Need For Secondary Procedures Research Articles

Outcomes and Risk Factors in Urogenital Mobilization

PURPOSE Urogenital mobilization is a recent advance in reconstruction for urogenital sinus anomalies. Use of the mobilized sinus has improved cosmetics and function. Concern remains regarding outcomes, particularly continence with total or urogenital mobilization techniques. Other concerns include delayed stress incontinence, sensation loss and vaginal foreshortening. MATERIAL AND METHODS We reviewed our last 50 vaginoplasties; 44 of whom had either a total or partial urogenital mobilization. This group of 44 was analyzed for early continence, cosmetics and vaginal stenosis, as well as underlyling neurologic status. RESULTS Eighteen underwent TUM (7 neurologically normal, 11 have significant neurologic or anatomic abnormalities): 26 underwent PUM (25 neurologically normal, only 1 had a neurologic abnormality). Neurologically normal children > 3 years old are continent regardless of TUM versus PUM. Of those neurologically impaired, 2 are dry voiding, 7 are dry with CIC and 2 are wet. Only 1 of 44 has vaginal stenosis. Cosmetics are excellent. CONCLUSIONS PUM and TUM appear safe from an early continence standpoint. Early continence appears to be related more to underlying neurological status than the procedure. Cosmetics are excellent. Vaginal stenosis has been rare. Late stress continence, sensation, or need for secondary procedures following TUM or PUM remain unknown.

Matched-pair Analysis of Endovascular versus Open Surgical Repair of Abdominal Aortic Aneurysms in Young Patients at Low Risk

To compare clinical outcomes of endovascular and open aortic repair of abdominal aortic aneurysms (AAAs) in young patients at low risk. It was hypothesized that endovascular aneurysm repair (EVAR) compares favorably with open aneurysm repair (OAR) in these patients. Twenty-five patients aged 65 years or younger with a low perioperative surgical risk profile underwent EVAR at a single institution between April 1994 and May 2007 (23 men; mean age, 62 years+/-2.8). A sex- and risk-matched control group of 25 consecutive patients aged 65 years or younger who underwent OAR was used as a control group (23 men; mean age, 59 years+/-3.9). Patient outcomes and complications were classified according to Society of Vascular Surgery/International Society for Cardiovascular Surgery reporting standards. Mean follow-up times were 7.1 years+/-3.2 after EVAR and 5.9 years+/-1.8 after OAR (P=.1020). Total complication rates were 20% after EVAR and 52% after OAR (P=.0378), and all complications were mild or moderate. Mean intensive care unit times were 0.2 days+/-0.4 after EVAR and 1.1 days+/-0.4 after OAR (P<.0001) and mean lengths of hospital stay were 2.3 days+/-1.0 after EVAR and 5.0 days+/-2.1 after OAR (P<.0001). Cumulative rates of long-term patient survival did not differ between EVAR and OAR (P=.144). No AAA-related deaths or aortoiliac ruptures occurred during follow-up for EVAR and OAR. In addition, no surgical conversions were necessary in EVAR recipients. Cumulative rates of freedom from secondary procedures were not significantly different between the EVAR and OAR groups (P=.418). Within a multivariable Cox proportional-hazards analysis adjusted for patient age, maximum AAA diameter, and cardiac risk score, all-cause mortality rates (odds ratio [OR], 0.125; 95% CI, 0.010-1.493; P=.100) and need for secondary procedures (OR, 5.014; 95% CI, 0.325-77.410; P=.537) were not different between EVAR and OAR. Results from this observational study indicate that EVAR offers a favorable alternative to OAR in young patients at low risk.

A Novel Technique Of Interlocking Nailing In Compound Fractures Of The Tibia Without Image Intensifier By Nail Overlapping Technique

