Fistula Repair Research Articles

(265) The Surgical Anatomy of Clitoral Innervation: A Review of the Current Medical Literature

Abstract Introduction The clitoris is a crucial structure for sexual arousal and orgasm in people with gynecological anatomy. Despite its functional importance, the innervation of the clitoris has historically been understudied. The innervation of the clitoris includes somatic afferents of the dorsal nerve of the clitoris, a branch of the pudendal nerve and sacral plexus, and autonomic afferents of the cavernous nerve, a branch of the inferior hypogastric plexus. Although we have identified these structures, there remains a paucity of research on surgical techniques to avoid clitoral innervation during pelvic surgery, despite the importance of these nerves in gynecological sexual function. Objective This paper aims to summarize the current literature on clitoral innervation with special attention paid to the anatomical locations of nervous structures within the pelvis to inform future pelvic surgeons and reduce sexual side effects related to clitoral nerve damage. Methods We performed a PubMed search from inception through June 14, 2023 utilizing the Medical Subject Headings (MeSH) search terms “(clitor*)) AND (innerv* OR nerv*) AND (surg*)” and imported this search into Covidence software. Included in the literature search were observational studies, clinical trials, review articles, correspondence, and communications, and only articles in English were included. Results An initial abstract screen of 200 articles resulted in 87 articles that were fully screened and 53 articles that were utilized as within the scope of this paper. 45 papers discussed the dorsal nerve of the clitoris, while 15 papers explored autonomic afferents via the cavernous nerve. Fourteen papers discussed both somatic and autonomic innervation to the clitoris. The anatomical location of the dorsal nerve of the clitoris has been tracked in 29 papers, most of which utilize cadaver dissection, with at least six anatomic variations identified. The cavernous nerve’s exact location, however, has not been traced as extensively as has the location of the dorsal nerve of the clitoris, perhaps due to its smaller diameter and shorter length. Additional innervation to the clitoris was proposed in 12 studies as well. Many studies suggested that commonly performed procedures, including midurethral sling placement for stress urinary incontinence, labiaplasty, clitoral hood reduction, clitoroplasty, and urogenital sinus repair may interfere with clitoral innervation if not otherwise modified. Two studies discussed sensory mapping techniques prior to pelvic surgery to account for anatomic variation in clitoral innervation. Conclusions The clitoris is a vastly innervated structure with both somatic and autonomic afferents whose locations and anatomic variations should be considered when performing pelvic surgery. Failure to consider not only the dorsal nerve of the clitoris but the cavernous nerve as well may have consequences that negatively impact clitoral sensitivity, engorgement and erection, orgasmic ability, and overall sexual function. Disclosure No.

Posterior Urethral Reconstruction at the Time of Rectourethral Fistula Repair: Technique and Outcomes

IntroductionRecto-urethral fistulas (RUF) remain a difficult management problem. To assess the impact of posterior urethral stenosis on outcomes following RUF repair, we present a cohort of 23 men who underwent posterior urethroplasty concurrent with RUF repair. MethodsWe identified 130 men who underwent RUF repair at our institution between 2003-2021. Of these, 23 (18%) underwent simultaneous posterior urethroplasty. Fifteen men received prior radiation for prostate cancer. Of the 8 men who were not radiated, 4 had a history of radical prostatectomy, 2 pelvic trauma, and 3 inflammatory bowel disease. All 23 men underwent fecal diversion prior to surgery (median, 6 months pre-operatively), and 20 men suprapubic catheter placement (median, 5.5 months pre-operatively). ResultsRUF repair was performed via perineal approach in 22 cases (96%) and prone Kraske position in 1 (4%). Intra-operatively, 20 men (87%) had urethral stenosis, and 3 (13%) had significant urethral defects due to cavitation and tissue loss. There was stenosis/stricture involving the prostatomembranous urethra in 18 cases (78%) and vesicourethral anastomosis in 5 (22%). Urethroplasty was performed with anastomotic repair in 18 patients (78%) and using a buccal mucosal graft in 5 (22%). Gracilis flap interposition was performed in 21 cases (91%).At a median follow up of 55.7 months (IQR, 23-82 months), 20 men (87%) had successful RUF closure, with 3 patients experiencing RUF recurrence requiring further surgery. Fourteen men (61%) reported postoperative urinary incontinence, with 7 (30%) ultimately undergoing artificial urinary sphincter placement. There were no isolated stricture recurrences requiring instrumentation. ConclusionsPosterior urethral stenosis associated with RUF complicates an already challenging problem. However, most of these patients can be successfully treated concurrent with RUF repair. This series demonstrates that patients with RUF should not be ruled out for restorative reconstructive surgery based on the presence of posterior urethral stenosis.

