Prior Surgical Intervention Research Articles

Ureteral Obstruction Promotes Ureteral Inflammation and Fibrosis

BackgroundHydronephrosis and renal impairment may persist even after relieving an obstruction, particularly in cases of chronic obstruction. Obstruction can cause fibrotic changes of the ureter, potentially contributing to long-term kidney damage. ObjectiveTo characterise pathophysiological changes of obstructed ureters with focus on inflammatory responses triggering fibrosis and potential impairment of ureteral function. Design, setting, and participantsEighty-eight mice were randomly assigned to unilateral ureteral obstruction (UUO) for 2 d, UUO for 7 d, and UUO for 7 d followed by 8 d of recovery, or a control group (no prior surgical intervention). Outcome measurements and statistical analysisPeristaltic rate was determined over 2 min by direct visualisation with a microscope, while hydronephrosis was assessed by ultrasound. Obstructed and contralateral ureters were harvested, and underwent histopathological evaluation. We quantified 44 cytokines/chemokines, and five matrix metalloproteases using Luminex technology. Cell composition was characterised via immunofluorescence. Statistical significance was assessed using Welch analysis of variance, Kruskal-Wallis test, and Dunnett’s T3 multiple comparison test. Results and limitationsObstruction resulted in hydronephrosis and significantly impaired peristalsis. Marked fibrosis was observed in lamina propria, muscle layer, and adventitia. Connective tissue in obstructed ureters showed hyperaemia and leucocyte infiltration. Unsupervised hierarchical clustering demonstrated different cytokine/chemokine patterns between groups. Ureters obstructed for 7 d followed by recovery were notably different from other groups. Inflammatory cytokines, chemoattractants, and matrix metalloproteases increased significantly in obstructed ureters. Contralateral unobstructed ureters showed significantly increased levels of chemokines and matrix metalloproteases. Immunofluorescence confirmed activation of T cells, Th1 and Th2 cells, and M1 macrophages in obstructed and contralateral ureters, and a shift to M2 macrophages following prolonged obstruction. ConclusionsUreteral obstruction triggers severe inflammation and fibrosis, which may irreversibly impair ureteral functionality. Function of the unobstructed contralateral ureter may be regulated by a systemic immune response as a result of the obstruction. Patient summaryHere, we studied in more detail the way the ureter responds to being blocked. We conclude that a strong immune response is activated by the blockage, leading to changes in the structure of the ureter possibly impacting function, which may not be reversible. This immune response also spreads to the opposite ureter, possibly allowing it to change its function to compensate for the reduced functionality of the blocked ureter.

Incidence of surgery after gamma knife radiosurgery for parasagittaland parafalcine meningiomas is higher than meningiomas in other locations: A 10-year institutional analysis and review of the literature

Background: Parasagittal and Parafalcine Meningiomas (PSPF) have a higher rate of recurrence, increased risk of postoperative morbidities, and less favorable outcomes after stereotactic radiosurgery compared to other ocations. Herein, we try to find factors associated with treatment failure after radiosurgery in patients with PSPF meningiomas. Methods: We retrospectively reviewed records of 104 patients with 130 Gamma Knife® Radiosurgery (GKRS) treatments for individual meningiomas at a single institution. 38 were PSPF compared to 92 in non-PSPF locations. Results: The PSPF group showed a significantly higher rate of surgical intervention after radiosurgery compared to the non-PSPF group (18.4% vs 4.4, p = 0.008 in univariate analysis). The relative risk for a PSPF tumor requiring surgery after GKRS was 4.24, with an odds ratio of 4.97 (95% CI: [1.32-13.63], p = 0.015). The average tumor size between the PSPF group and the non-PSPF group was 3.53 cm3 and 2.28 cm3, respectively; this difference was statistically significant (p = 0.035) on univariant analysis, but not multivariate (p = 0.125). In the whole sample, for tumors >5 cm3, the relative risk ratio for needing surgery after GKRS was 6.23 with an odds ratio of 8.32 (95% CI: [2.25-30.67], p = 0.0015). Both PSPF and non-PSPF meningiomas were similar in gender, follow-up length, prior surgical intervention, and WHO grades. Conclusion: Meningiomas’ outcome and response to radiosurgery depend on their location. We have two possible explanations. First, PSPF tumors are located near sensitive cerebral cortex areas. Second, the tumor’s mutational profile affects meningiomas’ location and prognosis.

