Blind End Research Articles

FRI412 A Case of 46,XX Gonadal Dysgenesis With Mayer-Rokitansky-Küster-Hauser Syndrome And Primary Hypothyroidism

Abstract Disclosure: S. Al Allawi: None. R. Osman: None. Introduction: The association between Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome and gonadal dysgenesis is rarely reported in the literature. Coexistence of hypothyroidism with this condition is scarce and clinical correlation remains unclear. We describe a case of this rare clinical entity in conjunction with primary hypothyroidism. Clinical case: A 27-year-old Female with a medical history of primary hypothyroidism was referred to our clinic for evaluation of primary amenorrhea. She was born with a female phenotype. Growth was appropriate, but puberty was delayed with self-reported late pubarche at age 19. She never had a menstrual cycle, and had received hormonal replacement therapy (HRT) for a few months but failed to trigger menarche. However due to financial constraints, treatment was not continued. She was diagnosed with hypothyroidism since birth, for which she is currently maintained on levothyroxine 225 mcg daily. On physical exam, blood pressure was 126/72 mmHg, pulse rate 83 BPM, height 5’9”, BMI 34 kg/m2. No facial dysmorphisms or skeletal deformity were apparent. She had normal pubic and axillary hair distribution, breast budding consistent with Tanner Stage II. Genital examination revealed normal external genitalia and a blind vaginal pouch. Hormonal workup revealed hypergonadotrophic hypogonadism with estradiol < 0.5 pg/mL and post-menopausal range follicle-stimulating hormone (FSH) 36.7 mIU/mL. Thyroid stimulating hormone (TSH) 2.19 uIU/ml (nl 0.45-4.5 uIU/mL) and anti-TPO antibodies 10 IU/mL (nl 0-34 IU/mL). Prior thyroid ultrasound reported a small thyroid gland. Fluorescence in situ hybridization (FISH) analysis revealed 46XX karyotype. Abdominal and pelvic ultrasound showed normal kidneys with a non-visualized uterus and ovaries. Pelvic MRI confirmed the absence of both and showed a blind end vaginal pouch, leading to the conclusion of the coexistence of gonadal dysgenesis with MRKH. She was then placed on transdermal estradioltherapy. Conclusion: The association between gonadal dysgenesis (the most common cause of primary amenorrhea) and MRKH syndrome (the second most common cause) is infrequent. HRT remains the only therapeutic option. It aims to trigger the development of secondary sexual characteristics and prevent osteoporosis by allowing appropriate bone mineral accrual. Unfortunately, infertility remains the most significant consequential issue; hence the availability of good caring and psychological counseling should not be underestimated. The co-existence of likely non-immune primary hypothyroidism is even less frequent. To our knowledge, our case is the second reported case of this trilogy. Given the paucity of data, the association of this condition with primary hypothyroidism cannot be well established and can be coincidental. More studies are needed to determine if this condition has a higher prevalence of hypothyroidism. Presentation: Friday, June 16, 2023

FRI445 A Late Diagnosis Of Complete Androgen Insensitivity Syndrome

Abstract Disclosure: J. Muuse: None. R.J. Shah: None. P.A. Belany: None. Introduction: Complete Androgen Insensitivity Syndrome (CAIS) is a rare disorder of hormone resistance characterized by a female phenotype in an individual with an XY karyotype. Individuals with CAIS are born unambiguously female without any apparent abnormalities. They develop a short blind ending vaginal canal, with absence of Wolffian duct derived structures (vas deferens, seminal vesicles). Breast development advances regularly at puberty, while there is absent pubic and axillary hair, both due to peripheral conversion of testosterone to estrogen. Testes remain undescended in the abdominal cavity. Case: A 28 year old female with a past medical history of bipolar disorder presented to her primary care physician’s office with a chief complaint of fatigue. Blood work revealed an elevated testosterone level of 686, at which time she was referred to endocrinology for further work up. On further history gathering, she endorsed a life long history of amenorrhea. She saw an OB-GYN at 19 years old and was told she had a short vaginal canal. A pelvic ultrasound revealed no uterus and one left ovary. She was not given a diagnosis other than congenital absence of a uterus. She was lost to follow up until 28 years of age when she sought medical help for her fatigue. Physical exam was pertinent for a tall female with no signs of hirsuitism. Additional blood work revealed normal LH, FSH, and DHEA-S. A chromosomal analysis revealed XY. She was referred to gynecology for further management and assessment for orchiectomy. Discussion: This was an unusual case of CAIS, as this was diagnosed far past menarche. Most cases are diagnosed during puberty- which aids in an early approach towards the psychological and social well being of the individual as well as close follow up for evaluation of orchiectomy. Orchiectomy is recommended due to the increased risk of gonadal malignancy following puberty. The risk of developing malignancy increases with age, and has been reported to be between 15-22%. Thus it is important to identify this syndrome early in life to ensure this is addressed. It is followed by long term hormonal therapy with estrogen to maintain normal breast and bone development. This case highlights the importance of maintaining a high clinical suspicion of CAIS in females presenting with short vaginal canal and absence of a uterus in order to prevent malignancy and provide optimal psychological support to the individual. Presentation: Friday, June 16, 2023

