Flank Incision Research Articles

Comparison of the postoperative effects of the erector spinae plane block and local infiltration analgesia in patients operated with lumbotomy surgery incision: Randomized clinical study.

Our aim was to observe the effects of local infiltration analgesia (LIA) or erector spinae plane block (ESPB) methods, which we applied preemptively in patients who were scheduled for surgery with a lumbotomy surgical incision and on intraoperative remifentanil consumption, and to compare the postoperative numerical rating scale (NRS), morphine demand, consumption, and pain degrees. Sixty American Society of Anesthesiologists I to III patients aged 18 to 75 years who were due to be operated on with a lumbotomy surgical incision were included in the study. The present study was conducted via prospective, randomized controlled, double-blind trials. After the induction of standard anesthesia, LIA was applied to 30 patients and ESPB was applied to 30 patients preemptively. The dose of remifentanil consumed in the intraoperative period was measured, and the hemodynamic parameters were measured every 5 minutes. Morphine bolus treatment with the postoperative patient-controlled analgesia and rescue analgesia with paracetamol were planned for the patients. Postoperative morphine and additional analgesia consumption, NRS, hemodynamic parameters, and complications were recorded for 48 hours. There was no difference between the groups in terms of demographic and hemodynamic data. The mean consumption of remifentanil was measured as 455 ± 165.23 µg in the intraoperative ESPB group and 296.67 ± 110.59 µg in the LIA group, and a statistical difference was observed (P = .001). In the postoperative follow-ups, the ESPB group drug consumption and NRS score averages were significantly lower at all times (P = .01; patient-controlled analgesia-morphine, 41.93 ± 14.47 mg vs 57.23 ± 15.5 mg and additional analgesic-paracetamol: 2.1 ± 1.06 vs 4.27 ± 1.14 g). The mean duration of additional analgesic intake of the groups was 10.6 ± 8.1 in the LIA group, while it was 19.33 ± 8.87 in the ESPB group, a significant difference. The patient satisfaction questionnaire was also significantly in favor of ESPB (P = .05). In conclusion, it has been shown that the intraoperative LIA method is more effective in terms of remifentanil consumption and in controlling pain in operations performed with a flank incision, but the ESPB method provides longer and more effective pain control in postoperative follow-ups.

Two-Port Minimally Invasive Nephro-Laparoscopic Retroperitoneal Debridement for Pancreatic Necrosis.

Walled-off necrosis (WON) occurs in approximately 20% of patients with necrotizing pancreatitis. Infection occurs in approximately 30% of necrosis patients, and despite advances in management, infected necrosis still confers a high mortality between 30 and 40%. While sterile necrosis requires drainage only for cases of symptom relief or "persistent unwellness," prompt intervention is critical for infected necrosis. Several management strategies exist depending on the location and anatomy of the necrosum. In particular, retroperitoneal collections away from the stomach are typically managed with a step-up approach that begins with percutaneous drain placement. While a minority of patients skirt further intervention, the majority require formal debridement at some point via the existing drain tract. These debridement techniques include video-assisted retroperitoneal debridement (VARD) through a flank incision or minimally invasive retroperitoneal pancreatic (MIRP) necrosectomy under continuous irrigation with a nephroscope. While effective, both debridement strategies have drawbacks: for VARD, the flank incision is prone to infections and hernia while MIRP debridements are tedious and often require repeat operative trips. To overcome these pitfalls, we describe a novel two-trocar minimally invasive hybrid nephro-laparoscopic retroperitoneal debridement technique for an efficient retroperitoneal pancreatic necrosectomy.

