Ancillary Procedures Research Articles

Effect of Novel Anteromedial Approach on Wound Complications Following Ankle Arthroplasty.

The purpose of this study was to evaluate all wound complications following total ankle arthroplasty (TAA) before and after the implementation of a novel extensile anteromedial surgical approach. We further investigated patients and operative factors associated with wound complications. A series of 660 TAAs were collected. The median follow-up was 84 months (range, 12-204 months). Minor wound complications included discoloration, swelling, or clinical concern that merited bringing the patient back sooner for review. Major wound complications included plastic surgical consultation, debridement by the nurse specialist, negative pressure therapy, or reoperation. All major complications initially had a course of empirical oral antibiotics. Since 2011, higher-risk patients have had their TAA performed through an extensile anteromedial approach. Fifty-six patients (8.5%) had wound healing issues (17 major [2.6%], 39 minor [5.9%]). All issues became evident <21 days postoperatively. Inflammatory arthritis, smoking, and coronary disease were patient factors associated with major wound complications. Four patients were treated with negative pressure therapy, 4 with debridement in the operating room, and 2 eventually converted to fusions. Fourteen patients (82%) who had major complications had an ancillary procedure to balance the TAA through a separate incision. All major wound complications had an anterior surgical approach for their TAA. Before 2011, there were 13 major wound complications. Since 2012, there have been 4 major wound complications overall, with no wound complications in the anteromedial approach cohort. We recommend an extensile anteromedial approach for smokers and patients with heart disease or inflammatory arthritis undergoing TAA. If a wound complication developed, a multidisciplinary team to evaluate wounds was useful. Level III, retrospective comparative series.

Guy’s Stone Score as a Predictor for Stone-Free Rate and Complications in Percutaneous Nephrolithotomy: A Single-Center Report from a Stone Belt Country

Objectives: To evaluate Guy’s Stone Score (GSS) as a grading system for the complexity of renal calculi before percutaneous nephrolithotomy (PCNL) and as a predictor for stone-free rate (SFR) and potential complications in the setting of a developing country with many cases of advanced complex stone disease. Patients and Methods: We performed a prospective study on 115 patients with renal stones who had PCNL between August 2017 and October 2018. Stone complexity was classified according to GSS using preoperative imaging. The rates of perioperative complications were assessed using the Clavien grading system, and the SFR was assessed in the 3rd postoperative week by abdominal X-ray and renal ultrasound. The χ² and one-way ANOVA tests were used for statistical analysis. A p value ≤0.05 was considered significant. Results: The study included 115 patients (77 males) with a mean age of 50.2 (±13.3) years. Cases were classified according to GSS into 4 grades; there were 24 (20.9%) grade I, 48 (41.7%) grade II, 25 (21.7%) grade III, and 18 (15.7%) grade IV cases. There was a significant inverse correlation between GSS grade and SFR (p < 0.001). The rate of complications using the Clavien grading system were significantly higher in GSS grades III and IV (p = 0.002). So were the rates of blood transfusion, the need for >1 access tract, and the duration of hospitalization. Conclusion: GSS is a simple and easily reproducible system to classify the complexity of renal stones. In our setting, it also proved an excellent tool to predict SFR, perioperative complications, and associated ancillary procedures. Ultimately, it can help surgeons and, above all, patients to make a more informed decision about their surgery.

Multi-modal treatment strategy for achieving an aesthetic lower face.

BackgroundMost women consider an oval-shaped face to be youthful and beautiful. In recent years, demand has grown for surgical procedures with a shorter downtime and fewer complications. These minimally invasive procedures include botulinum toxin type A (BoNTA) injection, filler injection, suction-assisted liposuction (SAL), laser-assisted lipolysis (LAL), thread lifting, and fat grafting. This study aims to introduce an effective method for creating an aesthetically pleasing lower face using a combination of minimally invasive procedures.MethodsFrom March 2017 to March 2019, 94 patients simultaneously underwent LAL, SAL, and thread lifting. Ancillary procedures such as BoNTA injections, hyaluronic acid filler injections, and removal of the buccal fat pad (BFP) were selectively performed according to the patient’s condition.ResultsPatients rated their postoperative satisfaction as very satisfied, satisfied, dissatisfied, or very dissatisfied. Approximately 83% of all respondents were satisfied with the results, whereas the remaining respondents had complaints regarding the outcomes. The most common reasons for dissatisfaction were a longer-than-expected recovery time and undercorrection, and the most severe complaint was skin depression as a result of overcorrection.ConclusionsOur method of simultaneously performing LAL, SAL, and thread lifting, while adding BoNTA, filler injections, and BFP removal as needed, was capable of producing consistent and reliable aesthetic outcomes for the lower face.

