Cases Of Intraoperative Complications Research Articles

Efficacy and safety of three - dimensional laparoscopic adrenalectomy: a single - center experience

Background: Laparoscopic adrenalectomy has emerged as the standard treatment for adrenal tumors. Although the application of high - resolution cameras has enhanced visualization in conventional two - dimensional laparoscopy, it has not fully overcome the limitations of depth perception and spatial recognition. However, thanks to significant advancements in three - dimensional technology in laparoscopic surgery, these issues have been totally solved. This study aims to evaluate the outcome of three - dimensional laparoscopic adrenalectomy. Methods: A prospective study included 38 patients with adrenal tumors who underwent three - dimensional laparoscopic adrenalectomy from April 2020 to December 2022 at the Department of Urology, Hue Central Hospital. Results: The mean age was 42.5 ± 5.1 years old. The most common reason for hospitalization was back pain, accounting for 39.5%. Adrenal incidentalomas were detected in 23.7% of patients. The proportion of patients with functional adrenal tumors was 55.3%; nonfunctioning adrenal lesion with progressive growth 13.1% and pheochromocytoma was 7.9%. Computed tomography showed a mean tumor size of 30.5 ± 9.2 mm. The mean operative time was 108.8 ± 12.3 minutes. There were no cases of intraoperative complications or conversion to open surgery. Early postoperative complications include wound infection (5.3%) and fluid accumulation (2.6%). The mean postoperative hospital stay was 5.5 ± 1.9 days. Postoperative pathological reports showed adrenocortical tumors in 81.6%. At follow - up, 35 of 38 (92.1%) cases were asymptomatic and had normal follow - up results in laboratory tests. Conclusions: Three - dimensional laparoscopic adrenalectomy is a minimally invasive, safe, and effective method.

Learning curve in the arthroscopic Latarjet procedure: An analysis of the first 171 cases

BackgroundArthroscopic Latarjet procedure is accepted as effective and safe. However, it is more likely to be challenging in execution. Therefore, the analysis of the learning curve remains to be worth examination. ObjectiveTo examine the learning curve in the arthroscopic Latarjet procedure through an analysis of the correlation between the average operative time, complications rate, and the total number of performed surgeries and execution frequency. Materials and methodA total of 171 patients who underwent arthroscopic Latarjet surgery between 2013 and 2020 were included. Clinical findings were recorded postoperatively. We fixed the operative time with account taken of the execution frequency and the number of intra- and postoperative complications. All procedures were completed by one surgeon. ResultsBy statistical analysis, a significant association between the operative time and the number of surgical interventions was found (p < 0.05). After 120 procedures, the average operative time demonstrated a constant reduction and reached 62.8 min (p < 0.05). We detected the relation between the average operative time and surgery frequency. The significant correlation between the number of intraoperative complications and the number of procedures performed manifests after the 20th surgery (p < 0.05). In total, 13 episodes of complications were recorded (7.6 %). 9 cases of intraoperative complications (5.3 %) conversed into the open Latarjet procedure. 4 episodes of postoperative complications (2.3 %) were documented, among them 2 hematomas which were treated conservatively, and 2 cases of recurrent shoulder instability. There were no neurological, neurovascular, and infection complications seen in our cohort. DiscussionIt took more than 120 arthroscopic procedures to reach the stable and reproducible indices in operative time, and more than 20 surgeries to achieve a significant reduction in the intraoperative complications rate. There was no correlation between the postoperative complication rate and the number of performed procedures. The overall level of complications did not exceed the level mentioned in the literature. The high surgical activity could be considered as a favorable factor to increase the efficiency of the learning process. ConclusionGaining clinical experience with the passing of the learning stages impacts significantly the rate of intraoperative complications and operative time. The arthroscopic Latarjet procedure is safe and characterized with good clinical results even within the initial stages of the learning curve.

Supine mini percutaneous nephrolithotomy in horseshoe kidney.