Tarsometatarsal Joint Preparation using a Modified Dorsal Approach vs Standard Approach: A Cadaver Study

Category: Midfoot/Forefoot Introduction/Purpose: Lisfranc injuries are a relatively common midfoot injury involving the tarsometatarsal (TMT) joint. Surgical fixation typically involves open reduction with internal fixation or primary arthrodesis of the joint(s). The standard surgical approach to the TMT joint involves two dorsal incisions however, a recent study has suggested the use of a modified single dorsal incision approach. The goal of this paper is to compare the total surface area of the joint that can be prepared for primary arthrodesis of the TMT using the standard vs modified single dorsal approach. Methods: Ten fresh frozen below-the-knee cadaver specimens were randomly assigned to receive either the standard or modified dorsal single incision operative approach to the TMT joint. Prior to initiating the study, specimens were inspected with fluoroscopic radiographs for preexisting pathology or prior surgical intervention. The joint surface was visualized and then underwent articular preparation as for a joint fusion. After adequate joint preparation, the TMT joint was disarticulated and the surface was photographed for image analysis. Using ImageJ, articular joint surface preparation areas were measured by two blinded reviewers. to assess the joint surface preparation and this was compared by surgical approach. Results: After ImageJ and Mann-Whitney U statistical analysis, there was no significant difference in the amount of joint prepared when comparing the standard versus modified dorsal approach for the first three TMT joints (p= 0.548, p=0.310, p= 0.548). The percentage of joint preparation utilizing the standard dorsal approach versus the modified dorsal approach for TMT joints one through three are as follows (percentages utilized are listed as the median value with its correlating range): First TMT- 67.6% (range 26%) by the standard approach versus 71.7% (range 9%) by the modified dorsal approach, second TMT- 67.9% (range 24%) versus 65.7% (range 12%), and third TMT- 65.9% (range 42%) versus 59.6% (range 24%). Table 1 summarizes our results between each operative approach. Conclusion: With our findings, we demonstrate that a modified single dorsal approach to the Lisfranc joint provided comparable joint preparation for primary arthrodesis as the standard dual incision approach. However, the modified dorsal approach may be beneficial in that it avoids creating a skin bridge which has potential for necrosis with the standard two incision approach. The authors believe the comparable joint preparation combined with its potential to alleviate soft tissue complications make the modified dorsal approach a viable surgical approach for a TMT arthrodesis.

Anatomic Structures at Risk When Utilizing Percutaneous Intramedullary Fibular Screw Fixation for Lateral Malleolus Fractures: A Cadaveric Study

Category: Ankle Introduction/Purpose: Isolated lateral malleolus fractures are a common ankle fracture that a foot and ankle surgeon will encounter. Retrograde intramedullary fixation for unstable lateral malleolus fractures has become a viable option for patients at higher risk for potentially devastating wound complications. The aim of this cadaveric study was to assess the relative risk of injuring adjacent anatomic structures with percutaneous implantation of an intramedullary fibular screw for lateral malleolus fractures to minimize iatrogenic injury. Methods: Seven fresh-frozen below-the-knee cadaver specimens were used for this study. Prior to investigations, specimens were inspected with fluoroscopic radiographs for preexisting pathology or prior surgical intervention. Lateral dissection of the lateral malleolus was performed after screw placement to determine the proximity of the peroneus longus (PL), peroneus brevis (PB), and sural nerve (SN) to the inserted hardware. The mean, standard deviation, and range for distances were calculated for all structures. Analysis of variance (ANOVA) was used to determine statistical significance. Results: Percutaneous intramedullary fibular screw placement was performed in seven specimens, six females and one male, with an average age of 79.3 +- 8.1 years. Amongst the seven specimens, only one resulted in an injury to a structure of interest (sural nerve). The peroneus longus and peroneus brevis were not injured in any of the specimens. Table 1 shows the average distance between the guidewire and each structure of interest. Conclusion: This study shows the potential risks to lateral structures when placing an intramedullary fibular screw for unstable lateral malleolus fractures. We suggest that orthopedic surgeons exercise caution when performing critical steps of the procedure to minimize avoidable injury to structures of importance that may increase the morbidity of the patient.

