Optimal Surgical Planning Research Articles

Thoracic and lumbar spine pedicle morphology in Japanese patients.

Pedicle morphology is important for intraoperative surgical anatomy and to define pedicle screw design and parameters. However, differences of pedicle size according to ethnicity and gender are not well studied. The purpose of this study is to investigate morphological characteristics of the pedicle in Japanese patients for determining adequate screw size and optimal surgical planning. We investigated thoracic and lumbar pedicle morphology in Japanese patients using computed tomography (CT) measurements and analyzed the standard size of pedicles on upper thoracic to lumbar spine CT images in 227 Japanese patients. Gender had a larger impact on the shape and size of pedicles than racial differences. In the distribution of pedicle width, we calculated the ratio of values less than 4.5mm, that in females resulted to be over 30% for the Th3-Th9 segment, and particularly high, above 60% at Th4 and Th5. Our measurement analysis showed that pedicle morphological parameters in Japanese patients showed tendency to be smaller to those found in other studies, and particularly in female patients, they were statistically significantly smaller. Adequate transpedicular instrumentation for Japanese patients will require smaller size pedicle-related devices that will match our anatomical findings to achieve safe device placement. In addition, serving ethnically non-homogenous patient population can require further to spinal morphometric for precise device selection.

Facial microcystic adnexal carcinoma — treatment with a “jigsaw puzzle” advancement flap and immediate esthetic reconstruction: A case report

BACKGROUNDMicrocystic adnexal carcinoma (MAC) is a rare malignant tumor of the skin that is commonly found on the face. It grows slowly and has a low mortality rate. However, for various reasons, including strong histological invasiveness, clinical inexperience and inadequate procedure design, immediate or permanent facial deformity may occur after surgical operations.CASE SUMMARYThis article describes a middle-aged female artist who was diagnosed with MAC on the left upper lip. She declined the recommended treatment plan, which included two-stage reconstruction, skin grafting, or surgery that could have resulted in obvious facial dysfunction or esthetic deformity. We accurately designed a personalized procedure involving a “jigsaw puzzle advancement flap” for the patient based on the lesion location and the estimated area of skin loss. The procedure was successful; both pathological R0 resection and immediate and long-term esthetic reconstruction effects were achieved.CONCLUSIONThis study suggests that when treating facial MAC or other skin malignancies, a surgical team should have sufficient plastic surgery-related knowledge and skills. An optimal surgical plan for an individual is needed to achieve good facial esthetics and functional recovery and shorten the treatment course.

Evaluation of complex congenital heart disease in infants using low dose cardiac computed tomography.

Despite advances in new CT techniques with radiation dose reduction, there are limited studies describing radiation dose. Describing radiation dose might help to educate physicians on how the benefit of cardiac CT outweighs the potential risk of radiation. The aim of this study was to describe the radiation exposure parameters in newborns and infants and the role of CT scan in providing useful information for optimal surgical planning and management of newborns and infants with complex congenital heart disease. In complex congenital heart disease delineating the anatomy and using the CT images as needed for three-dimensional modelling helps for optimal surgical planning. This single center, retrospective study included 74 infants with CHD (median age 2 months, range 1day to 9 months) who underwent cardiac CT evaluation from September 2018 to April 2019, using the Siemens Somatom Definition Edge scanner. Total dose length product (DLP) and computed tomographic dose index volume (CTDIvol) were recorded, and the estimated effective radiation dose was calculated using a previously published conversion rate. Median effective radiation dose for the computed tomographic angiography (CTA) was 0.6mSv. The median DLP was 13 mGycm and median CTDIvol was 3.5mGy. Cardiac CT can be done with a sub-mSv dose in infants. Cardiac CT completes the standard initial evaluation of neonates and infants with complex CHD, allowing thorough understanding of complex spatial relationships between anatomical and defective structures, and is achievable with minimal radiation exposure.

