethral calibration or internal urethrotomy postoperatively. Data was analyzed using PASW Statistics for Windows, Version 18.0. Results: Overall, 43 urethroplasties were done over the study period in elderly men. The age range was 65 to 87 years. The commonest aetiology was catheterization (62.79%) followed by urethritis (32.56%). Stricture length ranged from 0.5 cm to 16 cm with a mean of 3.93 cm. Most patients (60.46%) had bulbar urethral strictures. The repair methods employed were anastomotic urethroplasty (62.80%), fasciocutaneous flap (FCF) ventral onlay (13.95%), buccal mucosa graft (BMG) ventral onlay urethroplasty (4.65%), and staged urethroplasty (4.65%). Three of the patients (6.98%) had a combination of anastomotic and tissue transfer urethroplasty. The overall success rate was 88.37%. Complications included three surgical site infections, two urethral diverticula and one glans dehiscence. Conclusion: Elderly men tolerate urethroplasty well and the procedure should not be denied solely based on age.

Surgical Technique and Efficacy Analysis of Extra-pseudocapsular Transnasal Transsphenoidal Surgery for Pituitary Microprolactinoma

Objective To elucidate the role of transsphenoidal surgery in the treatment of pituitary microprolactinoma.Methods The clinical data of 107 prolactinoma cases treated by extra-pseudocapsular transnasal transsphenoidal surgery(ETTS)for different indications in our department since 2011 was retrospectively analyzed.Results The most common indication was the ineffectiveness of oral medication(41.1%),followed by the personal willingness of the patient(35.5%),and 20.6%of the patients were young women with clear tumor boundaries.The pseudocapsule was not observed in 63 cases(58.9%),incomplete pseudocapsule was observed in 26 cases(24.3%),and complete pseudocapsule in 18 cases(16.8%).A total of 97 patients(90.7%)obtained 1-year post-operation remission.According to the relative location of the adenoma and pituitary gland on the MRI scan,46 patients were classified into a central type,59 a lateral type,and 2 a supra-pituitary type.Two patients developed hypogonadism,one patient developed hypocortisolism,and one patient developed post-operative hypothyroidism.Two patients were administrated with hormone replacement treatment,and the treatment was stopped within one week.There was no permanent hypopituitarism.Further investigation demonstrated that the adenoma types could affect the remission rates of hyperprolactinemia and gross total resection rate in microprolactinoma.Conclusion ETTS was an effective treatment for pituitary microprolactinomas.This could be the first choice for patients who presented enclosed adenoma on the MRI and were potentially curable in a preoperative evaluation.Maximal safe removal of the adenoma by ETTS with the aim to increase the sensitivity of the drugs was also recommended for patients with invasive dopamine agonist resistant prolactinomas and patients with difficulty in childbirth.

The robot-assisted ureteral reconstruction in adult:A narrative review on the surgical techniques and contemporary outcomes

Despite the rapid increase in the use of robotic surgery in urology,the majority of ureteric reconstruction procedures are still performed using laparoscopic or open approaches.This is primarily due to uncertainty regarding the advantages of robotic approaches over conventional ones,and the unique difficulty in identifying the specific area of interest due to the lack of tactile feedback from the current robotic systems.However,with the potential benefits of minimal invasiveness,several pioneering reports have been published on robotic surgery in urology.By reviewing the literature on this topic,we aimed to summarize the techniques,considerations,and consistent findings regarding robotic ureteral reconstruction in adults.Robotic applications for ureteral surgery have been primarily reported for pediatric urology,especially in the context of relieving a congenital obstruction in the ureteral pelvic junction.However,contemporary studies have also consistently demonstrated that robotic surgery could be a reliable option for malignant,iatrogenic,and traumatic conditions,which generally occur in adult patients.Nevertheless,the lack of comparative studies on heterogeneous hosts and disease conditions make it difficult to determine the benefit of the robotic approach over the conventional approach in the general population;thus,qualified prospective trials are needed for wider acceptance.However,contemporary reports have demonstrated that the robotic approach could be an alternative option for ureteral construction,even in the absence of haptic feedback,which can be compensated by various surgical techniques and enhanced three-dimensional visualization.