Assessment of temporal changes in glomerular filtration rate following clamp ischemia in male and female rats using transcutaneous FITC-sinistrin clearance

Warm arterial clamping with reperfusion in rats is a commonly utilized model of ischemic kidney injury (IRI). Traditionally, changes in plasma creatinine or creatinine clearance have been utilized to assess kidney function in this model. A limitation of these approaches, however, is that changes in plasma creatinine are relatively slow to occur, resulting in low temporal fidelity. This limits our ability to relate changes in kidney function to histo-pathological changes observed during reperfusion of the kidneys. Transcutaneous assessment of FITC-sinistrin clearance enables accurate, repeated measurement of glomerular filtration rate in conscious animals over short segments of time (hours) without drawing blood. The goal of the current study was to characterize temporal changes in renal function in male and female rats after reperfusion from bi-lateral warm arterial clamp ischemia using transcutaneous FITC-sinistrin clearance. Our study was performed in age matched male (n=8) and female (n=5) Sprague Dawley rats (12-20wks of age). FITC sinistrin clearance was measured by affxing a miniaturized transcutaneous measurement device between the shoulder blades (MediBeacon) of rats. 50mg/kg of FITC-sinistrin was then injected i.v via the tail vein and the device allowed to record for ~3 hours. Measurements were taken either at pre-surgery (baseline), 1-3 hours, 24 hours or 7 days following reperfusion of the kidneys from warm bilateral arterial clamp ischemia. For the ischemic surgery, animals were anesthetized with isoflurane (2-5%, 95% O2) and the right and left kidneys were accessed by flank incisions. After being exposed, the renal arteries were separated from the renal veins via dissection. Both renal arteries were then clamped with microserrefines for 45 minutes. After the ischemic period, the clamps were removed, allowing blood flow to be restored to the kidneys. Body temperature was measured via a rectal probe and maintained at 37°C throughout the procedure by a servo-controlled heating table and UV heating lamp. The wounds were then closed, and the animals allowed to recover. Buprenorphine was administered as an analgesic. For each measurement, the ½ life of FITC sinistrin was determined using a 1-compartment model (MB Lab software) and glomerular filtration rate (GFR) per 100g of body weight rate calculated. Baseline GFR was 0.94±0.03ml/min/100g in males and 1.09±0.02/min/100g in females (PTTEST=0.04). Following 45 minutes of warm bilateral arterial ischemia and reperfusion, GFR fell to 0.24±0.08ml/min/100g in male and 0.36±0.15ml/min/100g in females within 1-3 hours of reperfusion. At 24 hours of reperfusion, GFR averaged 0.06±0.03ml/min/100g in males and 0.28±0.16ml/min/100g in females. GFR recovered in males and females by 7 days of reperfusion averaging 0.86±0.10ml/min/100g in males and 0.83±0.00ml/min/100g in females. There was no significant difference between FITC-sinistrin clearance between males and females at any time point after IRI. Our data indicate that most of the reduction in GFR is present immediately after releasing the clamp. This is consistent with continued vascular disturbances mediating the initial decline in glomerular filtration rate in this model (i.e. vasospasm). The absence of sex differences in GFR decline using this method suggests that sex-differences detected using plasma creatinine may be, at least in part, secondary to the more rapid production of creatinine in males than in females or greater baseline filtration/body weight ratio in females compared to males rather than differences in renal function decline to ischemia. American Heart Association Transformational Project Award 970585 to Paul O'Connor. This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Standing hand-assisted laparoscopic ovariohysterectomy to treat chronic pyometra in a mare.

To describe a standing hand-assisted laparoscopic ovariohysterectomy in a mare. A 15-year-old maiden Oldenburg mare. The mare was presented for evaluation of bucking under saddle and uncharacteristic aggressive behavior. Evaluation of a 24-hour video of the mare in a stall showed behavior consistent with caudal visceral abdominal discomfort. Reproductive evaluation revealed a pyometra secondary to complete transluminal cervical adhesions. The mare was initially managed medically with disruption of the adhesions and uterine lavage, but the adhesions reformed within 6 weeks and could not be manually disrupted. To eliminate the recurrence of pyometra, the mare underwent standing hand-assisted laparoscopic ovariohysterectomy through bilateral flank incisions. The only complication was a seroma at 1 flank incision that resolved after drainage. Complete ovariohysterectomy in the mare is a challenging procedure and has previously been performed under general anesthesia. This is the first report of the procedure being performed completely in the standing mare without inversion of the uterus through the cervix.