Articular Regional Reconstruction (ARR) for Large Osteochondral Lesions of the Talus using Viable Osteochondral Allograft Combined with Autograft: Technique Description and Case Series

Category: Ankle; Sports; Trauma Introduction/Purpose: Symptomatic osteochondral lesions of the talus (OLT) are challenging to treat, and large lesions (>10mm) with concomitant subchondral bony defects are particularly challenging. Standard treatments such as bone stimulation are limited and are often restricted to smaller lesions. Particulate and fragmented chondral allograft techniques face limitations with uncontained lesions. Structural allograft/autograft techniques often require removal of regions of native, uninjured bone and may encounter donor issues. Postoperatively, ensuring reliable osseous and cartilaginous healing responses can be difficult. Articular Regional Reconstruction (ARR) is a novel technique combining viable osteochondral allograft with morselized autograft bone to address large OLT lesions with bony defects, whether contained or uncontained. We describe a consecutive series of patients undergoing ARR here. Methods: Patients indicated for the ARR procedure had preoperative MRI and CT imaging identifying large (>10mm), unstable osteochondral lesions with bony defects; 11 consecutive patients that had undergone ARR were identified. OLT lesions were initially inspected arthroscopically, and then converted to open debridement. Medial malleolar osteotomies were used for access when necessary. A stable bony base and viable cartilage rim was established, removing all damaged cartilage and nonstructural material from the OLT and bony defect. Talar body structure and morphology was restored using iliac crest or tibial morselized autograft bone placed in the bony defect. Viable osteochondral allograft (Cartiform) was shaped and then secured over the autograft using suture anchors placed at the lesion periphery. Patient Reported Outcome (PRO) measures included PROMIS- physical function (PROMIS-PF), PROMIS-pain interference (PROMIS-PI), and single assessment numeric evaluation (SANE). Three patients without PRO data were excluded, leaving eight patients with preoperative and postoperative PRO data for analysis. Results: The ARR patients averaged 40 years old (range 28-60) with a mean follow up of 19 months (range 10-38). The lesion surface areas averaged 1.95 cm2 (range 1.17-2.99 cm2) with a depth of 7.25mm (range 5-9mm). Four were uncontained corner lesions. Postoperative PROMIS-PF improved from 41 to 47 (p = 0.036), and PROMIS- PI improved from 60 to 53 (p = 0.093). Average SANE scores improved from 60 to 69 (p = 0.148). No complications occurred. No revision OLT surgeries were required, though three patients returned to the OR (Two for osteotomy screw removal, one for anterior impingement of opposite corner). During these 'second looks', the implanted cartilage layer was found intact. In a recent survey, all patients indicated they would undergo the procedure again. Conclusion: Articular Regional Reconstruction (ARR) is a reproducible procedure with demonstrated potential for improvement in pain and physical function among patients with symptomatic, large osteochondral lesions of the talus with bony defects, whether 'contained' or 'uncontained'. It has particular utility as an alternative to bulk structural graft salvage procedures among patients who have failed prior procedures, as 5 of the 8 patients had undergone unsuccessful prior surgical intervention for their OLT by outside providers. Further studies on ARR of the talus are necessary to elucidate the prognosis of this procedure, establish indication boundaries, and strengthen long-term outcome data.

Evidence of Bacterial Biofilms in Human Chronic Sinusitis

Objective: The reason of this study design is to analyze the presence of bacterial biofilm on the sinus mucosal surface of humans with the presence of stubborn chronic sinusitis. Place and duration of study: The study is conducted in Khyber Teaching Hospital ENT Peshawar and the duration of study is March 2022 to August 2022. Material and Method: We have evaluated small Sinonasal samples from 20 numbers of patients having previous history of sinus surgery or surgical intervention. No courses of antibiotic and endoscopic sinus surgery work best for all the number of samples. By the use of cutting instrument we have seen the ethmoid sinus mucosal specimens and maxillary specimens. Scanning and microscopic evaluation techniques are used to detect patients with continuous manifestations of chronic sinusitis even with prior medical and surgical intervention. Results: Physical presence of microbial cluster of pseudomonas aeroginosa, a gram negative bacteria validate the existence of microbes in the sinus mucosa of patients. The existence of this microbial cluster may provide the evaluation of stubborn nature of some appearance of chronic sinusitis. Conclusion: Spire shaped cluster of microbes are the structural indication of the presence of microbial biofilms in a patient with chronic sinusitis.Not only antibiotics but the combination of peroperative antibiotics and surgical intervention treatment therapy is recommended in such kind of chronic infections. Keywords: Gram negative bacteria, sinonasal epithelium, electron microscopy

Botulinum toxin A injection to the external urethral sphincter for voiding dysfunction in females: A tertiary center experience.