Diverse ultrasound image features of unilateral genital tract obstruction with ipsilateral renal anomaly syndrome on genitourinary system segmental sequential ultrasound screening and the accuracy of ultrasonic diagnosis.

Unilateral genital tract obstruction with ipsilateral renal anomaly (UGTOIRA) syndrome is a rare congenital urogenital anomaly, characterized by different combinations of uterine abnormalities, unilateral cervical-vaginal obstruction, and ipsilateral renal abnormalities. Timely and correct diagnosis is critical. In this study, we analyzed the diverse ultrasound image features of UGTOIRA syndrome on genitourinary system segmental sequential ultrasound screening (SSUS) and the accuracy of ultrasonic diagnosis. The data from 59 patients with UGTOIRA syndrome over the last decade were analyzed retrospectively, which included ultrasound presentations and diagnoses of abnormalities of the uterus, cervix, and vagina, as well as the conditions associated with the bilateral fallopian tubes, ovaries, pelvis, kidneys and ureters, bladder, and urethra. All 59 patients (100%) were found to have ipsilateral renal agenesis, and the diagnostic accuracy of ultrasound was 100%. The uterus was correctively diagnosed as complete bicorporal uterus in 42 cases (71.2%), bicorporal septate uterus in 7 cases (11.9%), complete uterus septate in 8 cases (13.6%), partial uterus septate in 1 case (1.7%), and unilateral isthmus atresia in 1 case (1.7%). The cervix was correctively diagnosed as septate cervix in 28 cases (47.5%), double cervix in 17 cases (28.8%), unilateral small cervix in 5 cases (8.5%), unilateral obliterated cervical orifice in 5 cases (8.5%), partial development of the unilateral cervix with a blind end in 3 cases (5.1%), and unilateral completely undeveloped cervix appearing as a normal cervix in 1 case (1.7%). The vagina was correctively diagnosed as oblique vaginal septum (OVS) in 45 cases (76.3%), and normal vagina in 13 cases (22.0%) via preoperative ultrasound. In 1 case (1/59, 1.7%) of high OVS with ipsilateral obliterated external cervical orifice, the OVS was missed by preoperative ultrasound. The ultrasound diagnostic accuracy rates of uterine malformation, cervical malformation, vaginal malformation, hematoma location and volume, uterine communication, and cervical communication were respectively 100%, 100%, 98.3%, 100%, 100%, and 100%. The ultrasonic detection rate for a hole on the OVS was 0%, and the missed diagnosis rate was 100%. SSUS can be used to accurately evaluate uterine, cervical, and vaginal malformation, obstruction site, location and volume of keratocele, cervical or uterine communication, and ovarian endometriosis cyst in patients with UGTOIRA syndrome and ipsilateral urinary system malformation. However, ultrasound is unable to identify a hole on the OVS.

Pore-scale mechanisms and hysteresis effect during multi-cycle injection and production process in underground hydrogen storage reservoir

Injection and production of hydrogen gas storage through multiple cycles often lead to significant variations in the gas water occurrence state and the associated relative permeability curve (RPC). In this study, a visual sandstone etching model and numerical simulation method are used to analyze the alteration of the occurrence state after multiple cycles of gas-water inter drive. The influence of the occurrence state on the variation of the RPC is revealed. The experimental results demonstrate that with an increasing number of cyclic injection and production cycles, the gas saturation in the model shows an upward trend, rising from 64.26% to 73.89%. However, the water block phenomenon also increases, leading to only a small amount of gas bubbles undergoing discrete flow, resulting in a reduction of the porosity utilization from 51.06 % to 40.57 %. In different injection and production cycles, the liquid phase at the corners and blind ends of large pores is difficult to displace. The continuity of gas-liquid distribution enhances with the increase in injection and production cycles. The phenomenon of phase trapping during hydrogen multi-cycle injection is evident, and the relative permeability of the gas phase rapidly declines during the imbibition first stage. The difference in gas saturation between the displacement and imbibition processes gradually decreases, reducing from 0.314 to 0.054. The Carlson model achieves a final simulation accuracy of over 90 % for wettability hysteresis. The numerical simulation results indicate that the modified relative permeability curves can more accurately simulate the changes in hydrogen gas storage during injection and production. The relative error of the hydrogen saturation in the uppermost layer of the reservoir at 1673 days of operation is 8.51 %. And the pressure increase is 13.32% without considering the wetting hysteresis model.