Image-Guidance for Non-Anatomical Liver Resections: An ex-vivo Study

Introduction: Non-anatomical resections of liver tumors are becoming more popular because they spare a larger portion of healthy liver parenchyma. However, the lack of anatomical landmarks to follow during the resection process makes them technically more challenging than anatomical resections. Image-guidance systems have been introduced to provide additional guidance, but are rarely used due to their inaccuracy, time-effort and complexity in usage and setup. Therefore, we have designed a new navigation approach that renders a surgical plan intra-operatively in real time using only navigated ultrasound. Method: The ultrasound based navigation approach comprises the following steps:i)scanning the surface using the navigated ultrasound,ii)marking the tumor location and size on a midsection ultrasound image,iii)specifying a resection shape and a safety margin to create an optimal surgical plan. In this study, we evaluated this method in an ex-vivo porcine model by three experienced hepatobiliary surgeons with respect to R0 resection status. Results: In 22 out of 23 resections an R0 resection (margin > 1mm) was achieved (95.7%) with a median resection margin of 5.9 mm (IQR 3.5 - 7.7 mm). There was a difference between the surgeons in terms of resection margin with operators 1,2 and 3 having 7.8 mm, 4.15 mm and 5.1 mm median resection margin respectively (p = 0.054). Conclusions: This navigation approach could represent a useful tool for intra-operative guidance in non-anatomical resection alongside conventional ultrasound guidance. A clinical pilot trial with 10 patients is currently in planning and will start beginning of 2020.

Optimizing accuracy of freehand cannulation of the ipsilateral ventricle for intracranial pressure monitoring in patients with brain trauma.

Intracranial pressure (ICP) monitoring in traumatic brain injury (TBI) usually requires the placement of a catheter into the ipsilateral ventricle. This surgical procedure is commonly performed via a freehand method using surface anatomical landmarks as guides. The current accuracy of the catheter placement remains relatively low and even lower among TBI patients. This study was undertaken to optimize the freehand ventricular cannulation to increase the accuracy for TBI. The authors hypothesized that an optimal surgical plan of cannulation should give an operator the greatest degrees of freedom, which could be measured as the range of operation angle, range of catheter placement depth, and size of the target area. An imaging simulation was first performed using the computed tomography (CT) images of 47 adult patients with normal brain anatomy. On the reconstructed 3D head model, four different coronal planes of ventricular cannulation were identified: a 4-cm anterior, a 2-cm anterior, a standard (central), and a 2-cm posterior plane. The degrees of freedom during the cannulation procedure were determined, including the relevant angles, lengths of cannulation, cross-sectional area, and bounding rectangle of the lateral ventricle. Next, a retrospective assessment was performed on the CT scans of another 111 patients with TBI who underwent freehand ventricular cannulation for ICP monitoring. Postoperative measurements were also performed based on CT images to calculate the accuracy and safety of catheter placement between coronal planes in practice. Our simulation results showed that the 2-cm anterior plane had more extensive degrees of freedom for ventricular cannulation, in terms of length of catheter trajectory (7% longer, P<0.001), cross-sectional area of the lateral ventricle (14% larger, P=0.046), and length of the lateral ventricle (17% wider, P<0.001) than that of the standard plane, while both the 4-cm anterior and 2-cm posterior planes did not offer advantages over the standard plane in these ways. The mean length range of catheter trajectory in the 2-cm anterior plane was 41 to 58 mm. Retrospective assessment of TBI patients with ICP monitor placement also confirmed our simulation data. It showed that the accuracy of ipsilateral ventricle cannulation in the 2-cm anterior plane was 70.6%, which was a significant increase from 42.9% in the standard plane (P=0.007). Our imaging simulation and retrospective study demonstrate that different coronal planes could provide different degrees of freedom for cannulation, the 2-cm anterior plane has the greatest degrees of freedom in terms of larger target area and greater length range of the trajectory. The optimized surgical plan in this manner could improve cannulation accuracy and benefit a significant number of TBI patients.