The aim of this study is to examine the functional outcomes of ona-botulinum toxin A (BTX-A) injection into the external urethral sphincter (EUS) for female patients with nonneurogenic nonrelaxing sphincter as the underlying cause of voiding dysfunction (VD). A retrospective analysis was performed for all the patients with the urodynamic findings of higher than expected maximum urethral closure pressure (MUCP) who received their first injection during the study period. All patients were evaluated with preoperative videourodynamic study and urethral pressure profilometry and received 100 U of EUS BTX-A. Patients aged less than 18 years and those with neurogenic bladder were excluded. All patients were followed up with the free flow, postvoid residuals (PVR), and patient global impression of improvement (PGI-I) scale at 6 weeks and then at 3 monthly intervals. We identified 35 female patients with a mean age of 37.5 ± 15 years (range 18-72 years) with a mean follow-up of 20 months. More than 50% of patients had a history of prior surgical intervention and 28 (80%) patients were catheter dependent, a suprapubic catheterization, or clean intermittent self-catheterization. Mean MUCP was 97.1 ± 22 cm of water. After treatment with BTX-A, 21 (60%) patients were able to void per urethral (p = 0.02). The mean maximum flow rate (Qmax) improved from 8.8 to 11 mls/s and the mean PVRdecreased from 200 to 149 mls (p < 0.05). On multivariate analysis, we identified high preoperative PVR, high preoperative actualMUCP, and previous surgical intervention (urethral dilatation, sacral neuromodulation, and pelvic surgery) as predictors of successful voiding restoration. The mean duration of response was 4.7 months, 46% of patients requested repeat injection, and 29% were established on maintenance injections. On the 5-point PGI-I score, 13 (37%), 12 (34%), and 10 (29%) patients reported good, some, and no improvement, respectively. Quality of life was also improved in 60% of patients. Two patients had transient stress urinary incontinence (for<6 weeks) and there were no significant long-lasting adverse events. EUS BTX-A is a valid treatment option for VD considering therapeutic options are limited. The patient must be made aware of the need for repeat treatments.

Proximal Scar Progression in Idiopathic Subglottic Stenosis After Wedge Excision: Does it Happen?

To compare the incidence of glottic stenosis in idiopathic subglottic stenosis (iSGS) patients with no prior surgical intervention to those with a history of endoscopic dilation and characterize the incidence of glottic involvement, changes in scar length, and progression of scar toward glottis following laser wedge excision (LWE). A retrospective review of iSGS patients who underwent LWE between 2002 and 2021 was performed. Patients without prior airway surgery were labeled LWE primary (LWEP) and operative findings for LWEP patients were reviewed for glottic involvement, scar length (DL ), and distance from the glottis to superior-most aspect of scar (DGS ). Rates (in mm/procedure) of DΔL , reflecting an increase in length, and D-ΔGS , reflecting proximal migration, were calculated by dividing DΔL and D-ΔGS by the number of LWE procedures. 213 iSGS patients underwent LWE, with 132 beingLWEP patients. LWEP had a lower incidence of baseline glottic involvement (n=6, 4.5%) than LWE secondary (LWES; n=6, 7.5%). Four new cases of glottic involvement were noted in LWEP patients following LWE, with only one being clinically significant resulting in permanently decreased vocal fold mobility. With each procedure, scar length increased by 1.0 mm and DGS decreased by 0.7 mm, reflecting a migration or decrease in DGS of 9.5% with each procedure with respect to initial DGS . Overall rates of glottic stenosis following operations were similar between LWEP and LWES cohorts, 7.6% and 7.5% respectively. There appears to be a low risk of glottic involvement resulting from the LWE procedure in iSGS patients. 4 Laryngoscope, 133:875-882, 2023.

120 Diagnostic approach in pediatric patients with abnormal ovarian masses

Objective(s): the aim of the study is to present large pelvic mass as the first sigh of genetic disorder in adolescent Study Design: We report a case of 17-year-old, who suffer from pelvic pain. During examination a large 24 × 12 cm pelvic mass was discovered. In the suspicion of malignant tumor initially median laparotomy approach was chosen. Laparotomy showed a tumor in right ovary and very narrow strand of grey mass in a location of the left ovary. Right salpingo-oophorectomy was performed. Histopathological analysis revealed mucinous cystadenoma. Patient also complained of amenorrhea, therefore hormone analysis was performed: E2 (pmol/l) <37, FSH (U/l) – 90,8, LH (U/l) – 31,82. Results: Hypergonadotropic amenorrhea and laparoscopic findings raised suspicion of chromosome anomaly. Karyotype analysis showed XY genotype without mutations in SRY gene. Following laparoscopic left adnexectomy and histopathological analysis showed normal tissue without any malignancy. Conclusion(s): The majority ofovarian tumors are of germ cellorigin with excellent long-term prognosis even in advanced stages, therefore without a fear of prolonging the diagnostic process, we propose an initial genetic testing prior surgical intervention of children and adolescents with abnormal ovarian masses. Disclosure: Work supported by industry: no.