The percutaneous nephrolithotomy (PCNL) in Horseshoe kidneys (HSK) is usually performed in the prone position, allowing entry through the upper pole and providing good access to the collecting system. However, in patients with normal kidney anatomy, the supine position is reliable and safe in most cases, but it is unknown whether the supine position is adequate in patients with HSK. The purpose of this study was to describe the results of PCNL in HSK in three different surgical institutions and to evaluate the impact of supine position during surgery, comparing pre-operative and post-operative data, complications, and stone status after surgery. Between 2017 and 2022, a total of 10 patients underwent percutaneous renal surgery for stone disease in HSK. All patients were evaluated pre- and post- operatively with non-contrast CT. we evaluated patients (age and gender), stones characteristics (size, number, side, site and density ), and outcomes. The change in haemoglobin, hematocrit, creatinine and eGFr were assessed between the most recent preoperative period and the first postoperative day. Procedure success was defined as stone-free or presence of ≤4 mm fragments (Clinically Insignificant residual Fragments - CIrF). Complications were registered and classified according to Clavien-dindo Grading System, during the 30 - day postoperative period and Clavien scores ≥ 3 were considered as major complications. Statistical analysis was performed using "r 4.2.1" software, with a 5% significance level. we also compared pre-operative and post-operative data using "wilcoxon signedrank test". No statistical difference was observed between preoperative and post-operative renal function data. At one post operative day CT scan, an overall success rate of 100% was registered. 9/10 patients were completely free from urolithiasis (stone-free rate: 90%), while 1/10 patients had ≤4 mm residual stone fragments (CIrF rate: 10%). No cases of intraoperative complications were registered. Post-operative complications were reported in 1/10 patients. A patient developed urosepsis (defined as SIrS with clinical signs of bacterial infections involving urogenital organs - Clavien-dindo Grade II) after procedure, and was treated with intravenous antibiotic therapy successfully. Conclusions: This study shows that in patients with HSK mini- PCNL in supine position allows to achieve good stone free rate with a very low morbidity. According to our series, the described technique for PCNL in HSK should be an option. Nevertheless these results must be confirmed by further studies.

Sleeve gastrectomy in the surgical management of obesity in Cameroon (a sub-Saharan country): A single-institute retrospective review of 30-day postoperative morbidity and mortality

BACKGROUNDObesity is a major public health concern even in sub-Saharan Africa. In this part of the world, characterized by limited technical platform and resuscitation facilities, sleeve gastrectomy in the surgical management of obesity is a quite new procedure. We aimed to assess intraoperative complications and 30-day postoperative morbidity and mortality of this procedure in our setting.METHODSThis study was conducted in the digestive and laparoscopic surgery unit of the National Insurance Fund Health Centre of Essos (Cameroon, Central Africa region). Retrospectively, we reviewed the medical reports of all patients who had undergone a bariatric surgery through a sleeve gastrectomy from January 2016 to December 2020. The 3 end points were intraoperative complications, postoperative 30-day morbidity, and postoperative 30-day mortality.RESULTSWe included 21 patients among whom 19 were female (90.5%). Their mean age and body mass index were 40.3 ± 10.8 years and 44.9 ± 7.4 kg/m2, respectively. All of them presented with at least 1 comorbidity. All procedures were totally completed laparoscopically with 3 cases of intraoperative complications (14.3%) consisting on bleeding in all of them. The mean operative time was 192.2 ± 52.8 minutes, and the mean hospital stay was 4.7 ± 1.1 days. Eight patients (38.1%) presented a total of twelve 30-day postoperative complications, all of them classified as minor according to the Clavien–Dindo method. The main postoperative morbidity was represented by nausea and vomiting (n = 3, 14.3%). No 30-day readmission was recorded, and the 30-day mortality was nil.CONCLUSIONSleeve gastrectomy in the management of obesity is a safe procedure even in a limited setting like our own.

Outcomes of Laparoscopic Adrenalectomy: 19-Year Experience after 500 Cases

Background: Laparoscopic adrenalectomy, which was first introduced in 1992, is now regarded as the gold standard for treating various forms of adrenal masses. The authors reported their learning curve and the development of surgical techniques, as well as certain drawbacks associated with surgical outcomes. Materials and Methods: Between March 2000 and March 2019, the data of all patients that underwent laparoscopic adrenalectomy were compiled and examined. The primary outcome covered all the operative parameter, which include operative time and the learning curve, diagnosis with size, conversion rate, and blood loss. Pre-operative, intra-operative, and post-operative data, including all complications, were secondary outcomes. Results: Five hundred thirteen surgical procedures in a single center were studied during the 19-year period. In 421 cases, hormone-producing tumors were discovered and included Conn’s syndrome in 275 cases, Cushing’s syndrome in 75 cases, and pheochromocytoma in 71 cases. After the first 50 cases, the mean operative time was significantly lowered. There was also a moderate link between the tumor size and the operational time (Pearson correlation, r=0.315, p&lt;0.05). There were 22 (4.3%) cases of intraoperative complications and 29 (5.7%) cases of postoperative complications. Histopathological reports are available, including adrenocortical carcinoma with the mean tumor size of 3.2cm with a range of 2.5 to 12 cm. Conclusion: Laparoscopic adrenalectomy has proven to be a safe and successful treatment for most adrenal-related diseases with various sizes. The learning curve should be regarded as a part of training. This method can replace open surgery in a high-volume center, particularly in certain malignant patients. Keywords: Adrenalectomy; Laparoscopy; Surgical outcomes