Genitourinary / Fecal Fistulae: Etiology, Types and Surgical Outcomes

Introduction: Genitourinary/ fecal fistula is an abnormal communication between the genital tract and either the urinary tract or the gastrointestinal tract. Among genitourinary fistulae, most common is the vesicovaginal followed by ureterovaginal fistula. Aims & Objectives: The aim of our study is to determine various causes and types of genitourinary/fecal fistulae and their surgical outcome in our setting. Place and Duration of Study: A descriptive, retrospective cross-sectional study was conducted at Central Park Teaching Hospital Hospital, Department of Obstetrics and Gynaecology from December 2013-December 2021. Material & Methods: Total of 77 patients presented with various types of genitourinary/fecal fistulae during the study period. All details as demographic characteristics, type and cause of fistula, route of repair and surgical outcome were taken on a standardized proforma. All data was entered and analyzed in SPSS version 26 for statistical analysis.p-value of less than 0.05 was regarded as significant. Results: In this study, the age range was from 22 to 62 years with mean age 38.38 + 10.67 years. Mean duration of fistula was computed as 45.47 + 71.31 months with the range of 1 month to 27 years (324 months). Average fistula size was 1.14 + 0.96 cm with the range of 0.25 cm to 3 centimeters. The obstetric causes of fistulae accounted 44% (n=34) while iatrogenic causes were seen in 56% (n=43) of patients. The most common type of fistula was VVF with 53 (69%) patients followed by uretero-vaginal fistula with 08 (10.0%). The least common type of fistula was urethro-vaginal with only 01 (1%) case of 22 years, 05 (7%) patients had RVF and 08 (10%) had vesico-uterine and vesico-cervical fistulae. the overall success rate is 88.3%. Conclusion: The iatrogenic causes of genitourinary/fecal fistulae are more prevalent than obstetric causes. The successful outcome of fistula repair depends on number of previous attempts of repair and outcome of repair worsen with each number of previous attempts.

Efficacy, Feasibility, and Safety of the X-Tack Endoscopic HeliX Tacking System: A Multicenter Experience.

The application of endoscopic suturing has revolutionized defect closures. Conventional over-the-scope suturing necessitates removal of the scope, placement of the device, and reinsertion. A single channel, single sequence, through-the-scope suturing device has been developed to improve this process. This study aims to describe the efficacy, feasibility, and safety of a through-the-scope suturing device for gastrointestinal defect closure. This was a retrospective multicenter study involving 9 centers of consecutive adult patients who underwent suturing using the X-Tack Endoscopic HeliX Tacking System (Apollo Endosurgery). The primary outcomes were technical success and long-term clinical success. Secondary outcomes included adverse events, recurrence, and reintervention rates. In all, 56 patients (mean age 53.8, 33 women) were included. Suturing indications included fistula repair (n=22), leak repair (n=7), polypectomy defect closure (n=12), peroral endoscopic myotomy (POEM) site closure (n=7), perforation repair (n=6), and ulcers (n=2). Patients were followed at a mean duration of 74 days. Overall technical and long-term clinical success rates were 92.9% and 75%, respectively. Both technical and clinical success rates were 100% for polypectomies, POEM-site closures, and ulcers. Success rates were lower for the repair of fistulas (95.5% technical, 54.5% clinical), leaks (57.1%, 28.6%), and perforations (100%, 66.7%). No immediate adverse events were noted. This novel, through-the-scope endoscopic suturing system, is a safe and feasible method to repair defects that are ≤3cm. The efficacy of this device may be better suited for superficial defects as opposed to full-thickness defects. Larger defects will need more sutures and probably a double closure technique to provide a reinforcement layer.