A novel surgical technique of internal limiting membrane peeling for high myopic foveoschisis:a wide range of whole piece consecutive peeling without preservation of epi-fovea

AIM:To demonstrate an improved surgical technique of whole piece consecutive internal limiting membrane(ILM) peeling without preservation of the epi-fovea to treat high myopic foveoschisis(MF).METHODS:A 23-gauge 3-port pars plana vitrectomy was performed on 16 patients with high MF.A parallel arc line along the vascular arcades was scraped out with a curved membrane scraper DSP.Next,an ILM forceps was used to catch hold of the incisal edge of the ILM flap,and the action of releasing and separating was subsequently taken toward the direction of the macular fovea.Next,the ILM forceps was used to grasp the released area,and the whole area coherent ILM peeling covering the macular fovea was implemented thereafter.Finally,the ILM was folded backwards and peeled off in the arc direction.RESULTS:At the final visit,the average central macular thickness decreased remarkably from 423.76±177.67 to 178.24±66.21 μm.The mean logarithm of the minimum angle of resolution best-corrected visual acuity of 1.37±0.59 was significantly alleviated to 0.74±0.59.CONCLUSION:The wide range of whole piece consecutive ILM peeling without preservation of the epifovea is proven to be effective and significantly reduced the occurrence of retinal tear and macular hole.

Minimally Invasive Surgical Technique in Double Aortic Arch with Distal Atretic Left-Side in Infant:From a Single-Surgeon Clinical Experience

Background:Double aortic arch(DAA)with distal left-sided aortic arch atresia(LAAA)can form complete vascular ring by ligamentum connection.We aimed to introduce an uncommon DAA-LAAA diagnosis and treatment by the minimally invasive surgical technique(MIST).Methods:We retrospectively reviewed 7 cases of DAA-LAAA that were treated from January 2017 to July 2021.All infant patients underwent surgical repair by minimally invasive surgical technique.Mean follow-up was 14.43 months(range,5–21 months).Results:There were seven patients with DAA-LAAA,including six males and one female.Median age was 19.29 months(range,9.0–29.0 months).Median weight was 11.30 kg(range,9.6–13.0 kg).Three patients were found severe tracheal compression by cardiac computed tomography angiography(cCTA).Six patients with isolated DAA-LAAA were performed operations through left subaxillary minithoracotomy,and one patient with ventricular septal defect(VSD)was performed operation concurrently under the cardiopulmonary bypass(CPB)through right subaxillary minithoracotomy.All patients had symptom improvement in the postoperative period and discharged successfully.Follow-up data showed good results in short-term.Conclusions:We introduce a new surgical pathway for DAA-LAAA treatment with good symptomatic relief in short-term.MIST is a safe,feasible and economical approach for infant patients.

Usefulness of Detailed Analysis with Operative Procedure of Total Laparoscopic Hysterectomy (TLH) Done a Single Surgeon, to Master the Surgical Technique of TLH and Gain Higher Proficiency

Objective: To analyze the relationship between the numbers of cases experienced and the operation time for a single surgeon aiming to master the TLH surgical technique. Material and Methods: Retrospective data analysis of women who underwent TLH for benign diseases between April, 2014 and March, 2016 was conducted by a single surgeon in a single hospital (Showa University of Fujigaoka Hospital). We divided the main procedures of the TLH operation into five sections, and measured the time required for each section. These cases were divided into three groups, group 1, 2, and 3. Results: There were 54 cases of TLH over two years for a single surgeon, and 21 cases that included essential operative procedures were divided into three groups of seven cases each. The average duration of the surgery (min.) was 178.3 ± 48.2 in the group 1, 128.3 ± 15.6 in the group 2, and 111.3 ± 15.9 in the group 3. A significant reduction in the required time was observed between group 1, 2, and 3 groups. As the number of cases increased, the operation time became statistically significantly shorter for every section except B and D. The skill growth rate was different at each section. Conclusion: For a single surgeon, as the number of surgical cases increased, we recognized the increased skill with the procedure in every section and the rate of skill growth differed for different sections. The difference of growth rate for each section implied that the number of operative cases required for a surgeon in each section was different.

Modified surgical techniques in total en bloc spondylectomy for thoracic and lumbar tumors with a single posterior approach

Objective To investigate the operation key points,instrument improvement and shortterm effects in total en bloc spondylectomy (TES) via a single posterior approach for thoracic and lumbar tumors.Methods A series of modified