Application of R.E.N.A.L Nephrometry Score in Planning Type of Surgery and Predicting Complications in RCC Patients in Gezira Hospital

Background: Adult renal cell carcinomas account for 80–85% of all renal tumors, making them the most common primary renal tumors. As a method for categorizing renal masses by anatomical characteristics, R.E.N.A.L score is suggested to study the effect on surgical approach in addition to perioperative outcomes and complications.
 Methods: A cross-sectional prospective hospital-based study enrolled 48 RCC patients in GHRDS in the period between September 2020 and September 2021. Data regarding demographics, histological subtypes, surgical approach, intraoperative and postoperative complications were collected. Based on R.E.N.A.L score, the complexity of renal tumors is grouped into low, moderate, and high.
 Results: The study sample size was 48. Twenty-five participants (52.1%) were men with a mean age of 51 years. Most cases had clear cell RCC 22 (45.8%) and papillary RCC 19 (39.6%). Thirty-nine (81.5%) patients underwent radical nephrectomy (flank incision [extraperitoneal] in 32 [82.1%] and midline incision [transperitoneal] in 7 [17.3%]), and 9 (18.5%) patients underwent partial nephrectomy. One-third of the patients 15 (31.2%) had intraoperative complications and 7 (14.6%) had postoperative complications. All intraoperative and most postoperative complications were associated with radical nephrectomy (P = 0.001). According to complexity, 21 (43.8%) patients had moderate complexity, 15 (31.2%) high complexity, and 12 (25%) low complexity.
 Conclusion: Most RCC patients had moderate complexity and were subjected to radical nephrectomy. High complexities were linked to the decision of radical nephrectomy, and intraoperative and postoperative complications. More prospective research with large sample size and multi-centered studies is essential to ensure the generalizability of study findings.

Renal sympathetic denervation ameliorates the activated inflammatory response through JAK-STAT pathway in a chronic obstructive sleep apnea animal model

ObjectivesObstructive sleep apnea (OSA) is known to increase the risk of cardiovascular disease and inflammation plays a significant role in this process. Renal denervation (RDN) is a novel approach aimed at reducing sympathetic nervous system activity. The role of RDN in the inflammatory response to chronic OSA (COSA) is currently unclear. The main objective was to study inflammatory mechanisms in the rabbit heart with COSA and the effects of RDN. MethodsEighteen rabbits were randomized into three groups: sham control, COSA, and COSA-RDN. COSA and COSA-RDN groups received liquid silicone injections, while the sham control group received normal saline. We performed combined surgical and chemical RDN through bilateral retroperitoneal flank incisions in the COSA-RDN group after silicone injections. The inflammatory mechanisms were assessed through immunoblotting, real-time PCR, and ELISA after the experiment. ResultsH&E staining showed immune cell infiltration in COSA, which decreased after RDN treatment. The level of α7nAChR was significantly reduced in COSA compared to the sham control but was restored to a similar level in the COSA-RDN group. Furthermore, the expressions of p-JAK2 and p-STAT3 were significantly reduced in COSA but showed an up-regulation following RDN treatment. Similarly, levels of the inflammatory markers IL-6, IL-1β and TNF-α were markedly increased in COSA but decreased after RDN therapy. We observed NF-κB activation in the COSA rabbit model, which decreased after RDN treatment, as evidenced by decreased NF-κB expression. ConclusionsOur study suggests that RDN treatment may prevent COSA-associated heart inflammation via the JAK2-STAT3 signaling pathway.

Comment on “Luminescence chronology of the Sankosh river terraces in the Assam–Buthan foothills of the Himalayas: Implications to climate and tectonics” by Quaternary Geochronology 72, 101364

In a study of which the main objective was to assess the impact of climate change and tectonics on the formation of river terraces along the Sankosh River, the eastern foreland of the Himalayas, the authors obtained geochronological data using luminescence technique. Four strath river terraces (T4–T1) were distinguished within the valley bottom, and alluvial sediments from three terraces (T4, T2 and T1) were dated to the age range from 143 to 14 ka. The alluvial mantels of river terraces were then linked to the scheme of glacial-interglacial cycle. The paper, however, suffers from many inconsistent and missing information, and the assessment on the landscape evolution of the river valley is incomprehensive. For instance, the authors relied on feldspars and therefore the IRSL method was used, but “OSL ages” are discussed at the end. They state that (i) tectonics creates space for sediment accommodation and (ii) the luminescence ages flank deposition and incision phases. Despite the fact that the statements are questionable, the ways these happen are not elucidated by the authors. Due to the lack of geochronological data for T3 terrace, its formation is very enigmatic. It is even more mysterious in the light of the data for the other terraces, but the authors made no attempt to explain this riddle. However, that certain inability of reconstructing the history of T3 would shed a shadow on the robustness of the ages obtained.