P934 A delphi consensus on the optimisation of medical and surgical therapy in perianal fistulising Crohn’s disease, targeted at individual TOpCLASS classification groups

Abstract Background Perianal fistulising Crohn’s Disease (PFCD) is a challenging phenotype of IBD associated with poor outcomes. Classically, fistulae have been classified anatomically and guidelines have been generalised, with a lack of appreciation of disease heterogenicity. The recent ‘TOpCLASS classification system’ (Geldof et al. (2022) - figure below) addresses this and categorises patients based on clinical features and patient goals. There is a need to provide management guidance for PFCD that aligns with this approach, targeting differing PFCD manifestations seen in real-life. We present a consensus exercise delivering that guidance. Methods Position statements on ‘optimal’ PFCD management within the TOpCLASS classes were made via a consensus meeting in Apr 2023. The expert panel were members of the TOpCLASS Consortium, a group of PFCD specialists and researchers. This included 15 surgeons and 16 gastroenterologists, from IBD centres in Europe, North America, and Australia. Prior to the meeting, to inform provisional statements: 1) a systematic review of the literature was conducted (Oct 2021), 2) multidisciplinary team responses on the management of fictional PFCD cases from 8 leading IBD centres were obtained, and 3) an open discussion on PFCD management with the expert panel was conducted. Consensus was predefined as ≥80% ‘strongly agree’ [A+] or ‘agree with minor reservation’ [A]. Results 53 position statements were agreed by the expert panel. For Class 1 (minimal, asymptomatic) disease the panel agreed, given the lack of symptoms, there is no role for seton insertion (A+ 50%, A 50%), and no role for routine MRI monitoring in the absence of new fistula symptoms (A+ 46%, A 54%). Regarding Class 2 (chronic, symptomatic) disease, the panel agreed on detailed guidance for when fistulae are suitable for a repair attempt and where differing surgical modalities are best utilised in fistula repair. Additionally, statements on seton removal in PFCD were made, alongside statements on optimised medical therapy in Class 2 patients. Specifically, the panel suggest Infliximab first-line (A+ 80%, A 20%), ideally commenced within 30 days of initial drainage +/- seton insertion (A+ 100%). Statements were also produced regarding second-line options, topical therapy, and loss of response to biologics in PFCD. Specific statements were also developed for Class 2b, 2c-i, 2c-ii, and 4 disease, as well as on the psychological burden of PFCD. Conclusion The generated statements come from a highly expert Western group of PFCD specialists. We believe they provide pragmatic advice to gastroenterologists and IBD surgeons managing the full breadth of PFCD encountered in day-to-day practice.

Outcome and predictors of failure of abdominal surgical repair of high vesico-vaginal and vesico-uterine fistulae at Gezira Hospital for Renal Disease and Surgery