Locked intramedullary nailing is currently considered the treatment of choice for most type I, II and IIIa open and closed tibial shaft fractures. Intramedullary nailing preserves the soft tissue sleeve around the fracture site and allows early motion of adjacent joints. Unreamed medullary nails are used mostly in Gustillo's types II and III. Tibial intramedullary nailing is now regarded as an emergency procedure for stabilisation of compound fractures to allow early return of function and ambulation. It has replaced external fixator which serves as a temporary means to stabilise compound fractures in the present scenario. Interlocking nailing allows early healing of the wound with permanent stabilisation of the fracture thereby preventing the need for secondary procedure. We hereby describe a technique of intramedullary locked nailing for compound fractures of tibia without X-ray image intensifier by nail overlapping technique. We have applied this technique in 30 cases of compound type II and III fractures of tibia and could be very useful procedure in underdeveloped countries and in rural hospitals where facilities of image intensifier are not available in emergency departments where these patients first land up. TECHNIQUE The patient is prepared and draped in a standard manner as for routine interlocking procedure of tibia. Wound is debrided and irrigated. Preoperatively nail length is measured by tibial tubercle medial malleolar distance (TMD) and nail diameter is measured on a lateral radiograph at the level of isthmus. The tibia is approached via patellar tendon splitting approach and entry portal is properly identified (Fig.1). Figure 1 Figure 1: showing site of entry portal in tibial interlocking nail. Once medullary canal is opened, guide wire is put in and fracture is reduced by closed reduction and manipulation. Once fracture is reduced and there is no angulation at the fracture site as assessed clinically, guide wire is progressed distally into the distal fragment and its position in the distal A Novel Technique Of Interlocking Nailing In Compound Fractures Of The Tibia Without Image Intensifier By Nail Overlapping Technique 2 of 3 fragment is confirmed by gritty feel of the guide wire as it proceeds in the medullary canal of the distal fragment. Interlocking nail of proper size and diameter is assembled with proximal jig and inserted into the medullary canal via guide wire. We did not ream the medullary canal fearing further deterioration of endosteal blood supply as most of our cases were compound fractures. Once nail is properly inserted into the medullary canal so that its tip is barely visible at its entry point, we overlap another nail of the same size over the limb externally after putting k-wire through the proximalmost hole of the jig, through the proximal tip of the overlapped nail and then through the skin and proximal aspect of the intramedullary nail at the same site as that of the overlapped nail (Fig.2). Figure 2 Figure 2: showing overlapped nail with k-wire in the poximalmost hole of the jig and distally hand drill in the distal hole of overlapped nail. Distally overlapped nail is put in the alignment of centre of tip of the medial malleolus. We drill the hole in the distal fragment through the hole in the overlapped nail. Once drilling through the bone is complete and drill enters the intramedullary nail we confirm the drill position by guide wire put through the jig in the intramedullary nail. A definite confirmatory feel comes if drill lies within the intramedullary canal (Fig.3). Figure 3 Figure 3: showing how to confirm the intramedullary position of drill without image intensifier. Once drill position is confirmed to be within the intramedullary nail we drill the opposite cortex after removing the overlapped nail. Locking bolts of proper size are then put in the same drill hole and its position may again be confirmed by means of guide wire if you have any doubt. Similarly, another distal locking screw is put in. Proximal locking is done by means of jig attached. Once locking is complete surgical incision is closed in a standard manner and antiseptic dressing is done. This is followed by postoperative radiography. We have performed this technique in 30 cases of type II and IIIA compound fractures of tibia and the results of this technique are satisfactory with us. We have a very limited experience of the same technique in interlocking femur. CONCLUSION The purpose of presentation of this technique is to recommend it for immediate stabilisation of tibial fractures in institutions where X-ray image intensifier is not available in the emergency department. However this technique is blind one and has a definite learning curve.

Subtrochanteric Femoral Fractures

Subtrochanteric femoral fractures are complicated injuries that may be associated with other life-threatening conditions. Patients should be carefully evaluated and appropriately treated for hypovolemic shock. These fractures can be effectively stabilized with 95 degrees plates, femoral reconstruction nails, or trochanteric femoral nails with interlocking options. Nails produce very stable constructs and consistently can be placed with the patient in the lateral position on the radiolucent table or in the supine position on the fracture table. Standard antegrade femoral nails may be indicated in certain fracture patterns. The 135 degrees hip screw-plate is not suitable in the treatment of subtrochanteric femoral fractures; use of these implants may result in loss of fixation and fracture displacement. Chemical and mechanical prophylaxis for deep vein thrombosis should be initiated unless contraindicated by other medical comorbidities. An accurate reduction and excellent surgical technique with minimal soft-tissue dissection can routinely produce good results without the need for secondary procedures.