Microdiscectomy: An Observational Study. The New Armenian Medical Journal

Intervertebral disc herniation, which is an inevitable and aging process due to intervertebral discs unique anatomical and physiologic characteristics and spine biomechanics, can lead to compression of one or more nerve roots, producing radiculopathy. There are two treatment options non-surgical and surgical or the combination of both depending on individual clinical findings for this issue. Surgical management includes several options with different success and complications rate. The options also have different implementation rate. The aim of current study is to show the efficacy and safety of microdiscectomy as a surgical treatment option in our clinical practice. We enrolled 91 patients from 2019 to 2021, who were operated using microdiscectomy technique, discharged within few days and were prescribed to use semi-hard lumbar brace for a month and were followed up until 2022 November. No any patient was considered as a surgical management candidate simply for low back pain. Immediate and complete or nearly-complete pain relief, sensory deficit and motor weakness improvement were the predictors of surgical management success and were achieved in all patients. There were no cases of intraoperative complications and failed back surgery. One patient (1.1%, 1/91) developed cerebrospinal fluid leakage from the wound on postoperative day 7, which resolved with additional dermal sutures. Recurrence rate of disc herniation was 1.1% (1/91). This patient was successfully reoperated without significant quality of life affection. The implementation of microdiscectomy technique in our clinical practice was successful, and from medical point of view highly effective and safe surgical management option for treatment of disc herniation with radiculopathy in cases where non-surgical management options failed to resolve the issue or there were indications for urgent surgical management. We hope that this technique eventually will become a gold standard for surgical treatment of disc herniation with radiculopathy in Armenia.

Laparoscopic one anastomosis gastric bypass for the revision of failed laparoscopic sleeve gastrectomy

Introduction Sleeve gastrectomy is gaining more and more popularity among bariatric procedures; however, there is an increasing number of cases with insufficient loss of weight or weight regain after sleeve gastrectomy. Many operations can be used to revise the failed sleeve gastrectomy, and one of them is one anastomosis gastric bypass (OAGB). This study aims to assess the efficiency of the conversion of laparoscopic sleeve gastrectomy to laparoscopic OAGB. Patients and methods This is a prospective study that included 16 patients with failed sleeve gastrectomy who underwent revisional OAGB. This study was conducted in Ain Shams University Hospitals from August 2016 to December 2018. Results The mean age of the patients was 40.18±7.6 years. At least 24 months separated the sleeve gastrectomy from the revisional OAGB (24–82), with a mean of 49.4±14.4 months. The mean;Deg;BM;Deg;I at conversion was 46.1± 7 kg/m2. At 12 months after the revisional OAGB, the mean;Deg;BM;Deg;I was 33.5± 4 kg/m2. There were four cases of intraoperative complications; however, there were no mortalities. Conclusion OAGB after failed sleeve gastrectomy is feasible, leading to significant loss of weight and improvement in comorbidities, with minimal perioperative complications.

Portal Vein Injury During Laparoscopic Cholecystectomy: Case Report

The frequency of major vascular injury encountered during the cholecystectomy procedure is very low. In the present case report, a congenital anomaly of portal vein is addressed. A 26-year-old female patient was admitted for urgent laparoscopic cholecystectomy due to a new episode of acute cholecystitis. She is already scheduled 2 times for elective cholecystectomy but canceled the surgery due to anxiety. The patient underwent laparoscopic cholecystectomy in the same day of admission. A major and rare case of intra-operative complication of portal vein injury during the laparoscopic cholecystectomy was encountered. The injury was well managed by suture repair. The vascular injuries may cause significant morbidity and sometimes mortality if not managed appropriately. Thus, our report may help to highlight the prompt management of vascular injuries at early stage.

The Kite technique: a new all-arthroscopic technique for the treatment of acute acromioclavicular joint dislocation.