PD19-05 DOES PERCENTAGE OF SEMINOMA AT ORCHIECTOMY IMPACT PATIENT MORBIDITY AND PATHOLOGIC OUTCOMES AT POST-CHEMOTHERAPY RETROPERITONEAL LYMPH NODE DISSECTION FOR MIXED GERM CELL TUMOR?

INTRODUCTION AND OBJECTIVE: Post-chemotherapy retroperitoneal lymph node dissections (PC-RPLND) for pure seminoma are widely considered to have an increased potential for surgical complexity and morbidity secondary to increased post-chemotherapy desmoplastic changes. This places patients at increased risk, often with pathologic findings only revealing necrosis. We sought to determine if the percentage of seminoma in the orchiectomy specimen predicts necrosis on PC-RPLND for non-seminomatous germ cell tumors (NSGCT) and the associated impact on patient morbidity. METHODS: Patients with seminoma in the orchiectomy specimen who underwent PC-RPLND for NSGCT at Indiana University from 2009-2019 were identified to assess pathologic findings, required ancillary procedures at the time of PC-RPLND, and post-operative outcomes. Patients were categorized into quartiles to assess if increasing percentage of seminoma predicted necrosis. RESULTS: Of the 109 patients identified, pathologic analysis revealed necrosis in 30/109 (27.5%), malignancy 17/109 (15.6%), and teratoma 62/109 (56.9%). As percent seminoma increased by quartile, necrosis was more prevalent (23.7%, 25%, 33.3%, 41.7%), as was the radiographic size decrease in post-chemotherapy retroperitoneal masses. For patients with greater than 90% seminoma, necrosis was found 50% of the time. The incidence of concurrent nephrectomy, need for intra-operative vascular repair, and estimated blood loss during PC-RPLND was greatest in the 4th quartile. There was no significant difference in pre-operative serum tumor markers, patient age, body mass index, pre-operative comorbidities, length of stay, or post-operative Clavien-Dindo classification outcomes. CONCLUSIONS: As percent seminoma in the orchiectomy specimen increased, the incidence of necrosis, surgical complexity, and the need for concurrent ancillary procedures increased. However, it did not seem to change the hospital course or post-operative morbidity. Unfortunately, these results show that PC-RPLND cannot be eliminated even in patients with very high orchiectomy seminoma percentages as over half of these patients had teratoma or viable malignant elements in the retroperitoneum. Source of Funding: None

MP63-06 PREDICTING THE POSTOPERATIVE OUTCOME OF PERCUTANEOUS NEPHROLITHOTOMY WITH MACHINE LEARNING SYSTEM: SOFTWARE VALIDATION AND COMPARATIVE ANALYSIS WITH GUY’S STONE SCORE AND THE CROES NOMOGRAM

You have accessJournal of UrologyStone Disease: Surgical Therapy VI (MP63)1 Apr 2020MP63-06 PREDICTING THE POSTOPERATIVE OUTCOME OF PERCUTANEOUS NEPHROLITHOTOMY WITH MACHINE LEARNING SYSTEM: SOFTWARE VALIDATION AND COMPARATIVE ANALYSIS WITH GUY’S STONE SCORE AND THE CROES NOMOGRAM Alireza Aminsharifi*, Dariush Irani, Sona Tayebi, Tayebeh Shabanian, and Mehdi Parsaei Alireza Aminsharifi*Alireza Aminsharifi* More articles by this author , Dariush IraniDariush Irani More articles by this author , Sona TayebiSona Tayebi More articles by this author , Tayebeh ShabanianTayebeh Shabanian More articles by this author , and Mehdi ParsaeiMehdi Parsaei More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000938.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: To validate the output of a machine learning-based software as an intelligible interface for predicting multiple outcomes after percutaneous nephrolithotomy (PCNL). We compared the performance of this system with Guy’s stone score (GSS) and the Clinical Research Office of Endourological Society (CROES) nomogram. METHODS: Data from 146 adult patients (87 males, 59%) who underwent PCNL at our institute were used, and preoperative variables and postoperative outcomes were recorded. Stone-free status was determined by computed tomography scan postoperatively. Preoperative data were consecutively imported into the software and its output was extracted. To validate the system, accuracy of the software for predicting each postoperative outcome was compared to the actual outcome. Similarly, preoperative data were analyzed with GSS and CROES nomograms to determine stone-free status as predicted by these nomograms, and the predictive performance of these two systems was calculated. A receiver operating characteristic (ROC) curve was generated for each scoring system, and the area under curve (AUC) was calculated and used to assess the predictive performance of the nomograms versus ANN software. RESULTS: Overall stone-free rate (SFR) was 72.6% (106/146). Forty of 146 patients (27.4%) were scheduled for Forty-two ancillary procedures (shock wave lithotripsy (SWL) (n= 31) or repeat PCNL (n=11)) to manage residual renal stones. Overall, the machine learning system predicted the PCNL outcomes with an accuracy ranging between 80% and 95.1%. A higher GSS grade and lower CROES nomogram score were significantly associated with lower SFR (p=0.01 and p= 0.03, respectively). When ROC curves were plotted for each predictive model for stone-free status, the area under the ROC curve for ANN software (0.915) was significantly larger than the AUC for GSS (0.615) or CROES nomograms (0.621) (p<0.001) (Figure 1). CONCLUSIONS: At the internal institutional level, the machine learning-based software was a promising tool for recording, processing and predicting outcomes after PCNL. Validation of this system against an external dataset is highly recommended before its widespread application. Source of Funding: Shiraz University of Medical Sciences. © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e956-e956 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alireza Aminsharifi* More articles by this author Dariush Irani More articles by this author Sona Tayebi More articles by this author Tayebeh Shabanian More articles by this author Mehdi Parsaei More articles by this author Expand All Advertisement PDF downloadLoading ...