Long-term postplacement cost after endovascular aneurysm repair

Previous studies have demonstrated that the initial hospital cost associated with endovascular aneurysm repair (EVAR) is approximately $20,000. However, the cost of long-term surveillance and secondary procedures is poorly characterized. Between December 1998 and June 2006, 259 patients underwent EVAR for infrarenal aneurysms at a single institution. Follow-up costs were calculated using a relative value unit based hospital cost accounting system, which incorporates departmental direct and indirect costs. Institutional overhead costs were included using a conversion factor. Costs for professional services were determined by a cost-to-charge ratio, and outpatient visits were calculated with a time-based formula. Year 2006 costs were applied to prior years. To minimize costs associated with the early learning curve, the initial 50 EVAR patients between December 1995 and 1998 were excluded. Patients with <1 year follow-up were also excluded. Data are expressed as mean +/- standard error. The mean follow-up after EVAR for 136 patients was 34.7 +/- 1.8 months. The cumulative 5-year postplacement cost per patient was $11,351. The 27 patients (19.9%) who required secondary procedures had a 5-year cumulative cost of $31,696 compared with $3668 for 109 patients without secondary procedures (8.6-fold increase, P < .05). The 5-year cost for patients with endoleak was $26,739 compared with $5706 for those without endoleak (4.7-fold increase, P < .05). Overall, major cost components were 57.4% for secondary procedures and 32.5% for radiologic studies. During a 5-year period, the postplacement cost of EVAR increases the global cost by 44%. The subgroups of patients with endoleaks and those requiring secondary procedures generate a disproportionate share of postplacement costs. Efforts at minimizing cost should emphasize technical and device modifications aimed at reducing endoleaks and the need for secondary procedures.

Preliminary Results of Double Nerve Transfer to Restore Elbow Flexion in Upper Type Brachial Plexus Palsies

Restoration of elbow flexion is the main objective in the treatment of brachial plexus palsies affecting the upper roots. Transfer of the ulnar nerve to the nerve of the biceps has given satisfactory results, but the restored biceps is often weak in cases with avulsions of the C5-C6-C7 roots, in elderly patients, and after long preoperative delays. The authors decided to investigate a double nerve transfer: one or more fascicles of the ulnar nerve to the nerve to the biceps and a fascicle of the median nerve to the motor branch to the brachialis muscle. The authors operated on 15 patients using this technique. The authors have follow-up of more than 6 months in 10 of them. Six had C5-C6 injuries, three had C5-C6-C7 palsies, and one had sustained an infraclavicular injury. The average age was 27.2 years. The average delay before surgery was 6.6 months. The average follow-up was 12.1 months. Grade 4 elbow flexion was restored in each of the 10 patients. In 10 cases, the patients were able to lift 1 to 5 kg. There was no secondary deficit in grip strength or sensation. The results of this technique compare favorably with those of other methods. The percentage of success and the strength of elbow flexion restored were increased without any morbidity. This technique will probably reduce the need for secondary procedures to augment elbow flexion. The authors propose double nerve transfer as a standard procedure in C5-C6 and C5-C6-C7 injuries.

Prevention of retrograde stone migration during ureteroscopy

Retrograde stone migration during ureteroscopy leads to longer operating times, more-invasive endoscopy, and an increase in residual stones and the need for secondary procedures. In this Viewpoint, the author describes his experience with the various devices developed to prevent stone migration, focusing on the Stone Cone.

PROSPECTIVE, RANDOMIZED TRIAL COMPARING SHOCK WAVE LITHOTRIPSY AND URETEROSCOPY FOR LOWER POLE CALICEAL CALCULI 1 CM OR LESS

The optimal management of lower pole renal calculi is controversial. We compared shock wave lithotripsy (SWL) and ureteroscopy (URS) for the treatment of patients with small lower pole stones in a prospective, randomized, multicenter trial. A total of 78 patients with 1 cm or less isolated lower pole stones were randomized to SWL or URS. The primary outcome measure was stone-free rate on noncontrast computerized tomography at 3 months. Secondary outcome parameters were length of stay, complication rates, need for secondary procedures and patient derived quality of life measures. A total of 67 patients randomized to SWL (32) or URS (35) completed treatment. The 2 groups were comparable with respect to age, sex, body mass index, side treated and stone surface area. Operative time was significantly shorter for SWL than URS (66 vs 90 minutes). At 3 months of followup 26 and 32 patients who underwent SWL and URS had radiographic followup that demonstrated a stone-free rate of 35% and 50%, respectively (p not significant). Intraoperative complications occurred in 1 SWL case (unable to target stone) and in 7 URS cases (failed access in 5 and perforation in 2), while postoperative complications occurred in 7 SWL and 7 URS cases. Patient derived quality of life measures favored SWL. This study failed to demonstrate a statistically significant difference in stone-free rates between SWL and URS for the treatment of small lower pole renal calculi. However, SWL was associated with greater patient acceptance and shorter convalescence.

