Postoperative Computed Tomography Imaging Research Articles

Endoscopic Transclival Approach for Evacuation of Retroclival Hematoma: 2-Dimensional Operative Video.

Retroclival hematomas are a rare entity, presenting anteriorly to the brainstem in the epidural, subdural, or subarachnoid space. Although those that develop in the epidural space often arise from trauma, subdural retroclival hematomas frequently occur spontaneously in the setting of coagulopathy, aneurysm rupture, or pituitary apoplexy, with many cases having an unknown etiology.1-4 Although most are treated with conservative management, surgical intervention is preferred for those presenting with evidence of brainstem compression, hydrocephalus, worsening neurological deficits, and clinical deterioration.5 In this report, we present the case of a 75-year-old woman with a medical history of mitral regurgitation, nonischemic cardiomyopathy, and atrial fibrillation on warfarin presenting with 4 days of temporoparietal headaches and double vision. On examination, the patient demonstrated right abducens and hypoglossal nerve palsies. Computed tomography revealed a subdural hemorrhage within the retroclival cistern, extending into the dorsal inferior aspect of the C2 vertebral body, resulting in posterior displacement of the pons, medulla, and proximal cervical spinal cord. Spinal and cerebral angiograms did not show evidence of any vascular malformation. An endoscopic transclival approach was selected for hematoma evacuation. Key surgical steps included harvesting of nasoseptal flap, endoscopic transnasal approach to the sellar/subsellar space, transclival drilling, retroclival hematoma evacuation, and clival reconstruction. The patient tolerated the procedure well and was discharged 15 days postoperatively with resolution of prior cranial nerve deficits. Postoperative computed tomography imaging revealed complete retroclival hematoma evacuation. At her 3-month follow-up, the patient remained neurologically intact with imaging confirming no residual subdural hematoma. Institutional Review Board approval was obtained for this submission (2018-9379). Patient consent was not obtained as personal identifying information was kept confidential, following guidelines set forth by Institutional Review Board requirements.

An analysis of residual lung volume changes after segmentectomy based on three-dimensional computed tomography.

Based on the results of JCOG0802 and CALGB studies, segmentectomy has considered to be a standard procedure for early-stage non-small cell lung cancer (NSCLC). After lobectomy, the residual cavity is filled with mediastinal and diaphragmatic deviations, and compensatory volume changes are present in the residual lungs. In this study, we examined the efficacy of segmentectomy, a surgical procedure, by focusing on its impact on postoperative lung volume and function. We enrolled 77 patients who underwent segmentectomy as their initial surgical procedure, excluding those with additional lung resections and those who lacked postoperative computed tomography imaging. The predicted residual volume (mL) was defined as the total lung volume before surgery minus the volume of the resected area. Using the predicted residual volume (mL) and postoperative total lung volume (mL), we calculated the rate of postoperative lung volume increase [(postoperative total lung volume/predicted residual volume) × 100] (%). We also classified 52 cases with a rate of postoperative lung volume increase of ≥100% into a compensatory group, while those with a rate of <100% were classified into a non-compensatory group. The average postoperative lung volume increase was 104.6% among 77 cases. Age ≥65 years, pack year index ≥27.5, ≥3 resected segments, and use of electrocautery for intersegmental plane division were significantly associated with compensatory group classification. In 20 compensatory cases with preoperative and postoperative pulmonary function tests, postoperative vital capacity and forced expiratory volume in one second values exceeded the preoperative predictions. This study further examined the areas responsible for postoperative compensatory lung volume increase. In the compensatory group, significant expansion was observed in the ipsilateral lobes, excluding the resected segment and contralateral lung, while no significant changes were noted in the volume of the lobe, including the resected segment. Conversely, the non-compensatory group showed a significant volume decrease in the resected lobe, but no significant increase in other areas. This study emphasizes the importance of preserving lung segments in segmentectomy. The study demonstrates extensive compensatory volume changes in the ipsilateral lung and contralateral lung. There was no significant volume decrease in any residual segment. This underlines the potential of segmentectomy to maintain lung function and expand treatment options post-surgery. In addition, the compensated group included patients with a lower pack-year index and younger patients. These results suggest that postoperative compensatory lung expansion includes not only hyperinflation of the remaining lung, but also an increase in the functional lung parenchyma.

Plug-Based Embolization Techniques of Aortic Side Branches during Standard and Complex Endovascular Aortic Repair.