Assessing Secondary Upper Extremity Lymphedema Patients for Surgical Intervention

AIM: To evaluate preoperative assessment clinical tools forsecondary upper extremity lymphedema surgical candidates. METHODS: A prospective cohort study performed at a tertiary cancer center secondary lymphedema outpatient clinic. Lymphedema evaluation included limb volume measurements, bioimpedance, indocyanine green lymphography, lymphoscintigraphy, magnetic resonance angiography (MRA), lymphedema life impact scale, and upper limb lymphedema 27 (ULL-27) questionnaires. RESULTS: A total of 118 patients were evaluated. Limb circumference difference underestimated lymphedema diagnosis compared to limb volume excess. Bioimpedance (L-Dex) scores highly correlated with limb volume excess (r2 = 0.714; P < 0.001). L-Dex scores were highly sensitive and had a high positive predictive value for diagnosing lymphedema in patients with a volume excess of 10% or more. Indocyanine green was highly sensitive in identifying lymphedema. Lymphoscintigraphy had an overall low sensitivity and specificity for the diagnosis of lymphedema. MRA was highly sensitive in diagnosing lymphedema and adipose hypertrophy as well as useful in identifying axillary vein obstruction and occult metastasis. Patients with minimal limb volume difference still demonstrated significantly impaired quality of life. CONCLUSION: Preoperative assessment of lymphedema is complex and requires multimodal assessment. MRA, L-Dex, ICG, and PROMs are all valuable components of preoperative assessment. Lymphedema clinicians can use these tools findings accordingly to tailor an optimal surgical plan for each patient.

An analysis of surgical management of difficulties during cochlear implant with inner ear anomalies

Objective:The purpose of this study is to review the difficulties that can occur during cochlear implant surgery in patients with inner ear abnormalities and the management. Method:A retrospective analysis was made on 186 cases of cochlear implant with inner ear malformation, the types of inner ear malformations included 6 cases（3.23%） of isolated semicircular dysplasia, 137 cases（73.66%） of isolated large vestibular aqueducts, 26 cases（13.98%） of Mondini malformations, 6 cases（3.23%） of incomplete septal type Ⅲ, 3 cases（1.61%） of internal auditory stenosis, 7 cases（3.76%） of cochlear dysplasia and 1 case（0.54%） of incomplete septal typeⅠ. Two hundred patients with normal inner ear structures were randomly selected as the control group. The data collected included the types of inner ear abnormalities, intraoperative manifestations, clinical management strategies, and postoperative speech rehabilitation, and the literature was reviewed. Result:148 patients（77.49%） with inner ear malformation underwent successful surgery, electrode insertion was incomplete in 6 patients（3.14%）, and cerebrospinal fluid blowout occurred in 29 patients（15.18%）, it was difficult to locate the window because of the abnormal structure of the window in 8 cases（4.19%）. In 191 patients, the facial recess approach was adopted intraoperatively, and 17.8% of the patients had significant structural abnormalities of the facial nerve, significantly more than the group with normal inner ear structure. Only 1 patient showed delayed facial nerve paralysis 1 week after surgery, and recovered well after treatment. 6.81% of the patients adopted the expanded round window approach, which was significantly lower than that of the group with normal inner ear structure（28%）. There was no significant difference between patients with inner ear malformation and patients with extremely severe deafness with normal inner ear structure who received cochlear implant in speech rehabilitation. Conclusion:Cochlear implant is safe, feasible and effective for patients with inner ear malformation. For patients with inner ear malformation, special attention should be paid to the preoperative imaging reading to predict the possible risks during the operation. The safest surgical plan, including the type of electrode and the manner in which the window is opened, must be prepared before the operation, and the operation must be performed or directed by an experienced surgeon who can adjust the optimal surgical plan according to what is seen during the operation.