BackgroundUrogenital fistula can arise from various causes, leading to the development of diverse surgical procedures. The prevention and treatment of obstetric fistula continue to pose challenges in low-income countries.AimTo assess the outcomes and predictors of failure of surgical repair for urogenital fistulas, specifically high vesico-vaginal fistula (VVF) and vesico-uterine fistula (VUF), within our context.MethodsConducted a prospective hospital-based study involving 100 female patients with urogenital fistula (95 VVF and 5 VUF) who underwent abdominal surgical repair at Gezira Hospital for Renal Diseases and Surgery from 2018 to 2023. Collected data encompassing demographics, obstetric history, fistula etiologies, Swab test, cystoscopy findings, urine diversion, ureteric re-implantation, and repair outcomes.ResultsThe majority of women were aged 20–29 years (39%), illiterate (62%), and had a low socio-economic status (87%). Lack of antenatal care was noted in 77% of patients. Fistula etiologies were predominantly obstetric (70%), mainly due to spontaneous vaginal delivery (SVD), with the remaining 30% attributed to gynecological causes (hysterectomy). In terms of fistula characteristics, all patients had a high-level fistula, 95% had a single fistula, and 69% had a posterior wall fistula. Successful closure was achieved in 84% of cases, with 11% experiencing ureteric involvements. The analysis of failures pointed to recurrent fistulae (50%), larger fistula size (31%), and the presence of multiple fistulae (19%) as notable predictors of unsuccessful repair.ConclusionVVF was the prevalent type of urogenital fistula in our population. Risk factors included being in the third decade of life, illiteracy, low socioeconomic status, and a lack of prenatal care. Obstetric causes, particularly prolonged and obstructed labor through SVD, dominated the etiology. Surgical procedures resulted in successful closure in 84% of cases. Recurrent fistulae, larger size, and multiple occurrences emerged as predictors of surgical repair failure.

Minimally invasive transvaginal single-port laparoscopic vesicovaginal fistula repair: a case report and the point of this technique.

The optimal surgical method of vesicovaginal fistula (VVF) remains uncertain. Minimally invasive surgical approaches have become highly popular in line with technological advancements, namely, laparoscopic, robotic, and transvaginal techniques. However, these techniques still require invasiveness. This is the first case report that described a novel "zero-incision" technique for natural orifice transvaginal single-port laparoscopy used to repair a recurrent and high-position VVF. The patient underwent transvaginal single-port laparoscopic repair of a VVF. Methylene blue was used to locate the VVF, and a needle electrode was used to thoroughly remove the scar tissue of the VVF. In addition, this technique for transvaginal single-port laparoscopy provides more working space to expose and repair fistulas conveniently and adequately. One year after surgery, the patient remained asymptomatic and had no fistula recurrence. Minimally invasive transvaginal single-port laparoscopy provides a clear surgical field, is safe and feasible. This novel technique has promising as an additional personalized treatment option for VVF repair.

Vesicovaginal Fistula Repair Simulation Model and Hierarchical Task Analysis.

There is a need for surgeons skilled in vesicovaginal fistula (VVF) repair, yet training opportunities are limited. This study aimed to create a low-fidelity simulation model for transvaginal VVF repair, identify essential steps of VVF repair, and evaluate the model's ability to replicate essential steps. First, a low-fidelity VVF repair simulation model was designed and built by the authors. Next, a hierarchical task analysis was performed by urogynecologic surgeons with expertise in VVF repair. Each expert submitted an outline of tasks required to perform VVF repair. To control for bias, an education specialist de-identified, reviewed, and collated the submitted outlines. The education specialist then led a focus group, and through a modified Delphi process, the experts reached consensus on the essential steps. A separate group of urogynecologic surgeons then tested the model and completed an anonymous questionnaire assessing how well the model replicated the essential steps. Descriptive analyses were performed. Five experts submitted an outline of steps for transvaginal VVF repair, and 4 experts participated in a focus group to reach consensus on the essential steps. Nine urogynecologic surgeons, with a median of 10 years in practice (interquartile range, 7-12 years), tested the model and completed the postsimulation questionnaire. Most testers thought that tasks involving identification and closure of the fistula were replicated by the model. Testers thought that tasks involving cystoscopy or bladder filling were not replicated by the model. We developed a novel, low-fidelity transvaginal VVF repair simulation model that consistently replicated tasks involving identification and closure of the fistula.