CAN OUTCOME OF INTERNAL URETHROTOMY FOR SHORT SEGMENT BULBAR URETHRAL STRICTURE BE PREDICTED?

We predicted the outcome of visual internal urethrotomy (VIU) by measuring the percentage of lumen narrowing at the stricture site on retrograde urethrography (RGU). From January 1991 to June 2002 patients with primary bulbar urethral strictures who underwent VIU were selected for the study. Patients with a history of intervention, complete block of the urethral lumen and stricture greater than 2 cm were excluded from study. Urethral diameter at the area of maximum stenosis and at the normal distal urethra was measured on RGU with Vernier caliper and percentage narrowing was derived. Patients were followed 3 times monthly with symptoms, calibration and whenever required with RGU. Recurrence of symptoms, failure to self-calibrate and the need for secondary procedure were considered treatment failure. Complete followup data were available in 105 patients (44 grade 1 and 61 grade 2). Mean bulbar urethral stricture length was 0.86 cm. Inflammation was the cause of stricture in 83 (79%) and trauma the cause in 22 (21%) patients. In the Cox proportional hazards model only grade of narrowing had a significant impact on outcome. There were 41 cases of treatment failure in the total followup of 46 +/- 9 months. Mean recurrence-free duration +/- SD was 13 +/- 15 and 44.52 +/- 19 months in cases of treatment failure and success, respectively (p <0.0001). Mean percentage narrowing was significantly higher with treatment failure (69.9% +/- 16.1% vs 48.55% +/- 17.3%, p <0.0001). A cutoff of 74% for urethral narrowing was derived to predict the outcome with 78% probability. Percentage narrowing of the urethral lumen at the stricture site is a useful predictor of VIU outcome.

Early versus delayed surgical treatment of open tibial fractures: effect on the rates of infection and need of secondary surgical procedures to promote bone union

The purpose of this study was to evaluate whether there was any significant difference in the rates of infection and of secondary surgical procedures to promote bone union, between early(6 h or less after arrival to hospital) and delayed(more than 6 h) surgical treatment of open tibial fractures. Three hundred and eighty-three open tibial fractures were evaluated. 184 fractures had early and 199 had delayed surgical treatment. The rates of infection and secondary surgical procedures to promote bone union of the two groups were compared with univariate and multivariate statistical methods. There was no statistically significant difference between early and delayed treatment groups with respect to overall infection (53/184 versus 51/199 infection rates, P = 0.96), deep infection (8/184 versus 8/199 infection rates, P = 1.0), and rates of secondary surgical procedures to promote bone union (24/184 versus 20/198, P = 0.77). We were unable to demonstrate any significant difference in infection rates or need of secondary procedures to promote bone union, between early and delayed surgical treatment of open tibial fractures.

Clinical effect of abdominal aortic aneurysm endografting: 7-year concurrent comparison with open repair