Stone Burden Measurement by 3D Reconstruction on Noncontrast Computed Tomography Is Not a More Accurate Predictor of Stone-Free Rate After Percutaneous Nephrolithotomy Than 2D Stone Burden Measurements.

Purpose: Stone burden has been reported as an independent predictor of stone-free rate after percutaneous nephrolithotomy (PCNL); however no consensus exists on a standardized method for measuring stone burden. Recently, stone volume has been advocated as the most accurate means of measuring stone burden. We aimed to compare different measuring methods of stone burden and to identify the predictive value of each for outcomes after PCNL. Materials and Methods: We performed a retrospective review of a prospective database of patients who underwent PCNL between 2006 and 2013. A preoperative CT and postoperative imaging at discharge were necessary for eligibility. Stone burden was assessed through four different ways on CT images: (1) cumulative stone diameter; (2) estimated SA (surface area) calculated as longest × orthogonal diameter × π/4; (3) manual outline of stone and computer SA calculation; and (4) automated 3D volume calculation using specific software. Primary outcome was stone-free status (SFS) at discharge. Secondary outcomes included operative time and the need for an ancillary procedure. Regression analysis and receiver operating characteristic curve analysis were used to evaluate the predictive value of each method. Results: Of 313 included patients, 69.6% were stone free at discharge. All measures of stone burden were independent predictors of SFS [OR and 95% CI of 1.027 (1.014, 1.040), 1.481 (1.180, 1.858), 1.736 (1.266, 2.380), and 1.311 (1.127, 1.526), respectively] and demonstrated similar predictive accuracy (area under the curve = 0.630, 0.630, 0.627, and 0.638, respectively). Stone burden by any measure was an independent predictor of operative time and secondary procedure. Conclusions: We demonstrated that measuring stone burden by manual outline or automated 3D volume on reformatted CT images had no added value compared with orthogonal measurement for predicting outcomes after PCNL.

A New Simplified Biplanar (0-90°) Fluoroscopic Puncture Technique for Percutaneous Nephrolithotomy. Reducing Fluoroscopy Without Ultrasound. Initial Experience and Outcomes

ObjectiveTo present our simplified biplanar fluoroscopic puncture technique, its reduction in the fluoroscopic screening time as well as outcomes and the initial experience for percutaneous nephrolithotomy. MethodsWe performed a retrospective review of 136 patients operated with our simplified 0-90° puncture technique for percutaneous nephrolithotomy between 2015 and 2018. All patients were classified by stone complexity with Guy´s nephrolithometric stone score. The stone-free rate was evaluated by nonenhanced computerized tomography, and residual stones were defined as fragments ≥2 mm. Complications were divided according to the Clavien-Dindo classification. ResultsOne hundred and thirty-six patients were operated with our puncture technique; 121 patients were performed in supine and 15 in the prone position. Fifty-one were men, and 85 were women with an overall mean age of 44.36 ± 13.23 years. The overall stone-free rate was 62.5%, and 83.8 % after an ancillary procedure. The mean fluoroscopy screening time was 69.47 ± 7.1 and 6 ± 4.1 seconds for the total surgical procedure and the percutaneous puncture, respectively. Complications were present in 25.7%, and no grade IV and V complications were present. ConclusionOur first case series with the 0-90° simplified fluoroscopic puncture technique shows a similar stone-free rate and safety profile but a low fluoroscopic screening time compared to the most common previously reported fluoroscopic puncture techniques non-focused on low radiation protocols. Further studies are required to evaluate the reproducibility, external validation, and the learning curve of our simplified 0-90° technique.

