Confirmation Of Anatomy Research Articles

Duplicated, Ectopic Ureter Inserting into the Prostatic Urethra During Robot-Assisted Radical Prostatectomy

Introduction: Robot-assisted radical prostatectomy has been shown to be a valuable therapeutic option for patients with clinically localized prostate cancer. In the era of cost savings and avoiding unnecessary tests, patients with intermediate-risk prostate cancer have been recommended against preoperative cross-sectional imaging techniques such as CT or MRI. Ureteral duplication associated with ectopia is a rare finding in men and insertion of the ectopic ureter occurs above the external sphincter or pelvic floor. In the literature, this clinical presentation has been reported in five case reports.1–5 Materials and Methods: We present the case of an otherwise healthy 67-year-old male who was found to have an elevated prostate-specific antigen (PSA), which prompted a transrectal ultrasound-guided biopsy of the prostate demonstrating Gleason 3 + 4 adenocarcinoma in the left mid and base. A prostate examination showed an ∼90-g gland that was otherwise benign, therefore clinical stage T1c. He denied lower urinary tract symptoms, erectile dysfunction, or family history for prostate cancer. After weighing all treatment options, he proceeded to robot-assisted radical prostatectomy and pelvic lymph node dissection. From an anterior approach during anterior cystotomy, he was discovered to have left-sided complete ureteral duplication with the upper pole inserting into the prostatic urethra. The bladder neck was widened to ensure identification of ureteral orifices and confirmation of the anatomy. Results: Following confirmation of the above anatomy by dissecting out the ureters at the level of the pelvic brim and observing indigo carmine excretion from the ectopic ureter, we placed a Double-J ureteral stent to identify and protect the ureter while proceeding with our posterior cystotomy. Ultimately, we performed complex bladder neck reconstruction to displace the stented ectopic ureter posteriorly and laterally, while completing the vesicourethral anastomosis using the routine Van Velthoven technique. Final pathology revealed Gleason 3 + 4, pT2cN0 adenocarcinoma of the prostate with negative surgical margins. Conclusions: After a satisfactory cystogram demonstrating contrast refluxing through the stent to the upper pole and no contrast extravasation, the patient's catheter was removed at 3 weeks postoperatively. He returned 1 month later for ureteral stent removal through flexible cystoscopy. The first PSA recheck at 3 months returned as undetectable and the patient continued with routine prostate cancer surveillance. As shown in the above case, excellent oncologic outcomes can be obtained with complex bladder neck reconstruction when encountering a duplicated, ectopic ureter inserting into the prostatic urethra during robotic radical prostatectomy. If the ectopic ureteral orifice appears too distal to the bladder neck, we recommend performing ureteral reimplantation or ureteroureterostomy to maintain adequate cancer control. All authors have no competing financial interests. Presented at: 31st World Congress of Endourology & SWL, October 22nd–26th, 2013, New Orleans, LA. Runtime of video: 7 mins 58 secs

Laparoscopic management of left-sided appendicitis in situs inversus totalis

Situs inversus totalis is a rare autosomal recessive inherent disease in which the thoracic and abdominal organs are transposed. Incidence in the general population is only 0.001-0.01%. Symptoms of appendicitis may appear in the left lower quadrant making the diagnosis difficult. We report a case of left-sided appendicitis diagnosed preoperatively after dextrocardia that was detected by X-ray chest and ultrasonography revealed long retrocecal appendix in left iliac fossa with loops of bowel clumped in the area. The patient underwent laparoscopic appendectomy and post-operative recovery was uneventful. Although, technically more challenging because of the mirror nature of the anatomy, we used the conventional 3-port techniques after laparoscopic confirmation of anatomy and not the mirror image technique as is normally practiced. This method also provided the same comfort level to the surgeon.

Intraoperative Angiography during Cerebral Aneurysm Surgery

Intraoperative angiography (IOA) has been considered since the 1960s for use during surgical repair of cerebral aneurysms. The potential of IOA to confirm complete aneurysm occlusion and patency of the parent vasculature intraoperatively are of significant clinical value. Over the past 5 to 7 years, use of intraoperative angiography has been increasing, and many centres now use the technique frequently. However, no consensus exists regarding the routine use of IOA in cerebral aneurysm surgery. Different institutional paradigms include the use of IOA rarely or never, selectively based on aneurysm complexity, or routinely in all aneurysm cases. This article describes the authors’ use of intraoperative angiography with particular emphasis on practical recommendations for implementing an institutional program of routine IOA as an adjunct to all surgeries for aneurysm repair. Recent improvements in radiolucent headholders and retractors, as well as improved digital subtraction angiography using portable fluoroscopy units have enabled the more efficient and practical use of intraoperative angiography. Traditionally, successful aneurysm clipping has been confirmed intraoperatively by inspection of the aneurysm clip and adjacent vasculature, combined with aneurysm puncture to confirm occlusion, prior to the closure of the craniotomy. Intraoperative angiography had historically been reserved for the most complex cases. Between 5.1 and 7.3% of surgically treated aneurysms are unexpectedly incompletely occluded, leading to additional treatment or ongoing risk of rupture [1–5]. Without IOA, the surgeon’s only means to confirm complete aneurysm occlusion is to puncture the aneurysm dome. This is not necessary after ruling out residual filling of clipped aneurysm through intraoperative angiography. An incompletely occluded aneurysm will hemorrhage from the puncture site, which although not usually problematic, is certainly not an optimal means to discover incomplete aneurysm occlusion. Parent vessel occlusion during surgical clipping of a cerebral aneurysm occurs in approximately 3–14% of cases [1–6]. Although rare, parent vessel occlusion can lead to permanent neurological deficit or death. Furthermore, only a small window of time exists to recognize parent vessel occlusion and restore flow before irreversible ischemia of brain parenchyma occurs, and therefore, postoperative investigations demonstrating parent vessel occlusion do not generally lead to successful intervention. IOA can demonstrate parent vessel occlusion in a timely manner, and lead to corrective intervention during the initial craniotomy. Furthermore, IOA alters the aggressiveness required in confirmation of anatomy and inspection of the distal tips of the aneurysm clip. Although rare, complications related to aggressive clip inspection do occur, and can be mitigated by IOA in certain cases. Others studies of cerebral blood flow such as microdoppler auscultation and postoperative R. Kumar J. A. Friedman (&) Department of Surgery, Texas A&M Health Science Center College of Medicine, 3201 University Drive, Suite 425, Bryan-College Station, TX 77802, USA e-mail: jafriedman@medicine.tamhsc.edu

Percutaneous transcholecystic cholangiography during laparoscopic cholecystectomy.

Controversy still exists regarding the role of routine cholangiography in laparoscopic cholecystectomy. Although the need to identify common bile duct stones is perhaps less critical than it was in the past, confirmation of anatomy by peroperative cholangiography is important for both clinical and medico-legal purposes. Conventionally, contrast has been introduced into the biliary tree via the cystic duct after dissection of Calot's triangle. A simple technique of cholangiography by direct gall-bladder puncture is described, which can be done quickly and easily at the beginning of the operation. The retrospective analysis of 250 consecutive cases shows the technique to be safe, accurate and to provide useful cholangiograms in 85% of cases. Percutaneous transcholecystic cholangiography can be performed readily without special equipment. It provides valuable anatomical information in 85% of cases before commencing dissection of the cystic duct.