Stapled transperineal rectovaginal fistula repair for low- and mid-level rectovaginal fistulas: A comparison study with rectal mucosal advancement flap repair

BackgroundAs an innovative treatment, stapled transperineal rectovaginal fistula repair (STR) for rectovaginal fistula (RVF) has demonstrated effectiveness in preliminary reports. This study aims to compare STR with rectal mucosal advancement flap repair (RAF), a widely utilized surgical procedure, for the surgical outcome of the low- and mid-level RVF. MethodsIn this retrospective cohort study, patients with low- and mid-level RVF who underwent STR or RAF were included from both the Sixth Affiliated Hospital of Sun Yat-sen University and Xi'an Daxing Hospital. Among the 99 total patients, 77 underwent STR and 22 underwent RAF. Patient demographics, operative data, and outcomes were collected and analyzed. Recurrence rate and associated risk factors were evaluated. ResultsThere were no statistically significant differences among patients in terms of clinical characteristics like age, BMI, aetiology, and fistula features. During the follow-up period of 20 months (interquartile range 3.0–41.8 months), a total of 28 patients relapsed, with a significantly lower recurrence rate in the STR group (20.8 %) than in the RAF group (54.6 %) (P = 0.005). In the multivariate Cox analysis, STR was an independent protective factor against recurrence (HR: 0.37, 95%CI: 0.17–0.79, P = 0.01). Logistic regression indicated that there was no statistically significant difference between these two procedures in terms of surgical complications (OR: 0.53, 95%CI: 0.19–1.48, P = 0.23). ConclusionFor low- and mid-level RVF, STR may be an alternative option for treatment modality that offers a lower recurrence rate, without observed disadvantage in terms of surgical complication rates.

Staged repair of esophageal atresia, tracheoesophageal fistula, and duodenal atresia in a newborn

Staged repair of esophageal atresia, tracheoesophageal fistula, and duodenal atresia in a newborn

Identifying opportunities for prevention of adverse outcomes following female genital fistula repair: protocol for a mixed-methods study in Uganda

BackgroundFemale genital fistula is a traumatic debilitating injury, frequently caused by prolonged obstructed labor, affecting between 500,000-2 million women in lower-resource settings. Vesicovaginal fistula causes urinary incontinence, and other morbidity may occur during fistula development. Women with fistula are stigmatized, limit social and economic engagement, and experience psychiatric morbidity. Improved surgical access has reduced fistula consequences yet post-repair risks impacting quality of life and well-being include fistula repair breakdown or recurrence and ongoing or changing urine leakage or incontinence. Limited evidence on risk factors contributing to adverse outcomes hinders interventions to mitigate adverse events. This study aims to quantify these adverse risks and inform clinical and counseling interventions to optimize women’s health and quality of life following fistula repair through: identifying predictors and characteristics of post-repair fistula breakdown and recurrence (Objective 1) and post-repair incontinence (Objective 2), and to identify feasible and acceptable intervention strategies (Objective 3).MethodsThis mixed-methods study incorporates a prospective cohort of women with successful vesicovaginal fistula repair at approximately 12 fistula repair centers in Uganda (Objectives 1-2) followed by qualitative inquiry among key stakeholders (Objective 3). Cohort participants will have a baseline visit at the time of surgery followed by data collection at 2 weeks, 6 weeks, 3 months and quarterly thereafter for 3 years. Primary predictors to be evaluated include patient-related factors, fistula-related factors, fistula repair-related factors, and post-repair behaviors and exposures, collected via structured questionnaire at all data collection points. Clinical exams will be conducted at baseline, 2 weeks post-surgery, and for outcome confirmation at symptom development. Primary outcomes are fistula repair breakdown or fistula recurrence and post-repair incontinence. In-depth interviews will be conducted with cohort participants (n ~ 40) and other key stakeholders (~ 40 including family, peers, community members and clinical/social service providers) to inform feasibility and acceptability of recommendations.DiscussionParticipant recruitment is underway. This study is expected to identify key predictors that can directly improve fistula repair and post-repair programs and women’s outcomes, optimizing health and quality of life. Furthermore, our study will create a comprehensive longitudinal dataset capable of supporting broad inquiry into post-fistula repair health.Trial Registration ClinicalTrials.gov Identifier: NCT05437939.