358. CIRCULAR STAPLER METHOD FOR AVOIDING STRICTURE OF CERVICAL ESOPHAGOGASTRIC ANASTOMOSIS, ‘NON-TENSIONING METHOD’

Abstract Background The weakness for the circular stapler technique of esophagogastric anastomosis for esophageal cancer is anastomotic stricture. This study was performed to verify the superiority of a new ‘non-tensioning method’ for avoiding stricture of the cervical esophagogastric anastomosis by circular stapling compared with the conventional method. Methods In 461 patients who underwent McKeown esophagectomy with gastric conduit (GC) reconstruction were reviewed. A GC was pulled up at the cervical site through the retrosternal route. The esophagogastrostomy site of the GC was planned as far caudally as possible on the greater curvature side. In the conventional method, the stapler was fired while pulling the GC to avoid tissue slack. In the new method, the stapler was fired through the natural thickness of the stomach wall. The blind end length was changed from 4 to 2 cm. Anastomotic stricture was compared between the two techniques, and adjustment was performed using propensity score matching. Results The conventional group comprised 315 patients, and the non-tensioning group comprised 146 patients. Anastomotic leakage occurred in 22 (7%) and 6 (4%) patients, respectively (P = 0.211) [and in 9 (3%) and 3 (2%) patients, respectively, if leakage at the blind end was excluded]. Anastomotic stricture occurred in 92 (29%) and 7 (5%) patients, respectively (P < 0.001). The propensity score-matching analysis including 134 pairs of patients confirmed a lower stricture rate in the non-tensioning than conventional group (4% vs. 27%, P < 0.001). Conclusions The non-tensioning technique, the natural thickness of the stomach wall was fired with the stapler, significantly reduced the incidence of anastomotic stricture compared with the conventional technique.

Microscopic gas displacement efficiency of enhanced gas recovery in carbonate gas reservoirs with edge and bottom water

Carbonate gas reservoirs with edge and bottom water contain abundant reserves, making them key production targets in the Tarim Basin, Sichuan Basin, Ordos Basin, and other petroleum provinces. Water invasion may occur in the middle and late development stages of such reservoirs, leading to reduction of gas displacement efficiency and gas recovery. In this paper, a pore-scale water-gas immiscible flow model is established by coupling the fluid flow equation and the gas-water contact (GWC) tracking equation. The process of gas displacement with water is simulated in the heterogeneous porous media generated by the quartet structure generation set (QSGS). Finally, the mechanisms of remaining gas distribution and formation are analyzed, and the variation mechanism of microscopic gas displacement efficiency is discussed. The results are obtained in three aspects. First, the remaining gas is distributed at the blind end, in the pore-throat and as clusters, with their proportions and scales jointly controlled by microscopic pore structures, wettability and capillary number. The remaining gas can be further produced by changing the production pressure differential to disturb the original pressure system and gas expansion, so as to improve the microscopic gas displacement efficiency. Second, the microscopic gas displacement efficiency is closely related to the gas flow process. Formation or expansion of each water flow path may cause rapid increase of water cut and slows down the increase of gas displacement efficiency. Third, the microscopic pore structure and wettability are the inherent features of the gas reservoir, so the capillary number can be optimized to change the mode of GWC advancement, and then to effectively improve the microscopic gas displacement efficiency. It is concluded that for real gas wells, the evolution of mechanical mechanisms of GWC advancement should be revealed depending upon the microscopic pore structure and wettability of the reservoir, and then the optimal capillary number can be determined. Furthermore, clarifying the pore-scale water-gas flow characteristics and physical mechanism of microscopic gas displacement provides guidance for the planning of enhanced gas recovery.

Microfluidic investigation on asphaltene interfaces attempts to carbon sequestration and leakage: Oil-CO2 phase interaction characteristics at ultrahigh temperature and pressure

