Traumatic Urethro-Rectal Fistulas Associated with Pelvic Fractures: Diagnostic Approaches and Management Strategies

Successful Repair of an Unusual Hernia Associated With Traumatic Pubic Diastasis

Risk factors for pelvic insufficiency fractures and outcome after conservative therapy

Objective To evaluate the modified Stoppa approach in treatment of patients with pelvic and acetabular fractures. Methods We analyzed the outcomes of 26 consecutive patients with fractures of the pelvic ring and 9 patients with acetabular fractures who had been treated between March 2008 and December 2009 by open reduction and internal fixation through the modified Stoppa approach. The modified Stoppa approach was made through a low midline incision to fix the pelvis and acetabular fractures. By Tile classification, the 26 pelvic fractures included 2 cases of B1, 4 of B2, 7 of B3, 4 of C1-1, 2 of C1-2, 4 of C1-3, and 3 of C2. By Letournel classification, the 9 acetabular fractures included one case of anterior column, 3 transverse cases, 2 T type cases, one anterior column plus posterior transverse case, and 2 cases of both columns. For pelvic fractures, the modified Stoppa approach was used exclusively in 10 cases, in combination with the iliac fossa approach in 15 cases, and in combination with the posterior approach in one case. For acetabular fractures, the modified Stoppa approach was used exclusively in 3 cases, in combination with the Kocher-Langenbeck approach in 4 cases, and in combination with the Kocher-Langenbeck and iliac fossa approaches in 2 cases of both columns. Results The average operation time was 90 min (65 to 135 min)and the blood loss averaged 320 mL(150 to 1200 mL) in all but one patient with obsolete fracture of both columns. The reductions of the pelvic and acetabular fractures were all excellent and good. Twenty-two patients with pelvic fracture were accessible for an average follow-up of 4 months. Among them, one case of plate breakage and one case of screw loosening were found. Seven patients with acetabular fracture were accessible for an average follow-up of 4 months. One case of mild hip flexion and one case of ectopic ossification were found in them but there was no femoral head necrosis. Satisfactory functional results were achieved in the 29 cases that had been followed up. Conclusion The modified Stoppa approach may be used exclusively or in combination with other approaches to treat pelvic and acetabular fractures effectively, providing advantages of easy manipulation and a low complication rate. Key words: Pelvis; Acetabulum; Fracture; Surgical approach

Myringoplasty in children with cleft palate and craniofacial anomaly

Objective To explore the appropriate management for girls with posttraumatic urethral stricture or loss secondary to pelvic fracture . Methods Between January 2009 and December 2015, a total of 20 girls, mean age of 9.5 years (range 2-14 years), whose posttraumatic urethral stricture associated with urethrovaginal fistula were treated using a variety of procedures. The mean urethral stricture or loss length was 2.6 cm (range 2-4 cm). Six patients presented with vaginal distal stricture and associated with a large hydrocolpos in the proximal vagina. Of the 20 girls, urethroplasty was performed using labial pedicle flap or vulvar flap in 10 patients, using a bladder flap tube in 5 girls with total urethral loss, using vaginal flap in 5 cases. Colpoplasty using island vulvar skin flaps or hydrocolpos vagina were performed in the 6 patients associated with vaginal stricture during urethroplasty. Results There were no serious complications postoperatively. The mean follow-up period was 41 months (range 12-70 months) postoperatively. The overall anatomical success rate was 90% (18 /20) and the functional success rate was 70% (14 / 20). Of 10 patients underwent pedicle labial or an island flap of vulva urethroplasty, 2 patients were recurrent, and 2 patients present stress incontinence. Five patients underwent urethral reconstruction using a bladder flap tube and voiding well postoperatively, of which stress incontinence appeared in 2. All 5 patients who underwent vaginal flap urethroplasty could void normally and continently. The hydrocolpos disappeared in all 6 patients with vaginal distal severe stricture. Conclusions A differential surgical repair strategy should be determined by fistula location, stricture length and vaginal condition for posttraumatic urethral stricture associated with urethrovaginal fistula in girls. It is probably good choice to reconstruct distal urethra and vagina using a large hydrocolpos in the proximal vagina for the treatment of coexisting strictures of urethra and vagina. Key words: Girl; Urethral stricture; Vaginal stricture; Urethroplasty