Successful paraclavicular surgical decompression for recurrent venous thoracic outlet syndrome following transaxillary first rib resection in an elite athlete.

Recurrent effort thrombosis after prior surgical intervention for venous thoracic outlet syndrome (TOS) is an uncommon problem, and there are multiple alternative surgical approaches in the management of recurrent venous TOS. We present a case of a 23year-old female professional athlete who presented with arm swelling, pain, and recurrent effort thrombosis after prior transaxillary rib resection. Imaging at our institution revealed subclavian vein thrombosis, confirmed with dynamic venography, as well as a remnant first rib. Thrombolysis of the subclavian vein and balloon angioplasty was followed by paraclavicular thoracic outlet decompression with complete first rib resection. Success was confirmed with intraoperative dynamic venography demonstrating a patent subclavian vein and resulted in complete elimination of symptoms. Additional surgical decompression with complete medial first rib resection of remnant rib, which was potentially causing compression of the subclavian vein, may be necessary to prevent recurrent venous compression and thrombosis for venous TOS.

External Review and Validation of a Spinal Epidural Abscess Predictive Score for Clinical Failure

Spinal epidural abscess (SEA) is a rare but serious pathology that may result in delayed neurologic injury despite treatment with antibiotic therapy or surgery. Given this, the development of predictive scores for risk stratification has value in clinical decision making; however, external validation is necessary to understand their generalizability and reliability. A retrospective review was conducted of all patients presenting with SEA at a single institution. Patients were reviewed and graded according to the proposed SEA predictive score by Baum etal. Clinical failure was defined as documented laboratory or radiographic progression requiring surgical intervention, increased deformity requiring surgical intervention, or repeat surgical intervention if prior surgical intervention was undertaken as the initial treatment strategy. Brier score and receiver operating characteristic were used to calculate reliability. There were 224 patients presenting with primary spinal infections with associated SEA. Of these, 209 patients had no history of intravenous drug abuse. Clinical failure was demonstrated in 52 of 209 patients (24.9%). Antibiotic treatment alone compared with antibiotic therapy and surgical treatment on initial presentation was found to have a significantly greater chance of clinical failure (odds ratio= 3.0930, P= 0.01). The proposed epidural abscess prediction score did not correlate with clinical outcomes with a Brier score of 0.229 and receiver operating characteristic area under the curve of 0.5944. The proposed risk stratification scale for patients was not correlated with risk of clinical failure. Additionally, patients treated with antibiotics and surgical intervention on initial presentation had a significantly lower clinical failure rate.

Testicular Pain – Not Always What it Seems: A Cross-sectional Assessment of Patients Presenting for Chronic Scrotal Content Pain at a Tertiary Care Center