The SUPER reporting guideline suggested for reporting of surgical technique

Background:Existing reporting guidelines pay insufficient attention to the detail and comprehensiveness reporting of surgical technique.The Surgical techniqUe rePorting chEcklist and standaRds(SUPER)aims to address this gap by defining reporting standards for surgical technique.The SUPER guideline intends to apply to articles that encompass surgical technique in any study design,surgical discipline,and stage of surgical innovation.Methods:Following the EQUATOR(Enhancing the QUAlity and Transparency Of health Research)Network approach,16 surgeons,journal editors,and methodologists reviewed existing reporting guidelines relating to surgical technique,reviewed papers from 15 top journals,and brainstormed to draft initial items for the SUPER.The initial items were revised through a three-round Delphi survey from 21 multidisciplinary Delphi panel experts from 13 countries and regions.The final SUPER items were formed after an online consensus meeting to resolve disagreements and a three-round wording refinement by all 16 SUPER working group members and five SUPER consultants.Results:The SUPER reporting guideline includes 22 items that are considered essential for good and informative surgical technique reporting.The items are divided into six sections:background,rationale,and objectives(items 1 to 5);preoperative preparations and requirements(items 6 to 9);surgical technique details(items 10 to 15);postoperative considerations and tasks(items 16 to 19);summary and prospect(items 20 and 21);and other information(item 22).Conclusions:The SUPER reporting guideline has the potential to guide detailed,comprehensive,and transparent surgical technique reporting for surgeons.It may also assist journal editors,peer reviewers,systematic reviewers,and guideline developers in the evaluation of surgical technique papers and help practitioners to better understand and reproduce surgical technique.

Robot-assisted adrenalectomy:Step-by-step technique and surgical outcomes at a high-volume robotic center

Objective In the last years,robotic surgery was introduced in several different settings with good perioperative results.However,its role in the management of adrenal masses is still debated.In order to provide a contribution to this field,we described our step-by-step technique for robotic adrenalectomy(RA)and related modifications according to the type of adrenal mass treated.Methods We retrospectively analyzed 27 consecutive patients who underwent RA at Onze-Lieve-Vrouw hospital(Aalst,Belgium)between January 2009 and October 2022.Demographic,intra-and post-operative,and pathological data were retrieved from our prospectively maintained institutional database.Continuous variables are summarized as median and interquartile range(IQR).Categorical variables are reported as frequencies(percentages).Results Twenty-seven patients underwent RA were included in the study.Median age,body mass index,and Charlson's comorbidity index were 61(IQR:49-71)years,26(IQR:24-29)kg/m^(2),and 2(IQR:0-3),respectively,and 16(59.3%)patients were male.Median tumor size at computed tomography scan was 6.0(IQR:3.5-8.0)cm.Median operative time and blood loss were 105(IQR:82-120)min and 175(IQR:94-250)mL,respectively.No intraoperative complications were recorded.Overall postoperative complications rate was 11.1%,with a postoperative transfusion rate of 3.7%.A total of 10(37.0%)patients harbored malignant adrenal masses.Among them,3(11.1%)had adrenocortical carcinoma,6(22.2%)secondary metastasis,and 1(3.7%)malignant pheochromocytoma on final pathological exam.Only 1(10.0%)patient had positive surgical margins.Conclusion We described our step-by-step technique for RA,which can be safely performed even in case of high challenging settings as malignant tumors,pheochromocytoma,and large masses.The standardization of perioperative protocol should be encouraged to maximize the outcomes of this complex surgical procedure.

More accurate reporting of surgical techniques would be SUPER

Surgical education entails learning to care for patients in and out of the operating theater.Clinically,this encompasses everything from the preoperative work-up to managing potential postoperative complications.In the operating room,surgical technique includes common,widely applicable skills,like how to square a knot,but also the more nuanced anatomical considerations of each operation,intra-operative decision-making,and ways to adapt when faced with the unexpected.Historically,surgical technique was taught through the apprenticeship model with knowledge passed down from attending to trainee and through textbooks written by surgical masters.This mode of learning/teaching is still the enduring structure of most residency programs.

Technique of using Cionni-modified capsular tension ring in the management of severely traumatic lens subluxation