Objective: The objective of this study was to investigate the association between BMI, days spent in hospital, blood loss, and surgery time in patients who suffered from isolated pelvic fractures and pelvic fractures with concomitant injuries (polytrauma patients). Methods: This study included 76 consecutive patients who were admitted for pelvic ring fracture surgery between 2017 and 2022. The inclusion criteria were pelvic fractures and indications for operative treatment (LC II and III, APC II and III, and VS). The exclusion criteria were non-operative treatment for pelvic ring fractures, acetabular fractures and fractures requiring primary total hip arthroplasty (THA), and periprosthetic acetabular fractures. Demographic data were collected, including age (in years), sex, type of fracture according to Young–Burgess, date of injury and surgery, surgical approach and stabilization methods, mechanism of trauma, concomitant trauma in other regions, body mass index (BMI), blood transfusions, number of days spent in the hospital, and surgery duration. Results: Patients who suffered from a pelvic ring injury with concomitant injuries had a significantly greater amount of blood units transferred (1.02 units vs. 0.55 units), and the length of hospital stay was also longer compared to the mean results (5.84 days vs. 3.58 days), p = 0.01 and p = 0.001, respectively. Moreover, patients with a higher BMI had more frequent APC II and APC III fractures (p = 0.012). Conclusions: This study demonstrates that polytrauma patients who suffered from pelvic ring injury are, indeed, at risk of blood transfusion in terms of greater units of blood and a longer duration of hospital stay. Moreover, BMI has an impact on pelvic ring fracture morphology. However, there is no doubt that there is an absolute need for further studies and investigations to provide better overall management of polytrauma patients with pelvic fractures.

Update on community-acquired bacterial meningitis: guidance and challenges

Quality control in breast cancer screening programmes has been subject of several studies. However, less is known about the clinical diagnostic work-up in recalled women with a suspicious finding at screening mammography. The current study focuses on interhospital differences in diagnostic work-up strategies. In this retrospective analysis, using a prospectively obtained database, we included 17,809 women who participated in the Dutch national screening programme between 2009 and 2019 and were recalled to a hospital for analysis of a suspicious mammographic abnormality. The diagnostic work-up (e.g., type and frequency of additional imaging and biopsy) in the different hospitals were compared and analysed by multivariable analysis to correct for confounders. Use of biopsy varied from 36.7% to 48.7% (p < 0.001) between hospitals, and the use of problem-solving magnetic resonance imaging (MRI) from 2.1% to 6.9% (p < 0.001). These interhospital differences remained after correction for patients and tumour characteristics. The percentage of women with a delayed breast cancer diagnosis, defined as histopathological confirmation of breast cancer more than three months after recall or first analysis in the hospital, varied from 2.7% to 6.1% between hospitals (p = 0.07). In our screening region interhospital differences were observed in diagnostic work-up following recall at biennial screening mammography. Though statistically significant, absolute differences were small, and therefore, their clinical impact appears to be limited. Question It is unclear how diagnostic work-up strategies vary between hospitals for women recalled after suspicious findings in breast cancer screening. Findings Significant differences in biopsy techniques and the use of problem-solving MRI were observed, though the clinical impact of these variations is likely to be marginal. Clinical relevance Evaluation of interhospital variation in the diagnostic work-up strategies after recall may aid in optimising the quality of breast cancer care and, indirectly, the effectiveness of the screening programme.

Type I tympanoplasty in pediatric age – The results of a tertiary hospital

Pelvic Bone Fractures Mimicking Bone Metastases in a Patient with Hepatitis B Virus-Associated Liver Cirrhosis and Hepatocellular Carcinoma