CO2 huff-n-puff is a potential approach to improve the oil displacement efficiency in the deep reservoirs, which can achieve carbon sequestration and efficient oil production, simultaneously. However, the fundamental understanding of carbon mass transport, sequestration and leakage mechanism in deep geological reservoirs at the microscopic pore scale is still ambiguous. In this work, we innovatively designed a precise CO2 huff-n-puff microfluidic experiment under ultrahigh temperature and pressure conditions (55 MPa, 115 °C) to study the microscopic mechanism of CO2 utilization, storage and leakage (CUSL) in pore scale. Moreover, we proposed the quantitative analysis method for oil-CO2 interaction behavior to explicit dissolution and extraction characteristics, pressure threshold and interface stability by introducing Pseudo-Color algorithm and relevant parameters such as dynamic oil swelling factor, contact angle and gray value. Then, the pore-scale dynamics of the fluid interaction mechanism during the soak and puff process were quantitatively characterized, corresponding to the carbon sequestration efficiency of crude oil continuously exposed to scCO2 and the leakage risk with step-down production, respectively. The experimental results indicate that during the huff process, the oil-CO2 phase behavior characteristics at 115 °C can be divided into swelling, immiscible extraction and miscible extraction regions, which are coordinately controlled by dissolution mechanism, capillary effect and vaporization mechanism. Moreover, ultrahigh temperature oil generally requires higher pressure to start extraction and miscibility (Pext = 6.38 and 15.96 MPa, MMP = 9.71 and 23.73 MPa, T = 50 and 115 °C, respectively), while the asphaltene precipitation pressure Pasp is lower. At ultrahigh temperatures, the oil-CO2 interaction also enters the contact angle fluctuation region in advance, and the morphology of asphaltene particles is single, fine and uniform. When the soaking time is 36 min, the non-extractable oil component gradually evolves into a carbon sequestration interface. During the subsequent puff process, the more stable the carbon sequestration interface in the smaller blind end, the lower the leakage risk, corresponding to the leakage pressure difference of up to 40.93 MPa. This work has important practical significance for deep resource extraction and CUSL industrial application.

Double trouble: a rare presentation of mucocele of appendix

Appendix is a blind ending tubular structure present at the convergence of the three tenia coli the base of the caecum. Most commonly presented to the out-patient department with features of appendicitis, but mucocele of the appendix secondary to malignant etiology is a rare clinical finding, more than half of the patients are asymptomatic in their clinical presentation. An accurate diagnosis and proper treatment protocols are necessary for its management. If mucocele of appendix is treated incorrectly may lead pseudomyxoma peritonei. A case of a 54-year-old man with right lumbar pain, duration of 1 week, clinical findings and ultrasonography (USG) abdomen reported as ill-defined collection in front of the psoas muscle (psoas abscess). Hence contrast-enhanced computed tomography (CECT) abdomen and pelvis was performed and was reported as features suggestive of mucocele of appendix and a right proximal ureteric calculus (8 mm) with hydronephrosis. After obtaining consent, patient underwent open appendectomy with right ureteroscopic lithotripsy (URSL) + double J stenting. Post-operative period was uneventful but histopathology of the specimen revealed a malignant origin. In patients presenting with a right sided abdominal pain, a broad spectrum of differential diagnosis should be considered and evaluated accordingly.

Microscopic Distribution and Development Strategy of Residual Oil in Tight Sandstone

Pore and permeability are distributed discontinuously and unevenly in the dominant sedimentary model of the lateral accretion body inside the meandering river point bar of the Fuyang reservoir of the Yushulin oilfield. Based on the water flooding experiments of field core samples, the influence of pore permeability conditions on residual oil distribution type and water cutting rate was studied by using the microscopic visualization technology enabled through a photolithographically fabricated glass model. It is found that the residual oil in samples shows five discontinuous types, which are cluster, columnar, oil droplet, membrane, and blind end. In the stages with low, medium, and high water cutting rates, the proportion of clustered residual oil in the samples with different permeability is high, reflecting the situation that it is difficult for injected water to spread widely in tight oil reservoirs. With the decrease of permeability, the proportion of membrane and blind end residual oil gradually increases, which indicates that the thin pore throat can produce large restrictions on residual oil, resulting in residual oil enrichment. At the same time, the water flooding experiment was carried out by changing the displacement direction and periodic water injection. It was found that changing the displacement direction was beneficial to the recovery of residual oil in the thin pore throat and avoided the dominant seepage of injected water in the big pore throat, and the recovery rate was increased by more than 2.14%. Periodic water injection, which was conducive to adjusting the displacement pressure difference, reduced the constraining force of the throat on residual oil and increased the recovery rate by more than 3.98%. The actual well area with closed coring wells and dynamic production data is preferred for the application of experimental research results. Changing displacement direction and periodic water injection increased the residual oil recovery by more than 3%.

Cavernous sinus dural arteriovenous fistula embolized through an occluded superior petrosal sinus: illustrative case.

