Neurovascular Bundle Research Articles

Development of Ventral Hernia Repair Curriculum Using the AWSSOM-a Synthetic Abdominal Wall Surgical Skills Operational Model.

Ventral hernia repair cost the U.S. healthcare system nearly 3 billion dollars annually. Surgical repair is a critical competency for residents yet hernia recurrence rates following mesh-based repair range from 0.8% to 24%. Improving surgical techniques using cadavers is often cost-prohibited for many education programs and limited research exists using simulation models with a corresponding hernia repair curriculum in the graduate medical education setting. This pilot project aimed to develop a low cost, easily reproducible novel abdominal wall reconstruction model and pilot-test the ventral hernia repair curriculum to inform further refinement prior to formal evaluation. This descriptive study pilot-tested the newly refined Abdominal Wall Surgical Skills Operative Model (AWSSOM) simulator for ventral hernia repair with mesh and its corresponding 2-h training curriculum for use at all levels of general surgery graduate medical education. The AWSSOM is a 3D printed synthetic anatomically realistic abdominal wall model consisting of silicone cured layers of skin, fat, rectus abdominis and a posterior rectus sheath fascia, and silicone tubules to simulate lateral neurovascular bundles. The curriculum incorporated didactic content reflecting surgical practice guidelines, hands-on practice, and faculty guidance promoting interactive critical thinking development during task performance. A pre-/post-assessment included a 10-item knowledge test, a 19-item psychomotor assessment, and 4-items confidence survey to examine changes in performance, knowledge, and confidence in competently completing the ventral hernia repair technique. Descriptive statistics were used to report the limited results of six military surgical resident participants and inform further model and curriculum refinement prior to formal evaluation. The five-layer AWSSOM model was manufactured in 65 h at a material cost of $87 per model frame, is reusable model, and secure base. Six surgical residents were recruited; only four completed both pre- and post-tests due to resident schedule conflicts. The average increase in knowledge was 25%, although variable changes in confidence were observed over the four program year participants. A larger sample size and a control group are needed to demonstrate curriculum effectiveness at improving knowledge, performance, and confidence in ventral hernia repair with mesh and better delineate if high scores translate to better operative skills. A key improvement requested by residents was a more secure model base for dissection and performance of the hernia repair. The novel abdominal wall surgical skills operative model fills an important proof of concept gap in simulation training. It is low cost with the potential to improve cognitive and psychomotor skills, as well as confidence to competently complete ventral hernia repair with mesh in the graduate medical education setting. Prior to formal effectiveness testing, our lessons learned should be addressed in both the model and curriculum. Future studies must include an adequately powered statistical evaluation with a larger sample across all levels of training.

External validation of an algorithm to personalize nerve sparing approaches during robot-assisted radical prostatectomy in men with unilateral high-risk prostate cancer.

Limited evidence exists about preserving neurovascular bundles during radical prostatectomy (RP) for high-risk prostate cancer (HRPCa) patients. Hence, we validated an existing algorithm predicting contralateral extraprostatic extension (cEPE) risk in unilateral high-risk cases. This algorithm aims to assist in determining the suitability of unilateral nerve-sparing RP. Among 264 patients, 48 (18%) had cEPE. The risk of cECE varied: 8%, 17.2%, and 30.8% for the low, intermediate, and high-risk groups, respectively. Despite a higher risk of cECE among individuals classified as low-risk in the development group compared to the validation group, our algorithm's superiority over always/never nerve-sparing RP was reaffirmed by decision curve analysis. Therefore, we conclude that bilateral excision may not always be justified in men with unilateral HRPCa. Instead, decisions can be based on our suggested nomogram.