We compared the effectiveness and clinical outcome of open repair versus endovascular aortic aneurysm repair (EVAR) in achieving prevention of abdominal aortic aneurysm (AAA)-related death and graft-related complications. Over 7 years from 1997 to 2003, 1119 consecutive patients underwent elective treatment of infrarenal AAAs, 585 with open repair and 534 with EVAR. Patients were regularly followed up at 1, 6, 12 months, and every 6 months thereafter, in EVAR group, and at 3 and 12 months, and yearly thereafter after open repair. Preoperative, intraoperative, and follow-up data were stored in a prospective database. Median follow-up was similar in the 2 groups: 33 months (interquartile range [IQR], 13-50 months) in the EVAR group vs 35 months (IQR, 15-54 months) in the open repair group. EVAR group patients were older than patients in the open repair group: 73 years vs 72 years (P = .04). There were statistical significant differences between the EVAR group and the open repair group with respect to AAA median diameter (52 mm vs 56 mm), coronary disease rate (46% vs 37%; P = .001), pulmonary disease rate (56% vs 38%; P < .0001), and American Society of Anesthesiologists IV score rate (16% vs 6%; P < .0001). Thirty-day mortality in the EVAR group was 0.9% (5 of 534 patients), compared with 4.1% (24 of 585 patients; P = .001) in the open repair group, and major morbidity was 9.1% (49 of 534 patients) vs 18.6% (109 of 585 patients; P < .0001), respectively. The incidence of secondary procedures in the EVAR group was 15.7%, compared with 3% in the open repair group (P < .0001). There were no deaths related to secondary procedures in either group. Six AAAs (1.1%) ruptured after EVAR, 3 of which were fatal; in the open repair group 1 patient (0.2%) underwent successful repeat operatation to treat iliac pseudoaneurysm rupture 5 years after the original procedure. Kaplan-Meier estimates for freedom from aneurysm-related death at 84 months were 97.5% in the EVAR group and 95.9% in the open repair group (log rank test, P = .008). Kaplan-Meier survival estimates at 84 months were 67.1% in the open repair group and 66.9% in the EVAR group (P = NS). At the same interval the risk for secondary procedures was 49.4% for the EVAR group and 7.1% for the open repair group. Of the 11 variables analyzed with logistic analysis, open surgery (hazard ratio [HR], 11; 95% confidence interval [CI], 2.5-54.2; P = .002), American Society of Anesthesiologists IV score (HR, 7.1; 95% CI, 2.7-18.8; P = .0001), and age (HR, 1.06; 95% CI, 1.04-1.13; P = .04) were positive independent predictors of perioperative mortality. Our data suggest that at a maximum follow-up of 7 years, patients who undergo EVAR show lower perioperative and late aneurysm-related mortality compared with a younger and substantially healthier group of patients with aneurysms treated with open repair. The higher need for secondary procedures in the endovascular group did not affect superiority of the overall performance of EVAR in the early and late intervals.

THE ISLAND TUBE AND ISLAND ONLAY HYPOSPADIAS REPAIRS OFFER EXCELLENT LONG-TERM OUTCOMES: A 14-YEAR FOLLOWUP

We have used an inner preputial flap as a transverse island tube (IT) for the 1-stage repair of proximal hypospadias when the urethral plate could not be preserved and as an island onlay flap (IO) when the urethral plate could be preserved for more than 20 years at our institution. We report long-term followup and an outcome comparison of these 2 techniques. We retrospectively reviewed our records for all patients who underwent proximal hypospadias repair with either the IT or IO procedure between 1981 and 1992 by 1 surgeon (HMS). We randomly contacted these former patients to undergo a long-term followup examination, consisting of postoperative history, physical examination and uroflowmetry with post-void residual measurement. A review of patient charts was completed for perioperative complications or the need for secondary procedures. Patient information could be retrieved for 73 of 125 patients who underwent penoscrotal or more severe hypospadias repair with either the IT or IO procedure during the defined interval. We were able to contact 49 of these former patients following a minimum of 10 years and 30 patients agreed to return for a long-term followup examination. The IT and IO repairs were performed on 14 and 16 boys, respectively, at a mean age of 16.8 months (range 8 to 74). At a mean followup of 14.2 years for both groups (range 144 to 253 months) 2 boys in the IT group (14.2%) and none in the IO group had a fistula requiring repair. Distal stenosis requiring meatoplasty occurred in 1 and 2 patients in the IT and IO groups, respectively. There were no urethral strictures and uroflowmetry was available for 11 patients in the IT group and 14 in the IO groups with mean maximal flow rates of 17.3 and 21.8 ml per second (p = 0.343) and mean post-void residuals of 5.0 and 2.36 ml per second, respectively (p = 0.249). Unlike other forms of substitution urethroplasty, vascularized flaps based on preputial skin appear to be unique in that they do not have the long-term stricture rate seen with substitution urethroplasty using nongenital skin. The IT and IO repairs provided excellent long-term cosmetic and functional results. As the IT does have a higher incidence of postoperative complications, we have continued to extend our application of the IO to more proximal hypospadias repairs with continued success.

Endovascular aneurysm repair: gender-specific results.