Although many open techniques have been developed, no all-arthroscopic technique has been introduced to reduce acute acromioclavicular joint dislocation (ACJD) and augment both coracoclavicular (CC) ligaments. The Kite technique is the first all arthroscopic technique with this aim. Forty-one consecutive patients [35M-6F; median: 29.2years (range 23-36)] with acute type III and V acromioclavicular joint dislocation were treated with the Kite technique: it consists of positioning three titanium buttons connected by heavy sutures in an 8-strand configuration between clavicle and coracoid to restore the anatomy of CC ligaments. Patients were followed up for a median of 35months (range 30-43months). Median operation time was 70.6min (range 58-82), with no cases of intra-operative complications. At the final follow-up, the median post-operative Constant Score and SST were 94.1 (range 89-98) and 11.6 (range 10-12), respectively. At the final follow-up reduction maintenance was present in 39 patients; in one patient, signs of acromioclavicular joint dislocation recurrence were present 3months post-op. In another patient, medial suture ruptures occurred 4months after surgery with type II acromioclavicular joint dislocation recurrence but with scarce symptoms and full recovery to sport activity. Clavicle osteolysis was observed in four patients. Cosmetics of the arm were judged as excellent in 39/41. All patients, except two, were satisfied with the final result. The kite technique is a safe and reproducible arthroscopic procedure to treat acute ACJD. In daily clinical practice, due to the excellent results and the low complication rate, this technique might be considered by surgeons when operative treatment of an acute acromioclavicular joint dislocation is planned. IV.

Extracorporeal Shock Wave Lithotripsy verus Rigid Ureteroscopy in Treatment of Mid-Ureteric Stones; Randomized Prospective Study

Abstract Background Urinary stone disease or nephrolithiasis, the third most common disease of the urinary tract is a major health problem due to its high prevalence, incidence and recurrence. The lifetime incidence of kidney stones for men and women is approximately 13% and 7% respectively. Although stones may be asymptomatic, potential consequences include abdominal and flank pain, nausea and vomiting, urinary tract obstruction, infection, and procedure-related morbidity. Ureteral stones frequently cause renal colic and if left untreated can cause obstructive uropathy. Objectives A prospective randomized study to compare between extracorporeal shock-wave lithotripsy and rigid ureteroscopy in mid-ureteric stone treatment regarding efficacy, stone-free rate, retreatment rates, associated complications (intra-operative and post-operative), operative duration, hospital stay. Patients and Methods This study was performed at Ain Shams University (Urology department) and El Doaah hospital (Urology department), From August 2016 to August 2017, a total of 50 patients having solitary radiopaque middle ureteral stone ranges between 0.5 – 1.5 in size were divided into two groups 25 patients each enrolled in our prospective study. Results In this study the overall stone free rate was considered after two sessions of ESWL (in case of ESWL group) or one trial of ureteroscopy (in case of URS group). ESWL group: 14 cases became stone free after the first session, while the remaining 11 out of 25 patients needed second session, 6 cases became stone free after the second session. ESWL failure occurred in 5 cases and they were successfully managed by ureteroscopy. URS group: 23 cases became stone free after first ureteroscopy, while the remaining 2 patients needed second ureteroscopy due to proximal migration of the stone. In ESWL group, patients were already at outpatient clinic so there were no admission or hospital stay, all cases done without anesthesia, just analgesic ± sedation. While in URS group patients admitted and the hospital stay varies from one day to seven days according to the condition of the case, all URS cases had Spinal anesthesia. ESWL was shown to be less time consuming than URS with a mean operative time of 46.84±3.61 minutes versus 56.20±7.11 minutes respectively. In URS group there were 22 patients had ureteric catheter inserted for 24 to 72 hours postoperatively and 3 patients had double (J) stent inserted for 4 weeks postoperatively, while all the patients who underwent ESWL, no auxiliary procedure done as this procedure is completely non-invasive. Among ESWL cases, No case had an intra-operative complication, while URS group had 3 cases of intra-operative complication. There were 4 cases who had post-operative complications among ESWL group, while there were 5 cases who had post-operative complications among URS group. Conclusion In treatment of mid-ureteral stones range 0.5-1.5 in size, both URS and ESWL modalities are comparable but URS is recommended as a first option as it is more effective than ESWL regarding stone free rate and it provides immediate stone clearance with lower re-treatment rates and higher patient satisfaction, but URS requires anesthesia, longer hospitalization, and associated with a higher incidence of complications.