PENILE TORSION OF A TWO-YEAR-OLD BOY: A CASE REPORT

Objective: This case report presented Penile Torsion in pediatrics. Case(s) Presentation: A two-year-old boy with a chief complaint of rotated penile to the right side since birth. There were 45º in clockwise torsion, slight chordee, and uncircumcised. Patient underwent penile reconstruction surgery, including penile degloving, urethral mobilization, and plication. After seven days follow-up, parents were satisfied with straight penile erection and no torsion at all. After 3 months follow-up, parents reported satisfaction with the surgical outcome such as cosmetic appearance, straight erection, and normal stream urine. Discussion: Surgical techniques ranging from simple penile degloving with foreskin repositioning to more complex surgical procedure involving corporeal tissue. Surgery by using degloving of penile skin and realignment could be suitable for penile torsion <90°. For the cases of >90°, other techniques should be considered such as corporopexy procedure, rotation flap of dorsal dartos, or diagonal suturing of corporeal folds away from and parallel to the neurovascular bundle. Conclusion: Penile reconstruction surgery using penile degloving, urethral mobilization, and plication for penile torsion showed satisfaction result including cosmetic appearance, penile erection, and normal urine flow.
 Keywords: Chordee, penile reconstruction, penile torsion.

ОДНОЭТАПНАЯ КОРРЕКЦИЯ ПОСЛЕДСТВИЙ ПОВРЕЖДЕНИЯ ЛОКТЕВОГО НЕРВА

Objective: : To enhance the outcomes of surgical treatment for chronic ulnar nerve injuries by performing one-stage correction. Methods: From 2015 to 2023, 11 patients with chronic ulnar neurovascular bundle (NVB) injuries underwent one-stage reconstruction to restore hand function. The operations were performed on 8 men and 3 women aged 16 to 23. The duration of treatment for patients from the time of injury varied from 1.2 years to 5 years Results: In cases where there was a diastasis between the neural ends of no more than 3 cm in the upper third of the forearm due to nerve damage, restoration of the nerve with epineural suture was performed in 2 patients, while in two other cases with more significant gaps of 3.5 and 5 cm, epineural repair was carried out after anterior transposition of the nerve trunk. In one case of nerve damage in the middle third of the forearm, epineural sutures were applied to a 2.5 cm gap. Among 6 patients with damage to the ulnar NVB in the lower third of the forearm, 4 received epineural restoration of the ulnar nerve, and autologous neuroplasty was performed in gaps exceeding 3 cm in 2 patients. In cases of damage to the ulnar artery, 3 patients received autologous vein grafting, while in 3 other cases, there were no indications for vascular reconstruction. No infectious or inflammatory complications were observed in the immediate postoperative period, and there were no cases of thrombosis of autologous vein grafts of the ulnar artery. After evaluating all patients for 6 months to 2 years, it was found that 9 cases showed favorable and satisfactory long-term functional outcomes, while 2 cases exhibited unsatisfactory results. Conclusion: Restoring hand function after damage to the ulnar nerve is greatly influenced by the location, extent, and type of the damage, as well as the choice of an appropriate reconstruction method. Breaking the procedure into multiple stages can prolong patient recovery and negatively impact treatment outcomes. Conversely, performing the operation in a single stage within a relatively short timeframe can restore hand function and significantly reduce overall treatment and rehabilitation time Keywords: Ulnar nerve, neurovascular bundle, injury, tendon-muscular transfer, epineural suture

Postoperative Progress of Deep Grid Incision and Sealing with Collagen Fleece for Treatment of Peyronie's Disease: Prospective Observational Study for 3 Years.

Despite recent popularity, partial plaque excision and sealing with TachoSil has concern about tunica regeneration from graft and lack of long-term results. Previously, we introduced multiple deep grid incisions of Peyronie's plaque to minimize tunical defect with consequent veno-occlusal erectile dysfunction. To assess the efficacy of modified grid incision of plaque and sealing with collagen fleece in postoperative progress of 34 patients for 3 years. From Aug 2018, 34 patients with stable Peyronie's disease (PD) underwent surgery involving three major steps: 1) dissection of the neurovascular bundle or urethra according to plaque location, 2) multiple deep grid incisions of plaque for complete curvature correction, and 3) sealing with collagen fleece without suture. We assessed the stretched penile length, totally straightness, penile sonography, erectile function preoperatively and 3, 6, 12 months and annually postoperatively. This study was approved by the Institutional Review Board. Mean age was 59.4 years (29-72 years). Mean curvature was 53.5 degree (35-100 degree), with hinge and hourglass deformity in 12 and 8 patients, respectively. Five patients required inflatable penile prosthesis (IPP) insertion, with one more at 30 months. The mean follow-up was 42.3 months. Penile rehabilitation, including daily massage, reduced subcutaneous thickening by 12 months postoperatively. All patients initially achieved complete straightness, with two experiencing recurrent curvature. Four patients had subcutaneous hematomas, subsiding in two. Minor skin issues occurred in three IPP patients. Postoperative erectile function was satisfactory in 85.0% of patients. Most regained preoperative length by 1.6 years. Global Assessment Questionniare satisfaction increased from 69.0% at 1 year to 90.0% until 3 years. The modified grid incision with collagen fleece sealing effectively treats PD without causing tunica albuginea defects. Long-term follow-up is essential for monitoring erectile function and penile length recovery, ensuring successful clinical outcomes.