Vascular plugs are an evolving family of vessel occluders providing a single-device embolization system for large, high-flow arteries. Nitinol mesh plugs and polytetrafluoroethylene membrane plugs are available in different configurations and sizes to occlude arteries from 3 to 20 mm in diameter. Possible applications during complex endovascular aortic procedures are aortic branch embolization to prevent endoleak or to gain an adequate landing zone, directional branch occlusion, and false lumen embolization in aortic dissection. Plugs are delivered through catheters or introducers, and their technical and clinical results are comparable to those of coil embolization. Plugs are more accurate than coils as repositionable devices, less prone to migration, and have fewer blooming artifacts on postoperative computed tomography imaging. Their main drawback is the need for larger delivery systems. This narrative review describes up-to-date techniques and technology for plug embolization in complex aortic repair.

Reducing Postoperative CT Imaging for Children With Complicated Appendicitis: A Pediatric Surgical Quality Collaborative Quality Improvement Project

BackgroundDespite widespread initiatives to reduce ionizing radiation for appendicitis diagnosis, computed tomography (CT) scanning postoperatively remains common. The Pediatric Surgery Quality Collaborative (PSQC) aimed to identify differences between children's hospitals with high and low postoperative CT usage for complicated appendicitis. MethodsUsing National Surgery Quality Improvement Program Pediatric data from PSQC children's hospitals, we compared postoperative CT imaging for complicated appendicitis (April 2020–March 2021). Key stakeholders from 11 hospitals (5 low CT utilization, 6 high CT utilization) participated in semi-structured interviews regarding postoperative imaging. Qualitative analysis of transcripts was performed deductively and inductively based on the Theoretical Domains Framework (TDF). ResultsFive of twelve TDF domains were most prominent in influencing CT use: skills, beliefs about capabilities, intentions/goals, memory and decision processes, and environment. Children's hospitals with lower rates of postoperative CT use tended to: trust and educate the ultrasound technicians; believe US strengths outweigh weaknesses; image no sooner than 7 days postoperatively; have access to sufficient quality improvement resources; maintain trusting relationships between specialties; and prioritize radiation stewardship. ConclusionHospitals at extremes of postoperative CT use for complicated appendicitis reveal strategies for improvement, which include imaging protocol development and adherence, quality improvement resource availability, interdisciplinary collaboration, and promoting radiation stewardship. Level of EvidenceLevel V.

Inner Ear Breaches from Vestibular Schwannoma Surgery: Revisiting the Incidence of Otologic Injury from Retrosigmoid and Middle Cranial Fossa Approaches.

To assess the rate of iatrogenic injury to the inner ear in vestibular schwannoma resections. Retrospective case review. Multiple academic tertiary care hospitals. Patients who underwent retrosigmoid or middle cranial fossa approaches for vestibular schwannoma resection between 1993 and 2015. Diagnostic with therapeutic implications. Drilling breach of the inner ear as confirmed by operative note or postoperative computed tomography (CT). 21.5% of patients undergoing either retrosigmoid or middle fossa approaches to the internal auditory canal were identified with a breach of the vestibulocochlear system. Because of the lack of postoperative CT imaging in this cohort, this is likely an underestimation of the true incidence of inner ear breaches. Of all postoperative CT scans reviewed, 51.8% had an inner ear breach. As there may be bias in patients undergoing postoperative CT, a middle figure based on sensitivity analyses estimates the incidence of inner ear breaches from lateral skull base surgery to be 34.7%. A high percentage of vestibular schwannoma surgeries via retrosigmoid and middle cranial fossa approaches result in drilling breaches of the inner ear. This study reinforces the value of preoperative image analysis for determining risk of inner ear breaches during vestibular schwannoma surgery and the importance of acquiring CT studies postoperatively to evaluate the integrity of the inner ear.

An in vivo study to investigate an original intramedullary bone graft harvesting technology

BackgroundHarvesting bone graft (BG) from the intramedullary canal to treat bone defects is largely conducted using the Reamer–Irrigator–Aspirator (RIA) system. The RIA system uses irrigation fluid during harvesting, which may result in washout of osteoinductive factors. Here, we propose a new harvesting technology dedicated to improving BG collection without the potential washout effect of osteoinductive factors associated with irrigation fluid. This novel technology involves the conceptual approach of first aspirating the bone marrow (BM) with a novel aspirator prototype, followed by reaming with standard reamers and collecting the bone chips with the aspirator (reaming–aspiration method, R–A method). The aim of this study was to assess the harvesting efficacy and osteoinductive profile of the BG harvested with RIA 2 system (RIA 2 group) compared to the novel harvesting concept (aspirator + R–A method, ARA group).MethodsPre-planning computed tomography (CT) imaging was conducted on 16 sheep to determine the femoral isthmus canal diameter. In this non-recovery study, sheep were divided into two groups: RIA 2 group (n = 8) and ARA group (n = 8). We measured BG weight collected from left femur and determined femoral cortical bone volume reduction in postoperative CT imaging. Growth factor and inflammatory cytokine amounts of the BGs were quantified using enzyme-linked immunosorbent assay (ELISA) methods.ResultsThe use of the stand-alone novel aspirator in BM collection, and in harvesting BG when the aspirator is used in conjunction with sequential reaming (R–A method) was proven feasible. ELISA results showed that the collected BG contained relevant amounts of growth factors and inflammatory cytokines in both the RIA 2 and the ARA group.ConclusionsHere, we present the first results of an innovative concept for harvesting intramedullary BG. It is a prototype of a novel aspirator technology that enables the stepwise harvesting of first BM and subsequent bone chips from the intramedullary canal of long bones. Both the BG collected with the RIA 2 system and the aspirator prototype had the capacity to preserve the BG’s osteoinductive microenvironment. Future in vivo studies are required to confirm the bone regenerative capacity of BG harvested with the innovative harvesting technology.