Transvenous embolization for cavernous sinus (CS) dural arteriovenous fistulas (CS-DAVFs) with limitations of the major access routes to the CS is challenging. A 74-year-old woman presented with left-sided conjunctival injection and exophthalmos. Cerebral angiography showed a left CS-DAVF draining into the left uncal vein and superior ophthalmic vein, with the fistulous point located in the posterosuperior compartment of the left CS. The left inferior petrosal sinus and internal jugular vein were occluded, and no drainage route from the left superior ophthalmic vein was seen. The anterior segment of the left superior petrosal sinus (SPS) was occluded, but the posterior segment was not. Microangiography from the posterior segment of the left SPS showed a beak-like orifice in the anterior segment of the left SPS toward the left CS. A micro-guidewire was guided through the beak-like orifice, and the microcatheter was advanced into the left CS. The left CS was packed and the DAVF was occluded. Transvenous embolization through an occluded SPS may be an option in the endovascular treatment of CS-DAVFs. Penetration along the beak-like orifice of the occluded SPS visualized by venography at the blind end of the SPS may be useful in reaching the CS via the SPS.

Robotic pancreas-preserving total duodenectomy: first-world experience.

Pancreas sparing total duodenectomy (PSTD) is an exceedingly rare procedure that is performed mostly for benign disease, widely involving the duodenum, that cannot be treated otherwise. PSTD requires meticulous dissection as well as reconstruction of both biliary and pancreatic drainage. Despite these technical aspects appear to be ideal for robotic assistance, robotic PSTD has not been described yet.Robotic PSTD was successfully performed in two patients. In both patients biliary and pancreatic drainage were reconstructed on the second jejunal loop, which was pulled in the duodenal bed. In the first patient, gastro-jejunostomy was performed on the blind end of the neo-duodenum (Billorth I type gastric reconstruction). In the second patient, gastro-jejunostomy was achieved in an antecolic position, 40 cm downstream the neo-ampulla in the second patient (Billorth II type gastric reconstruction). In both patients, indication to PSTD was duodenal polyps not amenable to endoscopic removal. The first patient suffered from prolonged delayed gastric emptying, but she is currently doing well 5 years and beyond after the procedure. The second patient complained of mild delayed gastric emptying that resolved spontaneously. He is now doing well 5 months after surgery.We have shown the feasibility of robotic PSTD in what we believe to be a world premiere. Further experience is required to refine the procedure and improve outcomes.

Uterus Masculinus with a Patent Urethral Communication Documented with Positive Contrast Computed Tomography.

A 9 mo old male Labrador retriever presented for investigation into persistent urinary incontinence. Abdominal ultrasound and retrograde urethrocystogram with computed tomography documented a uterus masculinus (UM), which was confirmed on histopathology after surgical removal. A connection between the UM and the urethra was present, documented by positive contrast retrograde urethrocystography and confirmed with surgery. Typically, in the literature, UM are blind ending, and there are only a few case reports that demonstrate an assumed connection. This case has demonstrated a patent connection between the UM and the urethra, which should be considered a differential diagnosis for persistent urinary incontinence and urinary tract infection in juvenile male dogs.

Exstrophic bladder duplication in the sagittal plane: Surgical management of a rare case

The bladder-Exstrophy-Epispadias complex (BEEC) contains a wide spectrum of congenital malformations. A treatment naïve refugee was referred to our center with what was identified as BEEC. A 27-year-old female patient was referred for total incontinence since birth by the general practitioner from the refugee center. An exstrophic bladder with blind ending ureteral orifices and a second non-exstrophic bladder with two orthotopic ureters was identified, demonstrating the bladder duplication in the sagittal plane. Laparotomy was performed, dissecting the exstrophic bladder plate caudally and using it as a ventral onlay to augment the non-exstrophic bladder. A Mitchell-type bladder neck reconstruction was performed with an autologous fascia sling around the bladder neck to obtain continence. As the patient had never voluntarily voided, chances of spontaneous voiding after surgery were low. Therefore creation of a continent Mitrofanoff-type vesicostomy was additionally realized and genital reconstruction was achieved. 12 months post operatively, the patient was completely continent, had a bladder capacity of 250 ml, and performed self-catheterization 5 times a day. No post-operative complications were observed. Admission of political refugees can implicate challenging surgeries for congenital malformations in adults, such as BEEC. This demonstrates the importance of multidisciplinary transitional care.