Videothoracoscopic First Rib Resection for Neurogenic Thoracic Outlet Syndrome: Results of 13 Patients.

To present the clinical experience in video-assisted thoracic surgery (VATS) of first rib resection for patients with neurogenic thoracic outlet syndrome (NTOS). The files of 13 patients (10 males, 3 females) having unilateral NTOS undergoing first rib resection via VATS were retrospectively investigated. The symptoms, operative times, durations of chest tube and hospital stay, complications, and postoperative courses were analyzed. All patients underwent VATS using a camera port and 3-5 cm utility incision. There was no morbidity. The average operation time was 81 ± 11 min (range 65-100 min). Chest tubes were removed in the first or second postoperative day (mean 1.23 ± 0.43 days). The mean postoperative length of hospital stay was 2.1 ± 0.9 days (range 1-3 days). The average duration of follow-up was 19 ± 13 months (range 2-38 months). Ten patients completed a follow-up during 6 months. One patient (10%) had minor residual symptoms, and the remaining patients (90%) were fully asymptomatic. The VATS approach in the resection of the first rib for thoracic outlet syndrome is a safe method. It should be performed with acceptable risks under experienced hands. The magnified view and optimal visualization from the scope are beneficial. Avoiding neurovascular bundle retraction may seem to decrease the postoperative pain.

Quiz CORRECT ANSWER TO THE QUIZ. CHECK YOUR DIAGNOSIS Prostatic paraganglia-hyperplasia - ahistological mimic ofintraprostatic adipose tissue.

Prostatic paraganglia (PP) can simulate adenocarcinoma's fused gland pattern, and adifferential diagnostic panel is developed. Their differential diagnosis with benign prostatic lesions has been largely unreported. Intraprostatic adipose tissue (IPAT) is seen extremely rarely in prostatic specimens, but it must be known, to avoid false positive results for extraprostatic fat carcinomatous invasion in needle biopsy specimens. We present one case from 100 randomly selected radical prostatectomy specimens in which our diagnosis evolved from IPAT to PP-hyperplasia, after additional immunohistochemical investigations. Thepresence ofPP-hyperplasia, with both parenchymal and neurovascular bundle location, and its differential diagnosis with IPAT has not been previously reported.

Evaluation of calcium hydroxide mixed with propolis by ultrasonic activation as root canal dressing in delayed tooth replantation.

In cases of tooth avulsion, in which the neurovascular bundle responsible for nourishing the dental pulp is break, endodontic treatment is necessary before proceeding with tooth replantation. In this process, various substances have been tested in combination with calcium hydroxide Ca(OH)2 in an attempt to improve its effectiveness. This study aimed to examine the effects of using a mixture of Ca(OH)2 and 10% propolis, with subsequent application of ultrasonic treatment, on the delayed replantation of teeth in rats. Twenty-four rats underwent a surgical procedure to extract the upper right incisor, leaving it on a surface to dry for one hour. The pulp and periodontal ligament were removed and the teeth were submerged in a 2% sodium fluoride acidulated phosphate solution. The canals were dehydrated using paper cones and the teeth were divided into four groups, according to the type of intracanal dressing: Ca(OH)2 group, Ca(OH)2 group with ultrasonic agitation, Ca(OH)2 and propolis group, Ca(OH)2 and propolis group with ultrasonic agitation. The root canals were irrigated with saline solution and the teeth were reimplanted. Sixty days after reimplantation, the animals were euthanized. With regard to the presence of acute and chronic inflammatory infiltrate in the periodontal ligament, there was no statistically significant difference among some of the groups. Root resorption was identified in all groups, and there was no significant difference between them. It is concluded that the application of intracanal dressing containing Ca(OH)2 associated with 10% propolis, followed by ultrasonic agitation, did not prove to be more effective than the use of Ca(OH)2 alone in the repair process in the delayed replantation of rat teeth. Key words:Tooth replantation, Calcium hydroxide, Propolis, Ultrasound, Intracanal dressing.