Systemic Analgesia versus Continuous Erector Spinae Plane Block (ESPB) Infusion During Paediatric Nephrectomy: A Randomized, Controlled Trial.

A subcostal flank incision is required for open radical nephrectomy, which is a surgical procedure used to remove tumors of the kidney that are malignant. The erector spinae plane block (ESPB) and continuous catheter use in children are receiving more and more support by paediatric regional anaesthesiologists. Our objective was to compare systemic analgesic to continuous ESPB for pain relief in paediatric patients undergoing open radical nephrectomy. Sixty children with cancer ASA I or II and undergoing open radical nephrectomy between the ages of two and seven participated in this prospective, randomized, controlled, and open label study. The cases were divided into two equal groups (E and T groups); Group E received ipsilateral continuous ultrasound-guided ESPB at T9 (thoracic vertebrae), with a bolus of 0.4 mL/kg bupivacaine 0.25%. Immediately postoperatively, Group E (ESPB group) received continuous ESPB with a PCA (patient controlled analgesia) pump at a rate of 0.2 mL/kg/hour bupivacaine 0.125%. Group T (Tramadol group), Tramadol hydrochloride was administered intravenously at a dose of 2 mg/kg/8hour, which could be increased to 2 mg/kg/6hours. Then, we followed up on patients' total analgesic consumption for 48 hours following surgery, as well as the time it took for them to request rescue analgesic, their FLACC and sedation scores, and their hemodynamics and side effects immediately following surgery as well as at 2, 4, 6, 8, 12, 18, 24, 36, and 48 hours. A highly significant difference in total tramadol consumed in group T 11.97 ± 1.13 mg/kg while group E was 2.07± 1.54 mg/kg (p < 0.001). 100% patients in group T requested analgesia compared to 46.7% patients in group E (p < 0.001). From 2 to 48 hour, FLACC significantly decreased in E compared to T group (p≤ 0.006) at all-time points. Ultrasound-guided continuous ESPB significantly provided better postoperative pain relief, reduced postoperative tramadol consumption and reduced pain scores compared with the use of tramadol alone, in paediatric cancer patients undergoing nephrectomy.

Erratum: Noninvasive and Invasive Renal Hypoxia Monitoring in a Porcine Model of Hemorrhagic Shock.

Erratum: Noninvasive and Invasive Renal Hypoxia Monitoring in a Porcine Model of Hemorrhagic Shock.

TAVŞAN OMURGASINDA ANTERİOR BODY KAFES BORON UYGULAMASININ KEMİK FÜZYONUNA VE FÜZYON KALİTESİNDE ETKİSİ

OBJECTIVE: Our aim in this study was to demonstrate the effectiveness of hydroxyapatite (HA) and Boron compounds in operations using an Anterior Lumbar Interbody Fusion (ALIF). MATERIAL AND METHODS: In the study, 18 male rabbits of New Zealand breed weighing 2.5-3 kg were used. The animals who were hospitalized on the left side underwent flank incision after surgical cleaning. Lumbar 5-6 distance was reached from the lumbar retroperitoneal region. Following anterior discectomy; ALIF was performed using PEEK (polyethylene ether ketone) cage (Group I) in the control group, PEEK cage and 50 mg/kg boron (borax pentahydrate) (Group II) in the boron group, PEEK cage and 50 mg/kg powder ProOsteon (Group III) in the HA group. The ALIF operation has been applied to all groups. Six weeks later, the animals underwent a computed tomography (CT) scan. Then the lower and upper vertebrae of the sacrificed animals at the distance at which discectomy was performed and the cage was placed were removed, separated for pathology. After being microscopically detected with buffered 10% formaldehyde overnight, the sections prepared from the sample tissues that were routinely followed were stained with hematoxin-eosin and examined histopathologically with light microscopy. RESULTS: While the osteoclast score was 1 in 83.3% of the boron group, it was 2 in 16.6%. In the same group, the osteoblast score was found to be 1 in 50% and 2 in 50%. The osteoclast score of the HA group was 1 in 50%, 2 in 50%, while the osteoblast score was found in 50%, 1 in 2, 2 in 16.6%, and 3 in 33.4%. Higher osteoblast and osteoclast scores were observed in HA group compared to Boron and control groups. It was observed that the boron group had higher osteoblast and osteoclast scores than the control group and lower than the HA group. CONCLUSIONS: Boron and Hydroxyapatite have been shown to form stones of the same size. Although morphologically not as much as boron, hydroxyapatite, histopathological examination showed that it formed a better amount of fusion compared to the control group. The osteoblastic activity was most common in the hydroxyapatite group.