Outcome of anastomotic urethroplasty in traumatic stricture (distraction defect) of posterior urethra in boys

ABSTRACT Objective To report the outcomes of operative management of traumatic posterior urethral distraction defect in boys at our Centre, as traumatic posterior urethral stricture in children is a rare condition that presents a major surgical challenge to the paediatric urologist and consensus on the optimal treatment of these strictures in children has not been reached. Patients and methods We retrospectively analysed our data from July 2013 to June 2018. All boys aged ≤16 years with traumatic posterior bulbo-prostatic obliteration (distraction defect) were included. Initial suprapubic cystostomy and delayed definite anastomotic urethroplasty was done in all the boys. The boys were evaluated preoperatively with a retrograde urethrogram and simultaneous voiding cystourethrogram, as well as cystourethroscopy. Results A total of 38 boys, with posterior urethral distraction defect, were divided into primary and redo surgery groups. The primary group comprised 34 boys who were operated upon for the first time. A perineal approach with development of an inter-crural space was done in 12 boys and along with an inferior pubectomy in 19 boys. Three boys in the primary group needed a transpubic approach due to a longer defect. In the redo group, there were six boys, of which four were operated initially outside our hospital, while two were our own unsuccessful urethroplasties. In the redo group, a perineal approach with inferior pubectomy was done in two boys and a transpubic urethroplasty in the remaining four boys. The success rate of anastomotic urethroplasty without any ancillary procedures was 81.5% (strict criterion), while the overall success rate was 94.7% (permissible criterion, which included boys who were managed later with direct vision internal urethrotomy and dilatation). Conclusion The ideal treatment of post-traumatic posterior urethral defect/strictures in boys is tension-free bulbo-prostatic anastomosis. This was done using a transperineal approach in most of the boys, but a few required a transpubic approach, with good results. Abbreviations DVIU: direct vision internal urethrotomy; SPC: suprapubic cystostomy; SUI: stress urinary incontinence

Ancillary Procedures in Patients of Refractory Facial Palsy Patients Selection and Evaluation of the Outcomes

Ancillary Procedures in Patients of Refractory Facial Palsy Patients Selection and Evaluation of the Outcomes

Relevance of 3D virtual planning in predicting bony interferences between distal and proximal fragments after sagittal split osteotomy

After sagittal split osteotomy, the mandibular distal and proximal fragments do not always align themselves passively to one another, resulting in bony interferences and subsequent anomalous settlement of the condyles. Predicting these interferences could be an important ancillary procedure for avoiding intra- and postoperative surgical complications, rendering orthognathic surgery more effective and safer. This study evaluated the relevance of virtual surgical planning in assessing the displacement of the proximal segments after virtual distal segment repositioning, for predicting bony interferences between the segments and thus avoiding related intra- and postoperative surgical complications. The presence of interferences between the distal and proximal segments was compared between virtually predicted (computer-assisted simulation surgery, Dolphin software) and real cases in 100 consecutive patients diagnosed with dentofacial deformities who underwent orthognathic surgery with mandibular repositioning (using a short lingual osteotomy (SLO)). The results indicated that clockwise rotation of the mandible was the mandibular movement most prone to segment interference. Furthermore, virtual planning was sensitive (100%) but had low specificity (51.6%) in predicting proximal and distal segment interferences. This low specificity was due to the software-based automated design of the mandibular osteotomy, where the length of the distal segment was longer than the real SLO, and the mandibular ramus sagittal split was located just behind Spix’s spine. Thus, more precise simulated osteotomies are needed to further validate the accuracy of virtual planning for this purpose.

Advantages of Computed Tomography (CT) in Endoscopic Septopasty

Background and objective: Nasal obstruction is the most frequent presentation to the otolaryngologist all over the world. Symptoms are multisystem involvement such as headache, epistaxis, ophthalmological, otological, upper and lower respiratory tract infections; and many more. Septoplasty is commonly performed for nasal septal deviation as a primary indication of nasal airway obstruction. Physical examination, anterior rhinoscopy and nasal endoscopy are considered the gold standard for detecting septal deviation. Computed tomography (CT) can also be used to evaluate the nasal septum, anatomical variants and unveils the associated sinonasal diseases. This study aimed to find out the advantages of CT in endoscopic septoplasty for all out benefits to the patients. Patients and methods: 168 patients of nasal septal deviation were selected from 2015 to 2018 in the Bangladesh Medical and Popular Medical College Specialized Hospital. Age ranged between 10 years to 70 years of age. CT scanning in both coronal, axial and sagittal sections had been done in all patients after proper history taking, physical examination, anterior rhinoscopy and nasal endoscopy. Endoscopic septoplasty alone and/or other ancillary procedures were performed in all 168 patients under general anesthesia. Results: Amongst 168 patients, male was 116 (69%) and female was 52 (31%) with a ratio 2.2:1. Maximum 58 (35%) reported in 31 to 40 years and 48 (29%) was found in 21 to 31 years of age. Hypertrophied inferior turbinate (HIT) 54 (32%) and 48 (29%) concha bullosa (CB) were associated with 168 septal deviation. Associated pathologies like maxillary antral cyst 68 (40%) and maxillary sinusitis 62 (37%) were documented. Conclusion: CT scanning unveils the abnormal anatomic variants and associated sinonasal pathologies along with nasal septal deviation. Endoscopic septoplasty, correction of the anatomical variants and complete surgical clearance of the sinonasal pathologies can give the patient a grand success.