ABSTRACT Introduction Introduction:: Chronic scrotal content pain (CSCP) is generally defined by persistent and bothersome pain present for &amp;gt; 3-months. This symptom complex leads to frustration for patients and providers alike, as the underlying etiology varies and in many instances is unknown. Scrotal pain may arise from outside the scrotal contents, as is seen with musculoskeletal conditions involving the hips, lower back, and pelvic musculature. Identifying those patients who have signs or symptoms of a musculoskeletal etiology earlier in their clinical course will allow for a more streamlined treatment pathway and minimize the need for unnecessary referrals. Objective To review historical and examination findings in patients presenting to a tertiary care center for evaluation of chronic testicular pain. Methods We reviewed our clinical experience with referrals for surgical intervention for “chronic testicular pain” at a tertiary care medical center between July 2019 and October 2020. Prior to scheduling an appointment, patients are queried via a list of questions to gather additional information in order to determine whether specialist consultation is indicated. Pertinent information was collected including historical patient data, physical examination findings, laboratory and imaging results, and treatment as recommended by the assessing physician. In addition, we gathered data on the number of prior consults and interventions performed by outside clinicians. The data was summarized to present a cross-sectional representation of patients presenting for CSCP. Results In total, 126 patients were seen for a primary chief complaint of CSCP. Mean patient age was 45 years [standard deviation (SD) 15]. 31 (24%), 55 (44%), and 40 (32%) were self-referred or referred by their primary care provider or a urologist, respectively. 88 patients (70%) had seen at least one prior urologist. 22/126 (17%) reported bilateral testicular pain. 29 patients (24%) had undergone a prior unsuccessful surgical intervention for their pain. On examination, reproducible testicular tenderness was present in only 57 patients (45%), despite 109 patients (87%) stating testicular pain as their primary chief complaint. Digital rectal examination of the pelvic floor musculature was positive for tenderness in 31/126 patients (25%), suggesting a possible pelvic floor contribution. After thorough assessment, musculoskeletal etiologies were suspected to underlie CSCP in 49 patients (39%), prompting additional evaluation and/or referrals. This included 35 patients (28%) who were specifically referred to a pelvic floor physical therapy specialist. Surgery was recommended in 68/126 patients (54%), including microdenervation of the spermatic cord in 22% (after successful diagnostic spermatic cord block), and epididymectomy in 13%. Conclusions CSCP presents with a wide array of concurrent symptoms. The history and physical examination must include assessments for concurrent abdominal, back, hip, and other genital/pelvic pain that may lend towards an alternative non-urologic treatment pathway. Disclosure No

422 Safety and Efficacy of Responsive Neurostimulation for the Treatment of Medically Refractory Epilepsy: A 5-Year Follow-Up Study

INTRODUCTION: Despite antiepileptic drugs (AEDs), &gt;30% of patients with epilepsy continue to have seizures. Responsive Neurostimulation (RNS) provides a nondestructive treatment option for patients with drug-resistant epilepsy (DRE). To date, the safety and efficacy of RNS have not been fully studied due to the lack of prospective data. METHODS: We performed a retrospective analysis of prospectively collected data of DRE patients who underwent RNS implantation between September 2015-December 2020 at our Institution. Patients were followed postoperatively to evaluate seizure-freedom and complications. For each patient, response to RNS was determined as an overall percentage based on the relative reduction in seizure duration/severity, medication requirements and post-ictal state. RESULTS: A total of 103 patients underwent RNS placement. Seven patients developed infections: three required partial salvaging of the system, and only two (1.9%) required complete removal of the RNS device. Six (5.8%) patients experienced small asymptomatic post-operative hemorrhages; none required re-intervention. No cases of stroke or device malfunction/migration were seen. The average follow-up period was 20±13.6 months. Of 74 patients with = 6-month follow-up available, 15 (20.3%) became seizure-free, 18 (24.3%) achieved 75-99% control of seizures, 19 (25.7%) achieved 50-74%, 15 (20.3%) achieved 25-49% and 7 (9.5%) achieved &lt;25% success. Patients with seizures originated in the mesial temporal lobe had a tendency to achieve =75% seizure control (OR = 1.4, P = 0.056). Variables associated with worse outcome (&lt;25% seizure control) included: younger age at epilepsy onset (OR = 2.4, P = 0.043), syndromic etiology (OR = 3.6, P = 0.041), prior no response to =5 AEDs (OR 4.3, P = 0.026) and prior surgical intervention (OR = 1.8, P = 0.052). CONCLUSION: RNS achieved = 50% seizure control in ∼70% of patients. Infections and tract-hemorrhages are the most common complications, but rarely require re-intervention. Seizure-freedom after RNS implantation may be significantly lower in patients affected by aggressive epileptogenic syndromes since a young age, and those who have failed to respond to &gt;5 drugs and prior surgical interventions.

Complications Based on Prostate Size After Plasmakinetic Enucleation of the Prostate.