V04-03 COMBINED ROBOTIC TRANSPERITONEAL AND TRANSVAGINAL PULL-THROUGH FOR REPAIR OF DISTAL VAGINAL ATRESIA: A VIDEO CASE REPORT

You have accessJournal of UrologyCME1 Apr 2023V04-03 COMBINED ROBOTIC TRANSPERITONEAL AND TRANSVAGINAL PULL-THROUGH FOR REPAIR OF DISTAL VAGINAL ATRESIA: A VIDEO CASE REPORT Jeremiah Dallmer, Peris Castaneda, Andrew Freedman, and Paul Kokorowski Jeremiah DallmerJeremiah Dallmer More articles by this author , Peris CastanedaPeris Castaneda More articles by this author , Andrew FreedmanAndrew Freedman More articles by this author , and Paul KokorowskiPaul Kokorowski More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003252.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Distal vaginal atresia is a unique Mullerian pathology where the urogenital sinus, responsible for the lower 1/3 of the vagina, fails to cannulate during development. Unlike Meyer-Rokitansky-Kuster-Hauser syndrome, which is characterized by agenesis of the upper vagina and uterus, patients with distal vaginal atresia have normal Mullerian development including the uterus and proximal vagina. METHODS: We present the case of a 12 yo female with a three month history of cyclical abdominal pain. Upon outside workup, she was found to have a short, blind ending vagina. MRI showed a 9 cm x 8 cm dilated uterus, open cervix and proximal vagina filled with blood products. She was taken to the operating room for combined perineal and robotic transperitoneal pull-through. RESULTS: An 8.5 mm camera port was placed in the umbilicus and three 8.5 mm working ports were placed using a hidden incision approach below the belt line. We incised the peritoneum and dissected as distally as feasible along the rectovaginal space. At the blind-ending introitus, a U-shaped incision was made to create an anterior flap. This space was dissected proximally, monitoring the correct plane via a finger in the rectum and with direct visualization with the robotic camera. The two planes were connected. A 0-silk was robotically placed to manipulate the vagina. As the vagina was severely dilated from menstrual products, mobility was insufficient to reach the introitus. A small posterior incision on the proximal vagina was made and blood products were partially evacuated. The vesicovaginal space was then dissected robotically, maintaining the lateral attachments as blood supply and avoiding ureteral injury. The vaginal apex was then pulled to the introitus and anastomosed to the anteriorly based flap from the introitus. The patient remained hospitalized for two days with vaginal packing in place. She was trained in the use of vaginal dilators and has been progressively increasing the size without difficulty. CONCLUSIONS: Robotic dissection of the proximal vagina in the setting of distal vaginal atresia using a hidden incision approach allows for orthotopic reconstruction, and superior aesthetics as compared to traditional port placement. This approach obviated the need for the use of tissue grafting or more extensive open dissection. Source of Funding: N/A © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e338 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jeremiah Dallmer More articles by this author Peris Castaneda More articles by this author Andrew Freedman More articles by this author Paul Kokorowski More articles by this author Expand All Advertisement PDF downloadLoading ...

Delineating and sparing the ileal conduit in adjuvant radiotherapy for bladder cancer with modulated radiotherapy.

We undertook a prospective planning study to describe the delineation of ileal conduit (IC) loop on radiotherapy planning computed tomography (RTP CT) scan as an organ at risk (OAR) and its sparing using volumetric modulated arc therapy (VMAT) during adjuvant irradiation of bladder malignancies. Fifteen patients with bladder malignancy needing adjuvant radiotherapy postoperatively and having normal renal function underwent delayed phase RTP CT from June 2020 to March 2021, with certain modifications (Foley's catheter through stoma, additional delayed scans). We identified the course of ureters, external stoma, IC, and uretero-ileal (right and left) anastomotic sites. VMAT plans were generated. A step-by-step description is given. Genitourinary OARs include kidneys, ureters, uretero-ileal anastomoses, and IC. The contrast on delayed scan opacifies ureters and IC. IC can be seen three-dimensionally as a structure with two fixed ends (blind proximal end anterior to the right sacroiliac joint and the open distal end over the right anterior abdominal wall in parasagittal location) and a 15-20 cm hanging intraabdominal loop that lies adjacent to the right iliac vessels. For prescription doses (PD) of 50.4 gray and 54 gray, respectively, VMAT plan achieved IC dose maximum to less than PD and V50 lower than 10 cc. Stoma sparing traditionally used as a surrogate for IC sparing is insufficient due to the variable intraabdominal location of IC loop. Delineation of IC as an OAR is feasible with slight modifications in the RTP protocols. VMAT (or other forms of intensity modulated radiation therapy) can help IC sparing and should be considered when it lies in close proximity to target volumes and the risk of additional morbidity is considerable.