Percutaneous Nephrolithotomy in Horseshoe Kidneys: A Cross-sectional Study

Introduction: Horseshoe Kidneys (HSK) are the most common congenital fusion of the kidneys. After the reports of Wickham and Kellet in 1981 and Clayman in 1983, percutaneous extraction of stones in HSKs has been widely adopted. In this era of advancement of Retrograde Intra Renal Surgery (RIRS), Percutaneous Nephrolithotomy (PCNL) still holds strong position for HSK stone management, due to HSK vascular and pelvicalyceal anatomy. Aim: To evaluate PCNL in managing large HSK stone disease in the form of stone free rate and to assess procedure related complication between October 2016 to March 2020. Materials and Methods: A retrosepective cross-sectional study was conducted between October 2016 to March 2020, in total of 18 patients (21 renal units) underwent PCNL for stone disease in HSK. Stone size &gt;1.5 cm, failed Extra-Corporeal Shockwave Lithotripsy (ESWL) and recurrent stones were included in the study. Results: Mean age of the patients was 40.67±7.87 years, 12 were male and 6 were female. Three patients had stones in both renal units. The mean stone size was 22.19±7.43 (12.00-46.00) mm. Twelve units had stone in the pelvis (57.1%), 6 unit in upper calyx (28.6%). One unit (4.8%) had stone in isthmus and 3 units (14.3%) had staghorn calculi. Access site was upper calyx in majority 76.2% of the cases, 23.8% required additional puncture most commonly through middle calyx. Total 8 patients had postoperative complications, fever being the most common (19%). Complete clearance was obtained in 85.7%, while 14.3% had residual calculi for which ancillary procedures were performed. Conclusion: PCNL can be recommended as the first line of management in the treatment of HSKs with large stone burden, considering its higher clearance rate and minimal complications.

Lateral temporal bone resection for carcinoma external auditory canal with hearing preservation – Our approach

The case series is regarding effective management of carcinoma external auditory canal (EAC). Patients were assessed clinically and radiologically preoperatively, and an operative plan was decided. Patients were operated for carcinoma EAC, and lateral temporal bone resection along with ancillary procedures such as superficial parotidectomy and selective neck dissection were performed. With the help of frozen section, adjacent clinically suspicious tissue involvement was ruled out for malignancy. Hearing mechanism reconstruction was performed using autologous cartilage and instead of cul-de-sac closure of EAC, canal was kept open by doing wide conchomeatoplasty to aid in postoperative assessment and can avoid repeated imaging.

Frequency and risk factors for antegrade ureteral stone migration after percutaneous nephrolithotomy.

IntroductionPercutaneous nephrolithotomy (PCNL) is the minimally invasive procedure of choice for the treatment of large and/or complex nephrolithiasis. Migration of residual fragments (RFs) into the ureter after PCNL is presumed to be uncommon. However, should associated stone-related events (SREs) occur, ancillary procedures may be required. The objective of this study was to describe the frequency and to analyze predictors of antegrade migration of RFs after PCNL.Material and methodsA case-control study of patients who underwent PCNL for nephrolithiasis and had a postoperative computed tomography available within 48 hours was performed. Descriptive statistics and logistic regression analysis were carried out.ResultsThe final sample included 169 interventions. Mean age was 49 ±13 years, median maximum stone size was 26 (7 to 87) mm and mean stone density was 835 (70 to 2022) Hounsfield Units (HUs). 7.1% of the patients experienced migration of RFs into the ureter after PCNL, of whom 41.6% suffered SREs. Lithotripsy was performed using ultrasonic (67.5%), laser (23.7%), and pneumatic (14.8%) technologies. Univariate analysis found female gender (OR 4.1, p = 0.02) height ≥1.68 m (OR 5.52, p = 0.009), middle (OR 6.71, p = 0.01) and upper (OR 3.59, p = 0.04) caliceal location, staghorn calculi (OR 4.72, p = 0.02), stone area (OR 1.001, p = 0.03), lasertripsy (OR 3.61, p = 0.03) and operative time (OR 1.007, p = 0.02) statistically significant for migration of SFs into the ureter after PCNL. Of these, only height ≥1.68 m (OR 7.17, p = 0.01) and staghorn nephrolithiasis (OR 13.27, p = 0.02) remained independent predictors in the multivariate analysis with an area under the curve of 0.69.Conclusions71.% of patients undergoing PCNL had a SF migrating to the ureter. Of these 41% suffered a SRE that required ancilliary interventions. Staghorn nephrolithiasis and ≥1.68 mts of height were found to predict this event.