Outcomes of mitral valve re-replacement for bioprosthetic structural valve deterioration

ObjectivesReoperation for structural valve deterioration (SVD) of bioprosthetic mitral valves carries a presumed high operative risk, and transcatheter mitral valve-in-valve implantation has emerged as an alternative. However, surgical risk and long-term outcome following mitral valve re-replacement in these patients remain ill-defined. Hence, we sought to evaluate outcomes and long-term survival following surgical mitral valve re-replacement and to identify risk factors for mortality. MethodsFrom January 1990 to January 2017, 525 patients underwent surgical mitral valve re-replacement at Cleveland Clinic for bioprosthetic SVD: 133 (25%) isolated operations and 392 (75%) with concomitant procedures. Surgical complications and modes of death were compiled, long-term mortality assessed, and risk factors identified using a multivariable nonproportional hazards model and random forest analysis. ResultsSVD was characterized by bioprosthetic regurgitation in 81% (425 out of 525) and stenosis in 44% (231 out of 525). One in-hospital death occurred after isolated valve re-replacement (0.75%) and 28 deaths occurred (7.1%; P = .003) after nonisolated re-replacement, 19 (68%) of which were from coagulopathy, vasoplegia, and multisystem organ failure. In the nonisolated group, incremental risk factors for time-related death after re-replacement included New York Heart Association functional class IV symptoms, concomitant coronary artery bypass grafting, prolonged cardiopulmonary bypass time, and transfusions. ConclusionsMitral valve re-replacement for bioprosthetic SVD was associated with low surgical risk and excellent long-term survival. Isolated mitral valve re-replacement for bioprosthetic SVD had near-zero surgical risk. Excessive cardiopulmonary bypass duration and multiple transfusions correlated with increased early mortality in nonisolated procedures, as did preoperative severe heart failure. Optimal surgical plan and timing of surgery are keys to success.

Development status and application of neuronavigation system

The neuronavigation system is a combination of navigation technology and neurosurgery. It can be used to assist in neurosurgery through three-dimensional reconstruction of medical image data, extraction of lesions, optimal surgical path planning, tracking and positioning of surgical instruments, and real-time intraoperative display. Accurate and maximal treatment of lesions, while effectively avoiding secondary injuries to patients during surgery. Therefore, the development and application of neuronavigation systems are reviewed.

Comparative Outcomes of Primary Arterial Switch Operation for Transposition of Great Arteries within the First Month of Life

Background: The optimal surgical plan to correct the simple transposition of the great arteries (TGA) is the arterial switch operation (ASO). This study aimed to assess the outcomes of ASO in infants with simple TGA with a special focus on the time of surgery. Methods: This retrospective study enrolled 105 infants with simple TGA who underwent ASO and categorized them into 3 groups based on the time of repair: first week of life: Group A; second week of life: Group B; and third week of life: Group C. The endpoints, comprised of an assessment of pre- and postoperative outcomes, complications, and survival, were compared between the groups. Results: The mean age of the infants was 10.50±6.26 days, and 61 (58.1%) cases were male. The mean number of days on dopamine was 1.85±0.12 in Group A, 2.48±0.03 in Group B, and 2.67±0.08 in Group C (P<0.001). The mean number of days on epinephrine was 1.25±0.07 in Group B and 1.27±0.08 in Group C (P<0.001). The mean number of days on the ventilator was 3.52±0.20 in Group A, 4.56±0.24 in Group B, and 5.06±0.21 in Group C (P<0.001). The mean number of days of ICU stay was 6.69±0.21 in Group A, 8.46±0.57 in Group B, and 9.70±0.64 in Group C (P<0.001). The infants in Group A had a greater survival rate (97.0%) than those in Group B (94.1%) and Group C (78.4%) (P=0.042). Conclusion: ASO in infants with simple TGA can be done within the first week of life with satisfactory outcomes and survival.

Pediatric Posterior Fossa Medulloblastoma: The Role of Diffusion Imaging in Identifying Molecular Groups.