Optimizing Nerve Sparing in Robotic-Assisted Radical Prostatectomy: A Comparative Investigation of Traditional and Modified Endopelvic Fascia Preservation Techniques.

Prostate cancer (PCa) is the second most common cancer and the sixth leading cause of cancer-related mortality in men. In 2000, Abbou performed the first robot-assisted radical prostatectomy, and radical prostatectomy has developed rapidly. Robot-assisted radical prostatectomy (RARP) is a valuable therapeutic option for the management of localized Pca. To present the functional outcome of robot-assisted laparoscopic radical prostatectomy using traditional and modified endopelvic fascia preservation methods in a single center in Vietnam. We prospectively analyzed a series of 65 patients diagnosed with prostate cancer from 2020 to 2023. All of those were operated by DaVinci Si system robot-assisted laparoscopic prostatectomy. Twenties patients were applied with a modified nerve-sparing technique, intrafascial dissection, and lateral prostatic fascia preservation, leaving the lateral tissue, including the neurovascular bundle, untouched and covered. We used the traditional approach, intrafascial nerve-sparing with open endopelvic fascia and lateral prostatic fascia in 45 cases. Patients were followed up to 12 months to assess the continence and erectile function by using IIEF-5 and EPIC questionnaires. The study sample included 65 cases; the mean patient age was 64.21 ± 6.68, erection rate after surgery at six months in bilateral NS was 36.58% (15/41) in the traditional group, and 68.42% (13/19) in the modified group (p=0.028). The patient did not recover erectile ability in the group of elderly patients (>65 years old) and unilateral nerve-sparing group. The continence rate six months after surgery was 86.66 % in the conventional group and 85% in the modified group, with no significant difference between the two groups. In the potency group, the IIEF-5 score was 13 ± 4.9, and the EPIC-26 score was 62.20 ± 10.04. Erectile ability in the modified group was better than the traditional group at six months after surgery. Our results showed better potency recovery in the modified group. These results should be tested in future research with randomized studies.

Giant cervical lipoma adjacent to carotid artery: a case report and literature review

Cervical lipomas accompanied by neurovascular compression are extremely rare and require surgical treatment in case of appropriate symptoms. The preferable method is gross total resection, as otherwise they tend to recur. Invasive growth is not typical for lipomas. However, large tumors can involve adjacent nerves and vessels and significantly complicate resection. We present a 57-year-old patient who underwent resection of giant soft tissue cervical lipoma invading neurovascular bundle and compressing the oropharynx and esophagus with dysphagia and positional asphyxia. The patient was followed-up for previous 5 years. Resection was necessary due to tumor enlargement with appropriate symptoms. Searching for literature data was performed in the Pubmed, Medline, EMBASE, Cochrane Library and eLibrary databases. Gross total resection of 7-cm tumor was accompanied by mobilization of hypoglossal and vagus nerves, common, external and internal carotid arteries and jugular vein with repositioning of the oropharynx and esophagus. There was mild Horner's syndrome in early postoperative period. The patient was discharged in 4 days after surgery with regression of complaints. We found only 5 reports describing giant cervical lipomas invading neurovascular bundle. Giant cervical lipomas are extremely rare, and total resection with preservation of critical structures is possible in a specialized hospital.