The outcome for a wide variety of diseases and treatment methods varies by gender. In an effort to determine whether gender has a role in the outcome of endovascular aortic aneurysm repair, we analyzed data from consecutive patients treated at a single institution over 6 years. Over 6 years ending in March 2002, 704 patients underwent endovascular repair of an infrarenal abdominal aortic aneurysm at The Cleveland Clinic. Six hundred six patients (86.1%) were men and 98 patients (13.9%) were women. Preprocedure and postprocedure imaging studies were evaluated to determine the frequency of aneurysm sac shrinkage or growth, defined as diameter change equal to or greater than 5 mm. Presence and type of endoleak was assessed with non-contrast material-enhanced, post-contrast-enhanced, and delayed post-contrast-enhanced computed tomography scans. These and other clinical variables were assessed with the Kaplan-Meier method and the Cox-Mantel log-rank test, and values were expressed as mean +/- SE. Male and female patients were comparable with respect to baseline comorbid conditions. Women, however, were slightly older (76.7 +/- 0.7 years vs 74.4 +/- 0.3 years; P =.009), and had slightly smaller aneurysms (5.2 +/- 0.1 cm vs 5.4 +/- 0.04 cm; P =.033). There were no gender-specific differences in perioperative mortality (men, 1.3%; women, 3.1%; P =.197) or mid-term (24 months) survival (men, 80% +/- 2.6%; women, 78% +/- 8.1%). Similarly, there were no differences at 24 months in risk for graft migration (7.5% +/- 2.0% vs 5.4% +/- 3.2%), need for secondary remedial procedures (24% +/- 2.9% vs 21% +/- 6.3%), conversion to open surgery (3.9% +/- 1.5% vs 3.8% +/-2.7%), or post-repair aneurysm rupture (1.1% +/- 0.9% vs 2.2% +/-2.2%) in male and female patients, respectively. In contrast, risk for graft limb occlusion at 24 months was significantly higher in women than in men (11% +/- 5.2% vs 3.3% +/- 1.1%; P =.022). While frequency of endoleak of any type did not differ among male and female patients, aneurysm sac shrinkage at 24 months was more rapid in women (76% +/- 8.1% vs 57% +/- 3.5%; P =.019). With the exception of slightly older age and somewhat smaller aneurysm, female patients are similar to male patients undergoing endovascular aneurysm repair. A greater frequency of graft limb occlusion was observed in female patients, but no statistically significant differences were detected in survival, rupture risk, or need for secondary procedures. Moreover, a more rapid rate of aneurysm sac shrinkage was detected in women. These observations suggest that endovascular aneurysm repair should be offered to suitable candidates irrespective of gender.

What Determines the Costs of Repair and Rehabilitation of Flexor Tendon Injuries in Zone II? A Multiple Regression Analysis of Data From Southern Sweden

The epidemiology and costs of repair and rehabilitation of zone II flexor tendon injuries in 135 patients from the southern part of Sweden were analysed. The little finger was most frequently injured (43%), usually with a knife (46%), and 30% of the injuries were work related. Total median costs within the health-care sector for the injuries were SEK 48,500 (1 EURO=9.23 SEK, 4/1/2002). Costs in other sectors were SEK 93,000. Active mobilization or mobilization with rubber band traction increased costs within the health-care sector (SEK 7400 or SEK 6000, respectively) but improved range of movement (5–7%). Immobilization had a higher complication rate (rupture or need for secondary procedures), which in itself increased total costs by 57%. Non-linear effects were found between age and costs within the health-care sector and the outcome.

Urinary Calculi in Aviation Pilots: What is the Best Therapeutic Approach?

We reviewed treatment outcomes in a series of aviation pilots treated in the era of modern surgical techniques and provide recommendations regarding treatment in this unique group. We retrospectively analyzed the records of all aviation pilots surgically treated for urinary calculi at our 4 tertiary stone centers from January 1988 to June 2000. Preoperative data and postoperative results were evaluated. Primary outcome measures included stone-free status after initial therapy, time lost from work and overall stone-free rates. Secondary outcome measures included the need for secondary procedures and complications. Of the 36 patients 17 had renal and 19 had ureteral stones. In 4 patients the stones passed spontaneously, while 17 were initially treated with extracorporeal shock wave lithotripsy (ESWL) (Dornier Medical Systems, Marietta, Georgia), 9 were initially treated with ureteroscopy and 6 were treated with percutaneous nephrolithotripsy. There was 1 complication. The stone-free rate for ESWL, percutaneous nephrolithotripsy and ureteroscopy after initial therapy was 35%, 100% and 100%, respectively. All patients were rendered stone-free after secondary therapy. Mean time lost from work for ESWL, percutaneous nephrolithotripsy and ureteroscopy was 4.7, 2.6 and 1.6 weeks, respectively. Aviation pilots with surgical urolithiasis are best treated with an initial endoscopic procedure. Stone-free rates can be maximized, while time lost from work can be minimized when an endoscopic approach is used initially. All pilots with urolithiasis should undergo mandatory metabolic evaluations to institute medical therapy when indicated.