The Clinical Outcomes of Syndesmotic Flexible Fixation for Syndesmotic Injury With Ankle Fracture.

We evaluated whether the quality of syndesmotic reduction affects the short-term clinical outcomes of flexible fixation in patients with a rotational ankle fracture. This study included 59 patients (32 men and 27 women) who underwent syndesmotic flexible fixation. The degree of syndesmotic reduction was evaluated on computed tomography (CT) images acquired within 3 days after surgery. We measured the divergence between anterior and posterior incisura at 1 cm above the distal tibial articular joint, then evaluated the degree of fibular rotation relative to the tibia. At 1 year after surgery, an objective clinical evaluation was performed using the American Orthopaedic Foot & Ankle Society (AOFAS) score, the visual analog scale (VAS), and the Foot and Ankle Outcome Score (FAOS). Additionally, repeat arthroscopy was performed during routine implant removal at nearly 1 year postoperatively. Among 59 patients who underwent syndesmotic flexible fixation, 56 patients had syndesmotic stability on repeat arthroscopy. At 1 year postoperation, AOFAS, VAS, and FAOS scores were, respectively, 90, 2.0, and 94 in the accurate reduction group (n = 24) and 90, 1.0, and 94.5 in the malreduction group (n = 35). Reduction quality after syndesmotic injury with flexible fixation, as determined by early postoperative CT imaging, did not affect patient prognosis. In this cohort, syndesmotic reduction and flexible fixation may produce good clinical outcomes in patients with syndesmotic injury and ankle fracture. Level III, retrospective cohort study.

Intraoperative Assessment of Stone Free Status for Percutaneous Nephrolithotomy Surgery: Surgeon’s Eye

Objective: In patients who underwent percutaneous nephrolithotomy(PNL),it was aimed to determine the accuracy of the surgeon's intraoperative stone-free status(SFS) prediction,the factors affecting it,the predictors that caused the wrong estimation, and finally to evaluate the reliability of the "surgeon's eye".&#x0D; &#x0D; Material and Methods: The data of 1025 patients who underwent PNL and met the inclusion criteria were evaluated retrospectively.Since the basis of our study was based on the evaluation of the surgeon's stone-free prediction,patients identified as "absence of residual stone fragment(RF)" by the surgeon were grouped and compared with postoperative computed tomography imaging according to the presence of RF.&#x0D; &#x0D; Results: Sensitivity, specificity, positive predictive value and negative predictive value were calculated as 67.87%, 96.23%, 91.67% and 83.04%, respectively.In our study, it was found that the "surgeon's eye" predicted SFS incorrectly at a rate of 16.9%.There was no statistically significant correlation between gender,stone side,stone density and hemoglobin decrease between the two groups.Stone size,operation time,fluoroscopy time,location of the stone,number of stones in the calyces and GUY's stone score(GSS) were statistically significantly associated with "surgeon's eye".As a result of multivariate logistic regression analysis of the parameters that were found to have a statistically significant relationship with the surgeon's eye,stone size,the number of stones in the calyces and GSS were significant predictors.&#x0D; &#x0D; Conclusion: The most important predictors of "surgeon's eye" in PNL were stone size,number of stones in the calyces and GSS. These predictors can be used as an effective criterion in the use of methods to reduce radiation exposure in postoperative imaging of patients who are predicted to be stone-free.