Management of postoperative Complications after posterior lumber spinal fixation

Background: For increasing safety and reducing complications that may occur with Trans-Pedicular Scre Placement, different ways have been reported including application of C-arm X-ray view, application of axial computed tomography scan (CTS), frameless stereotactically guided screw placement and different guidance devices. However, the application of all these devices and techniques are not so easy and even in many operating rooms such kinds of instruments are not available. A posterior approach to anterior and middle column reconstruction is often preferred in the lumbar spine for two reasons, the first is that the morbidity associated with an anterior approach is significant and delays recovery, the second is that pedicle screws and rods or plates can be placed before dural retraction and dissection of the intervertebral disk. Aim of the Work: The aim of this work was to evaluate the postoperative Complications. In posterior lumber transpedicular fixation and their management. Patients and Methods: Retrospective and prospective study for evaluating the history, clinical state, laboratory investigations, radiological findings and way of management in 25 cases of postoperative Complications after posterior lumber spinal fixation. Results: 25 patients operated upon for posterior lumbar fixation were included in the present work, In the current work we divided complications of posterior lumbar fixation into intraoperative complications and postoperative complications, Among the 25 patients of our work we had 5 cases of intraoperative complications (20 %) and 20 cases of postoperative complications (80%), Dural tear was the most common intraoperative complications (8%), instrument failure was the most common postoperative complications 12 cases (48%). Conclusion: According to medical history smoking was statistically significant risk factor for intraoperative complications; significant epidural bleeding and dural tear. Hypertension was statistically significant risk factor for intraoperative complications; inappropriate screw insertion and fracture pedicle. Also, smoking was Statistically significant risk factor for development of postoperative complications; infection, C.S.F leak, infection, nerve root injury and pseudoarthrosis.

Interventions for managing medication-related osteonecrosis of the jaw.

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: (A) To assess the effects of interventions versus no treatment, placebo or an active control for prophylaxis of MRONJ in patients exposed to antiresorptive or antiangiogenic drugs. (B) To assess the effects of nonsurgical or surgical interventions (either single or in combination) versus no treatment, placebo or an active control for treatment of patients with manifest MRONJ.

Clinical outcomes of additional surgery for adjacent segment disease after single-level anterior cervical decompression and fusion.

Adjacent segment disease (ASD) is one of the problematic complications following anterior cervical decompression and fusion (ACDF). The impact of additional surgery with instruments is still unknown. The objective of this study was to investigate the surgical outcomes of additional ACDF with instruments for symptomatic ASD after an initial ACDF using autogenous iliac grafts without instruments. A total of 56 patients who underwent an additional ACDF with instruments for symptomatic new radicular or myelopathic symptoms from ASD between 2006 and 2012. In this study, subjects were 30 men and 26 women with a mean age of 59.2 ± 9.7 years (range, 50-70 years) at revision surgery. Clinical evaluations were performed preoperatively and repeated at 3 years after operation. There were no cases of intraoperative complications, major neurological or vascular, pseudoarthrosis or wound complications. All of them reported significant improvements in JOA, NDI and VAS on arm pain and neck pain from the preoperative means (P< 0.05). According to our study, additional ACDF with instruments had achieved favorable clinical results on patients who underwent initial ACDF using autogenous iliac grafts without instruments for symptomatic new radiculopathy or myelopathy.

Perioperative complications during radical cystectomy and double cutaneous ureterostomy using Clavien system

Objective To explore the Clavien complications of patients given radical cystectomy and double cutaneous ureterostomy and to analyze the influencing factors. Methods The clinical data of 117 cases undergoing radical cystectomy and double cutaneous ureterostomy from January 2002 to June 2015 were reviewed. The Clavien classification system was carried out to stratify perioperative complications. Logistic regression analysis was applied to define possible predictors of the perioperative complications. Results Of the 117 subjects at least 1 perioperative complication developed in 51, including 3 cases of intraoperative complications. According to the Clavien system, 30 patients had grade 1-2, and 21 patients had grade 3-4 complications. The most frequent complication was incision-related complications, followeb by the gastrointestinal complications and lung infections. The total incidence of perioperative complications was lower in the laparoscope group than in the open surgery group (28.57% vs. 48.31%, χ2= 0.171, P=0.680), and the incidence of perioperative complications of Clavien 1-2 was lower in the laparoscope group than in the open surgery group with the difference being statistically significant (17.86% vs. 39.33%, χ2=4.363, P=0.037). Logistic regression analysis showed that hypoproteinemia, hospital stay and intranperative transfusion were the influencing factors of perioperative complications in patients undergoing radical cystectomy and double cutaneous ureterostomy (Respectively, χ2=10.131, P=0.003; χ2=8.685, P=0.012; χ2=6.675, P=0.018). Conclusion Radical cystectomy with double cutaneous ureterostomy is associated with a high perioperative comlications. Hypoproteinemia, longer hospital stay and intraoperative transfusion are independently associated with any complication in these patients. The Clavien system is a validated method that can be successfully used to stratify and evaluate perioperative complications during radical cystectomy and double cutaneous ureterostomy. Key words: Radical cystectomy; Double cutaneous ureterostomy; Perioperative complications; Clavien classification system; Urinary bladder neoplasms