The molecular groups WNT activated (WNT), Sonic hedgehog activated (SHH), group 3, and group 4 are biologically and clinically distinct forms of medulloblastoma. We evaluated apparent diffusion coefficient (ADC) values' utility in differentiating/predicting medulloblastoma groups at the initial diagnostic imaging evaluation and prior to surgery. We retrospectively measured the ADC values of the enhancing, solid portion of the tumor (EST) and of the whole tumor (WT) and performed Kruskal-Wallis testing to compare the absolute tumor ADC values and cerebellar and thalamic ratios of three medulloblastoma groups (WNT, SHH, and group 3/group 4 combined). Ninety-three children (65 males) were included. Fifty-seven children had group 3/group 4, 27 had SHH, and 9 had WNT medulloblastomas. The median absolute ADC values in the EST and WT were .719×10-3 and .864×10-3 mm2 /s for group 3/group 4; .660×10-3 and .965×10-3 mm2 /s for SHH; and .594×10-3 and .728×10-3 mm2 /s for WNT medulloblastomas (P = .02 and .13). The median ratio of ADC values in the EST or the WT to normal cerebellar tissue was highest for group 3/group 4 and lowest for WNT medulloblastomas (P = .03 and .09), with similar results in pairwise comparisons of the corresponding thalamic ADC values (P = .02 and .06). ADC analysis of a tumor's contrast-enhancing solid portion may aid preoperative molecular classification/prediction of pediatric medulloblastomas and may facilitate optimal surgical treatment planning, reducing surgery-induced morbidity.

Unique characterization of complex endocarditic vegetations using 3D TOE

SummaryA 31-year-old male was admitted with suspected infective endocarditis, given a history of i.v. drug use, lung and cerebral abscesses and Staphylococcus aureus bacteraemia. TTE imaging was limited given supine positioning and mechanical ventilation but suggested a posterior mitral valve leaflet (PMVL) mass. Three-dimensional TOE provided uniquely detailed assessment of two complex infective masses. The attachment of the presumed P2 mass on TTE was indeterminant even on 2D-TOE, appearing attached to the PMVL or AMVL depending on rotational view (Fig. 1). 3D-TOE imaging and subsequent multiplanar and volume-rendered reconstruction revealed this to be a complex, large vegetation attached to the anterior aspect of the anterolateral commissure with mobile heads prolapsing into the left atrium and causing mild mitral regurgitation through a small basal perforation (Figs 2, 3 and Video 1). The second mass was a filamentous vegetation attached to the LVOT, prolapsing towards but not contacting the aortic valve (Fig. 4 and Video 2). Comprehensive assessment of complex vegetations is crucial for optimal surgical planning. 3D-TOE allows rapid, accurate, unique assessment of such masses through unlimited multiplanar reconstructions, volume-rendered real-time imaging and colour full-volume regurgitation assessment which may not always possible on 2D-TTE or 2D-TOE. 3D imaging should be routinely used in TOE and in particular in suspected endocarditis.

Polydactyly Of The Foot Repair With Circumferential Racquet-Shaped Incision Technique And Collateral Ligament Reconstruction: Case Report And Literature Reviews

&#x0D; &#x0D; &#x0D; &#x0D; Introduction: Polydactyly of the foot is the most common anomaly in congenital diseases. This abnormality is characterized by the presence of additional digits outside the normal complement of the foot. Polydactyly has reported about 1 in 1,000 births. The Watanabe classification is used in assessing polydactyly in the feet as a fifth ray duplication. Various operating techniques can sometimes be an option. Each method has advantages and disadvantages that can be considered in the selection of surgical in the correction polydactyly.&#x0D; Patient and Method: we report a case of polydactyly of the foot reconstruction using circumferential racquet-shaped incision, osteotomy and collateral ligament reconstruction that was carried out at Bahteramas Hospital, Kendari. A circumferential racquet-shaped incision design was performed over the sixth MTP joint. Complete excision of the lateral sixth toe was performed, followed by osteotomy of the fifth metatarsal lateral head with a micro-sagittal oscillating saw. The collateral ligament was reconstructed using ligamentoperiosteal flap and fixed using syringe needle to replace K-Wire.&#x0D; Result : After postoperative control for 3 months the patient was declared good wound healingConclusion: Optimal surgical planning, good patient orientation and surgical techniques that are carefully considered are essential for optimal results. Herein, we report a case of polydactyly and racquet shaped incision technique performed to reconstruct the polydactyly.&#x0D; &#x0D; &#x0D; &#x0D;

Treatment Of Palatoplasty Repair With Von Langenbeck Technique And Hemostatic Absorbable Gelatin: Case Report And Literature Reviews