Impacted third molar root abnormality with mandibular canal close position as a presupposing factor to inferior alveolar nerve trauma

The aim of the study is reducing the risks of surgical injury to the inferior alveolar nerve, by taking into account individual topographic and anatomical features, improving diagnostic methods, and techniques for removing retinated teeth with a close fit to the mandibular canal. An examination was conducted in the Department of Surgical Dentistry (CBCT/OPG) and surgical treatment of 223 patients, with a close fit of the roots of the retinated lower third molar to the mandibular canal. Microslips of teeth with roots intact during removal (n=96) of the main group and the control group (n=52) were prepared with a Micromet Remet manual petrographic machine. The sections were carried out along the longitudinal axis of the tooth with the capture of the area of close fitting of the nerve, the teeth from the control group were sawed longitudinally along the axis of the root. The measurement of the macroanatomic features of the roots was carried out with a micrometer (MCC-MP-100 0.001 electronic «CHEESE», manufactured in the Russian Federation), measurements of the thickness of dentine and cement tissues on macroglyphs were carried out using a microscope calibration ruler with an accuracy of 0.01 mm. In the main group, three types of attachment of the mandibular canal to the root of the third molars were distinguished: 20 (96) cases of inter-root attachment of the mandibular canal, 42 (96) apical, 34 (96) lateral (buccal and lingual). A number of anomalies in the structure of the roots of the third molars have been revealed, which are a factor in injury to the neurovascular bundle of the mandibular canal during tooth extraction. The surface of the roots, as well as the microscopes of the tooth sections adjacent to the mandibular canal, were studied under a microscope. A number of specific anomalies of the roots of retinated third molars formed by root dilaceration, thinning of cement tissues, hypercementosis, which are formed at the site of the mandibular canal.In the presence of a deep indentation on the root of the tooth, as well as in the presence of areas of apical hypercementosis in the form of a «spike», the probability of nerve injury during tooth extraction increases many times, which must be taken into account when removing retinated third molars.

Flexor Pronator Slide Under Local Anesthesia without a Tourniquet for Non-Ischemic Contractures of the Forearm.

Flexor Pronator Slide Under Local Anesthesia without a Tourniquet for Non-Ischemic Contractures of the Forearm.

Neoadjuvant Radiotherapy Is Associated with Fewer Acute Adverse Skin Reactions Without Increased Risk of Postoperative Wound Complications in High-Grade Extremity Soft Tissue Sarcoma - A Retrospective Comparative Study with A Mean Follow-Up of 7 Years

Aim: In this study, we aim to compare the adverse effects and oncological outcomes of patients with high-grade extremity soft tissue sarcoma receiving neoadjuvant or adjuvant RT. Methods: From 2008 to 2022, Sixty-four patients underwent limb-preserving surgery in our institute for localized high-grade extremity soft tissue sarcoma were included. Thirty-nine patients received adjuvant radiotherapy while twenty-five patients received neoadjuvant RT before surgery if the soft tissue sarcomas were close to the neurovascular bundles, bones or histological types of myxoid liposarcoma or rhabdomyosarcoma. Primary outcomes were acute RT-related skin adverse reactions and significant side effects comprising postoperative wound complications, pathological fractures and RT-induced sarcoma. Secondary outcomes included surgical margin quality, Local-Recurrence (LR)-free survival, metastasis-free survival and overall survivorship. Results and Discussion: Patients in the neoadjuvant RT group had significantly fewer acute RT-induced adverse skin reactions than the adjuvant RT group (p=0.044, Table 2). None in the neoadjuvant RT group suffered severe acute skin reaction (RTOG grade 3-4). Wound infection (n=2) and pathological fracture (n=1) were rare in both adjuvant and neoadjuvant RT groups (P=0.640 & 1.000 respectively). Survival curves for local-recurrence-free survival, metastasis-free survival and overall survivorship of both neoadjuvant and adjuvant groups were analyzed via Kaplan-Meier Curve. All results are statistically insignificant, with p=0.835, 0.948 and 0.540, respectively. Presence of metastasis was the only statistically significant predictor of the overall survival-adjusted hazard ratio of 8.7 (95%CI 2.7-28), p<0.001. Conclusion: Patients with neoadjuvant RT had lower cumulative radiation doses and fewer acute adverse skin reactions. There was no increased risk of postoperative wound complication compared to adjuvant RT. The LR-free survival, metastasis-free survival and overall survival were comparable in both groups. Our results suggested that postponing surgery to eight weeks after neoadjuvant RT and primary wound closure were associated with fewer wound complications, but further studies were warranted.

Use of PIRADS 2.1 to predict capsular invasion in patients with radiologic T3a prostate cancer.