IS IT NECESSARY TO INSERT A SILICONE TUBE AFTER ENDOSCOPIC ENDONASAL DACRYOCYSTORHINOSTOMY? AND FOR HOW LONG? A COMPARATIVE PROSPECTIVE STUDY

This study aimed to evaluate the necessity for silicone tube insertion following endonasal endoscopic dacryocystorhinostomy (DCR), and the optimal time for its removal. A prospective study was done at Al-sadr Teaching and Al-Shafaa General Hospitals in Basrah, Iraq on seventy two patients with nasolacrimal duct obstruction diagnosed and referred from ophthalmologist to ENT clinic. Preoperative assessment with investigations were done and all patients were subjected to endoscopic endonasal DCR. The patients were divided into three groups; the first group included those with long period stenting (silicone tube removed three months or more), the second group included those patients with short period stenting (tube removed 2-3 weeks after surgery), and the last group included those with no silicone tube stenting. The success rate and complications after surgery were studied in each group for more than one year. The 72 patients were; 63 females (87.5%) who affected more than males (9, 12.5%). the most common age group was 21-45 years. Left side of disease 41(56.9%) is more than right side 31(43.1%). Sixty eight operations (94.4%) out of 72 were primary surgery while four (5.6%) were revision surgery. Ancillary procedures were done also; 13 (18%) septal surgery and 3(4.1%) endoscopic sinus surgery. Success rate was more among short period stenting group 22 out of 24 (91.6%), then without stenting group 19 (82.6%) and those with long period stenting was only 20 from 25 (80%). In conclusion, no statistical significant difference (benefit) about the usage or not of the silicone tube and also about how long keeping the tube, but it is preferable to use silicone tube (for 2-3 weeks only) to improve success rate. Keywords: Silicone tube, Insertion, Endonasal, Endoscopic, Surgery

Gender Surgery Beyond Chest and Genitals: Current Insurance Landscape.

Plastic surgery plays an essential role in the treatment of gender dysphoria. International standards of care currently consider genital and chest surgeries to be medically necessary. Ancillary procedures such as facial surgery, chondrolaryngoplasty, hair restoration/removal, and body contouring are considered cosmetic surgeries except in individual circumstances. The authors sought to assess the frequency of coverage provision for ancillary transition-related surgeries through a cross-sectional analysis of US insurance policies. The authors selected insurance companies based on state enrollment data and market share. Policies were identified through web-based search and telephone interviews. A list of eligible procedures was compiled and grouped into 5 categories: body masculinization, body feminization, facial procedures, hair restoration/removal, and chondrolaryngoplasty. Medical necessity criteria from publicly accessible policies were then abstracted. Sixty-one insurance companies held an established policy. One-third of these policies offered favorable coverage for at least 1 ancillary procedure. Chondrolaryngoplasty was the most covered category (26%, n = 16), whereas body masculinization was the least covered (8%, n = 5). Almost two-thirds of the companies with favorable policies listed coverage criteria. We identified 4 recurring requirements: age, hormone therapy, continuous living in a congruent gender role, and referral from a mental health professional. There is a low prevalence of US insurance coverage for ancillary gender surgeries and wide variability in coverage criteria. Reevaluation of ancillary transition-related procedures from cosmetic to medically necessary based on clinical judgement or establishment of defined coverage criteria may augment coverage and better address the needs of transgender patients.