Endoscopic Forehead Rejuvenation: Using Bone Channels for Soft-Tissue Suspension

Introduction: The use of endoscopic procedures to facilitate the rejuvenation of the upper face offers today's cosmetic surgery patient a less invasive and less morbid procedure, with comparable results to the various open techniques. Multiple methods of soft-tissue suspension have been utilized with varying results while performing endoscopic browlift procedures. All methods of suspension attempt to maintain the elevated brow, however they differ in length of time for fixation, use of hardware, and the need for secondary procedures. Purpose: The purpose of this article is to review various techniques of soft-tissue suspension for endoscopic forehead rejuvenation and describe the bone channel technique. Methods: The authors present a brief review of the history of soft-tissue suspension in endoscopic forehead rejuvenation ranging from the use of scalp excision to resorbable suspension screws. A procedure for the use of bone channels to maintain suture suspension of the soft-tissue flap, which is currently in use at their institutions, is presented. Results: The bone channel procedure is a simple, predictable technique that provides long term suspension of the soft-tissue flap, eliminates the use of hardware, and allows for immediate closure of the instrumentation ports. Conclusions: This simple technique of suture suspension using bone channels in the outer cortex of the cranial bone provides an inexpensive and predictable alternative for endoscopic forehead rejuvenation. Proper use can successfully effect a pleasing and natural look for the facial cosmetic surgery patient.

FREE VASCULARIZED TEMPORAL PARIETAL FLAP IN HAND SURGERY

Free vascularized temporo-parietal fascia (TPF) flap is a flap of thin, pliable and vascularized tissue which can cover an area measuring up to 12 cm x 14 cm. The flap is harvested based on temporal vessels, which provide a smooth, gliding surface for tendon function and eliminates the need for secondary procedures usually required by the pedicled or bulky free vascularized myocutaneous flaps. The donor pedicle is long and consistent with an average diameter of 3 mm in adults. This flap is versatile. In 12 resurfacings for traumatic wounds of hand and wrist, no flaps were lost. Donor site morbidity, except for a transient sideburn hair loss in one case, was not encountered. We recommend this flap as a viable one-stage procedure for coverage of complex hand wounds.

Dilatation and evacuation at 13 to 15 weeks' gestation versus intra-amniotic saline after 15 weeks' gestation

To evaluate the clinical practice of deferring abortion in patients at 13 to 15 weeks' gestation for abortion by intra-amniotic saline at gestations of 16 weeks or over, the complication rates for 338 gravidas aborted by dilatation and curettage (D&C) and/or vacuum aspiration (VA) at 13 to 15 weeks' gestation, and 442 gravidas at 16 to 18 weeks' gestation aborted by the intra-amniotic instillation of saline were compared. In the 13- to 15-week period, VA is associated with significantly higher rates of cervical injury and the need for secondary procedures to complete the abortion when compared to D&C. Although the total complication rates of D&C at 13 to 15 weeks' gestation and intra-amniotic saline after 15 weeks' gestation were similar, the saline method appeared to be associated with higher rates of potentially serious complications—infections, pulmonary complications—and the need for additional procedures to complete the abortion.

The effectiveness and complications of abortion by dilatation and vacuum aspiration versus dilatation and rigid metal curettage

To evaluate the efficacy and complications of dilatation and curettage (D&C) and vacuum aspiration (VA), pertinent data on 4,463 patients at seven to 19 weeks' gestation undergoing artificial abortion were analyzed. Before nine weeks' gestation VA appears to be safer than D&C, but after 12 weeks' gestation VA is associated with higher rates of uterine injury and excessive blood loss. At nine to 12 weeks' gestation there is little difference in the over-all complication rates of the two procedures. Data on 614 patients undergoing suction curettage within two weeks of a missed menstrual period (a time when pregnancy cannot be reliably diagnosed) were analyzed. The morbidity was lower in this group than in any group undergoing abortion. Thus, the earlier the abortion is performed the lower the morbidity. The need for secondary procedures, anesthesia, or cervical dilatation is infrequent for early VA when compared to abortion by D&C and VA at later stages of gestation.