Using multi-parametric magnetic resonance imaging (mpMRI) to identify patients with clinical T3a (cT3a) who were overestimated on mpMRI with final pathological T2 (pT2). To suggest that the neurovascular bundle (NVB) can be preserved by evaluating the characteristics of patients according to their pathological grade among cT3a prostate cancer (PCa) patients using mpMRI. Patients who underwent robot-assisted laparoscopic radical prostatectomy (RALP) were retrospectively analyzed and those patients with clinical T3aN0M0 were enrolled. These enrolled patients were divided into a localized cancer group with pT2 PCa and a locally advanced group with pT3a or higher. Factors affecting the diagnosis of localized PCa after RALP in patients with cT3a PCa were evaluated. Among the preoperative parameters of patients with cT3a PCa, the prostate specific antigen density (PSAD) (OR: 3.76, 95% CI: 1.85-7.64, p<0.001), international society of urological pathology (ISUP) grade (p<0.05), and index lesion size (OR: 1.44, 95% CI: 1.85-7.64, p<0.001) were significantly associated with pathological locally advanced PCa. Optimal cut-off values for prediction of pT3a or higher were 0.36 ng/mL2 for PSAD (sensitivity: 55.7%, specificity: 70.8%), 1.77cm for index lesion size (sensitivity: 54.3%, specificity: 66.0%), and 2.5 for ISUP grading (sensitivity: 67.6%, specificity: 53.2%). For prediction of pT3a or higher among patients with cT3a PCa, a nomogram was developed using ISUP grade, index lesion size, and PSAD on prostate biopsy (area under the curve: 0.71, 95% CI: 0.670-0.754, p<0.001). PSAD less than 0.36 index lesion size less than 1.77cm, and biopsy ISUP grade 1-2 are highly likely to indicate that there is no actual extracapsular extension in cT3a PCa patients. PSAD, ISUP, and index lesion size showed significant associations with the classification of pathologic localized and locally advanced PCa in patients with cT3a PCa. A nomogram including these features can predict the diagnosis of locally advanced PCa in patients with cT3a PCa.

Identification of the length and location of the A1 pulley combining palpation technique with palm landmarks: a cadaveric study

Through anatomical morphology, to accumulate the relevant parameters of the A1 pulley of each adult finger. A total of 100 fingers were selected, dissected layer by layer, and the A1 pulley and neurovascular of each finger were observed. Measure the length of the A1 pulley, the distance between the needle knife insertion point and the proximal edge of A1 pulley, and the nerves and blood vessels on both sides. (1) The length of A1 pulleys of each finger is 6.18 ± 0.33 mm, 6.58 ± 0.73 mm, 5.98 ± 0.67 mm, 5.36 ± 1.08 mm, 5.63 ± 1.09 mm. (2) The distances between the needle knife entry point of each finger and the volar proper nerve of the ulnar finger are 7.00 ± 1.55 mm, 8.29 ± 1.46 mm, 5.10 ± 0.25 mm, 5.30 ± 0.24 mm, 0 mm; the distances from the volar proper nerve of the radial finger are 9.08 ± 0.87 mm, 4.70 ± 1.10 mm, 7.03 ± 0.72 mm, 6.81 ± 0.22 mm, 7.81 ± 0.57 mm. (3) The distances between the needle knife entry point of each finger and the proper volar artery of the ulnar finger are 10.40 ± 0.75 mm, 8.89 ± 0.53 mm, 6.35 ± 0.44 mm, 7.26 ± 0.16 mm, 0 mm, respectively; The distances from the volar proper artery of the radial finger are 8.75 ± 1.07 mm, 6.10 ± 0.35 mm, 11.44 ± 0.41 mm, 8.19 ± 0.60 mm, 9.78 ± 0.68 mm, respectively. The landmarks of the needle entry points are located at the position corresponding to the highest point of the metacarpal heads, except the tail finger. From the needle knife entry point to distal, cut the proximal edge of the A1 pulley longitudinally along the midline until the patient can flex autonomously, and pay attention to the distance between the two sides of 3.60–11.85 mm neurovascular bundle.