Postoperative computed tomography imaging of pediatric patients with craniosynostosis: radiation dose and image quality comparison between multi-slice computed tomography and O-arm cone-beam computed tomography

BackgroundWhen postoperative multi-slice computed tomography (MSCT) imaging of patients with craniosynostosis is used, it is usually performed a few days after surgery in a radiology department. This requires additional anesthesia for the patient. Recently, intraoperative mobile cone-beam CT (CBCT) devices have gained popularity for orthopedic and neurosurgical procedures, which allows postoperative CT imaging in the operating room.ObjectiveThis single-center retrospective study compared radiation dose and image quality of postoperative imaging performed using conventional MSCT scanners and O-arm CBCT.Materials and methodsA total of 104 pediatric syndromic and non-syndromic patients who were operated on because of single- or multiple-suture craniosynostosis were included in this study. The mean volumetric CT dose index (CTDIvol) and dose-length product (DLP) values of optimized craniosynostosis CT examinations (58 MSCT and 46 CBCT) were compared. Two surgeons evaluated the subjective image quality.ResultsCBCT resulted in significantly lower CTDIvol (up to 14%) and DLP (up to 33%) compared to MSCT. Multi-slice CT image quality was considered superior to CBCT scans. However, all scans were considered to be of sufficient quality for diagnosis.ConclusionThe O-arm device allowed for an immediate postoperative CBCT examination in the operating theater using the same anesthesia induction. Radiation exposure was lower in CBCT compared to MSCT scans, thus further encouraging the use of O-arms. Cone-beam CT imaging with an O-arm is a feasible method for postoperative craniosynostosis imaging, yielding less anesthesia to patients, lower health costs and the possibility to immediately evaluate results of the surgical operation.

Robotics Coupled With Navigation for Pediatric Spine Surgery: Initial Intraoperative Experience With 162 Cases.

This study assesses intraoperative efficacy, accuracy, and complications of pedicle screw placement using robotic-assisted navigation (RAN) in pediatric spine surgery. A retrospective review of patients who underwent spine deformity surgery using RAN at a single pediatric institution from 2019 to 2021 was conducted. Patient demographics, perioperative metrics, screw execution and accuracy, technical difficulties, and other outcomes were summarized. In cases with postoperative computed tomography scans, screws were classified using the Gertzbein and Robbins classification scale. Fisher exact tests were used to assess the relationship between procedural changes and lateral screw malposition. One hundred sixty-two cases with an average patient age of 15.1 years (range, 4 to 31y) were reviewed. The most common diagnosis was adolescent idiopathic scoliosis (n=80) with an average major curve of 65 degrees. Of 1467 screws attempted, 1461 were executed successfully (99.6%). All failures were in Type D pedicles and were lateral deviations recognized with routine intraoperative fluoroscopy. In cases with postoperative computed tomography imaging, 100% of screws (n=197) were placed with complete containment (Grade A). Remaining screws were graded as accurate by mirroring fluoroscopy and planned computer software positions. In 4% of cases, loss of registration was detected by a safety check before drilling at the planned level. There were no neurological deficits or returns to the operating room. Two changes occurred as part of the learning curve associated with this technique. (1) Adoption of a high-speed navigated drill: Change 1 (last 74 cases). (2) Drilling all pilot holes robotically first, then placing screws within the robotically established tracts to avoid motion and subsequent registration disruption: Change 2 (last 39 cases). Change 1 was less likely to result in screw malposition as no screws skived lateral with the technique ( P =0.03). Change 2 trended toward statistical significance for avoidance of screw malposition and loss of registration, as no loss of registration occurred after adopting this technique. This study highlights the safety and screw accuracy associated with the use of RAN in pediatric patients. Level III.

Soong Classification Using X-Rays Only Moderately Correlates with Distal Radius Plate Position on Computed Tomography

HYPOTHESIS: The Soong classification grades the prominence of volar locking plates used to treat distal radius fractures in relation to the volar rim. The basis of the classification scheme was that increasing plate prominence over the volar rim and distal radius watershed zone would be associated with injuries of the flexor tendons and increased need for plate removal. Recent studies, however, report mixed results on the predictive value of the Soong classification for these outcomes. We hypothesized this misclassification is secondary to a suboptimal correlation between the Soong classification on radiographs (XR) and computed tomography (CT). METHODS: Fifty distal radius fractures treated by volar locking plate, collected from the international collaborative, publicly available ICUC database, were reviewed. All cases with a postoperative XR and CT were included. Soong classification of the volar locking plate to the volar ulnar rim was determined on both modalities by two independent, fellowship-trained hand surgeons, using CT imaging as the gold standard. The distribution of Soong grades on XR and CT was compared using Pearson’s chi-square test, and correlation was calculated using the Matthews’ correlation coefficient (MCC). A multi-class confusion matrix was used to calculate each grade’s positive predictive value (PPV). RESULTS: The distribution of Soong grades was significantly different when using XR versus CT (p<0.001). We found an MCC of 0.65 indicating only moderate correlation between the two modalities. Per individual Soong grade, the PPV was the highest for grade 2 (0.96), with lower PPVs for grade 0 (0.63) and grade 1 (0.60). SUMMARY POINTS: The Soong classification demonstrates only moderate correlation between grades based on radiograph and CT. •Although grade 2 was reliably established on both modalities, grades 1 and 0 have a lower positive predictive value when graded using radiographs. •Radiographs may be less suitable to distinguish between Soong grades 1 and 0, and thus the subsequent risks of volar plate prominence may be underestimated on radiographs compared to CT. •Further study of the value of postoperative CT imaging in predicting plate-related complications is needed.