AIM:To investigate the effect of Cionni-modified capsular tension ring(CTR)implantation in patients with severely traumatic subluxated cataracts.METHODS:All patients who totally had traumatic cataracts and lost zonule support and underwent cataract surgery were retrospectively analyzed.Corrected distance visual acuity(CDVA),extent of zonulysis,intraocular lens(IOL)position,intraoperative presentation,and complications were assessed.The primary outcomes included IOL centration stability and other postoperative complications.RESULTS:Twenty patients(20 eyes)were included in this study.The mean age in this study was 58.0±11.3y,and the average follow-up time was 17.3±12.8mo.Capsule bags were saved by Cionni-modified CTR.Nine eyes(45%)underwent simultaneously anterior vitrectomy due to the presence of vitreous in the anterior chamber.The preoperative mean CDVA was 0.83±0.24 log MAR,and the postoperative average CDVA was 0.23±0.30 log MAR(P<0.05).The horizontal and vertical IOL decentration after surgery was 0.27±0.12 mm and 0.41±0.19 mm,respectively;the vertical and horizontal IOL tilt after surgery was 5.5°±2.5°and 6.1°±2.2°,respectively.None of the eyes had obvious IOL decentration during the follow-up time.Eight eyes(40%)had posterior capsule opacification(PCO)that was severe enough to cause poor vision.Neodymium:YAG laser capsulotomy were performed on these eyes when the CTR was stabilized.CONCLUSION:With the help of Cionni-modified CTR,capsular bag preservation and better IOL concentration can be achieved without major complications in patients with severely traumatic subluxated cataracts.

New Surgical Technique Helps Blind Man See Again

本文介绍一种眼外科手术,这种眼外科手术被称为“多年来最重要的进展”。一个比方,使这种手术明白易懂:Put simply,it s like moving a carpetwhich has a worn patch in it and tucking(打摺)the worn part away.

Hydromassage of macular hole edges for large and persistent full-thickness macular holes

●AIM:To introduce the macular hole(MH)hydromassage technique as a potentially beneficial approach for the treatment of large or persistent MH.●METHODS:This retrospective observational case series comprised 16 consecutive patients(17 eyes)diagnosed with MH.Inclusion criteria involved a hole aperture diameter larger than 600μm or the presence of an unclosed MH larger than 600μm following the previous vitrectomy.Standard MH repair procedures were administered in all cases,involving the manipulation and aspiration of the hole margin through the application of water flow with a soft-tip flute needle.A comprehensive assessment was conducted for each case before and after surgery,and optical coherence tomography(OCT)images were captured at every follow-up point.●RESULTS:The mean preoperative aperture diameter was 747±156μm(range 611-1180μm),with a mean base diameter of 1390±435μm(range 578-2220μm).Following surgery,all cases achieved complete anatomical closure of MH,with 13 cases(76.5%)exhibiting type 1 closure and 4 cases(23.5%)demonstrating type 2 closure.No significant differences were observed in the preoperative OCT variables between the two closure types.Eyes with type 1 closure showed a significantly improved visual acuity(0.70±0.10,range 0.50-0.80)compared to those with type 2 closure(0.90±0.12,range 0.80-1.00,P=0.014).●CONCLUSION:The MH hydromassage technique demonstrates promising results,achieving acceptable closure rates in cases of large or persistent MH.This technique may serve as an effective adjunctive maneuver during challenging MH surgery.

Extra-pseudocapsular Transnasal Transsphenoidal Resection of Pituitary Macroadenoma:Technique Note and Evaluation of Endocrine Function

Objective In this study,we investigated the surgical technique and endocrine assessment of pituitary function of patients with macroadenoma treated by extra-pseudocapsular transnasal transsphenoidal surgery(ETTS).Methods Clinical data of 144 patients with pituitary macroadenomas in the same surgical group at the Department of Neurosurgery,Tongji Hospital,Tongji Medical College,Huazhong University of Science and Technology were retrospectively analyzed from January 2019 to June 2021.Based on the results of the endocrinological evaluation and MRI examinations before and after surgery,the fluctuation of pituitary function and the extent of resection were analyzed.Multiple Logistic regression analysis was used to determine the predictors affecting postoperative tumor residual.Results Among the 144 patients with pituitary macroadenomas,72(50.0%)were female and 72(50.0%)were male,the median age was 50 years,26(18.1%)had invasiveness grade 0,46(31.9%)had grade I,57(39.6%)had grade II,and 15(10.4%)had grade III according to Lu’s classification method.Based on observation during surgery,37 cases(25.7%)had no pseudocapsule,54 cases(37.5%)had incomplete pseudocapsule,and 53 cases(36.8%)had intact pseudocapsule.In addition,91(63.2%)patients had total resection,39(27.1%)had subtotal resection,and 14(9.7%)had partial resection.As for anterior pituitary function,13 of 19 hypothyroid patients had recovery after surgery,with a remission rate of 68.4%.Eighteen of the 26 decreased cortisol patients got back to normal,with a remission rate of 69.2%.A total of 27 of 51 patients with hypogonadism improved,with a remission rate of 52.9%.Univariate and multivariate analyses indicated that gender,tumor size,and invasiveness were predictors of postoperative residual in patients(P<0.05).Conclusion The results showed that ETTS is an effective treatment modality for restoring the function of pituitary gland of the patients with macroadenomas.Tumor size and invasiveness are predictors of the extent of surgical resection and postoperative residual of macroadenomas.