Can Endoanchors be Used in Any Endovascular Aortic Procedure? Lessons Learned After 674 Endoanchors in 109 Patients in a Two-centre Experience

Introduction - Endovascular aortic aneurysm repair (EVAR) for thoracic, thoracoabdominal, pararenal, juxtarenal and abdominal aortic aneurysms has been troubled by complications during follow-up, mainly related to loss of seal and graft migration causing endoleaks and sac expansion. Different techniques have been applied ranging in grade of complexity, such as branched, fenestrated, chimney/periscope or standard EVAR/TEVAR or even hybrid surgery including arch/visceral debranching. The role and safety of EndoAnchors (Aptus Heli-FX, Medtronic, Minnesota, USA) as an adjunctive technique for supplementing fixation and seal in standard and complex EVAR/TEVAR needs to be addressed. Methods - We report on a two academic vascular centre experience with high volume of endovascular procedures with the use of EndoAnchors in different aortic anatomies and sectors. The number of total EndoAnchors deployed is described. Primary outcome is description of the safety of EndoAnchor deployments. Recommendations related to secondary outcomes such as complications, limitations and inadequate use are also described Results - 109 high-risk patients (male 81.7%, female 18.3%; ages 73.92 ± 10.9 years) were treated during the study period (2013-2018) with adjunctive EndoAnchors, 79 in centre A and 30 in centre B. Sixteen were treated with TEVAR (zone 1, n=4 (3 open debranching and 1 combined open/endo-debranching; zone 3, n=3; zone 4, n=12; 3 patients across 2 zones) 3 with Ch-EVAR (1 chimney each) and 90 with EVAR. All were considered complex due to anatomical constraints. 674 EndoAnchors were placed, 87 in TEVAR, 587 for EVAR/Ch-EVAR (2 in a bell-bottom iliac endograft) and a mean of 6.18 ± 2.2 per case. Ninety-eight were prophylactic (44 conical, 31 hyper-angulated > 60°, 30 short and 14 ‘bubble’ necks) and the remaining 11 were revision/type Ia endoleaks. Issues related to endoanchoring procedure were found in 17 (15.6%) cases. Thirteen (76%) occurred during the initial half of centres’ experience. Of the 17 cases we found 4 mal-deployment (0.5%), 4 fractures (0.5%, without clinical relevance), 3 (27.3%) type Ia endoleak persistence after endostapling (1 undersized diameter of endograft, 2 ruptured AAA unsuccessfully treated with cuff plus EndoAnchors - 1 solved with aortic banding, the other died due to unstability/3 patients with delayed type Ia sealing), 3 catheter ruptures/twisting (0.4%) and 3 (0.4%) losses (2 were retrieved and one caged by a sandwich technique using an aortic cuff). Eight (7.3%) patients received less than 4 endoanchors. Six (75%) occurred during the first half of centres experience. Four received only one EndoAnchor, two of these due to rupture of the catheter, in one other case further deployments were not possible due to severe sheath twists causing inability to pass the applicator and the remaining one due only iliac by-pass access limited manoeuvrability. Two received 2 EndoAnchors, due to extreme angulation and impossibility to get correct position, and remaining 2 patients received 3 endoanchors due to a loss during procedure Conclusion - Endovascular approach of complex aortic aneurysms with adjunctive use of EndoAnchors seems to be a safe ancillary procedure. Appropriate use of the device, including choice of adequate access, proper catheter manoeuvring, anatomical patient selection and increased expertise for technically demanding cases remain the most important issues to avoid misuse of the device or failure in the endovascular technique

Comparative Study of Holmium Laser Enucleation of the Prostate With MOSES Enabled Pulsed Laser Modulation

To compare outcomes for patients undergoing holmium laser enucleation of the prostate (HoLEP) for lower urinary tract symptoms secondary to benign prostate hyperplasia using 3 different laser fibers and 2 different laser energy modes. This is a review of a clinic registry of men with lower urinary tract symptoms secondary to benign prostate hyperplasia who underwent HoLEP between August 2018 and January 2019. Patients were assigned to group 1 (50 patients), group 2 (50 patients), and group 3 (50 patients) based on the HoLEP being completed with either a Slimline 550µm, Slimline 1000µm, or MOSES 550 µm laser, respectively. The groups were compared using SSPS for ANOVA comparison of means and multivariate logistic regression. Ten patients who underwent concomitant stone surgery (2 PCNL, 8 ureteroscopy , 3 bilateral cases) and 11 patients had bladder stones removed; ancillary procedures did not significantly differ between groups(P=.2). Prostate enucleation times differed significantly (22.5+7.3, 16.4+6.9, 18.1+8.6 minutes P ≤.001) between groups. However, statistical significance was lost once enucleation time was indexed against enucleated tissue weight. Time to achieve hemostasis (minutes) was statistically different between groups (10.6+6.1, 7.7+5.2, 6.3+4.8 P <.001). This difference in hemostatic time was maintained on multilogistic regression demonstrating that MOSES laser enucleation was associated with a 3.9-minute decrease time to achieve hemostasis after enucleation compared to Slimline 550 HoLEP (P <.001). Our findings suggest that modulated pulsed laser energy can improve hemostasis during the enucleation phase of a HoLEP resulting in shorter Operating Room times.