Gluing blood into gel by electrostatic interaction using a water-soluble polymer as an embolic agent

Liquid embolic agents are widely used for the endovascular embolization of vascular conditions. However, embolization based on phase transition is limited by the adhesion of the microcatheter to the embolic agent, use of an organic solvent, unintentional catheter retention, and other complications. By mimicking thrombus formation, a water-soluble polymer that rapidly glues blood into a gel without triggering coagulation was developed. The polymer, which consists of cationic and aromatic residues with adjacent sequences, shows electrostatic adhesion with negatively charged blood substances in a physiological environment, while common polycations cannot. Aqueous polymer solutions are injectable through clinical microcatheters and needles. The formed blood gel neither adhered to the catheter nor blocked the port. Postoperative computed tomography imaging showed that the polymer can block the rat femoral artery invivo and remain at the injection site without nontarget embolization. This study provides an alternative for the development of waterborne embolic agents.

P133. Measuring the radiographic efficacy of indirect decompression following minimally invasive lumbar interbody fusion: a computed tomography (CT) analysis study

<h3>BACKGROUND CONTEXT</h3> The advancement of MIS techniques has led to increased reliance on indirect decompression techniques. The latest generation of MIS TLIF cages are typically expandable cages that restore disc height and achieve ligamentum flavum unbuckling with associated increased central canal area. While prior studies have measured the extent of indirect decompression associated with ALIF and LLIF, the degree of decompression achieved via MIS-TLIF has not been described. <h3>PURPOSE</h3> Assess the degree of indirect decompression following minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). <h3>STUDY DESIGN/SETTING</h3> Single-center, multi-surgeon, retrospective review. <h3>PATIENT SAMPLE</h3> Patients undergoing MIS-TLIF without direct decompression between 3/2017 and 3/2021. Patients were included if they had a pre- and postoperative CT scan. <h3>OUTCOME MEASURES</h3> Pre- and postoperative CT scans were used to measure disc height, foraminal area (left and right) and central canal area at the operative level(s). The most recent postoperative patient reported outcome measures (PROMs) between 6 months and 2 years were used to compare against preoperative values. <h3>METHODS</h3> Postoperative CT was performed at 1-43 months based on surgeon-specific protocols. Both pre- and postoperative CT measurements were performed by two observers. PROMs were collected in a prospectively maintained database. Paired tests were used to compare changes in CT measurements and PROMs. Bivariate analysis was also done to assess correlations between the changes in CT measures and PROMs improvement. <h3>RESULTS</h3> A total of 40 patients (48 operative levels) were assessed; 16 (33.3%) of the subjects were female and 24 (50%) were male. The average age was 56.6 ± 15.9 years. The average length of follow-up was 17.9 ± 7.9 months for PROMs and 13.5 ± 9.3 months for postoperative CT imaging. There were 32 (80%) single-level and 8 (20%) two-level cases, with 23 (47.9%) operated at L4L5 and 25 (52.1%) at L5S1. Disc height, foraminal area, and central canal area all increased significantly (p < 0.001). Mean disc height increased 50%, from 4.2 to 6.3mm. Right sided foraminal area increased 23%, from 144 .5 to 177.8mm2, the left increased 21.4% from 142.8 to 173.4mm2, and the central canal increased 16.4% from 228.6 to 266 mm2. All PROMs except for SF12-MCS (p=0.439) showed a statistically significant improvement (p < 0.05). There was no correlation between each change in PROM and the increase in cross sectional canal area. <h3>CONCLUSIONS</h3> MIS-TLIF provides a significant degree of indirect decompression. Disc height, foraminal area and central canal area were all increased following insertion of the interbody cage via the MIS-TLIF technique. PROMs by 2 years demonstrated a statistically significant improvement. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Postoperative Bildgebung des muskuloskeletalen Systems – Hand

Postoperative imaging is essential to document the surgical outcome of the musculoskeletal system of the hand. Common radiological findings in the postoperative musculoskeletal system of the hand are explained in the context of the preoperative findings. For important surgical procedures of the hand, classifications, surgical procedures, and complications are presented. Diagnostic criteria in postoperative radiography and computed tomography (CT) imaging are described for each indication group. Clinical information and postoperative findings are systematically presented for fractures of the radius, scaphoid, metacarpal and phalanges, scapholunate dissociation, perilunate injuries and for procedures of arthrodesis and arthroplasty in the hand. Complications are pointed out. Precise reporting in postoperative radiography and CT imaging of the hand is based on awell-defined order, astandardised examination technique and on synoptic evaluation of clinical and radiological criteria.