MP70-10 PEDIATRIC SINGLE PORT ROBOTIC PYELOPLASTY COMPARED TO OPEN AND MULTIPORT COHORTS

You have accessJournal of UrologyCME1 Apr 2023MP70-10 PEDIATRIC SINGLE PORT ROBOTIC PYELOPLASTY COMPARED TO OPEN AND MULTIPORT COHORTS Jordan Smith, Alexandra Hernandez, Brian Wiseman, Christopher Bayne, and Romano Demarco Jordan SmithJordan Smith More articles by this author , Alexandra HernandezAlexandra Hernandez More articles by this author , Brian WisemanBrian Wiseman More articles by this author , Christopher BayneChristopher Bayne More articles by this author , and Romano DemarcoRomano Demarco More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003338.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The Da Vinci SP® (single port) surgical system has been used widely in adult urology with comparable peri-operative outcomes compared to multi-port (MP) robotic surgery. However, reports in pediatric urology are limited. We sought to compare operative outcomes in a single pediatric urologist’s open, MP, and SP pyeloplasty experience. METHODS: A retrospective review was performed of all pyeloplasties by a single pediatric urologist in patients <18 y at a tertiary academic center from January 2021 to July 2022. Cases were categorized by approach: open, multiport (MP), or single port (SP). The primary outcomes were entire operative time (OT; defined as cystoscopy to incision close), length of hospital stay (LOS), inpatient opioid use, and post-operative complications (≤30 days). Surgical success (defined as improved nuclear renography drainage or improved renal collecting system dilatation on ultrasonography with resolution of pain) was evaluated as a secondary outcome. RESULTS: During the study period, 6 open, 5 MP, and 11 SP cases were performed. Open cases were performed via flank incision. MP cases were performed via mix of midline port placement and hidden incision endoscopic surgery (HIdES) approach with 3 or 4 trocars. Technique for SP cases evolved during the period. The SP cohort included older children (median 16 y) and larger children (60.1 kg) than open (2.3 mo; 5.7 kg) and MP (4 mo; 6.6 kg) cases. There was no difference in LOS, opioid use, or complications between groups. SP cases were notably longer (median 390 min [376–480 min]) than both open (240 min [240–360 min]) and MP (300 min [200–258 min]) cases. OT for SP cases improved over the last 5 cases (median 388 min) versus the initial 6 (median 405 min). All cases have continued to show a successful repair at a minimum 3 months. Due to sample size, inferential statistics were not able to be performed. CONCLUSIONS: In this single-surgeon experience during early adoption of the SP robot in pediatric urology, SP pyeloplasty cases took substantially longer. This may represent the early learning curve of developing a novel technique. There was no noted difference in other outcomes or complications. Multicenter collaboration of open, MP, and SP data would help account for individual surgeon differences and generate robust samples sizes for inferential statistical analysis. Knowledge of patient-centered opinions regarding the SP incision is warranted to justify SP pyeloplasty over current MP techniques. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1007 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jordan Smith More articles by this author Alexandra Hernandez More articles by this author Brian Wiseman More articles by this author Christopher Bayne More articles by this author Romano Demarco More articles by this author Expand All Advertisement PDF downloadLoading ...