Clinical study of functional outcome of intertrochanteric fracture treated by Trochanteric fixation nail (TFN) in North Indian population: A prospective study

Background: Trochanteric fixation nail (TFN) is a newer device used for the treatment of the intertrochanteric femoral fracture. This study reports the outcome in such fractures treated by using the TFN at northern part of India. Materials & Methods: In a prospective study from October 2014 to September 2016, we included 64 patients (38 female, 36 male; mean age 59.25years; range 21 to 80 years) who were treated with the TFN for intertrochanteric hip fractures and followed up minimum of six months. According to the AO/OTA classification, there were 14 cases of type 31A1, 42 cases of type 31A2, and 08 cases of type 31A3 fractures. The patients were evaluated clinically (Harris hip score) and radiographically for a minimum period of six months with all complications were recorded. Results: In our series, most of the patients sustained trauma after simple fall (87.5%) and 12.5% as a result of road traffic accident (RTA).Fractures were classified according to AO/OTA classification, 14 patients had 31-A1 type of fracture, 42 had 31-A2 type of fracture and rest 8 had 31-A3 type of fracture. Mean average delay for surgery was 11.56 days (range 3 to 27 days). Out of 64 patient post-operative radiograph showed near anatomic reduction in 60 patients. We found 6 cases of intraoperative complication in the form of 2 cases of fixation in varus and 4 cases of loss of reduction. We found 8 cases of post-operative complication in which 2 cases of superficial and deep wound infection and 6 cases of varus malunion. No fractures of the femoral shaft, Z-Effect and reverse Z-Effect were noticed. We did not encountered any case of implant failure or avascular necrosis of femoral head. All the patient shows radiological union in our study with mean time of union was 11.02 weeks (12-18 weeks). According to harris hip score, we had good to excellent results in 88%, fair to poor result in 12% of cases. Conclusions: With proper patient selection, good instrumentation, image intensifier and surgical technique, TFN is a good choice in the management of intertrochanteric fractures leading to high rate of bone union and good functional result with minimal soft tissue damage.

Supine pediatric percutaneous nephrolithotomy (PCNL)

Many authors reported their experience with supine PCNL in adult population comparing the outcome with prone PCNL and they found that the stone free rate and the operative time were in favor of prone PCNL with a lower patient morbidity among patients with supine PCNL. This encouraged us to perform supine PCNL in pediatric population. In this study we evaluated the safety and efficacy of supine PCNL in pediatric population. Between April 2011 and February 2014 a total of 27 children (6 girls and 21 boys) presented with renal calculi. The stones were single pelvic stone in 14 cases, pelvic stone with lower calyceal stones in 7 cases and pelvic stone with upper calyceal stones in 6 cases. The mean stone size was 32 mm (range 20-47 mm). All patients were managed with supine PCNL performed by a single surgeon. Marking the posterior axillary line in standing position before the operation is a mandatory initial step. The patients were placed in supine position with elevation of the ipsilateral shoulder and hip by means of two bags one underneath the shoulder and the other underneath the hip to widen the operative field. The technique was performed using a sheathless 19 fr. Richard wolf rigid nephroscope after acute tract dilation by amplatz dilators. Complications (intraoperative and postoperative) and stone free rate rates were reported. A single lower calyceal access was used in all cases through which we could successfully remove even the upper calyceal stones. Kinking of the guide wire during tract dilatation were encountered in 4 cases and the guide wire was successfully exchanged using a small Teflon dilator in 2 cases while ultrasonographic guided lower calyceal repuncture was done in 2 cases. The average operative time (from the beginning of the puncture trial to nephrostomy tube insertion) was (41 ± 15) min. The operation was successfully completed as planned in all cases with two cases of intraoperative complications (one case of pelvicalyceal system perforation and another case of intraoperative bleeding and blood transfusion). The initial stone free rate was (92.5%). Postoperative complications was reported in the form of 2 cases of fever that respond to medical treatment for 72 h. The main advantages of supine pediatric PCNL is that it is comfortable for the surgeon, the anesthetist and the child. The main disadvantages of supine pediatric PCNL is that it is not familiar for most urologists and small field of operation. The short outcome of our study is the small number of cases and the lack of comparative study with prone pediatric PCNL. Pediatric supine PCNL is a safe and effective method for management of pediatric renal stones. It carries the advantages of easily upper calyx access through the lower calyceal tract, low incidence of fluid absorption or hypothermia and easy anesthesia monitoring. However a larger number of cases are needed to be evaluated.