A New ‘Approach’ to Reduce Wound Complications Following Ankle Arthroplasty

Category:Ankle ArthritisIntroduction/Purpose:Despite advancements with instrumentation and implant design, total ankle arthroplasty (TAA) is still associated with a high rate of wound complications, which can lead to poorer outcomes. The aim of this study was to evaluate all wound complications following TAA and to determine any demographic or operative associations.Methods:A retrospective review of 660 consecutive TAAs was performed between November 2001 and May 2017. Data was collected on wound complications and potential risk variables, including age, sex, body-mass index, diabetes, smoking, and inflammatory arthritis. All wounds were seen at the clinic by the surgical team and a wound specialist nurse who independently recorded any issues. Major wound complications were those that required consultation with plastic surgeons, debridement by the nurse specialist, use of negative pressure therapy, or return to the operating room. All major complications were treated initially with oral antibiotics. Minor wound complications included any mention of discoloration, swelling, or clinical concern that merited the patient returning for further review. Minor wound complications were not treated with oral antibiotics. Operative notes were also reviewed to collect data on the surgical approach and additional incisions.Results:Fifty-nine patients (8.9%) had wound healing issues: 19 major (2.9%) and 40 minor (6.1%). All issues became evident <21 days postoperatively. Major wound complications were associated with a history of inflammatory arthritis, smoking, or coronary heart disease. Four patients were treated with negative pressure therapy, four with debridement in the operating room, and two were eventually converted to fusions. Fourteen (83%) patients with major complications had an ancillary procedure to balance the TAA through a separate incision. From 2001 to 2010, the standard surgical approach for TAA was performed anteriorly. All TAA patients with major wound complications were operated via an anterior surgical approach as their primary incision. No major wound complications were reported among the 22 anteromedial approaches.Conclusion:Potential TAA patients with a history of smoking, heart disease, or inflammatory arthritis should be considered with caution. A multidisciplinary team is valuable for evaluating wounds, as the majority of wound complications can be managed in the outpatient clinic with debridement, bespoke dressings, or negative pressure therapy from a specialist nurse. The anteromedial approach (see attached figure), which we have previously described, has great potential for patients who have a higher risk of developing a wound complication. Further investigation is necessary to evaluate its role in reducing the incidence of wound complications.

Two-Year Outcomes of Total Ankle Replacement with the Cadence Total Ankle Replacement System

Category:Ankle, Ankle ArthritisIntroduction/Purpose:Over the last few decades, total ankle replacement (TAR) emerged as a reliable treatment option in end-stage ankle osteoarthritis (OA) while preserving motion and physiological load. The Cadence™ prosthesis, manufactured by Integra LifeSciences, is a two-component, fixed-bearing implant with minimal tibial and talar resection and has been in clinical use since June 2016. The purpose of this study is to assess the two-year validated clinical outcome scores and radiological parameters of the Cadence™ prosthesis at our hospital.Methods:Thirty-one consecutive patients who received the Cadence™ prosthesis between June 2016 and December 31st, 2016 were enrolled. All patients who underwent a primary TAR with the Cadence™ prosthesis and who had at least two years follow- up were included. All surgeries were performed by a single surgeon with experience in total ankle arthroplasty. At the yearly clinical evaluation, patients were administered the Ankle Osteoarthritis Scale (AOS) and the Short Form Health Survey (SF-36), and their radiological outcomes pre and post-surgery were assessed.Results:Thirty-one patients fulfilled the inclusion criteria. Forty ancillary procedures were performed on twenty-four TAR’s. Radiological analyses showed preoperative talar sagittal translation with 25 anterior, 2 posterior, and 4 neutral. Sagittal translation decreased from an average 3.11 mm to 1.0 mm. Eleven ankles had a perioperative talar Varus and Valgus deformity that was corrected, with neutral alignment in all. At the two-year clinic visit, x-rays showed no lucencies or stress fractures and none of the ankles required revision of metal components. The pre and post-operative pain and disability scores displayed major improvement wherein AOS pain scores decreased -20.28 ± 14.34 points from an average of 47.86 points while AOS disability scores decreased -32.11 ± 22.70 from an average of 57.15 points.Conclusion:The overall outcome of the total ankle arthroplasty with the Cadence™ prosthesis showed excellent clinical and radiological outcomes. Compelling clinical evidence shows that the quality of life, functional measures, and pain in patients suffering from end-stage arthritis significantly improved following surgery with the Cadence™ total ankle replacement system. The semi- constrained design of this two-component implant and utilization of biased polyethylene inserts allowed for correction of the talus in both the sagittal (talar anterior / posterior translation) and coronal planes (talar varus / valgus).