Negative pressure wound therapy for the management of surgical site infections with zoonotic, drug‐resistant pathogens on the upper body of the horse

SummaryThis case series reviews the use of negative pressure wound therapy (NPWT) for surgical site infections (SSI) on the upper body of six horses at an academic referral institution between 2016 and 2020. The SSIs consisted of three ventral midline celiotomy incisions post‐abdominal exploratory, one paralumbar flank incision for removal of an ovarian abscess, an incision for resection of a septic jugular vein, and a large defect resulting from the resection of chronically abscessed skin and subcutaneous tissue on the shoulder and pectoral region. All SSIs contained zoonotic, polymicrobial, multi‐drug resistant pathogens (methicillin‐resistant Staphylococcus aureus or extended spectrum beta‐lactamase Klebsiella or Enterobacteriaceae) that were managed without systemic, regional, or topical antimicrobials. All horses were discharged from the hospital, and long‐term follow‐up revealed satisfactory functional and cosmetic outcomes according to owner questionnaires. Duration of NPWT ranged from 4 to 15 days in five horses, but one horse required NPWT for 70 days due to the large nature of the defect. The NPWT system was easy to use, well‐tolerated by patients, and produced acceptable functional and cosmetic outcomes for the clients. By containing wound exudate and reducing daily wound care, it improved hospital biosecurity and reduced exposure to hospital personnel.

The roles of AMPK/mTOR autophagy pathway in the acute kidney injury-induced acute lung injury.

Acute kidney injury (AKI) is one of the most challenging clinical problems in kidney disease due to serious complications and high mortality rate, which can lead to acute lung injury (ALI) through inflammatory reactions and oxidative stress. Adenosine monophosphate-activated protein kinase (AMPK)/mammalian target of rapamycin (mTOR) pathway has been reported to be involved in the development of renal ischemia-reperfusion through autophagy and it remains unclear whether AMPK/mTOR pathway has an effect on the AKI-induced ALI. In this study, we aimed to investigate the effects of autophagy-related AMPK/mTOR signaling pathway on inflammatory factors and oxidative stress in an AKI-induced ALI model. The 48 male Sprague-Dawley rats were divided into four groups randomly: (i) sham, (ii) ischemia/reperfusion injury (IRI), (iii) IRI + rapamycin (RA), and (iv) IRI + 3-methyladenine (3-MA). Unilateral flank incisions were made and right kidneys were excised. The left kidney was subjected to 60 min of ischemia followed by 12, 24, 48, and 72 h of reperfusion. The levels of Scr, blood urea nitrogen (BUN), Wet/Dry ratio, indexes of inflammation, and oxidative stress were assayed. Histological examinations were performed. The protein expression of AMPK, mTOR, LC3-II/LC3-I ratio, and Beclin-1, ULK1 was evaluated by western blotting and immunohistochemistry. Compared to the rats from the sham group, IRI rats showed significantly pulmonary damage after AKI with increased Scr, BUN, Wet/Dry ratio, indexes of inflammation, and oxidative stress. The expression of AMPK, LC3-II/LC3-I ratio, Beclin-1, and ULK1 and were increased, while p62 and mTOR were decreased. In addition, RA treatment significantly attenuated lung injury by promoting autophagy through the activation of the AMPK/mTOR pathway, and 3-MA treatment exhibited adverse effects inversely. Therefore, the activation of the AMPK/mTOR pathway after renal IRI induction could significantly attenuate kidney injury and following AKI-induced ALI by inducing autophagy, which alienates inflammation, oxidative stress, and apoptosis.

Upper Ureteral Reconstruction with a Tapered Descending Colon after Failed Pyeloplasties in a 13-Year-Old Boy