Intraoperative floppy iris syndrome (IFIS): what complication rates can we expect?

Dear Editor, In a very interesting paper, Haridas et al. have shown that patients with intraoperative floppy iris syndrome (IFIS) receiving tamsulosin or doxazosin differ in terms of morbidity rates [1]. Among 2,785 cataract operations performed in 2,028 patients, the authors identified 52 (1.9 %) cases treated with tamsulosin and 109 (3.9 %) cases in which doxazosin was administered. They compared morbidity rates between these two groups. In our opinion, however, some aspects of this study need to be discussed. In their retrospective analysis, the authors found at least one IFIS feature in 17 out of 106 eyes (16 %) from the doxazosin group and in 25 out of 52 eyes (48 %) from the tamsulosin group. Alpha-1 antagonists, used in the symptomatic treatment of benign prostatic hyperplasia, may increase the surgical difficulties and risk of iris damage, corneal edema, posterior or anterior capsule rupture, and postoperative increase in intraocular pressure [2–4]. Nevertheless, analysis of data expressed as percentages can be misleading and provide false information on the prevalence of IFIS and expected intraoperative morbidity rate. In Table 1 of their paper, Haridas et al. presented data on the size of the pupil and status of the iris in the tamsulosin and doxazosin groups [1]. However, the prevalence of various abnormalities (large or small pupil, iris prolapse, etc.) was expressed as a percentage of IFIS cases in a given group, i.e. per 25 and 17 eyes in tamsulosin and doxazosin group, respectively. In our opinion, however, the prevalence should be rather expressed per the whole group administered a given agent, i.e. per 52 and 106 eyes of patients treated with tamsulosin and doxazosin, respectively. Only in this way can we estimate the potential risk of intraoperative complications in patients treated with α-1 antagonists. Furthermore, it should be noted that expressing seven cases of intraoperative complications in the tamsulosin group as 13.5 % (7 out of 52 eyes) suggests that such morbidity can be expected in patients subjected to cataract surgeries. This is not true, as intraoperative complications documented in the tamsulosin IFIS group (iris damage – 5 cases, anterior capsule rupture – 1 case, corneal edema – 1 case) corresponded to only 0.3 % of all 2,785 operated eyes, the average rate of cataract complications in non-IFIS patients. Takmaz analyzed a group of 858 operated eyes and identified intraoperative complications in 6 eyes of patients who were treated with tamsulosin [8]. However, he emphasized the lack of significant differences in the morbidity rates of tamsulosin-treated patients with and without IFIS (p = 0.245). According to Haridas et al., patients treated with tamsulosin differed significantly from the controls in terms of the morbidity rates (13.5 %, i.e. 7 out of 52 eyes vs. 3.3 %, i.e. 5 out of 150 eyes; p = 0.014) [1]. However, we postulate that statistical analyses are not justified in the case of such a large disproportion in group size. Furthermore, this analysis was not adjusted for surgeon’s experience and other intraoperative factors. Table 1 Studies reporting the rate of intraoperative floppy iris syndrome (IFIS) complications The exact data on the type and prevalence of intraoperative complications is missing in available literature. (Table 1) Chang et al. spoke to the intraoperative use of retractors in five cases but did not provide any data on the percentage of postoperative iris damage in patients with IFIS [2]. In turn, the report by Oshika et al. not only lacks any data on postoperative morbidity rates but does not provide any information about intraoperative strategies of performing cataract phacoemulsification in patients with IFIS [6]. Concluding: Although the use of α-1 antagonists, especially tamsulosin, can constitute a potential risk of intraoperative complications in cataract surgery, such complications occur sporadically, and therefore, the morbidity rates should be presented in a uniform manner in order to avoid their inadvertent overestimation.