Rational use of Ga-68 PSMA PET-CT according to nomograms and risk groups for the detection of lymph node metastasis in prostate cancer

ObjectivesThe aim was to ensure efficient utilization of PSMA PET-CT by examining the correlation of pathological lymph node metastasis with nomogram scores and risk classifications. Methods and materialsRobot-assisted radical prostatectomy and bilateral pelvic lymph node dissections for pelvic lymph nodes were performed using the same template. Bilaterally pelvic lymph nodes were removed within the boundaries of genitofemoral nerves, psoas muscle and lateral pelvic wall laterally, ureteric crossing of the iliac vessels superiorly, lateral bladder wall medially, Cooper ligaments distally, and endopelvic fascia, neurovascular bundles and internal iliac arteries posteriorly. Clinical nomograms were used to calculate the probability of lymph node metastasis preoperatively. Using receiver operating characteristics analysis, discriminatory cut-offs were calculated. The diagnostic performance of PSMA PET-CT was determined for detecting lymph node metastasis. ResultsFor 81 patients, the median age was 64 years. The median PSA was 6.8 ng/ml. Most patients were in the D'Amico intermediate (56.8%) and high (37%) risk groups. Median Briganti 2017, MSKCC, and Partin scores were 35 (4–99), 37 (8–90), and 12 (2–38), respectively, in pN1 patients. The area under the curve for Briganti 2017, MSKCC, Partin nomograms and PSMA PET-CT scans were 0.852, 0.871, 0.862, and 0.588. Sensitivity, specificity, positive predictive value and negative predictive value for Ga-68 PSMA PET-CT for lymph node metastasis detection were 21.4%, 94%, 42.9%, and 85.1%, respectively, for the whole group. By using higher threshold values for clinical nomograms (Briganti 2017 >32, MSKCC >12, Partin >5), PSMA PET-CT had higher sensitivity (42.9, 30, 27.2) in detecting lymph node metastasis. ConclusionsPatients in the D'Amico high-risk group and those with high nomogram scores are the best candidates who will benefit from preoperative PSMA PET-CT staging to estimate lymph node metastasis.

Thoracic outlet syndrome: single-center experience on the transaxillary approach with the aid of the TRIMANO Arthrex arm

Thoracic outlet syndrome (TOS) is a pathology caused by compression on the neurovascular bundle by the first rib. The treatment of TOS is conservative management by analgesia and physiotherapy; however, if there is no response to conservative treatment, surgery is indicated through thoracic outlet decompression by first rib resection. Several surgical techniques are available, including supraclavicular, transaxillary, and transthoracic first rib resection approaches. The transaxillary approach provides better visualization on the neurovascular bundle and, thus, is sometimes the preferred method of treatment. The transaxillary approach has been criticized due to safety concerns regarding the neural bundle during surgical exposure. During surgery, hyperabduction of the arm is obtained by a surgical assistant, and the quality of exposure can decrease with time, or an iatrogenic injury to the neural bundle (brachial plexus) can occur from the hyperabduction. The use of the TRIMANO Arthrex arm can help in the exposure, instead of a surgical aide, because it provides stable exposure and visualization for the operating surgeon. We performed a retrospective review of patients undergoing transaxillary first rib resection using the TRIMANO Arthrex arm between June 2021 and December 2022. During installation, the patient is placed in the lateral decubitus position and the TRIMANO Arthrex arm is fixed at the operating table at the height of the patient’s shoulder. Thus, the surgical aide can help the surgeon during the surgery, rather than placing the arm into and out of hyperabduction. The use of hyperabduction is limited to 15 minutes, followed by 5 minutes of rest, to decrease the tension on the neurovascular bundle. The surgeon then performs the transaxillary approach and systematically resects the first rib, scalene muscles, and subclavian muscles. By this approach, the inferior brachial plexus is also lysed. In our review, we found a total of 15 procedures of first rib resection for the treatment of TOS with the aid of the TRIMANO Arthrex arm that met our inclusion criteria. All procedures were performed by the same surgeon. None of the patients sustained an injury to the neurovascular bundle. All the patients had an uneventful hospital stay postoperatively, and none presented with a hematoma. The drain placed during surgery was removed on postoperative day 2. All patients had at least one radiograph taken during their hospitalization, with no pleural effusion or pneumothorax found. The use of the TRIMANO Arthrex arm is safe and can help in the positioning and installation of the patients undergoing transaxillary first rib resection. It decreases the number of surgical assistants and offers great comfort for the surgeon because it provides stable exposure for the operating surgeon.