Simultaneous Antegrade and Retrograde Endoscopic Management of Complete Short-Segment Ureteroileal Anastomotic Stricture: Technique and Early Outcome

Background: Ureteroileal anastomotic strictures have a prevalence of up to 10%. Although open surgical revision remains the gold standard treatment, endoscopic and robotic approaches are described to reduce morbidity.1 Patients with complete occlusive strictures are usually not considered candidates for endoscopic management. There are limited publications with small number of patients who employed endoscopic management for complete occlusive ureteroileal anastomotic stricture. Objective: The aim of this video is to describe surgical approach in a stepwise manner for endoscopic management of a complete short-segment (<1 cm) ureteroileal anastomotic stricture.2–6 Methods: A 51-year-old woman underwent an anterior pelvic exenteration and ileal conduit followed by adjuvant chemoradiotherapy for cervical cancer management. After 1 year, she underwent nephrostomy tube placement for pyelonephritis associated with a left hydroureteronephrosis. Subsequent antegrade nephrostogram demonstrated a complete ureteroileal anastomotic stricture. The patient was counseled regarding various management options, and she opted for endoscopic management. Under general anesthesia we initially performed a flexible cystoscopy through the ileal conduit and were unable to identify the left ureteroileal anastomotic site. We then dilated percutaneous renal access and placed 13F ultra-mini percutaneous nephrolithotomy sheath in kidney under fluoroscopic guidance. Antegrade simultaneous ureteroscopy and nephrostogram confirmed a short-segment complete stenosis of ureteroileal anastomosis. Using 200 micron holmium laser fiber at 1 J × 10 Hz, we incised the distal blind end of ureter near conduit allowing passage of the ureteroscope in periureteral tissue. We then incised the ileal conduit, allowing antegrade advancement of a guidewire into the conduit. This wire was retrieved cystoscopically through an ileal conduit and secured at the level of stoma. Finally, a 7F/14F endoureterotomy stent was placed followed by nephrostomy tube placement. Results: The patient had an uneventful postoperative recovery and was discharged home the next day with an open nephrostomy tube. After 10 days, we confirmed free drainage of contrast into the conduit without extravasation on antegrade nephrostogram and clamped the nephrostomy tube. We later removed nephrostomy tube at 2 weeks and endoureterotomy stent by office cystoscopy at 6 weeks. At 3-month and 1-year follow-up, the patient remained asymptomatic. A renal ultrasonography revealed residual mild left hydronephrosis and a renal scan showed stable split left renal function of 25% with adequate drainage. Conclusion: Our video provides detailed technical nuisances to novice endourologist for a safe and effective treatment of a complete short-segment ureteroileal anastomotic occlusion with simultaneous antegrade and retrograde endoscopic management. No competing financial interests exist. Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. Runtime of video: 4 mins 58 secs

Microscopic Visualization Experimental Study on the Effect and Mechanism of Viscosity Reducer on Emulsification of Heavy Oil

Viscosity-reducer flooding is an effective method to improve oil recovery after the water flooding of heavy oil, and water-in-oil emulsion (W/O emulsion) is easily formed during this process. W/O emulsion has a strong ability to improve mobility ratio and block off high permeability layers, which can effectively improve sweep coefficient and enhance oil recovery. The microscopic visual glass model is mainly used to study the microscopic oil displacement mechanism of dilute oil; however, there are few studies on the emulsification mechanism and influencing factors of heavy oil. The purpose of this paper is to study the mechanism of heavy oil emulsification caused by viscosity reducer at the microscopic level, and the effect of emulsification on heavy oil recovery. The visible physical experiments with the glass microscopic models with different permeability and pore sizes were carried out to study the mechanism and main controlling factors of emulsification and the oil displacement effect of viscosity reducer. On this basis, the software was used to calculate the oil recovery in different areas of the model in different flooding stages, which provides a more intuitive understanding of the oil displacement effect of viscosity reducer. The results showed that there are mainly three types of emulsifications between pores: pore throat-breaking emulsification, blind-end emulsification, and pore channel extrusion emulsification. Hence, the mechanism of the three types of emulsifications and the relationship between droplet size with shear stress have been explored. The shear stress increased with the increase of the shear rate, and the oil droplet size in the model decreased with the increase of the shear. The blocking mechanism of pore throat and the shearing action of viscosity-reducer solution are the main mechanisms of viscous oil emulsification between pores. Generally, the particle size of the emulsified oil droplets formed by the blocking action is large, and it is easy to form pore throat emulsion. The particle size of emulsified oil droplets formed by shearing of viscosity-reducer solution is small. When the pore diameter is smaller than the particle size of oil droplets, the mobility of oil droplets between pores is poor, which means the oil droplets easily accumulate at the blind end to form residual oil. From the results of viscosity-reducer flooding experiments, the heavy oil recovery in each area of the model has been significantly improved after viscosity-reducer flooding compared with water flooding, with the recovery factor in the edge area of the model improving by up to 24.22%. The viscosity-reducer solution has a significant displacement effect on the residual oil in the edge area of the model.