Background: Cleft is a common congenital abnormality in the lip and palate. Cleft palate or palatoschisis is a congenital abnormality occured during pregnancy, resulting in cleft of the palate that does not coalesce into the nasal cavity area, so there is a relationship between the nasal cavity and mouth. Various surgical techniques for cleft palate correction can be used and each method has advantages and disadvantages.&#x0D; Patient and Method: Here, we report a case of palatoschisis reconstruction using Von Langenbeck technique and hemostatic absorbable gelatin that was carried out at Aliyah 3 Hospital, Kendari.&#x0D; Result: After initial diagnosis, the patient underwent surgery about two weeks later. Von Langenback palatoplasty was performed to close the palate defect. The defect then closed primarily with 4/0 optime and 6/0 corolene.&#x0D; Conclusion: Optimal surgical planning, good patient orientation and surgical techniques that are carefully considered are essential for optimal results. Herein, we report a case of palatoschisis and reconstructive surgery using von Langenback technique performed to restore the cleft of palate.

Ischemic mitral regurgitation: modern evidence based echocardiography diagnosis, quantification and risks stratification review

Ischemic mitral regurgitation (IMR) is a frequent complication in the patients after acute myocardial infarction (AMI) or in ischemic cardiomyopathy (ICM), associated with significant prognosis worsening. Mitral valve (MV) involvement may be primary (organic MR) or secondary (functional MR). Primary MR develops because of mitral subvalvular apparatus rupture as an AMI complication. Secondary IMR develops in the conditions of normal MV cusps and chords structure because of balance impairment between MV closure and tension forces secondary to left ventricle (LV) geometry alterations. According to evidence data both scenarios of IMR are associated with at least one major coronary artery critical stenosis (&gt;70%). Secondary IMR is the most frequent consequence of ischemic cardiomyopathy. IMR diagnosis is associated with elevated patients mortality compared to those without it. It has been shown, that survival within patients with IMR after AMI down to 40% in case of moderate-to-severe IMR, compared to 62% in the patients with mild IMR or 84% in the patients without IMR at all. Pathophysiological mechanisms of IMR are not fully understood, but it is well known, that IMR is a complex entity, having left chambers, especially left ventricle (LV) remodeling as a key cause. Echocardiography (EchoCG) significantly contributes to understanding the underlying mechanisms of IMR. The aim of this review is to summarize modern evidence based data about IMR mechanisms and analysis of contemporary EchoCG indices for diagnosis, evaluation and risks stratification in the patients with IMR. IMR develops in approximately 20% of patients after AMI with increasing occurrence over past years, significantly influencing patients’ prognosis. IMR is a complex and dynamic entity, where LV remodeling is the main factor of MV dysfunction. EchoCG plays the clue role in IMR diagnosis giving the detailed information about its mechanisms and severity grading. Comprehensive EchoCG in the patients with coronary arteries disease (CAD) allows a better and comprehensive approach in risks stratification and optimal surgical IMR treatment planning.

Application value of Revolution CT combining three-dimensional visualization technique in precision resection of hepatic alveolar echinococcosis

To explore the application value of Revolution CT combining three -dimensional visualization technique in the precision resection of hepatic alveolar echinococcosis. Totally 12 patients with surgical treatment and pathologically confirmed hepatic alveolar echinococcosis in Qinghai Provincial People's Hospital were retrospectively analyzed. All the patients underwent the Revolution CT plain and enhancement scan before surgery, and the 0.625 millimeter scan data were obtained. The DICOM format data were imported into MI-3DVS for three-dimensional reconstruction, simulated cutting, volume measurement, and surgical planning. The data of 12 patients were reconstructed successfully, and the sizes and locations of the lesions as well as the hepatic vascular systems were clearly displayed. The liver volume, hydatid volume, simulated resection volume, and residual liver ratio were measured accurately. The average whole liver volume and the lesion volume of the 11 surgical treated patients were (2 429.8 ± 335.9) mL and (919.6 ± 262.8) mL respectively. The average actually removed volume was highly associated with the average simulated resection volume (r = 0.979, P < 0.01). Revolution CT combining three-dimensional visualization technique can achieve accurate diagnosis as well as optimal surgical planning before operation, which is of great value for the precision resection of difficult hepatic alveolar echinococcosis.