An 11-year-old boy was referred for further management of a 6-cm-long grossly stenosed ureter following two failed left ureteropelvic junction (UPJ) obstruction repairs elsewhere. A tapered segment of the descending colon (TDC) was used successfully for ureteral reconstruction. The UPJ was exposed through a left flank incision. The stenosed segment was excised; both ends appeared severely inflamed and thickened. Tissue interposition was required and ureteroplasty with a TDC was performed by incising the peritoneum adjacent to the excised ureter to mobilize the descending colon to the retroperitoneal space. To prepare the TDC, an 8-cm segment of the colon with intact blood vessels was isolated, tapered, and sutured into a funnel shape using a 14-Fr catheter as a temporary stent. After colocolostomy, the colon was returned to the abdominal cavity, the peritoneum was closed carefully to prevent vascular compromise, and the TDC was anastomosed to the ureter and renal calyx with interrupted absorbable sutures. A double J stent (DJS) and percutaneous nephrostomy tube were placed. Postoperative recovery was uneventful. The DJS was removed on day 50 after confirming smooth urine flow through both the ureter-TDC and calyx-TDC anastomoses. Diuretic renography performed 68 days postoperatively was unobstructed. The patient is currently well after 12 months follow-up. This would appear to be the first report of a TDC being used to create a funnel-shaped segment to reconstruct a long, grossly stenosed ureter. The TDC is simpler than the re-tubularizing colon but requires monitoring for postoperative mucus-related complications and malignant transformation.

Retrocaval Ureter: A Case Series of Three Cases Managed with Uretrouretrostomy

Retrocaval ureter is a very rare congenital malformation. We report a 10 years’ experience in the diagnosis and treatment of retrocaval ureter, a case series of 3 cases in two different countries of the Middle East. This is a retrospective study that included 3 cases of retrocaval ureters in Egypt and Saudi Arabia. Standard open ureteroureteric anastomosis was performed through a flank incision for each case. Patients’ symptoms were re-evaluated after two to four months. Complete recovery from symptoms occurred, and hydroureter and hydronephrosis regressed in all cases. Early diagnosis and treatment are the keys to prevent hydronephrosis and deterioration of renal functions.

A Case Report of a Rare Huge Ureteral Fibroepithelial Polyp: Challenges and Clinical Management

Ureteral fibroepithelial polyps (UFPs) are rare abnormality that may cause ureteral obstruction. Herein, we report a 35- year- old woman with flank pain, dysuria, frequency and transient total gross hematuria. A mass in the right ureter was reported on imaging and in endoscopic evaluation, small polypoid mass protruding from the right ureteral orifice in the bladder, and a huge ureteral mass originating from proximal ureter was observed. A right subcostal flank incision was done, a huge polypoid mass with a segment of ureteral was excised, and end-to-end anastomosis of the ureter was done. Histopathological examination showed a UFP without malignancy.

Transabdominal self-expandable metal stent placement as a rescue therapy for drainage of walled-off necrosis.

Video 1CT scan of a walled-off necrosis in the right pararenal space extended to the iliac area.

Quadratus Lumborum Block for Upper Tract Urological Surgery in Pediatric Patients

Abstract Objective Among regional blocks, the quadratus lumborum fascial plane block (QLB) has been well described, but the description of its use and efficacy for pediatric patients undergoing upper abdominal urologic surgery is limited. We present a case series examining the use of the QLB for postoperative pain management in children undergoing upper tract surgery. Methods From August 2019 to August 2020, through a chart review, we identified 5 patients who had undergone a QLB for upper urinary tract surgery via a flank incision. Posterior QLB was performed after induction of general anesthesia. A single injection of 0.5mL/kg of either 0.25% or 0.5% ropivacaine with 1mcg/kg of clonidine was administered. Patients received fentanyl IV (1 mcg/kg), and acetaminophen IV (15mg/kg) as adjuvants during the operation. Postoperative pain was managed with oral acetaminophen and ibuprofen. Results The average postoperative pain score during the entire admission was 1, with the lowest being 0 and highest, 3. No administration of rescue narcotics was required in the postanesthesia care unit or on the floor. The average length of stay ranged from 0 to 1 day. No complications associated with the regional QLB were identified. Conclusions Our series suggests the QLB may be considered as a regional anesthetic option to minimize narcotic requirements for children undergoing upper abdominal urological surgery via flank incision. Additional studies are needed to compare the efficacy of the QLB versus alternate regional anesthetic blocks for upper tract urological surgery via flank incision in children and to determine effective dosing and use of adjuvants.

Various Techniques and Outcomes of Arterial Anastomosis in Live Renal Transplant: An Institutional Experience.