Purpose: Lower urinary tract symptoms among adult men can significantly impact quality of life. We evaluated complications based on prostate size following plasmakinetic enucleation of the prostate. Materials and Methods: Patients were grouped into the small prostate group (SPG, <75 g) and large prostate group (LPG, >75 g) based on preoperative imaging. Patient data on demographics, comorbidities, preoperative international prostate symptom score (IPSS), bother index (BI), prostate-specific antigen (PSA) if indicated, postvoid residual volume (PVR), indwelling catheter or self-catheterization status, and any prior surgical intervention were evaluated. Postoperative IPSS, BI, and PVR values were assessed at 6 weeks, 4 months, and yearly. Postoperative urge urinary incontinence (UUI), stress urinary incontinence (SUI), and pad use were assessed. Results: Between September 2015 and December 2020, 296 patients who underwent bipolar enucleation with minimum follow-up of 4 months were evaluated. Postoperative IPSS, BI, PVR, and PSA values at all time points were significantly decreased compared with preoperative values (p < 0.05). There was no significant difference in the complications between groups. Univariable and multivariable analysis found that size <75 g was predictive of stricture formation and bladder neck contracture (BNC). UUI was more common at 6 weeks in the SPG, and SUI was more common at 6 weeks in the LPG, but no difference was noted at the 4-month and 1-year time points. Pad use was equal between the two groups at all time points. Conclusions: Plasmakinetic enucleation of the prostate provides an effective treatment option for prostates of all sizes; however, prostates <75 g have a higher rate of BNC and urethral strictures compared with those >75 g.

Development and Assessment of a Predictive Score for Vertebral Compression Fracture After Stereotactic Body Radiation Therapy for Spinal Metastases

Vertebral compression fracture (VCF) is a potential adverse effect following treatment with stereotactic body radiation therapy (SBRT) for spinal metastases. To develop and assess a risk stratification model for VCF after SBRT. This retrospective cohort study conducted at a high-volume referral center included 331 patients who had undergone 464 spine SBRT treatments from December 2007 through October 2019. Data analysis was conducted from November 1, 2020, to August 17, 2021. Exclusions included proton therapy, prior surgical intervention, vertebroplasty, or missing data. One and 3 fraction spine SBRT treatments were most commonly delivered. Single-fraction treatments generally involved prescribed doses of 16 to 24 Gy (median, 20 Gy; range, 16-30 Gy) to gross disease compared with multifraction treatment that delivered a median of 30 Gy (range, 21-50 Gy). The VCF and radiography components of the spinal instability neoplastic score were determined by a radiologist. Recursive partitioning analysis was conducted using separate training (70%), internal validation (15%), and test (15%) sets. The log-rank test was the criterion for node splitting. Of the 331 participants, 88 were women (27%), and the mean (IQR) age was 63 (59-72) years. With a median follow-up of 21 months (IQR, 11-39 months), we identified 84 VCFs (18%), including 65 (77%) de novo and 19 (23%) progressive fractures. There was a median of 9 months (IQR, 3-21 months) to developing a VCF. From 15 candidate variables, 6 were identified using the backward selection method, feature importance testing, and a correlation heatmap. Four were selected via recursive partitioning analysis: epidural tumor extension, lumbar location, gross tumor volume of more than 10 cc, and a spinal instability neoplastic score of more than 6. One point was assigned to each variable, and the resulting multivariable Cox model had a concordance of 0.760. The hazard ratio per 1-point increase for VCF was 1.93 (95% CI, 1.62-2.30; P < .001). The cumulative incidence of VCF at 2 years (with death as a competing risk) was 6.7% (95% CI, 4.2%-10.7%) for low-risk (score, 0-1; 273 [58.3%]), 17.0% (95% CI, 10.8%-26.7%) for intermediate-risk (score, 2; 99 [21.3%]), and 35.4% (95% CI, 26.7%-46.9%) for high-risk cases (score, 3-4; 92 [19.8%]) (P < .001). Similar results were observed for freedom from VCF using stratification. The results of this cohort study identify a subgroup of patients with high risk for VCF following treatment with SBRT who may potentially benefit from undergoing prophylactic spinal stabilization or vertebroplasty.

Prevalence, distribution and correlates of pain in patients with mucormycosis-A cross-sectional study

Context:COVID-19 has led to a spate of rhino-orbital-cerebral mucormycosis cases in India, the epidemiology of which was least understood before. Only a few case series and case reports discuss the symptomatology of mucormycosis.Aims:The primary objective of our study was to estimate the prevalence of pain in patients with mucormycosis. The secondary objectives include the type, regional distribution, characteristics and determinants of pain in patients with mucormycosis.Settings and Design:A cross-sectional study was conducted on consecutive adult patients with mucormycosis in our hospital.Materials and Methods:Following recruitment, a preplanned written questionnaire that was tested for validity with peers, with closed-ended queries was filled on a sole visit by an anesthesia postgraduate based on the response by the patient.Statistical analysis used:Categorical variables were summarized as proportion and percentage. To compare quantitative variables, Chi-square test was used.Results:A total of 69 out of the 80 patients recruited complained of pain (P value = 0.468). A total of 76.8% of patients had pain in the supraorbital region with 84% of the patients complaining of throbbing pain and 98.6% needing analgesics. Gender, pre-existing diabetes mellitus, organs affected due to mucormycosis, prior steroid usage, prior COVID illness, surgical intervention, and previous experience of pain in the same region had no influence on the presence or severity of pain.Conclusions:Pain is one of the presenting symptoms in patients with mucormycosis which is usually in the supraorbital and maxillary region, nociceptive type and throbbing in nature, and moderate to severe in intensity usually managed with simple analgesics.