Clinical, diagnostic imaging, surgical findings and long-term outcome in a Cavalier King Charles Spaniel with thoracolumbar vertebral articular process hyperplasia

A 2-year-old female spayed Cavalier King Charles Spaniel presented with 10-day history of progressive painful T3–L3 myelopathy. MRI of the spine revealed an extradural dorsal spinal cord compression at the...

Surgical Outcomes after Abdominoperineal Resection with Sacrectomy and Soft Tissue Reconstruction: Lessons Learned.

Abdominoperineal resection (APR), which involves resection of the rectum, anal canal, and perianal skin, results in a large dead space in the pelvis, devascularized tissues, and high bacterial loads. This predisposes to wound complications, especially in the setting of neoadjuvant chemoradiotherapy. Additional sacral resection further compounds these effects. We aimed to assess perineal wound outcomes and complications in patients who underwent flap reconstruction for APR with sacrectomy (APRS) at our institution. We reviewed the charts of all patients who underwent flap reconstruction for APRS over a 20-year period (1999-2018). Medical comorbidities, details of the surgical procedure, and major and minor wound complications were recorded and analyzed. Forty-six patients underwent flap reconstruction following APRS-28 (60%) for colorectal cancer, 8 (17%) for sacral chordoma, and 10 diagnosed with other malignant histologies. Rectus abdominis myocutaneous (RAM) flap reconstruction was used in 42 patients (91%). The median time to the first major perineal complication was 111 days (interquartile range: 22-660 days). Half of our cohort (n = 23) experienced a major perineal complication. No significant differences were found in major or minor perineal or abdominal wall complications between RAM flap and other flaps. APR with high sacrectomy was performed in 27 patients (59%) and was associated with significantly increased full-thickness dehiscence in the perineal region when compared with APR with low sacrectomy, 33 versus 0%, respectively (p = 0.0076). Complete flap loss occurred in one patient. The RAM flap was the workhorse flap for pelvic reconstruction following APRS in our cohort. Wound complications are common following APRS. High sacrectomy is associated with higher incidence of complications compared with low sacrectomy. Optimal surgical planning and patient counseling is fundamental to improve current surgical outcomes.

3D imaging applications for robotic urologic surgery: an ESUT YAUWP review.

Despite the current era of precision surgery in robotics, an unmet need still remains for optimal surgical planning and navigation for most genitourinary diseases. 3D virtual reconstruction of 2D cross-sectional imaging has been increasingly adopted to help surgeons better understand the surgical anatomy. To provide a short overview of the most recent evidence on current applications of 3D imaging in robotic urologic surgery. A non-systematic review of the literature was performed. Medline, PubMed, the Cochrane Database and Embase were screened for studies regarding the use of 3D models in robotic urology. 3D reconstruction technology creates 3D virtual and printed models that first appeared in urology to aid surgical planning and intraoperative navigation, especially in the treatment of oncological diseases of the prostate and kidneys. The latest revolution in the field involves models overlapping onto the real anatomy and performing augmented reality procedures. 3D virtual/printing technology has entered daily practice in some tertiary centres, especially for the management of urological tumours. The 3D models can be virtual or printed, and can help the surgeon in surgical planning, physician education and training, and patient counselling. Moreover, integration of robotic platforms with the 3D models and the possibility of performing augmented reality surgeries increase the surgeon's confidence with the pathology, with potential benefits in precision and tailoring of the procedures.