IntroductionRenal transplantation with multiple arteries is associated with a major index of surgical complications. Relevant papers and meta-analyses have shown relatively more vascular and urological complications in transplant of donor kidneys with multiple arteries. In live donor grafts due to the unavailability of a carrel patch, several techniques for bench and in situ reconstruction have been described in order to reduce the incidence of these vascular complications. In this study, the short and long-term results of living donor kidney transplants with multiple renal arteries (MRAs) versus single renal artery (SRA) were compared retrospectively.MethodsThis is a retrospective study done on patients who received a living donor kidney between January 2012 and January 2018 at the Institute of Urology, Madras Medical College, Chennai. We have excluded deceased donor kidney transplants and ABO-incompatible cases done in the same time period. The study was approved by the Institutional Ethics Committee (Approval No: IES-MMC-008) and performed in accordance with the guidelines of the Declaration of Helsinki. Open live donor nephrectomy was performed through an extra-peritoneal flank incision in all cases. In the SRA group, the renal artery was anastomosed end to end to the Internal iliac artery, while the renal vein was anastomosed to the external iliac vein in the end to side fashion. Urinary tract reconstruction was accomplished by the Gregoir technique in both groups. We looked at recipient complications, baseline and postoperative serum creatinine, total ischemia time, mean operating time, and short- and long-term graft and patient survival as postoperative outcomes.ResultsIn a six-year period (2012-2018) at our institute, 256 living donor transplantations were performed; 36 (14%) kidneys had two or more renal arteries which were anastomosed using various techniques. Cold ischemia time was relatively longer in the MRA group (45 mins vs 28 mins in the SRA group) (p-value <0.05). while warm ischemia time was comparable in both groups (2.5 vs 2.9 mins) serum creatinine was comparable in both groups at the 30th postoperative day (1.4 in SRA group vs 1.2 in MRA group) (p-value >0.05). Incidence of surgical complications in SRA and MRA groups was: vascular - 3.6% and 2.7%; urological - 3.2% and 2.7%; the incidence of lymphocele was 4.5% and 5.5% and delayed graft function 4.5% and 5.5% respectively.ConclusionMultiple renal arteries are no longer a relative contraindication with advanced surgical techniques. in renal grafts with multiple arteries, all techniques of vessel anastomosis are comparable in terms of post-surgical complications.

Donor Nephrectomy Through Mini-Flank Incision: A Single-Centre Experience Among Nigerian Patients.

Background and objectiveThe field of kidney transplantation in sub-Saharan Africa is still in the rudimentary stages. The majority of patients with chronic kidney disease have no access to renal replacement therapy, leading to very high mortality rates. Donor nephrectomy (DN) is an important aspect of kidney transplantation. Over the last two decades, open DN (ODN) has given way to minimally invasive techniques like laparoscopic DN (LDN) and robotic-assisted DN. In this study, we aimed to describe our experience with mini-flank incision donor nephrectomy (MIDN) at a Nigerian renal transplant center.Materials and methodsWe conducted a retrospective review of all DN cases performed at a single Nigerian kidney transplantation center over a three-year period. Information obtained from these patients was classified into pre-, intra-, and postoperative. The data included sociodemographic characteristics, preoperative preparation, details of intraoperative techniques, and postoperative findings. These were entered into a proforma and analyzed using SPSS Statistics version 21 (IBM Corp., Armonk, NY).ResultsA total of 230 patients underwent ODN during the study period. The majority of the donors were males (92.8%) with a mean age of 30.83 ±8.43 years. The body mass index (BMI) of most (76.1%) of the donors was within the normal range (18.5-24.9 kg/m2). The duration of DNs ranged from 72 to 154 minutes with a mean duration of 130 ±28 minutes. The length of flank incisions ranged from 7.8 to 12 cm with a mean incision length of 10.8 ±1.0 cm. Donors who had MIDN attained satisfactory postoperative pain control with about 90% of them having a BMI of <30 kg/m2. Oral intake and ambulation were commenced on the first postoperative day, and the cosmetic outcomes were deemed acceptable in over 90% of kidney donors.ConclusionMini-incision for DN through the flank approach is a suitable alternative to LDN in the developing world where facilities and skills for LDN or robotic nephrectomies are largely unavailable. It offers a short recovery time, early ambulation, and excellent allograft outcomes.