Patient-specific automated cerebrospinal fluid pressure control to augment spinal wound closure: a case series using the LiquoGuard®

Objective Spinal cerebrospinal fluid (CSF) leaks are common, and their management is heterogeneous. For high-flow leaks, numerous studies advocate for primary dural repair and CSF diversion. The LiquoGuard7® allows automated and precise pressure and volume control, and calculation of patient-specific CSF production rate (prCSF), which is hypothesized to be increased in the context of durotomies and CSF leaks. Methods This single-centre illustrative case series included patients undergoing complex spinal surgery where: 1) a high flow intra-operative and/or post-operative CSF leak was expected and 2) lumbar CSF drainage was performed using a LiquoGuard7®. CSF diversion was tailored to prCSF for each patient, combined with layered spinal wound closure. Results Three patients were included, with a variety of pathologies: T7/T8 disc prolapse, T8-T9 meningioma, and T4-T5 metastatic spinal cord compression. The first two patients underwent CSF diversion to prevent post-op CSF leak, whilst the third required this in response to post-op CSF leak. CSF hyperproduction was evident in all cases (mean >/=140ml/hr). With patient-specific CSF diversion regimes, no cases required further intervention for CSF fistulae repair (including for pleural CSF effusion), wound breakdown or infection. Conclusions Patient-specific cerebrospinal fluid drainage may be a useful tool in the management of high-flow intra-operative and post-operative CSF leaks during complex spinal surgery. These systems may reduce post-operative CSF leakage from the wound or into adjacent body cavities. Further larger studies are needed to evaluate the comparative benefits and cost-effectiveness of this approach.

Gallstone Ileus: Unfortunate Encounter

Gallstone disease is a common burden that affect worldwide that carry broad spectrum of its complications and severities. Gallstone ileus (GSI) remained the rare complication that arise form gallstone disease that mainly affected the elderly population. The mainstay of treatment for GSI is to relieve the small bowel obstruction by extraction of the impacted gallstone. Surgical options for GSI remained the long-standing arguments involve single-staged procedure (enterolithotomy, cholecystectomy and fistula repair) or twostaged procedure (enterolithotomy alone, and cholecystectomy with fistula repair later). We reported a case of a 76-year-old male who presented with symptoms of small bowel obstruction and computed tomography (CT) of abdomen confirmed the presence of calcified lesion at ileum with pneumobilia which was successfully managed with two-staged procedure.
 Bangladesh Journal of Medical Science Vol. 23 No. 01 January’24 Page : 272-275

A case of cirsoid aneurysm: Case report

Scalp cirsoid aneurysm is an arteriovenous fistula of the scalp that is usually unconnected by intracranial or cerebral vessels. Variceal dilatation of draining veins can produce cosmetic concerns, masses, local pain, palpable thrills, audible bruits, headache, tinnitus, and torrential hemorrhage. Its etiopathogenesis is not well understood. Treatment includes surgery (fistula repair by simple surgical ligation until gross total resection), embolization (whether percutaneous or endovascular), or a combination of the two. Here is a case report of a 40-year-old male patient who had right superficial temporal artery cirsoid aneurysm who underwent surgical ligation with complete excision of the lesion.

The Rolling Stones: A Systematic Review and Meta-Analysis of the Management of Gallstone Ileus.