CT after emergency surgery in penetrating trauma: a seven-year experience in a level I Nordic trauma center.

Patients with severe penetrating trauma may require emergency surgery on arrival, and postoperative computed tomography (CT) can reveal significant additional injuries. To determine the utility of postoperative CT performed within 48 h of emergency surgery after penetrating trauma. Trauma registry data were retrieved over a seven-year period at a single level 1 trauma center. All patients aged ≥17 years, admitted with penetrating injury, who underwent urgent surgery and postoperative CT imaging within 48 h, were included. Pre- and intraoperative medical records were compared to CT findings. Age, sex, Injury Severity Score (ISS), New Injury Severity Score (NISS), 30-day mortality, injury mechanism, surgical intervention, and intensive care unit length of stay were extracted. Out of 1262 patients, 38 fulfilled the study criteria (36 men [94.7%], 2 women [5.3%]; mean age = 31.5 years. Stab wound (SW) was the most common injury mechanism (26/38, 68.4%) followed by gunshot wound (GSW; 10/38, 26.3%). Patients with GSWs were more severely injured than SW victims (median NISS = 34 [range = 3-75]; for GSWs = 34; for SWs = 26; P = 0.045). Out of 38 patients, 20 (52.6%) had additional findings at postoperative CT. Six patients (15.8%) had unidentified or underestimated findings at CT that were severe enough to warrant additional surgery or angiography. Postoperative CT imaging after emergency surgery in penetrating trauma is an important tool in evaluating the injury panorama. Out of 38 patients, 6 (15.8%) had findings at postoperative CT that warranted additional surgical or angiographic intervention.

V01-10 ROBOTIC-ASSISTED LAPAROSCOPIC URETEROCALICOSTOMY AND PYELOLITHOTOMY FOR PROXIMAL URETERAL STRICTURE

You have accessJournal of UrologyCME1 May 2022V01-10 ROBOTIC-ASSISTED LAPAROSCOPIC URETEROCALICOSTOMY AND PYELOLITHOTOMY FOR PROXIMAL URETERAL STRICTURE Grace Lee, Hiren V. Patel, Joshua Sterling, and Sammy Elsamra Grace LeeGrace Lee More articles by this author , Hiren V. PatelHiren V. Patel More articles by this author , Joshua SterlingJoshua Sterling More articles by this author , and Sammy ElsamraSammy Elsamra More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002520.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Ureterocalicostomy is a repair option for proximal ureteral strictures indicated in the setting of prior failed pyeloplasty, intrarenal pelvis, or significant lower pole caliectasis. In this video, we demonstrate a case of proximal ureteral stricture and recurrent nephrolithiasis, refractory to shock wave lithotripsy, treated with robotic-assisted laparoscopic ureterocalicostomy. METHODS: This procedure was performed using the da Vinci Xi robotic platform. The patient was prepped in the right lateral decubitus position and ports were placed. To begin, the bowel was mobilized, the ureter was identified, and the renal hilum was skeletonized. Next, the proximal stricture, intrarenal pelvis, and its high insertion were verified. Once the lower pole of the kidney was defatted, intraoperative ultrasonography was used to identify the location of the partial nephrectomy. After clamping the renal artery, a wedge resection of the lower pole parenchyma was performed. The parenchyma was then oversewn and the clamps were removed. At this point, a 16-French flexible cystoscope was placed through the assistant port and into the pyelotomy for stone basket extraction. The ureter was incised at the ureteropelvic junction and spatulated at the posterior aspect for 3cm. The kidney was then mobilized completely and affixed to the left psoas muscle. Next, the ureter was anastomosed to the lower calyx in a tension-free fashion and a ureteral stent was placed. The bladder was backfilled using methylene blue dyed saline and watertight seal of the anastomosis was confirmed. Finally, the anastomosis was wrapped with a Gerota’s flap. RESULTS: The procedure lasted approximately 4.5 hours without any complications. Estimated blood loss was 70cc. On postoperative day one, the drain was removed and the patient was discharged home. Postoperative computed tomography imaging revealed decreased stone burden. Six-week ureteroscopy revealed a wide-open lumen at the anastomotic site and retrograde pyelography showed no evidence of obstruction. At six months, a Lasix renogram once again demonstrated no evidence of obstruction. CONCLUSIONS: Robotic-assisted laparoscopic ureterocalicostomy is a safe and effective repair option that should be considered for proximal ureteral strictures with intrarenal pelvis and dependent lower pole calyx. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e55 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Grace Lee More articles by this author Hiren V. Patel More articles by this author Joshua Sterling More articles by this author Sammy Elsamra More articles by this author Expand All Advertisement PDF DownloadLoading ...