The planning, simulating and executing for the surgery of bilateral renal masses used the three-dimensional intelligent qualitative and quantitative analysis system(IQQA)

Objective To explore the application of three-dimensional intelligent qualitative and quantitative analysis system (IQQA) in the planning, simulation and implementation of precise surgery for bilateral renal tumors. Methods A retrospective analysis a total of 7 patients with bilateral kidney tumors in our center from June 2017 to August 2018 was performed. There were 5 males and 2 females, with an average age of (54.6±6.0)years , ranging 47.0-63.0 years. The average BMI index was (23.4±2.4) kg/m2, ranging 21.2-28.0 kg/m2. The average diameter of 14 renal tumors in 7 patients was (3.8±1.1) cm, ranging 1.9-5.3 cm. The average R. E.N.A.L score was 6.6±1.2 , ranging 5.0-9.0. The tumor stage was T1N0M0. The mean preoperative hemoglobin, albumin, creatinine and GFR were (138.6±17.0)g/L and (47.3±2.5 g/L), (51.6±19.1)μmol /Land (56.9±6.7)ml/min, respectively. Before operation, the original data of CT were input into IQQA system. Then we reconstructed kidney, blood vessel, collecting system and tumors using system. And the structure of kidney, tumors and vessels was visualized directly. The systematic analysis of the operation is carried out at terminals vary from various angles, and the surgical resection simulation. The position, angle and curvature of the cut surface are adjusted according to the effect. The plan of partial nephrectomy is designed. The resection area, remaining area of kidney is calculated. In this way, we can construct individualized and accurate laparoscopic partial nephrectomy planning before operation. Last, we carried out the operation according to the designed plan. The laparoscopic standard partial nephrectomy was performed in 11 cases. The laparoscopic selective partial nephrectomy was performed in 2 cases. One underwent laparoscopic partial nephrectomy without obstruction. We achieved precise resection of tumors and rapid suture of wounds according to the preoperative planning of excision and suture. We collected of the surgical success rate, conversion to opening rate, operation time, warm ischemia time, intraoperative bleeding volume, complications and hospitalization after operation. The related laboratory indicators such as eGFR and creatinine were followed up for 3 months, and the prognostic indicators such as renal CT and pulmonary CT for 6 months after operation were evaluated and analyzed. Result 14 renal tumors were successfully reconstructed by IQQA in 7 patients. The operations were completed successfully without conversion to open surgery or radical nephrectomy. The average operative duration was (68.9±9.2) minutes, ranging 50.0-80.0 minutes. The average renal artery occlusion duration was (20.7±4.1) minutes, ranging 15.0-29.0 minutes. The average intraoperative bleeding volume was (70.7±29.7) ml, ranging 30.0-120.0 ml. The average indwelling time of drainage tube was (5.5±0.7) days, ranging 5.0-7.0 days. The average hospitalization time was (6.3±0.5) days, ranging 6.0-7.0 days. There were no perioperative complications such as bleeding, urinary leakage, infection, incision dehiscence and pulmonary infection. Postoperative pathology revealed 13 clear cell renal carcinoma and 1 renal angiomyoma. No recurrence or metastasis was found in chest CT and lung CT after 6 months follow-up. The creatinine and GFR in 3 months after operation were (52.0±15.2)μmol/L(36.0-72.0 μmol/L)and (56.7±5.3)ml/min(46.7-66.3 ml/min). There was no significant difference of creatinine and GFR with the preoperative (P>0.05). The mean Hb and albumin levels in 3 months after operation were (120.9±17.0)g/L(90.0-147.0 g/L) and (41.4±2.6)g/L(38.0-46.0 g/L), which were significantly lower than those before operation (P<0.05). Conclusions The three-dimensional intelligent qualitative and quantitative analysis system (IQQA) can visualize the kidney, tumor and the vasculature of bilateral kidney tumors by preoperative three-dimensional reconstruction. The optimal surgical plan of partial nephrectomy can be designed by preoperative operation planning and computer terminal in order to enhance the safety of partial nephrectomy for bilateral kidney tumors and preserve the possibility of kidney, and protect the renal function to the greatest extent. To accurately predict the retention of renal function after operation, so that patients with bilateral renal tumors can get the greatest benefit in partial nephrectomy. Key words: Bilateral renal tumors; Intelligent qualitative and quantitative analysis; Laparoscopic partial nephrectomy; Surgical planning