A simple new technique for the induction of residual posterior vitreous cortex removal and membrane peeling

AIM:To describe a quick,cost-effective alternative to using a scraper to remove the residual posterior vitreous cortex and create an inner limiting membrane(ILM)flap during vitrectomy.METHODS:The surgical technique and a retrospective interventional single-center series of cases were described.A hook was made on the tip of a conventional syringe needle(outer diameter,0.6 mm;23 gauge)by bending the needle against a plate.We used this hook to remove the residual posterior vitreous cortex and create an ILM flap during vitrectomy.The efficacy and safety of using this instrument in ophthalmological procedures for a variety of vitreoretinal disorders were evaluated.RESULTS:The hook was effective for removing focal or diffuse residual posterior vitreous cortex in eyes with rhegmatogenous retinal detachment,proliferative diabetic retinopathy,and pathological myopia.It was also successfully used to make a free edge of the ILM and help strip the epiretinal membrane.There were no serious complications associated with using the hook in delicate ophthalmological procedures.CONCLUSION:The hook,made by bending a conventional needle,is a simple and cost-effective instrument for removing residual posterior vitreous vortex and to create epiretinal and ILM flaps during vitrectomy in eyes with various vitreoretinal diseases.

Current and future of anterior cruciate ligament reconstruction techniques

In recent years,anterior cruciate ligament(ACL)reconstruction has generally yielded favorable outcomes.However,ACL reconstruction has not provided satisfactory results in terms of the rate of returning to sports and prevention of osteoarthritis(OA)progression.In this paper,we outline current techniques for ACL reconstruction such as graft materials,double-bundle or single-bundle reconstruction,femoral tunnel drilling,all-inside technique,graft fixation,preservation of remnant,anterolateral ligament reconstruction,ACL repair,revision surgery,treatment for ACL injury with OA and problems,and discuss expected future trends.To enable many more orthopedic surgeons to achieve excellent ACL reconstruction outcomes with less invasive surgery,further studies aimed at improving surgical techniques are warranted.Further development of biological augmentation and robotic surgery technologies for ACL reconstruction is also required.

A Modified, Rapid and Safe Technique of Kidney Only Procurement from Donors after Circulatory and Brain Death (DCD, DBD)

There is currently a lack of standard kidney-only procurement technique. Known techniques such as kidney-only procurement using the standard multi-organ procurement technique could potentially cause more iatrogenic injuries due to less adequate exposure. An alternative using the live open kidney donation technique could also be less than ideal due to prior unknown anatomical variation and potential the inability to adequately topically cool the kidneys. We describe here a novel easy kidney-only technique leading to an improved exposure, better cold perfusion and topical cooling. Herein we show how total bowel evisceration can be achieved by stapling the hepatic hilum, superior mesenteric artery and coeliac trunk. There is a need of a kidney only procurement in order to increase the quality of deceased kidney donation in our opinion. Results have to be compared in the future to determine the potential benefits.

A novel approach for 25-gauge transconjunctival sutureless vitrectomy to evaluate vitreous substitutes in rabbits

AIM:To improve the standard three-port vitrectomy for establishing and evaluating an endotamponade model in rabbits.METHODS:Three ports were prepared near the third eyelid of rabbits,and the infusion port was placed at the inferior nasal quadrant with the inserted cannula linking with a self-designed handheld rigid infusion catheter.All right eyes of rabbits underwent a modified 25-gauge vitrectomy and were subsequently filled with balanced salt solution,silicone oil,and eight-arm polyethylene glycols(8-arm PEGs)hydrogel separately for comparison.Ophthalmic examinations were performed regularly to record the changes after the surgery.RESULTS:Successful vitrectomy was achieved among 44 chinchilla rabbits.The mean operation time was 4.51±1.25min.Four eyes(9.1%)presented limited lens touch and two eyes(4.5%)showed retinal touch during surgery.Incision leakage was found in three eyes(6.8%)after surgery.There was no endophthalmitis,hemorrhage,or retinal detachment during the observation period and ophthalmic examinations after the implantation of vitreous substitutes.CONCLUSION:The modified technique of the standard vitrectomy applied in the endotamponade model in rabbits shows excellent safety and practicality.

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.