Functional Impact of Neuro-Vascular Bundle Preservation in High Risk Prostate Cancer without Compromising Oncological Outcomes: A Propensity-Modelled Analysis.

Nerve sparing (NS) is a surgical technique to optimize functional outcomes of radical prostatectomy (RP). However, it is not recommended in high risk (HR) cases because of the risk of a positive surgical margin that may increase the risk of cancer recurrence. In the last two decades there has been a change of perspective to the effect that in well-selected cases NS could be an oncologically safe option with better functional outcomes. Therefore, we aim to compare the functional outcomes and oncological safety of NS during RP in men with HR disease. A total of 1340 patients were included in this analysis, of which 12% (n = 158) underwent non-NSRP and 39% (n = 516) and 50% (n = 666) uni- and bilateral NSRP, respectively. We calculated a propensity score and used inverse probability of treatment weighting (IPTW) to balance the baseline characteristics of Pca patients undergoing non-NSRP and those having uni- and bilateral NSRP, respectively. NS improved functional outcomes; after IPTW, only 3% of patients having non-NSRP reached complete erectile function recovery (without erectile aid) at 24 months, whereas 22% reached erectile function recovery (with erectile aid), while 87% were continent. Unilateral NS increased the probability of functional recovery in all outcomes (OR 1.1 or 1.2, respectively), bilateral NS slightly more so (OR 1.1 to 1.4). NSRP did not impact the risk of any recurrence (HR 0.99, 95%CI 0.73-1.34, p = 0.09), and there was no difference in survival for men who underwent NSRP (HR 0.65, 95%CI 0.39-1.08). There was no difference in cancer-specific survival (0.56, 95%CI 0.29-1.11). Our study found that NSRP significantly improved functional outcomes and can be safely performed in carefully selected patients with HR-PCa without compromising long term oncological outcomes.

The Cavernous Nerve Injury Rat Model: A Pictorial Essay on Post-Radical Prostatectomy Erectile Dysfunction Research.

Understanding and addressing post-radical prostatectomy (RP) erectile dysfunction (ED) is of paramount importance for clinicians. Cavernous nerve (CN) injury rat model studies have provided consistently promising experimental data regarding regaining erectile function (EF) after nerve damage-induced ED. However, these findings have failed to translate efficiently into clinical practice, with post-RP ED therapeutic management remaining cumbersome and enigmatic. This disparity highlights the need for further standardization and optimization of the elaborate surgical preparation protocols and multifaceted reporting parameters involved in reliable CN injury rat model experimentation. Even so, despite its technical complexity, this animal model remains instrumental in exploring the functional implications of RP, i.e., surgical lesions of the neurovascular bundles (NVBs). Herein, besides cavernous nerve (CN) dissection, injury, and electrostimulation, multiple pressure measurements, i.e., mean arterial pressure (MAP) and intra-cavernosal pressure (ICP), must also be achieved. A transverse cervical incision allows for carotid artery cannulation and MAP measurements. Conversely, ICP measurements entail circumcising the penis, exposing the ischiocavernous muscle, and inserting a needle into the corporal body. Finally, using an abdominal incision, the prostate is revealed, and the major pelvic ganglia (MPG) and CNs are dissected bilaterally. Specific surgical techniques are used to induce CN injuries. Herein, we provide a narrative and illustrative overview regarding these complex experimental procedures and their particular requirements, reflecting on current evidence and future research perspectives.

Prevalenca e kanalit retromolar–rishikim i literaturës

The retromolar canal is an anatomical variation located in the posterior part of the mandible. The retromolar canal contains the accessory neurovascular bundle of the inferior alveolar nerve and myelinating fibers of the buccal nerve. The prevalence of retromolar canal with panoramic radiography varies from 0.08–8.3%, while with cone beam computed tomography (CBCT) it varies 10–66%, so knowledge about retromolar canal would facilitate oral surgical treatment in the retromolar area, avoiding complications resulting from damage to its contents.