Objective To investigate the influencing factors of short-term and long-term outcomes in patients with acute ischemic stroke. Methods From March 2015 to March 2016, patients with acute ischemic stroke treated at the Department of Neurology, the Second Hospital of Tianjin Medical University were enrolled prospectively. The demographic and baseline clinical data of the patients were recorded. The modified Rankin scale (mRS) was used to assess the short-term outcomes at 14 d and one year after onset. Good outcome was defined as mRS 0-2, and poor outcome was defined as >2. Death or new cardiocerebrovascular events were recorded. Multivariable logistic regression analysis was used to determine the influencing factors of short-term and long-term outcomes in patients with acute ischemic stroke. Results A total of 514 patients with acute ischemic stroke were enrolled, including 338 (65.8%) with short-term good outcome and 176 (34.2%) with poor outcome. There were significant differences in age, atrial fibrillation, history of past stroke or transient ischemic attack (TIA), etiological typing of stroke, baseline NIHSS score, severity of stroke, pulmonary infection, dysphagia, and urinary incontinence between the short-term good outcome group and the poor outcome group (P<0.05). Multivariable logistic regression analysis showed that history of past stroke or TIA (odds ratio[OR]2.188, 95% confidence interval[CI]1.192-4.014; P=0.011), baseline NIHSS score (OR 1.504, 95% CI 1.362-1.661; P=0.001), and urinary incontinence (OR 4.114, 95% CI 1.934-8.751; P=0.001) were the independent influencing factors of short-term outcome. A total of 467 patients completed 1-year follow-up, including 315 (67.5%) with long-term good outcome and 152 (32.5%) with poor outcome. There were significant differences in age, history of ischemic heart disease, stroke or TIA, etiological typing of stroke, baseline NIHSS score, severity of stroke, pulmonary infection, dysphagia, urinary incontinence, secondary prevention of antiplatelet drugs and statins between the long-term good outcome group and the poor outcome group (all P<0.05). Multivariable logistic regression analysis showed that age (OR 1.029, 95% CI 1.004-1.055; P=0.022), past history of stroke or TIA (OR 1.983, 95% CI 1.082-3.633; P=0.027), baseline NIHSS score (OR 1.271, 95% CI 1.153-1.400; P=0.001), urinary incontinence (OR 4.996, 95% CI 2.308-10.813; P=0.001), and secondary prevention using antiplatelet drugs (OR 0.227, 95% CI 0.125-0.414; P=0.001) were the independent influencing factors of long-term outcome. The baseline NIHSS score (OR 1.184, 95% CI 1.070-1.310; P<0.001) and secondary prevention using antiplatelet agents (OR 0.064, 95% CI 0.014-0.284; P<0.001) were the independent influencing factors of death or occurring vascular events. Conclusion Age, past history of stroke or TIA, baseline NIHSS score, urinary incontinence, antiplatelet drugs for secondary prevention were independently associated with the outcomes in patients with acute ischemic stroke. Early and targeted intervention of modifiable factors and the emphasis on the use of antiplatelet agents in secondary prevention might reduce stroke recurrence and improve outcomes. Key words: Stroke; Brain Ischemia; Treatment Outcome; Risk Factors; Time Factor

The aim of the study was to evaluate the results of anterior pelvic ring fractures and acetabular fractures fixation with the specially designed plate by miniinvasive surgical approach.&#x0D; Materials and methods. 54 patients with anterior pelvic ring fractures and antrerior acetabular column admitted in Sklifosovsky Clinical and Research Institute for Emergency Care in the period from 2012 to 2020 year were analyzed. In 12 patients of the first group Judet-Letournel surgical approach was used. In 42 patients of the second group miniinvasive suprapubic and ilial surgical approach were used. In all patients novel J-plate was implanted. Mean operative time, mean blood loss, infectious complications were evaluated. Harris Hip Score for functional assessment after pelvic fractures was used for evaluation of long-term results. &#x0D; Results. Mean operative time in the first group was 181±25.4 min., mean blood loss amounted to 384±51.6 ml. Mean operative time in the first group was 98 ±21.5 min, blood loss - 183±59.8 ml. There were no infectious complications. The amount of good and excellent treatment results in the main group was 72%. Unsatisfied results amounted to 4%.&#x0D; Conclusion. J-plate for pelvic injuries fixation is indicated in patients with anterior column and anterior wall acetabular fractures associated with contralateral pubic bone fracture or pubic symphysis rupture. Combination of ilial and suprpubic surgical approaches can be used in less than 2 weeks after trauma to minimize operation time and blood loss.

Male sexual dysfunction after fracture of the pelvis is more common than previously supposed with rates as high as 30% reported when the complaint is specifically sought. With the increase in survival from major injuries, the long-term consequences of trauma are being seen with increasing frequency