Cerebral amyloid angiopathy: early presentation in a patient with prior neurosurgical interventions

Background: Cerebral amyloid angiopathy (CAA) has classically been described as a disease of the elderly. Genetic predisposition has been linked to the APOE e3/e3 allele. Evidence suggests that brain insult in the form of injury, prior surgical intervention, or radiation can exacerbate the clearance of toxic proteins in patients susceptible to CAA. Case: We describe a unique case of CAA in a 30-year-old male who had prior surgical interventions for spina bifida, Chiari malformation, and hydrocephalus as a child. Conclusions: The case is used to teach important components regarding diagnosis, clinical suspicion, and highlight the need for further investigation regarding the emerging role of the glymphatic system and its role in clinical pathology.

RADT-10. DEVELOPMENT AND INTERNAL VALIDATION OF A PREDICTIVE SCORE FOR VERTEBRAL COMPRESSION FRACTURE AFTER STEREOTACTIC BODY RADIATION THERAPY FOR SPINAL METASTASES

Abstract PURPOSE Vertebral compression fracture (VCF) is a potential adverse effect following stereotactic body radiation therapy (SBRT) for spinal metastases. In this analysis, we developed and internally validated a risk stratification model for VCF. METHODS From an initial set of 680 treatments, we excluded those with proton therapy, prior surgical intervention, or missing data. The final dataset had 464 treatments in 313 patients. Delineations of VCF and all radiographic components of the spinal instability neoplastic score (SINS) were determined by a radiologist. Recursive partitioning analysis (RPA) was conducted using separate training (70%), internal validation (15%), and test (15%) sets. The log-rank test was used as the criterion for node splitting. RESULTS With a median follow-up of 21 months, we identified 84 VCF (18%), including 65 (77%) de novo and 19 (23%) progressive fractures. There was a median 9 months (IQR: 3 – 21) to VCF. From an initial set of 15 candidate variables, six were identified using the backwards selection method, feature importance testing, and a correlation heatmap. Four were then selected in the highest-fidelity RPA models: epidural tumor extension, lumbar location, gross tumor volume &amp;gt; 10 cc, and SINS &amp;gt; 6. One point was assigned to each variable, and the resulting multivariate Cox model had a concordance of 0.760. Each one point increase in score was associated with increasing rates of VCF. Low-risk lesions (score: 0-1, n=273) had 2-year freedom from VCF of 92%, compared to 80% for intermediate-risk (score: 2, n=99) and 56% (score: 3-4, n=92) for high-risk lesions (p &amp;lt; 0.0001). Cumulative incidence curves with death as a competing risk showed increased VCF with higher scores via Gray’s test (p &amp;lt; 0.001). CONCLUSIONS Our internally-validated model identifies a subgroup of patients with high risk for VCF who may benefit from prophylactic surgical stabilization or vertebroplasty.

Fontan operation for tricuspid atresia with absent pulmonary valve: a case series.

Combined tricuspid atresia and absent pulmonary valve with dysplasia of the right ventricular myocardium is a very rare congenital heart anomaly with a poor prognosis. We present three cases of this rare disease that reached the Fontan operation without prior surgical intervention of the right ventricle or pulmonary artery; no right ventriclar dilation was detected. All patients had uneventful post-operative courses.

PD06-02 AN EVALUATION OF WOMEN WITH PERSISTENT OR RECURRENT STRESS URINARY INCONTINENCE (SUI) FOLLOWING SURGERY IN A DOUBLE-BLIND, RANDOMIZED, CONTROLLED TRIAL COMPARING SAFETY AND EFFICACY OF AUTOLOGOUS MUSCLE DERIVED CELLS FOR URINARY SPHINCTER REPAIR (AMDC-USR) WITH PLACEBO (PBO)

INTRODUCTION AND OBJECTIVE:Women with persistent or recurrent SUI following prior surgical intervention have an unmet medical need with symptoms which substantially impact daily functioning and qua...