Background: Gallstone ileus is a rare but potentially life-threatening condition resulting from the migration of gallstones into the gastrointestinal tract, which often necessitates surgical intervention. Three surgical procedures are well known and are practiced in clinical medicine; they include entero-lithotomy alone, entero-lithotomy with cholecystectomy, and enterolithotomy with fistula closure. However, there is no consensus regarding the best surgical approach as far as mortality, morbidity, and operative outcomes are concerned. The objectives of this systematic review and meta-analysis are to assess the relative efficacy and safety of these surgical procedures. Methods: A Preferred Reporting for Systematic Reviews and Meta-Analyses-compliant systematic literature review was conducted following the year 2000. Ovid MEDLINE, Embase and PubMed databases were searched using key terms gallstone, ileus, cholecystenteric fistula, cholecystocolonic fistula to identify cases. Two authors independently checked each study against the inclusion and exclusion criteria at each stage of screening and extraction. After applying the inclusion and exclusion criteria and quality assessment of the Newcastle Ottawa Scale (NOS), 10 studies involving 293 participants were included in the analysis. The quality of included studies was "moderate to high" according to the selection, comparability, and outcome criteria. Mortality and morbidity were analysed using pooled odds ratios (ORs) in the randomeffects model and fixed-effects model, and operative time using mean differences (MDs). In addition, subgroup analysis was conducted according to the type of intervention, and heterogeneity was evaluated by Iò and �ò. Results: The meta-analysis showed a significant reduction in mortality with combined enterolithotomy and cholecystectomy (OR: 2.39 [95% CI: 1.87, 3.04], Iò = 33%), compared to enterolithotomy alone (OR: 3.09 [95% CI: 1.36, 7.02], Iò = 69%). Morbidity was also higher in the fistula repair group (OR: 4.92 [95% CI: 3.38, 7.14], Iò = 0%). Operative time was significantly longer for combined procedures, with a mean difference of 62.47 minutes [95% CI: 60.14, 64.81], in contrast to enterolithotomy alone. Subgroup differences were statistically significant, with p 0.01 for both mortality and operative time. Conclusion: This meta-analysis indicates that the combined approach of enterolithotomy and cholecystectomy has a reasonable risk benefit ratio in terms of decreasing mortality and controlling operative difficulty as compared to enterolithotomy alone or enterolithotomy with fistula repair. However, it is worth noting that the procedures that are considered as combined are characterised by longer operative time. These results provide evidence for the decisionmaking process surrounding intervention by taking into account individual features such as the presence of diseases or risks during surgery. These findings warrant additional high-quality research for the improvement of surgical approaches to manage gallstone ileus.

Factors Affecting Success Rates in Endoscopic Repair of CSF Rhinorrhea.

Our aim in this study is to assess the effect of factors such as age, etiology, defect size, application of lumbar drainage and surgical technique on Cerebrospinal Fluid (CSF) fistula repair success rates. The Electronic Medical Records (EMR) system of our clinic was retrospectively reviewed for cases that were operated between 2006 and 2020 for CSF fistula originating from anterior skull base with endoscopic transnasal technique. A total of 35 patients were included in the study. Patients were grouped according to the number of layers used in repair (two, three or four-layered reconstruction) and defect size (smaller than 5 mm, 5 to 10 mm and larger than 10mm), etiology, location of the defect and application of lumbar drainage as LD (+) and LD (-). Complications and CSF leak recurrence were compared between groups. Recurrence rates in patients who had 2 layered reconstructions were significantly higher compared to patients who had 3 or 4 layered reconstructions (p=0.049). The recurrence rate in LD (+) group (41.7%) was significantly lower compared to LD (-) group (4.3%) (p=0.012). There were no significant difference in recurrence rates between groups in terms of age, defect size, defect location and etiology. In endoscopic transnasal repair of anterior skull base-derived bos fistulas, planning the reconstruction at least 3 times and applying lumbar CSF drainage increases the success rates.

Clinical efficacy of transverse preputial island flap urethroplasty for single-stage hypospadias repair in Children Hospital Faisalabad” A Retrospective Study.