An unusual presentation of chordoma as a pyloric ring submucosal tumor: The first case report of a primary gastrointestinal lesion in humans.

Introduction and importanceChordomas are rare malignant bone neoplasms that are presumed to arise from chordal remnants in the fetal stage and typically occur along the axial skeleton. The extra-skeletal chordomas reported to date include soft tissue of the extremities and nasopharynx. Chordoma arising from the gastrointestinal wall has not been previously described.Case presentationWe report on a 42-year-old man with primary chordoma presenting as a gastroduodenal submucosal tumor centered on the pyloric ring. The patient was consistently asymptomatic, and the tumor was an incidental finding. However, during a follow-up at approximately 1.6 years, an increase in tumor size was identified on computed tomography (CT), and surgical resection was performed without a definite pathologic diagnosis. The patient was successfully treated with distal gastrectomy, and the histological diagnosis was a conventional chordoma. The diagnosis was confirmed via immunohistochemical staining for brachyury, pan-cytokeratin, S-100, and SOX9. Postoperative CT and magnetic resonance imaging revealed no recurrence or metastasis during the 1.5-year follow-up period.Clinical discussionPrimary chordomas of the digestive tract are rare. Embryologic development of the notochord does not explain the existence of remnants in the gastrointestinal wall. Moreover, notochordal remnants, as precursors of chordoma, were not identified in the current case. The gastroduodenal chordoma may not have originated from embryonic notochordal remnants but through aberrant brachyury activation without a notochordal precursor.ConclusionWe report the first case of primary gastrointestinal chordoma in humans. The tumor was completely removed surgically, without postoperative recurrence.

Bone Fragment Resorption and Clinical Outcomes of Traumatic Bony Bankart Lesion Treated With Arthroscopic Repair Versus Open Latarjet

Background: Bony Bankart lesions can perpetuate chronic anterior glenohumeral instability. When surgical treatment is pursued, several factors need to be considered to obtain optimal outcomes. Purpose: To (1) quantitatively describe patterns of bone fragment resorption and associated risk factors for developing glenoid bone loss (GBL) and (2) to compare clinical and radiological results of attritional bone loss treated with either the arthroscopic Bankart or the open Latarjet procedure. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective analysis of prospectively collected data was conducted for patients who underwent arthroscopic stabilization (group A1, 10%-20% GBL; group A2, >20% GBL) or open Latarjet (group B, >10% GBL) for recurrent shoulder instability with bony Bankart lesion. Patient characteristics, number of dislocations, and Western Ontario Shoulder Instability Index (WOSI) scores were obtained. Pre- and postoperative computed tomography imaging was used to quantitatively describe patterns of bone fragment resorption. Results: A total of 120 consecutive patients (group A1, 40; group A2, 23; group B, 57) were included in the study, with a mean age of 25.6 years (range, 19-35 years). The average follow-up was 5.0 years for all groups (range, 4.83-5.16 years in group A1, 4.58-5.41 years in group A2, and 4.33-5.67 years in group B). The mean times between dislocation event and surgery were 12.8 months (range, 6-32 months) and 13.6 months (range, 6-38 months) for groups A and B, respectively. Redislocation rates were 7.5% in group A1 versus 13.0% in group A2, and only occurred in patients with ≥13.5% GBL. There were no redislocations for group B (0%). Patients had better WOSI scores in group B (234.1 ± 126.9) than in group A (576.1 ± 224.6) (P < .0001). In group A, smaller preoperative bone fragment size displayed a higher percentage of resorption after surgery (r = −0.64; P < .05). Conclusion: A significant inverse relationship exists between preoperative bone fragment size and percentage of postoperative resorption. Patients treated with arthroscopic bony Bankart repair who had final GBL ≥13.5% had worse outcomes. When planned GBL approaches 13.5% in high-demand patients, a smaller fragment size can result in worse clinical outcomes because of resorption. In these cases, choosing the open Latarjet procedure leads to better clinical results.