Objective To study the application of pediculated skin flaps in the treatment of com-plicated long urethratresia. Methods From March 1999 to May 2006, a total of 18 male patients with complicated long urethratresia were treated by using the pediculated skin flaps. The causes of urethratresia were 7 cases of postoperative pelvic fractures with posterior urethral stricture, 4 cases of transurethral intravesical chemotherapy, 3 cases of postoperative bulbar urethral stricture, 2 cases of gonorrhea, and 2 cases of long-time urethral catheter placement. Four cases were urethratresia nf cor-pus penis, 7 cases were anterior urethral obliteration, 7 cases were posterior urethral and anterior ure-thral obliteration. Urethro-perineal fistulas were found in 8 cases, posterior urethrorectal fistulas in 7 cases, false passage formations in 8 cases. The average length of urethratresia was 15.1 cm (range 8. 7 to 23. 0 cm). The urethral scar was rasected, the posterior urethrorectal fistula was repaired, and different kinds of pediculated skin flaps depending on the length of urethratreaia was used. Results All the patients were followed up for 12 to 18 months (mean 14 months). Fifteen patients voided well 3 months postoperatively, none of the urography showed stricture. The mean peak urinary flow rate was 16. 9 ml/s (range from 16. 5 to 21.7 ml/s). Of the other 3 cases, 1 case experienced difficult voi-ding due to the long and circuitous tabularized skin flap but recovered after proper shortening;1 case had restenosis for the infection of anastomosis but voided well after excision and reanastomnsis;1 casehad a urinary fistula resulting from hematoma and infection, but was successfully treated by the neo-plasty of the urinary fistula. The mean peak urinary flow rate was 17.0 ml/s (range 15.0 to 22.0 ml/s) for 17 patients 6 months postoperatively, except for one who experienced genuine urinary incon-tinence. At 9-18 months after operations, the mean peak urinary flow rate was 17.5 ml/s (range 15.8 to 22.5 ml/s) for 17 patients. Conclusion The single-stage urethroplasty based on pediculated skin flaps is a reliable and durable method for complicated long urethratresia. Key words: Urethral obstruction; Surgical flaps; Surgical procedures,operative

Objective To explore the efficacy of constructing the neourethra using a bladder anterior wall for the treatment of female total urethral stricture or atresia. Methods We retrospectively reviewed 11 female patients with total urethral stricture or oblitalition, who were underwent a procedure of reconstructive neourethra using a bladder anterior wall, from January 2009 to November 2015. Of the 11 patients , urethral stricture was associated with vesicovaginal fistula and a severe hydrocolpos in the proximal vagina because of vaginal anterior strictures or atresia in four girls. The mean age was 16 years (ranging 5-48 years) in all patients. The etiology was posttraumatic urethral injuries after pelvic fracture in 9 patients, radical urethral resection because of urethral cancer in 1 patient and congenital bladder exstrophy with an absent urethra in 1 patient. All patients underwent a procedure of neourethral construction under general anesthesia. The bladder anterior wall, which was about 2.0 to 2.5 cm in width and 4.0~4.5cm in length, was separated from bladder neck to middle partion of the anterior bladder wall. The bladder flap was tubularized around a 12-14 French catheter using continuous 4-0 polyglycolic acid sutures for the mucosa and interrupted sutures of 3-0 polyglycolic acid for the muscle. The tubularized flap was then flipped caudally to the site of the original external urethral meatus to form a new urethra. 4 patients with severe stenosis or oblitalition of the distal vagina underwent a procedure of vaginoplasty at same time, including island vulvar flaps enlarging vaginoplasty in two girls and reconstructive vaginal orifice using the proximal enlargedvagina wall in other two girls. Results There were no serious complications postoperatively. The catheter was removed 3~4 weeks after the operation. 7 patients were completely continent with excellent voiding, 3 patients had stress incontinence. One patient experienced dysuria. And the urethroscopy in this case showed that the mucosal prolapse was present at the 12 to 3 o'clock position on the neck of the bladder, which caused urinary obstruction. Endoscopic resection of the prolapsed mucosa was performed. The patient could easily void without incontinence after the operation. The patients were followed up a median of 38 months, (ranging 6-72 months). 2 patients experienced dysuria 3 and 4 months after operation, separatively. Examination showed that the mucosal prolapse was present at the position on the neck of the bladder in one patient and urethral meatal stenosis in another patient. The two patients were separatively underwent a procedure of endoscopic resection of the prolapsed mucosa and meatal urethroplasty, using vulvar flap. All of them could easily void without incontinence after the operation. Of the 3 patients with stress urinary incontinence, one underwent a procedure of TVT-O one year later, and after which continence was achieved with good voiding; the other two cases were awaiting for reoperation. Four cases of postoperative vaginal fluid disappeared with unobstructed micturition. Conclusions Female neo-urethral reconstruction using the bladder anterior wall flap was a reliable technique for the management of complete urethral stricture or obliteration. Key words: Female; Bladder wall flap; Urethra; Reconstruction