Posterior percutaneous plating of the humerus

This is a prospective case series study, which was designed to evaluate the clinical outcome of posterior percutaneous plating of the humerus. From the year 2010 to 2011, 37 patients with middle and distal third humeral fractures who met the inclusion criteria were surgically treated by minimally invasive plate osteosynthesis through posterior approach. Their age ranged from 19 to 43 with an average of 27.8years. Type of fractures varied from B to C, and all of them were traumatic. Patients were followed up for a period varied from 12 to 24months with an average of 18. There were no cases of intraoperative complications, infection or metal failure. Union was achieved in all of them within 16-21weeks with an average of 18. Iatrogenic postoperative temporary neuropraxia of the radial nerve palsy was observed in two patients. All patients achieved normal range of shoulder and elbow motion within 3months after surgery. The average Quick DASH score at 12-month follow-up was 30. According to patient's satisfaction, all of them returned to the usual pre-injury activity level within 6months. This study suggests that the principles of minimally invasive plate osteosynthesis can be applied safely through posterior approach of the humerus to treat middle and distal third humeral fractures. This approach has the advantage of preserving the triceps anatomy and function facilitating rapid postoperative rehabilitation.

Comparison of robotic adrenalectomy with traditional laparoscopic adrenalectomy with a lateral transperitoneal approach: a single‐surgeon experience

Although several recent studies have demonstrated the feasibility and safety of robotic adrenalectomy, it is unknown whether this procedure has advantages over the traditional laparoscopic approach. This study compared our initial experience using the da Vinci-S® robotic surgical system during laparoscopic adrenalectomy with our experience with traditional laparoscopic adrenalectomy. From October 2009 to May 2012, 23 consecutive patients (13 women, 10 men) underwent laparoscopic adrenalectomy by the same surgeon at Anam Hospital, Korea University Medical Center. Fifteen patients (9 women, 6 men) underwent robot-assisted adrenalectomy (right-sided, 4 patients; left-sided, 11 patients). Eight patients (4 women, 4 men) underwent traditional laparoscopic adrenalectomy (right-sided, 5 patients; left-sided, 3 patients). The lateral transperitoneal approach was used for all patients. There were no cases of conversion to traditional laparoscopic or open surgery. The mean operative time was longer in the robotic group (208.2 minutes, range 120-320) than the laparoscopic group (181.13 minutes, range 75-270). There were no cases of intraoperative complications or mortality. The mean hospital stay did not differ significantly between groups (robotic group, 5.86 days (SD 1.16); laparoscopic group, 6.71 days (SD 1.38)). With its magnified stereoscopic three-dimensional vision, elimination of tremor, and ability to articulate and rotate surgical instruments, the da Vinci-S® robotic system may be an ideal surgical tool for the operation of adrenal lesions. Robotic adrenalectomy appears to be a safe and effective alternative to traditional laparoscopic adrenalectomy.

The analysis of perioperative complications during radical cystectomy using a standardized reporting system

To analyze the perioperative complications of radical cystectomy using a standardized reporting methodology. The clinical data of 233 cases of radical cystectomy from January 1996 to December 2008 were reviewed. Two hundred male patients and 33 female patients were included. The mean age was 58.9 years old. All complications within 30 days of surgery were recorded and classified using a 5-grade modification of the Clavien system. Overall mean operative time was 339 (170 - 610) minutes, and mean blood loss was 818 (range 100 to 3500) ml. Of the 233 subjects at least 1 postoperative complication developed in 84 (36.1%), including five cases of intraoperative complications. According to the modified Clavien system, 27 patients (11.6%) had grade 1, 38(16.3%) had grade 2, 16(6.9%) had grade 3, and 3(1.7%) had grade 4 complications. The most frequent complication was gastrointestinal complications (15.9%), then the incision-related complications (15.0%) and lung infections (4.7%). An association between hypoproteinemia and any complication was found after adjusting for confounding variables (OR = 2.963, 95%CI: 1.451 - 6.050, P = 0.003), and American society of anesthesia score (ASA score) was significantly associated with any major complication (OR = 2.520, 95%CI: 1.003 - 6.332, P = 0.049). Radical cystectomy is associated with a high perioperative complications, using the modification of the Clavien system has allowed us to stratify complications during radical cystectomy. Hypoproteinemia is independently associated with any complication in these patients and ASA score was significantly associated with any major complication.