New or enlarging hiatal hernias after thoracic surgery for early lung cancer

ObjectiveThe study objective was to determine the relationship between lung resection and the development of postoperative hiatal hernia. MethodsPreoperative and postoperative computed tomography imaging from 373 patients from the International Early Lung Cancer Action Program and the Initiative for Early Lung Cancer Research on Treatment were compared at a median of 31.1 months of follow-up after resection of clinical early-stage non–small cell lung cancer. Incidence of new hiatal hernia or changes to preexisting hernias were recorded and evaluated by patient demographics, surgical approach, extent of resection, and resection site. ResultsNew hiatal hernias were seen in 9.6% of patients after lung resection (5.6% after wedge or segmentectomy and 12.4% after lobectomy; P = .047). The median size of new hernias was 21 mm, and the most commonly associated resection site was the left lower lobe (24.2%; P = .04). In patients with preexisting hernias, 53.5% demonstrated a small but significant increase in size from 21 to 22 mm (P < .0001). All hernias persisted through the latest postoperative computed tomography scan. When 110 surgical patients without preexisting hernia were matched by sex, age, and smoking to nonoperative controls, the incidence of new hernia at follow-up was significantly higher among those who underwent surgery (17.3% vs 2.7%, P = .0003). ConclusionsBoth open and minimally invasive lung resection for clinical early-stage lung cancer are associated with new or enlarging postoperative hiatal hernia, especially after resections involving the left lower lobe.

Implant Related Artifact Around Metallic and Bio-Integrative Screws: A CT Scan 3D Hounsfield Unit Assessment

Category:Basic Sciences/Biologics; HindfootIntroduction/Purpose:Implant-related artifact (IRA) represents an important limitation in Computed Tomography (CT) assessment of osteotomy and fracture healing, bone-implant integration, and success of fusion procedures. Metallic implants are the most used in foot and ankle surgery and are recognized as important IRA generators. Absorbable and bio-integrative (BI) implants are attractive options for bone fixation when postoperative CT imaging is likely, particularly in procedures with higher risk for nonunion. However, the literature comparing IRA with metallic and BI implants is scarce. The objective of this study was to assess the degree of IRA around metallic and BI cannulated screws. Our hypothesis was that BI implants would demonstrate significantly decreased IRA around the inserted screws.Methods:In this cadaveric/CT imaging study, 2 below-knee specimens were used. Medial displacement calcaneal osteotomy was performed through a 5-cm long lateral heel approach. Calcaneal tuberosity was displaced medially by 10mm and fixed provisionally with 2 parallel K-wires under fluoroscopic guidance. Specimens were fixed with two headless 4.0 millimeters cannulated screws, either metallic or BI. Cone-beam CT imaging of both specimens was acquired following osteotomy screw fixation (120kVp, 5.5mA, 0.25mm isotropic). Using a dedicated software, the overall dispersion of Hounsfield units (HU) in a 3D cube of 30mm edge length was assessed. Four HU lines were then traced parallel to the screws, crossing the osteotomy site. Lines 1, 2, 3 and 4 were positioned respectively: In close proximity, over, inside the cannulation and away from the implant. The HU dispersion in these lines was measured and compared between metallic and BI implanted specimens, using T-tests/Wilcoxon analysis. P-values<0.05 were considered significant.Results:When compared to the BI implant, the average HU was pronouncedly and significantly increased around metallic implants in the lines with more close proximity (Line 1), over the screw wall (Line 2) and inside the screw cannulation (Line 3), when considering both the whole line extension inside the 3D cube as well as in a selected 8mm line-segment across the calcaneal osteotomy line: Line 1 (entire, 7.26 vs -159; selected, -5 vs -249) Line 2 (entire, 4.846 vs 108; selected, 6286 vs 151.2); Line 3 (entire, 1664 vs 144; selected, -277.7 vs 198.7) selected). However, across Line 4 (away from the implant), the HU dispersion was interestingly and significantly decreased around the metallic implant (entire, -49 vs 178.5; selected, -110 vs 221), potentially as result of beam hardening artifact, concentrating HU close to the metal, and shielding the surrounding cancellous bone from being accurately reconstructed.Conclusion:In this cadaveric imaging study, we compared Implant-related artifact (IRA) around metallic and bio-integrative (BI) implants utilized to fix medial displacement calcaneal osteotomies. We found metallic implants to demonstrate significantly and pronouncedly increased HU dispersion in in close proximity with the implants and significantly decreased dispersion more distantly from the implant, shielding the surrounding cancellous bone, and potentially hindering the assessment of bone density quality and bone/osteotomy/fusion healing in its neighborhood. BI implants represent an alternative to decrease these IRA effects. Additional clinical studies are needed to confirm and expand our findings.