Complete bladder duplication presenting in adulthood: A case report on reconstructive technique and reflections on translational urology in refugees

Introduction and aim of studyThe bladder-Exstrophy-Epispadias (BEEC) complex is a spectrum of congenital malformations with many variations. A never operated political refugee with BEEC was referred to our center for management upon arrival in Europe. Our aim is to report the technique and outcomes on a never operated on BEEC adult, highlighting the importance of transitional urologic care for congenital malformations in adult patients.Materials and methodsA 27-year old female patient was referred to our center for complete incontinence since birth by the General practitioner from the refugee center who suspected BEEC. Upon further investigation, an exstrophic bladder with blind ending ureteral orifices and a urethral meatus caudal to the exstrophic bladder plate were highlighted. A second non-exstrophic bladder with two orthotopic ureters was demonstrated, thereby a bladder duplication in the sagittal plane was diagnosed, presenting a wide-open bladder neck and a 7 cm pubic diastasis, causing the incontinence she was initially referred for. With the patient in a supine position, laparotomy incision was done with excision of the umbilical scar. The exstrophic bladder plate is dissected caudally. As it presents good detrusor quality, decision is taken to use it as a ventral inlay to augment the non-exstrophic bladder. A Mitchell-type bladder neck reconstruction is performed with a classical fascia sling wrapped around the bladder neck to increase the continence mechanism given the very wide pubic diastasis. Given the risk for hyper-continence, interposition of a continent Mitrofanoff-type vesicostomy is additionally realized. Genital reconstruction is achieved.ResultsOver 1 year post operatively, the patient is completely dry, can holp up to 250ml between catheterization she performs five times per day and once at night. No post-operative complications were observed.ConclusionThe case of one adult patient with a rare urological condition like bladder exstrophy with duplication is presented, illustrating challenges political refugees referred to Europe implicates in terms of surgery regarding congenital malformations in adult patients. A multidisciplinary approach is highly important, demonstrating the importance of transitional care.

Investigation on immiscible N2 WAG and SWAG after water flooding in the paleo-subterranean river of fractured-vuggy reservoirs

The complex spatial distribution of caves and fractures results in the low oil recovery after water flooding in paleo-subterranean river of fractured-vuggy reservoirs. This paper tries to solve the problem of how to adopt water-alternating-gas (WAG) and simultaneous-water-and-gas (SWAG) to enhance oil recovery in paleo-subterranean river reservoirs. Aiming at this objective, we constructed one physical experimental and numerical model according to the geological section in Tahe Oilfield. The research on water flooding, WAG, and SWAG were carried out through experiments and simulations. The results show that there were four kinds of remaining oil after water flooding in the paleo-subterranean river karst reservoirs, i.e., blind end remaining oil, shielded remaining oil, attic remaining oil, and corner remaining oil. WAG can extract the shielded remaining oil, attic remaining oil, and part of the corner remaining oil efficiently, while SWAG can only work on the attic remaining oil. In addition, too low injection rate lacked driving force support and restricted the expansion of the swept zone. Too small gas-water ratio and slug size can’t play a good role in gas displacement. This paper is the first systematic study of the paleo-subterranean river reservoirs, and the results can provide a basis for production practice.

Intraoperative Bronchoscopic Inspection Facilitates Thoracoscopic Repair of Esophageal Atresia with Tracheoesophageal Fistula.

Aim: The value of intraoperative bronchoscopic inspection (IBI) for accurate confirmation of the location and distance between the distal tracheoesophageal fistula (TEF) and the proximal blind end of the esophagus (GAP) was evaluated in Type C esophageal atresia (EA)+TEF. Methods: IBI involved inserting the tip of a bronchoscope into the TEF and a nasogastric tube into the blind end of the EA and measuring GAP with fluoroscopy. EA+TEF patients (n = 23) treated thoracoscopically between 2007 and 2020 were classified according to IBI as IBI+ (n = 16) and IBI- (n = 7) to compare demographics, operative time, and time taken for TEF division. Results: Demographics were similar. Mean time for TEF division (15.4 ± 4.6 minutes for IBI+ versus 38.6 ± 20.9 minutes for IBI-; p < .05) and mean operative time (215.3 ± 48.9 minutes for IBI+ versus 286.4 ± 51.7 minutes for IBI+; p < .05) were significantly shorter. Mean GAP measured radiographically was 0.5 cm (range: 0-1.2 cm); mean GAP measured with IBI was 0.9 cm (range: 0-2.2 cm). Postoperative complications were 3 anastomotic leakages (1/16 in IBI+ and 2/7 in IBI-) that resolved without surgery and 8 strictures (3/16 in IBI+ and 5/7 in IBI-) treated by dilatation. Conclusions: IBI was effective for measuring GAP and is recommended for improving the efficiency of thoracoscopic repair.