Objective: To summarize the clinical outcomes of single stage hypospadias surgery with preputial-island flap method in the Children Hospital, Faisalabad. Study Design: Retrospective Study. Setting: Department of Paediatric Urology, Children Hospital, Faisalabad. Period: March 2018 to March 2023. Material & Methods: First of all, approval of study from the Hospital Ethical Review Committee was taken for research work. For last five years, all patients of hypospadias repair were admitted in the ward via OPD of Pediatric Urology Department of Children Hospital, Faisalabad. According to inclusion and exclusion criteria, these patients were considered to be included in study. After analyzing the patients with history and physical examination, the diagnosis was confirmed and after the informed consent of surgery and consent of data for research purposes the patients were put in the research work. Results: There were one hundred and fifteen patients (n=115), who were operated using single stage hypospadias repair with method where we used dorsal prepuce in transverse manner as flap known as preputial-island-flap method during the study period time. The complication of surgery rate was found 48.7% in the study. There were five patients (4.34%) suffering from mild infection. Six patients (5.2%) had disruption of repair; secondary surgical correction was successful in all of them. Ten patients (6.7%) suffered necrosis and slugging of new urethral tube followed by disruption of repair. Urethro-cutaneous fistula was observed in sixteen patients (13-9%), it was single in eleven patients and the rest of five had more than one fistula. Four patients needed fistula repair, rest of the eleven healed with self-urethral dilatation, seven patients (6%) had meatal stenosis, while four patients (3.5%) had urethral stricture. Conclusion: Single staged hypospadias repair where dorsal prepuce in transverse manner were taken as flap known as preputial-island-flap is also an acceptable choice for surgery. Results of study showed transverse preputial-island-flap technique is an acceptable option. Because the vascularity of tube is intact and good, secondly results are better, thirdly this technique has lower rate of complications, fourthly we completed in single stage which was the time saving.

Laparoscopic fistula repair for high-level rectovaginal fistula by combined transabdominal-transvaginal approach: a case report.

Laparoscopic fistula repair for high-level rectovaginal fistula by combined transabdominal-transvaginal approach: a case report.

Repair of radiation-induced rectovaginal fistula with rectal stricture by a combined Tuttle, Turnbull-Cutait and Singapore flap approach.

Radiation-induced rectovaginal fistula (RI-RVF) with associated rectal stricture represents a challenging problem in management. The aim of the present technical note is to describe a surgical technique aimed at minimizing disease recurrence by avoiding radiated tissue in the reconstruction: 1. Tuttle longitudinal incision of posterior vaginal wall with sharp excision of proximally located fistula; 2. Resection of strictured rectum via a combined transvaginal/laparotomy access, reconstruction with Turnbull-Cutait colon pull-through, and delayed handsewn coloanal anastomosis with loop ileostomy; 3. Bridge closure of the posterior vaginal wall by the interposition of a Singapore flap. This approach resulted in a favorable outcome at the 1-year follow-up in one patient with a medical history of gynecological carcinoma status after hystero-salpingo-oophorectomy followed by adjuvant radiation.

Pseudovicarious Renal Contrast Excretion in a Postoperative Tracheo-Esophageal Fistula patient: Contrast in Pleural Space can be the cause. A Case Report

BACKGROUND: Iodinated contrast is normally not introduced into the intrapleural space except for detecting diaphragmatic injury in stable patients on Computerized Tomography scans, and these studies are limited. Thus, the literature on pleural absorption of contrast is non-existent. We report a novel case with images of renal excretion of contrast after pleural absorption. CASE PRESENTATION: In this case there was inadvertent leakage of contrast into pleural space with subsequent systemic absorption of contrast with renal excretion in a child with a remote history of tracheo-esophageal fistula repair and recent esophageal resection and anastomosis for esophageal stenosis. The child developed a right pleural effusion after the second surgery, proven to be due to anastomotic site leakage. An esophagogram was performed using iodinated contrast, showing the leak and communication with the pleural space. Four hours later, a confusing abdominal radiograph showed excretion of contrast in the kidneys confusing the radiologist reader. CONCLUSION: This imaging finding was due to the systemic absorption of iodinated contrast that had leaked from the anastomotic site into the pleural cavity.